Dr(Mrs) M.S.Panapitiya Consultant Paediatrician Fever & rashes Dr(Mrs) M.S.Panapitiya Consultant Paediatrician

why Viral exanthum Serious illness

Main features Well child / ill child Erythematous / haemorrhagic rash

Diagnostic clues Association with fever Distribution Morphology

Classfication of rashes Mobiliform rashes Scarlantiform rashes

Mobilliform rash Rash that looks like measles Patients with Kawasaki disease drug reactions The rash consists macular lesions red 2-10 mm in diameter may be confluent papular lesions solid elevated above the rest of the skin

Scarlatiniform rash Has the pattern of scarlet fever has innumerable small red papules Patients with other conditions such as Kawasaki disease viral infections drug reaction

Aetiology VIRAL INFECTIONS BACTERIAL INFECTIONS NONINFECTIVE

Viral infections Chicken pox Hand foot mouth disease Measles Rubella Fifth disease Sixth disease Dengue fever

Fifth Disease Erythema infectiousum Parvovirus B19 The preceding four exanthems were 1. Measles 2. Scarlet fever 3. Rubella 4. Atypical Scarlet fever ( Filatov-Dukes disease) 6. Roseola infantum (sixth disease)

Fifth Disease Benign, self-limited exanthematous illness of childhood. The prodromal phase low-grade fever headache mild upper respiratory tract infection

Fifth Disease Characteristic rash erythematous facial flushing occurs in three stages erythematous facial flushing "slapped-cheek" appearance.

extremities as a diffuse macular erythema 2. Spreads rapidly to the trunk and proximal extremities as a diffuse macular erythema

Central clearing of macular lesions occurs giving the rash a lacy, reticulated appearance.

Fifth Disease Palms and soles are spared, more prominent on extensor surfaces rash resolves spontaneously without desquamation

Roseola infantum Exanthem subitum Sixth disease Human herpes virus 6 (HHV-6)

Roseola infantum Primary HHV-6 infection occurs early in life. Peak acquisition of primary HHV-6 infection, from 6-15 m of age By 3-5 yr, 80-100% of children are seropositive

Roseola infantum The prodromal period usually asymptomatic but may include mild upper respiratory tract signs mild conjunctival redness cervical or, less frequently, occipital lymphadenopathy mild palpebral edema.

Roseola infantum Clinical illness 101-106°F with an average of 103°F irritable and anorexic Seizures may occur in 5-10% of children Infrequently abdominal pain, vomiting, and diarrhea. Fever persists for 3-5 days, and then typically resolves rather abruptly (crisis)

Roseola infantum A rash appears within 12-24 hr of fever resolution Begins as discrete, small (2-5 mm), slightly raised pink lesions on the trunk and spreads to the neck, face, and proximal extremities Not pruritic, and no vesicles or pustules remain discrete but occasionally may become almost confluent. After 1-3 days, the rash fades.

Measles (rubeola)

Measles Measles has three clinical stages Incubation stage 10-12 days Prodromal stage 2- 4 days Disease stage 6-10 days

Measles prodromal phase characterized by low-grade to moderate fever conjunctivitis coryza dry cough red mottling on the hard & soft palate Koplik spots

Measles Koplik spots The pathognomonic sign of measles, appear by 2-3 days Grayish white dots, usually as small as grains of sand Opposite the lower molars They appear and disappear rapidly, usually within 12-18 hr.

The temperature rises abruptly as the rash appears Measles EXANTHEMATOUS PHASE The temperature rises abruptly as the rash appears neck, behind the ears, along the hairline, and on the posterior parts of the cheek

Measles Lesions macular, maculopapular confluent,haemorrhagic Spreads rapidly over the entire face, neck, upper arms, and upper part of the chest within the first 24 hr

Measles Mx admit iv fluids vit A antiotics NUTRITION

Measles Complictions pneumonia diarrhoea malnutrition blindness encephalitis death

RUBELLA The incubation period is 14-21 days (German or three-day measles) The incubation period is 14-21 days The prodromal phase of mild catarrhal symptoms is shorter than that of measles and may go unnoticed Two thirds of infections are subclinical.

RUBELLA Lymphadenopathy. An enanthem most characteristic sign retroauricular, posterior cervical, and occipital An enanthem appears in 20% of patients just before the onset of the skin rash. discrete rose-colored spots on the soft palate (Forchheimer spots) Lymphadenopathy.

