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+ Pediatric Exanthems and rashes + Viral Classic I Measles (Rubeola) II Scarlet Fever III Rubella (German measles) IV Filatow-Dukes disease V Erythema Infectiosum VI Roseola Infantum + 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 + Bacterial Group A Streptococcus Other Gianotti-Crosti Unilateral laterothoracic exanthem Pityriasis Rosea + 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 + 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 + Measles: Fever + Triad + Measles: exanthem + Measles complications Respiratory - Common - Secondary bacterial inftection - OM - LTB Cardiac - Myocarditis - Pericarditis - ECG Changes + Measles Complications Neurological - Abnormal EEG common - Encephalitis - 1:1000 - Usually during exanthem - 25% sequalae - CSF increased wcc (pleocytosis), protein + Measles Complications Others - Black measles (haemorrhagic skin eruption) - SSPE - - 0.6/100,000 Mean incubation 7 years Increased CSF IgG 6-9 months until death Keratitis (blindness) + Measles: diagnosis Serology IgM Detectable 3 – 30 days after exanthem IgG Detectable from 7 days after the exanthem appears + 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 + GAS Aerobic gram-positive coccus Forms chains + Scarlet Fever Symptoms of primary infection, ie pharyngitis Strawberry tongue Perioral pallor + Scarlet fever: Rash + Scarlet fever: rash + Scarlet Fever: rash + 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 + 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%) + 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 + 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 + Rubella Togavirus Incubation period: 2 - 3weeks Transmission: droplet + 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 + + 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 + Rubella: Diagnosis Serology Rubella IgM (false positive EBV, CMV) Follow-up serology 4 weeks (paired sera) Treatment Supportive + 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 + + 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 + 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 + EI: Slapped cheek + Parvovirus B19: reticular/lace rash + Papular-pruritic glove and sock syndrome + EI: Treatment Paracetamol, Ibuprofen IVIG only in patients with aplasia Supportive + 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 + 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%) + HHV6: Rash + HHV6: treatment Supportive Anti-virals in immunocompromised + Varicella Zoster DNA virus Incubation: 10-21 days Tramission: Droplet Highly infectious (1-2 days before rash, until crusts) + Chickenpox: clinical Prodrome Fever Headache Malaise Pharyngitis Rash Pruritic Macules papules vesciles Hairline + Chickenpox: Rash + 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 + CMV DNA virus (HHV) 60-70% seroprevalence Infection usually asymptomatic Most improtant cause of congenital infection Important in immunocompromised hosts Associated with malignant transformation + CMV: Clinical Immunocompetent 90% asymptomatic Fever and lethargy up to 4 weeks Usually self-limiting Immunocompromised CMV pneumonitis (90% mortality) GIT disease CMV retinitis + CMV: Diagnosis, Treatment Diagnosis PCR and CMV antigenaemia Treatment Nucleosides (Target DNA polymerase) Ganciclovir and cidofovir Foscarnet + 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 + Enteroviruses Picornaviridae family RNA virus Transmission Faecal-oral Respiratory secretions (CoxsackieA21) Droplets (Enterovirus 70) + 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 + 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 + + HMFD Coxsackie A16, enterovirus 71 Summer Hihgly infectious Prodrome Vesicular eruptions of hands, feet, oral cavity Conservative, symptomatic Rx + + + Pityriasis rosea ?viral aetiology Mulitple viruses implicated Often viral prodrome “Herald” patch Single scaling patch Appears 1-21 ays prior to general rash + Herald patch + Herald patch + 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%) + Pityriasis rosea + Pityriasis rosea + Langer’s Lines + Distribution along Langer’s lines + Pityriasis rosea Symptomatic treatment Lasts 6-12 weeks Some cases photosensitive ?non-infectious + Pityriasis lichenoides ?Aetiology Post-infectious T-cell lymphoproliferative disorder Immune-complex mediated hypersensitivity vasculitis Pityriasis lichenoides chronica (PLC) Pityriasis lichenoides et varioliformis acuta (PLEVA) + 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 + Pink papule + Scaly plaque + 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 + PLEVA + 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 + Important complication Coronary artery abnormalities Aneurysms An unfavourable outcome Related to duration of fever + Atypical Kawasaki disease Usually at extremes of age Additional diagnostic criteria to aid in diagnosis ?associated with higher rate of coronary artery complications + + Rash Polymorphous Macular/papular/morbilloform/scarlatiniform/urticarial/erythr odermatous Never vesicular or bullous Associated with desquamation of perineal region days later + Polymorhous rash + Mucous membrane changes + Conjunctivitis + Palmar erythema + Peripheral oedema + Investigations FBE Neutrophilia Thrombocytosis Normochronic, normocytic anaema ASOT CRP ESR LFT Hypoalbuminaemia Elevated liver enzymes Echocardiogram + 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