Transcript Rash and Disease

Pediatric Exanthems
‫‪ ‬بيماران مبتال به تب و راش جلدي به توجه فوري‬
‫نيازمند مي باشند ‪ .‬علل اين تظاهرات ممكن‬
‫است عوامل كشنده و حياتي باشند و تشخيص‬
‫هاي افتراقي فراواني كه براي آن مطرح مي‬
‫باشند درخواست تستهاي باليني زيادي را توسط‬
‫پزشكان متخصص ايجاب مي نمايد ‪ .‬گرفتن شرح‬
‫حال باليني كامل ‪ ،‬مسافرت اخير بيمار ‪ ،‬سابقه‬
‫تماس با حيوان يا انسان مبتال به عفونت ‪ ،‬يا‬
‫مصرف ماده خاصي نكات كليدي مهمي براي‬
‫كشف علت بيماري مي باشند ‪.‬‬
‫مشخصه راش جلدي نيز در معاينه فيزيكي بسيار‬
‫ارزشمند است از آنجائيكه معموال ً قبل از آماده شدن‬
‫جواب كشت ها و آزمايشات اين بيماران بطور‬
‫تجربي‪ ) (empiric‬درمان مي گيرند لذا محدود كردن‬
‫دامنه تشخيص هاي افتراقي كمك كننده مي باشد‬
‫‪.‬‬
‫در طبقههب بيههدو عيههتعف و شا ه ت ههي ج رع هههيو اههدو بههب شرش هها عيههتعف‬
‫پش ي ‪ ،‬ويكتلتپيپتلر ‪ ،‬بتلتس ت ز كتلر ‪ ،‬عر شويشتس‬
‫‪ ،‬كه ر شقس م بيدو وي تد ‪.‬‬
Pediatric Exanthems
Six separate childhood exanthems were 
defined from what was once called the
“measles.”
In the early part of the 20th century, these 
were often referred to by number
Classic Childhood Exanthems
Measles
Scarlet fever
Rubella (“German measles”)
Atypical scarlet fever
Erythema Infectiosum
Roseola
.1
.2
.3
.4
.5
.6
Today, dozens of exanthems
are recognized:
Adenovirus
Anthrax
Mononucleosis
Colorado tick fever
Mumps
Cat-scratch fever
Rat-bite fever
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Rocky Mountain 
spotted fever
Relapsing fever 
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Meningococcemia
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Typhus 
Hand-foot-mouth 
disease
#1- Measles
Virus: Rubeola 
Demographics Winter or spring Infancy to 
young adulthood 8- to 12-day incubation
Epidemics until 96% immunized
Prodrome 2–4 days. High fever, cough, 
coryza, conjunctivitis, photophobia, Koplik
spots, lethargy, sneezing.
#1 Measles
Rash and Disease
Enanthem: Koplik spots = gray 
pinheads, ring of erythema, buccal
mucosa. 0.5–2d.
Exanthem: erythematous blanching 
macules.
Starts forehead, spreads downward
Confluent by 72 hr
Spares palms, and soles, 4–6 days.
Toxic appearance.
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#1- Measles
Diagnosis Leukopenia, IgG and IgM
serologies, acute and convalescent titers
Treatment Symptomatic. Antipyretics.
In severe disease, vitamin A.
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#1- Measles
Complications Otitis media, diarrhea, 
pneumonia (common in atypical rubeola).
Rarely, laryngo-tracheobronchitis,
myocarditis, encephalitis. Subacute sclerosing
panencephalitis
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#1- Measles
Prevention
Vaccinate all at 12–18 mo. 
Two doses for 13 years and older. 
Post-exposure vaccine if immuno- 
compromised
VZIG if pregnant, premature, or 
immunocompromised
#2- Scarlet Fever
Streptococcal, erythrogenic toxin. 
Demographics 1 to 10 yr 
Prodrome 2 to 4 days 
#2- Scarlet Fever
Rash and Disease
Strawberry tongue
Exudative pharyngitis
Generalized; spares palms and soles
Pinpoint papules
Desquamation of the tips of the fingers and toes
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Pastia line
#2 Scarlet Fever
Diagnosis
Group A streptococcal positive throat culture
Elevated WBC count and ESR
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Treatment : penicillin, cephalosporins, 
erythromycin, ofloxacin, rifampin, or the
newer macrolides
#3- Rubella
Virus: Rubivirus (Rubella)
Demographics
5–14 yr before vaccines
Now teens and young adults 2- to 3-wk
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Prodrome
Mild catarrhal symptoms, often overlooked.
