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Pediatric Exanthems and rashes
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Viral

Classic
I
Measles (Rubeola)
II
Scarlet Fever
III
Rubella (German measles)
IV Filatow-Dukes disease
V
Erythema Infectiosum
VI Roseola Infantum
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 Other
Herpes
HSV 1 and 2
Varicella-zoster
Cytomegalovirus
Epstein-Barr virus
Human Herpes virus 6 and 7
Human herpes virus 8
Enterovirus
Coxsackie A16
Coxsackie A
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
Bacterial
Group A Streptococcus

Other
Gianotti-Crosti
Unilateral laterothoracic exanthem
Pityriasis Rosea
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Measles
 Paramyxovirus
 Incubation
period: 7 –14 days
 Infectious
period: 1- 2 days before prodrome
to 4 days after onset of rash
 Very infectious (90% attack
contacts)
 Droplet spread –
rates in household
oral secretions
 Typical course 7‐10 days (without
 Risk
factors: non-vaccination
complications
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Measles: clinical features

Prodrome: day 7-14 after exposure

Fever

Cough

Coryza

Conjunctivitis

Koplik’s spots (1-2 days before rash)

Rash (D3‐7) started behind ears

Miserable
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Measles: Fever + Triad
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Measles: exanthem
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Measles complications
Respiratory
- Common
- Secondary bacterial inftection
- OM
- LTB
Cardiac
- Myocarditis
- Pericarditis
- ECG Changes
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Measles Complications
Neurological
-
Abnormal EEG common
-
Encephalitis
-
1:1000
-
Usually during exanthem
-
25% sequalae
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CSF increased wcc (pleocytosis), protein
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Measles Complications
Others
-
Black measles (haemorrhagic skin eruption)
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SSPE
-
-
0.6/100,000
Mean incubation 7 years
Increased CSF IgG
6-9 months until death
Keratitis (blindness)
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Measles: diagnosis

Serology

IgM


Detectable 3 – 30 days after exanthem
IgG

Detectable from 7 days after the exanthem appears
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Scarlet Fever
Group A beta-haemolytic streptococcus
Primary


Pharyngitis
Skin


Cellulitis
Impetigo
Non-Suppurative complications




Scarlet fever
Streptococcal toxic shock syndrome
Acute glomerulonephritis
Acute rheumatic fever
Suppurative complications



Tonsillar abscess
OME
Necrotizing fasciitis
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GAS

Aerobic gram-positive coccus

Forms chains
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Scarlet Fever

Symptoms of primary infection, ie pharyngitis

Strawberry tongue

Perioral pallor
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Scarlet fever: Rash
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Scarlet fever: rash
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Scarlet Fever: rash
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Streptococcal Toxic Shock
Syndrome
Definition: GAS infection associated with the
acute onset of shock and organ failure
Virulence factors:

M protein (Type 1, 3, 12, 28 most commonly isolated)


Anti-phagocytic, cell membrane protein
Exotoxins (SPEA, SPEB)

Streptococcal pyrogenic exotoxin A,B

Trigger inflammatory cytokine release
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Streptococcal Toxic Shock
Syndrome: Clinical Features

Fever

Hypotension

Altered mental status (50%)

Multiorgan dysfunction


Renal (All)
ARDS 55%

Influenza-like syndrome (20%)

Soft tissue infection


Progresses to fasciitis/myositis 70-80%
Scarlatinaform rash (10%)
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Staphylococcal toxic shock
syndrome vs Streptococcal
Findings
Staph
Strep
Age
15-35
20-50
Sex
F>M
F=M
Absent
Present
Erythroderma
Present
Absent
N/V/D
Present
Absent
Bacteraemia
Uncommon
60%
Mortality
3%
30%
Local invasive
Disease
Generalized
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Streptococcal Toxic Shock
Syndrome: Diagnosis
Working Group on Severe Streptococcal
Infections:
Isolation of GAS from a normally sterile site
Plus
 Hypotension
Plus > 2 of the following
 Renal impairment
 Coagulopathy
 Liver impairment
 ARDS
 Erythematous macular rash, may desquamate
 Soft tissue necrosis