Rubella Exanthem It begins on the face and spreads quickly. Discrete maculopapules are present in large numbers Spread rapidly over the entire body, usually within 24 hr. May be confluent The eruption usually clears by the third day. Rubella without a rash has been described.

Hand foot and mouth disease Vesicular exanthum CHICKEN POX Hand foot and mouth disease

Hand foot and mouth disease Coxsackievirus A Coxsackie B viruses Enterovirus 71

Hand foot and mouth disease It is usually a mild illness, with or without low-grade fever. The oropharynx is inflamed and contains scattered vesicles on the tongue, buccal mucosa, posterior pharynx, palate, gingiva, and/or lips. These may ulcerate, leaving 4-8 mm shallow lesions with surrounding erythema.

Hand, foot, and mouth disease Develop the rash on the palms of the hands, soles of the feet, maybe on buttocks. Rash is not itchy, Starts out as small, flat, red dots turn into bumps or blisters(3-7mm)

Hand, foot, and mouth disease They are generally more common on the extensor surfaces Vesicles resolve in about 1 week

Mx Symptomatic No specific therapy

CHICKEN POX Patients are contagious 24-48 hr before the rash appears Vricella-Zoster Virus Patients are contagious 24-48 hr before the rash appears and until vesicles are crusted, usually 3-7 days after onset of rash

CHICKEN POX Prodromal phase 24- 48 hr before the rash malaise, headache, anorexia fever - variable - resolves 2-4 days after the onset of the rash

CHICKEN POX The rash often appears first on the scalp, face, or trunk. It can then spread over the entire body. Ulcerative lesions involving the oropharynx are common

CHICKEN POX The initial exanthem Intensely pruritic Vricella-Zoster Virus The initial exanthem The initial exanthem Intensely pruritic Erythematous macules Papular stage Blisters on a pink base Dry brown crusts New waves of blisters often spring up as the illness progresses

CHICKEN POX Vricella-Zoster Virus Varicella is a more serious disease with higher rates of complications and deaths among infants, adults, and immunocompromised patients.

Newborn with varicella Newborns have particularly high mortality around the time of delivery. Maternal varicella one week before or 2 days after birth frequently results in the newborn developing severe varicella The initial infection is intrauterine, although the newborn often develops clinical chickenpox postpartum.

Newborn with varicella Rx : ZSIG IV Acyclovir

CONGENITAL VARICELLA SYNDROME Up to 2% of fetuses whose mothers had varicella in the first 20 weeks of pregnancy may demonstrate VZV embryopathy Fetuses infected at 6-12 wk of gestation appear to have maximal interruption with limb development at 12-20 wk may have eye and brain involvement

Skin Eye Brain Limbs Stigmata of Varicella-Zoster Virus Fetopathy Cicatricial skin lesions Hypopigmentation Microphthalmia Cataracts Chorioretinitis Optic atrophy Skin Eye Brain Limbs Microcephaly Hydrocephaly Calcifications Aplasia of brain Hypoplasia of an extremity Motor and sensory deficits Absent deep tendon reflexes

Varicella vaccine Live virus vaccine Recommended for children at 12-18 mo Can be given at any age Children 12 mo to 12 yr receive a single vaccine dose Adolescents and adults require 2 vaccine doses, a minimum of 4 wks apart

Breakthrough varicella 2-6 weeks after vaccination Could be due to either the wild or vaccine strains Usually very mild Potentially infectious

Scarlet fever Upper respiratory tract infection associated with a characteristic rash Infection with pyrogenic exotoxin producing group A streptococcus

Scarlet fever The rash appears within 24-48 hr after onset of upper respiratory symptoms begins around the neck and spreads over the trunk and extremities

Scarlet fever Diffuse, finely papular, erythematous eruption producing a bright red discoloration Blanches on pressure

Scarlet fever More intense along the creases of the elbows, axillae, and groin P

Scarlet fever Cheeks may be erythematous with pallor around the mouth.

Scarlet fever Pharynx is red The tongue is usually coated and the papillae are swollen After desquamation, the reddened papillae are prominent, giving the tongue a strawberry appearance.

Scarlet fever After 3-4 days, the rash begins to fade and is followed by desquamation Sheetlike desquamation may occur around the free margins of the fingernails, the palms, and the soles.

