Transcript Exanthems
Common Exanthems Adam Goldstein, MD Associate Professor UNC Department of Family Medicine Chapel Hill, NC [email protected] Objectives Understand nomenclature for common exanthems Know an appropriate differential dx for most exanthems Improved ability to diagnose: Measles (rubeola) German Measles (Rubella) Chicken Pox (Varicella) Fifth Disease (Erythema infectiosum) Roseola (exanthem subitum) Hand, foot & mouth disease Pityriasis rosea Asymmetric periflexural exanthem of childhood (APEC) Kawasaki disease Smallpox Scarlet fever Drug eruptions Unknown exanthems Exanthems Anyone of a number of systemic processes giving generalized eruption Usually not isolated Caused by: Viruses Bacteria Fungal Drugs Idiopathic Exanthems (Historical) 1 Measles 2 Scarlet fever 3 Rubella 4 "Dukes' disease”- ? measles, rubella, scarlet fever, Staph infection, or one of several unspecified enteroviral infections; 5 Erythema Infectiosum 6 Roseola. Measles (Rubeola) Diff Dx S/S’s: Fever, conjunctivitis, cough Characteristic Koplik spots 24-48 hours before rash Rash: Days 4-5, red & blotchy begins on face & behind ears usually with onset high fever spreads to body Usually spares palms/soles Rash coalesces on trunk/face Rubella (German measles) "little red”; 3rd Disease Schoolchildren highest infectivity in unvaccinated populations Congenital Rubella Syndrome deafness, eye lesions, heart malformations & mr 24 cases 1997-1999, mostly immigrant 25-50,000 cases Mexico 1998 Higher suspicion cases in patients immigrating from countries with higher rates Vaccination contraindicated pregnancy (MMWR, 2001) Rubella Diffuse rash, LN enlargement, h/a, malaise, mild cough and conjunctivitis Pink rash appears on face and spreads to body www.info.gov.hk/dh/diseases/ CD/rubella.htm Chicken Pox- Varicella caused by varicella-zoster virus blister-like rash, itching, fatigue & fever 250-500 itchy blisters, 3 stages at same time (papule, vesicle, scab) 1 in 10 complications: bacterial, pneumonia, encephalitis Chicken Pox- Varicella Fifth Disease (Erythema infectiosum) Parvovirus B19 S/S’s: low fever, cold, mildly ill Skin: "slapped-cheek" rash on face lacy red rash trunk & limbs infected adults may develop joint pains hands, wrists, knees kids may return to school- no longer infectious pregnant women exposed- refer to guidelines (Crane J, J Obstet Gynaecol Can, 2002) Roseola/Exanthem Subitum Human Herpes Virus 6>7 spread via saliva 72-95% sero + in US early age S/S’s: irritable, diarrhea, cough, fever 102-105F, for 3-7 days; 10% seizure Skin: As fever resolves, faint macules develop on trunk and extremities that blanch upon pressure Rash resolves 1-2 days Roseola/Exanthem Subitum Skin: As fever resolves, faint macules develop on trunk and extremities that blanch upon pressure Rash resolves 1-2 days Hand Foot and Mouth Disease Common acute febrile illness of children Group A coxsackie viruses 2-7 days resolves Hand washing Rare complications HFM Disease hand foot mouth Pityriasis rosea Unknown cause Lasts 6-12 weeks Herpes viruses 6 & 7 associated Herald patch 1-20 days before rash Sometimes confused with T. Corporis or psoriasis Pityriasis rosea Oval patches follow line of ribs like fir tree Erythromycin may be effective tx (Sharma, JAAD, 2000) Asymmetric periflexural exanthem of childhood (APEC) Laterothoracic exanthem Uncommon, G > B Viral symptoms can occur Often mistaken for eczema, fungal Skin: Usually starts in armpit or groin and extends outwards, on one side of body May spread to face, genitalia, hands or feet Patches are net-like or in rings Pruritic Resolves within 3 months Kawasaki disease 80% in children < 4 years Self-limiting & resolves spontaneously without treatment 4-8 weeks 15-20% have damage to coronary arteries and 2% of patients die from heart attack (Brogan PA, Arch Dis Child, 2002) Kawasaki disease Kawasaki disease Kawasaki disease http://www.dermnetnz.org/index.html Smallpox Classic generalized exanthem Latin word for “spotted” referring to the raised bumps on the face and body Rash, high fever & mortality rate 30% Last natural case Somalia in 1977 http://www.bt.cdc.gov/agent/smallpox/overview/disease-facts.asp Smallpox Exanthem from vaccination 1/100,000 Vaccinia rash or outbreak of sores Generalized vaccinia Erythema multiforme http://www.bt.cdc.gov/agent/smallpox/ Smallpox From Vaccination 1/50,000 Eczema vaccinatum Progressive vaccinia Postvaccinal encephalitis Scarlet fever Group A streptococcus toxin children aged 4-8 contagious by coughing/sneezing or touching the infected skin sudden fever with sore throat, swollen LN’s, h/a, n, v, loss of appetite, swollen and red strawberry tongue, abdominal pain, body aches, and malaise Scarlet fever Skin: rash 12-48 hours after fever ears, neck, chest, armpits, groin, then rest of body over 24 hours scarlet spots or blotches, often the first sign starts to look like sunburn with goose pimples skin may have a rough sandpaper-like feel as rash fades, it peels similar to that of sunburned skin Drug eruptions Almost all drugs Drug eruptions Dilantin Drug eruptions Minocycline Drug eruptions Fixed drug eruption Unknowns 1 Unknowns 2 Unknowns 3 Unknowns 4 Unknowns 5 Unknowns 6 Unknowns 7 Unknowns 8 Unknowns 9 Unknowns 10 BONUS BONUS BONUS References Trizna Z. Viral diseases of the skin: diagnosis and antiviral treatment. Pediatr Drugs 2002;4:9-19. http://home.mdconsult.com/das/guideline/view/26827010/N/1119682 0?sid=166362089&source=MI Crane J. Parvovirus B19 infection in pregnancy. J Obstet Gynaecol Can 2002; 24: 727-43. Glatman-Freedman A. Rubella vaccine. Pediatr Rev 2002; 23(3): 1067. Smallpox Vaccine. Pediatrics 2002. American Academy of Pediatrics, Committee on Infectious Diseases; 110: 4. Bromberg K. Group A beta-hemolytic streptococcal pharyngitis. Am Fam Physician 2001; 63(8): 1486-7. Bisno AL. Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Infectious Diseases Society of America. Clin Infect Dis 2002; 35(2): 113-25. References Gable EK. Pediatric exanthems. Prim Care 2000; 27: 353-69. Brogan PA. Kawasaki disease: an evidence based approach to diagnosis, treatment, and proposals for future research. Arch Dis Child 2002; 86: 286-90. Hairston BR. Viral diseases of the oral mucosa. Dermatol Clin 2003; 21(1): 17-32. De Araujo T. Human herpesviruses 6 and 7. Dermatol Clin 2002; 20(2): 301-6. Sharma PK. Erythromycin in pityriasis rosea: A double-blind, placebo-controlled clinical trial. J Am Acad Dermatol 2000; 42: 2414. MMWR. Control and prevention of rubella: evaluation and management of suspected outbreaks, rubella in pregnant women, and surveillance for congenital rubella syndrome. July 13, 2001; 50: 1-23. Thank you.