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Rubella

Togavirus

Incubation period: 2 - 3weeks

Transmission:
droplet
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Rubella: Clinical Features
 Mild/subclinical
 Prodrome

Eye pain, conjunctivitis, headache, fever, malaise
 Rash



Maculopapular
Starts on face, spreads caudally to trunk, extremities
Similar to Measles, but spreads quicker
 Lymphadenopathy

Posterior cervical, posterior auricular, suboccitpital
 Forchheimer

spots (20%)
Petechiae on soft palate
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Rubella: complications
Joints



Arthralgia/arthritis
Rare in children
Lasts about 9 days
Neurological



Encephalitis rare
2-4 days after rash
Parasthesia
Other





Thrombocytopaenia
Purpura
Myocarditis
Testicular pain
Haemolytic anaemia
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Rubella: Diagnosis


Serology

Rubella IgM (false positive EBV, CMV)

Follow-up serology 4 weeks (paired sera)
Treatment

Supportive
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Erythema Infectiosum

Parvovirus B19

Common: 5-10% aged 2-5 seropositive

Incubation

4 – 14 days

Replicates in erythroid progenitor cells in bone marrow/blood
 anaemia
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Erythema Infectiosum: Clinical

Biphasic illness

Non-specific prodrome (fever, headache, myalgias (5-7 days
after infection)

1 week later – rash (“slapped cheek”, reticular rash
extremities)

Papular-pruritic glove and sock syndrome

Arthritis/arthralgia

Aplastic crisis
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EI: rare manifestations
Arthritis

Association b/w B19 and RA
Neurological





Encephaliis
Meningitis
GB syndrome
Facial palsy
CT syndrome
Myocarditis
Cutaneous



EM
HSP
Petechiae
Haematological




TTP
Pancytopaenia
Haemophagocytic
DB anaemia
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EI: Slapped cheek
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Parvovirus B19: reticular/lace rash
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Papular-pruritic glove and sock
syndrome
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EI: Treatment

Paracetamol, Ibuprofen

IVIG only in patients with aplasia

Supportive
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HHV 6: Roseola Infantum

DNA virus

Sixth disease

Incubation: 9 days

Transmission: oral secretions

80% children seropositive by age 1

Peak infection 9 – 21 months
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HHV6: Clinical
 Fever
and convulsion (6-15%)
 Diarrhoea
 Usually
(70%)
well
 Rash
 evolves over 12 hours, fades 2-3 days
 Appears as fever abates
 Starts on neck/trunk, spreads to extremities
 Erythematous, blanching, macular/mac-papular
 Bulging
fontanelle (25%)
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HHV6: Rash
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HHV6: treatment

Supportive

Anti-virals in immunocompromised
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Varicella Zoster

DNA virus

Incubation: 10-21 days

Tramission: Droplet

Highly infectious (1-2 days before rash, until crusts)
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Chickenpox: clinical
Prodrome




Fever
Headache
Malaise
Pharyngitis
Rash



Pruritic
Macules  papules  vesciles
Hairline
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Chickenpox: Rash
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VZV Chickenpox: Complications
Skin

Cellulitis (GAS)
Neurological

Encephalitis



Acute cerebellar ataxia (1:4000)
Diffuse encephalitis (1:100,000)
Reye Syndrome


No salicylates
N/V, headache, excitability, delirium
Respiratory

Pneumonia (SA, GAS)
Zoster
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CMV

DNA virus (HHV)

60-70% seroprevalence

Infection usually asymptomatic

Most improtant cause of congenital infection

Important in immunocompromised hosts

Associated with malignant transformation
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CMV: Clinical
Immunocompetent

90% asymptomatic

Fever and lethargy up to 4 weeks

Usually self-limiting
Immunocompromised

CMV pneumonitis (90% mortality)

GIT disease

CMV retinitis
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CMV: Diagnosis, Treatment
Diagnosis

PCR and CMV antigenaemia
Treatment

Nucleosides (Target DNA polymerase)

Ganciclovir and cidofovir

Foscarnet
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ZIG immunoglobulin
Indications

Neonates whose mother develops VZV from 5 days prior to 2
days after delivery

Neonates if mother no history or negative serology

Premature infants < 28/40

Where vaccine may be contrindicated
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Enteroviruses