Scarlet fever Treatment Group A streptococcus is sensitive to penicillin, and resistant strains have never been encountered. Penicillin is, therefore, the drug of choice (except in patients who are allergic to penicillin) Treatment with oral penicillin V for 10 days is recommended It must be taken for a full 10 days even though there is symptomatic improvement in 3-4 days

Toxic shock syndrome Toxic shock syndrome is caused by a toxin produced by certain types of Staphylococcus bacteria. A similar syndrome, called toxic shock-like syndrome (TSLS), can be caused by Streptococcal bacteria.

Toxic shock syndrome The onset is abrupt high fever vomiting diarrhea sore throat headache myalgia

Toxic shock syndrome Very ill Alteration in the level of consciousness Oliguria, hypotension progress to shock Disseminated intravascular coagulation

Toxic shock syndrome Exanthum A diffuse erythematous macular rash (scarlatiniform) appears within 24 hr Hyperemia of pharyngeal& conjunctival, mucous membranes Strawberry tongue is common

Kawasakie disease Diagnostic criterias Fever lasting for at least 5 days Presence of at least four of the following five signs: Fever lasting for at least 5 days

Bilateral bulbar conjunctival injection, generally nonpurulent

the oropharynx, injected pharynx red, dry & fissured lips 2. Changes in the mucosa of the oropharynx, injected pharynx red, dry & fissured lips strawberry tongue

3.Changes of the peripheral extremities Edema and/or erythema of the hands or feet in the acute phase Periungual desquamation in the subacute phase

4.Rash, primarily truncal polymorphous but nonvesicular Rash of various forms (maculopapular, erythema multiforme, or scarlatiniform) with accentuation in the groin area

5.Cervical adenopathy, ≥1.5 cm usually unilateral nonpurulent

Mycoplasma pneumoniae Skin lesions include a variety of exanthems, most notably Maculopapular rashes Erythema multiforme Stevens-Johnson syndrome

Dengue fever rash A transient, macular, generalized rash that blanches under pressure may be seen during the first 24-48 hr of fever. A generalized, morbilliform, maculopapular rash appears that spares the palms and soles. Rarely there is edema of the palms and soles. Petecial rash - Usually found on the limbs this rash is as a result of bleeding under the skin surface. Bright red rash - skin becomes florid and bright red in appearance. there will be some 'normal' areas of skin which are unaffected.

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?TRANSIENT APLASTIC CRISIS The incubation period for is shorter than for erythema infectiosum because it occurs coincident with the viremia. B19-induced aplastic crises occur in patients with all types of chronic hemolysis These patients are ill with fever, malaise, and lethargy and have signs and symptoms of profound anemia Rash is rarely present. TRANSIENT APLASTIC CRISIS.

C0NGENITAL INFECTION (PARVOVIRUS B19) Primary maternal infection is associated with nonimmune fetal hydrops and intrauterine fetal demise The mechanism of fetal disease appears to be a viral-induced red cell aplasia at a time when the fetal erythroid fraction is rapidly expanding. The second trimester seems to be the most sensitive period, but fetal losses are reported at every stage of gestation

Oral HSV primary infection probably the most common cause of stomatitis in children 1-3 yr of age, The symptoms may appear abruptly, with pain in the mouth, salivation, fetor oris, refusal to eat, and fever, often as high as 40-40.6°C Fever and irritability may precede the oral lesions by 1-2 days. The initial lesion is a vesicle which is seldom seen because of its early rupture. The residual lesion is 2-10 mm in diameter and is covered with a yellow-gray membrane. the tongue and cheeks are most commonly involved, no part of the oral lining is Submaxillary lymphadenitis is common. The acute phase lasts 4-9 days and is self-limited

reatment Any foreign materials, such as tampons, vaginal sponges, or nasal packing, will be removed. Sites of infection (such as a surgical wound) will be drained. The goal of treatment is to maintain important body functions. This may include: Antibiotics for any infection (may be given through an IV) Dialysis (if severe kidney problems are present) Fluids through a vein (IV) Methods to control blood pressure Intravenous gamma globulin may help in severe cases

Dukes' disease or fourth disease An exanthem-producing infectious disease of childhood of unknown aetiology. Synonym: Filatov's disease, fourth disease,

Signs and tests No single test can diagnose toxic shock syndrome. The diagnosis is based on several criteria: fever, low blood pressure, a rash that peels after 1-2 weeks, and problems with the function of at least three organs. In some cases, blood cultures may be positive for growth of S. aureus. Treatment