Picornaviridae family

RNA virus

Transmission

Faecal-oral

Respiratory secretions (CoxsackieA21)

Droplets (Enterovirus 70)
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Enterovirus

Poliovirus
subclinical, aseptic
meningitis, paralytic
poliomyelitis

Non-polio virus

Coxsackie A
HFMD, Herpangina

Coxsackie B
Herpangina, pleurodynia,
myocarditis, pericarditis,
meningoencephalitis

Echovirus

Enterovirus
URTI, aseptic meningitis, acute
haemorrhagic conjunctivitis
Gastroenteritis
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Herpangina

Coxsackie A16, Enterovirus 71

Mainly 3-10yo

Fever, sore throat, odonyphagia

Vesicular enanthem on the tonsillar fauces, soft palate,
posterior pharynx

Conservative, symptomatic Rx
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HMFD

Coxsackie A16, enterovirus 71

Summer

Hihgly infectious

Prodrome

Vesicular eruptions of hands, feet, oral cavity

Conservative, symptomatic Rx
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Pityriasis rosea

?viral aetiology

Mulitple viruses implicated

Often viral prodrome

“Herald” patch

Single scaling patch

Appears 1-21 ays prior to general rash
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Herald patch
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Herald patch
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Pityriasis rosea

Scaly patches/plaques

Chest and back

Uncommon on face/scalp

Smaller than herald patch

Follow Langer’s lines

Collagen bundle direction

Christmas tree distribution

Pruritic (75%)
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Pityriasis rosea
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Pityriasis rosea
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Langer’s Lines
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Distribution along Langer’s lines
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Pityriasis rosea

Symptomatic treatment

Lasts 6-12 weeks

Some cases photosensitive

?non-infectious
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Pityriasis lichenoides

?Aetiology

Post-infectious

T-cell lymphoproliferative disorder

Immune-complex mediated hypersensitivity vasculitis

Pityriasis lichenoides chronica (PLC)

Pityriasis lichenoides et varioliformis acuta (PLEVA)
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Pityriasis lichenoides (PLC)

Various stages

Small pink papule  reddish-brown

A fine mica-like adherent scale attached to a central spot

Spot flattens out spontaneously leaving behind a brown mark,
which fades over months

Commonly trunk, buttocks, arms, legs

Not itchy/irritable
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Pink papule
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Scaly plaque
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PLEVA

Red patches that evolve quickly into papules 5-15mm
diameter

Often covered in mica-like scale

Papules can contain pus/blood

Trunk , extremities commonly, but can be widespread

Pruritic and burning sensation
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PLEVA
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Kawasaki Disease

Systemic vasculitis

Aetiology

Still unkown

Predominantly < 5yo

Diagnostic criteria

Fever for 5 days
PLUS 4 of 5

Polymorphous rash

Bilateral (non purulent) conjunctivitis (90%)

Mucous membrane changes



Erythema, fissuring of lips

Strawberry tongue
Peripheral changes

Erythema of palms/soles

Oedema of hands/feet

Desquamation in convalescent phase
Cervical lymphadenopathy (75%)

>15mm

Usually unilateral, single, painful
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Important complication

Coronary artery abnormalities

Aneurysms

An unfavourable outcome

Related to duration of fever
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Atypical Kawasaki disease

Usually at extremes of age

Additional diagnostic criteria to aid in diagnosis

?associated with higher rate of coronary artery
complications
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Rash

Polymorphous

Macular/papular/morbilloform/scarlatiniform/urticarial/erythr
odermatous

Never vesicular or bullous

Associated with desquamation of perineal region days later
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Polymorhous rash
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Mucous membrane changes
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Conjunctivitis
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Palmar erythema
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Peripheral oedema
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Investigations

FBE



Neutrophilia
Thrombocytosis
Normochronic, normocytic anaema

ASOT

CRP

ESR

LFT



Hypoalbuminaemia
Elevated liver enzymes
Echocardiogram
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Management


IVIG

2g/kg over 10 hours

Preferably within first 10 days of illness
Aspirin

3-5mg/kg once a day for 6-8weeks

For coronary complications