Marked tender lymphadenopathy seen 24 hr
before rash
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#3 Rubella
Rash and Disease
Exanthem:
Starts face, spreads by 24 hr to trunk,
extremities.
Day 1: 1- to 4-mm macules, usually distinct,
sometimes reticular.
Day 2: pinpoint papules.
Day 3: clears. Sometimes mild desquamation.
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Low-grade fever, pruritus possible.
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#3 Rubella
Diagnosis
Acute and convalescent titers
rubella IgM antibody (esp. for exposed
pregnant women)
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Treatment
Symptomatic.
NSAIDs for arthritis.
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#3 Rubella
Complications
Self-limiting polyarthritis in girls, young
women. Hands and wrists, large joint
effusions.
Fetuses of nonimmune women infected may
have deafness, eye, cardiac and endocrine
anomalies, and retardation.
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#3 Rubella
Prevention
Vaccine at 12–15 mo 
Second dose at 11–12 yr. 
Immune globulin not indicated. 
#5- Erythema Infectiosum
Virus: Parvovirus B19
Demographics:
Spring
5–17 yr
4- to 21-d incubation
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Prodrome 
Low-grade fever, headache, malaise.
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#5- Erythema Infectiosum
Rash and Disease
“Slapped cheeks” facial erythema with
abrupt onset –conjunctivitisCircumoral and perioral pallor, sparing of
nasal bridge.
Body develops pale maculopapular
exanthem; may involve palms and soles.
Lasts 3–5 daysand can be brought by
stresses 2-39 Days
Gloves and Socks syndrome (only hands and
feet affected)-also hemorrhagicAtypically,
Papular-Purpuric
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#5- Erythema Infectiosum
Diagnosis 
IgM and IgG serologies, acute and 
convalescent antibody titers, DNA hybridization
ANA-RF-Aplastic Anemia Fetal Hydrops
Treatment
Symptomatic.
IVGG and transfusions if hematologic
complications
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#5- Erythema Infectiosum
Complications
In anyone: 
Henoch-Schonlein purpura,
Polyarteritis nodosa
Infectious mononucleosis.
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In HIV+ or those with hemolytic anemia: 
aplastic anemia.
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In pregnancy: fetal hydrops or stillbirth. 
#5- Erythema Infectiosum
No vaccine. 
No isolation once symptomatic (not 
contagious);
Pregnant women should avoid 
outbreak sites for 3 wk and get
serologic testing.
#6- Roseola
Virus: HHV-6 /HHV-7 
Demographics 0–3 yr 
Prodrome: 
3–5 d intermittent fever to 40.5°C.
Child appears well.
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#6- Roseola
Rash and Disease
Exanthem: 
0–2 d after defervesces
1- to 5-mm rose macules with pale areola densest on
neck and trunk.
Can get confluent.
Lasts 1–3 d.
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Enanthem: pinpoint papules or streaks on 
uvula, soft palate. LAD, periorbital edema,
cough, headache, coryza, abdominal pain.
#6- Roseola
Diagnosis 
Clinical.
Specific IgM and IgG for acute and
convalescent titers not widely available.
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Treatment 
Symptomatic. Antipyretics for fever.
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#6- Roseola
Complications
Febrile seizures. 
More rarely: 
mononucleosis
neonatal hepatitis
fatal hemophagocytic syndrome
encephalitis
thrombotic thrombocytopenic purpura
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Prevention: none 
Hand, Foot, and Mouth disease
aka Papular-purpuric gloves and socks syndrome
Virus: Enteroviruses 
Demographics 
Summer (less pronouncedin tropics)
6 mo to 13 yr
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Prodrome Brief. Sore throat, anorexia,
malaise, low-grade fever.

Hand, Foot, and Mouth
disease Rash and Disease
Enanthem:
Oral mucosal vesicles that erode to form
ulcers 2 mm to 2 cm in diameter.
Painful!
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Exanthem:
3- to 7- mm vesicles on dorsal hands, feet,
and sometimes palms, sole.
Tender, pruritic, or asymptomatic
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B19
Hand, Foot, and Mouth
disease
Diagnosis
Clinical
Specific serotype testing should clinician
suspect a particular enterovirus
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Treatment
Symptomatic. Analgesia to help child with
oral intake, steroids for itch
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Hand, Foot, and Mouth
disease Complications
Rare with Coxsackie A and B.
CNS or pulmonary complications possible
with enterovirus-71.
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DDx of an Erythematous
Maculopapular Rash
Rubella
Rubeola
Scarlet fever
Kawasaki disease
Secondary syphilis
Drug eruption
Coxsackie virus
ECHO virus
Adenovirus
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Infectious 
mononucleosis
Parvovirus 
Meningococcemia 
Toxoplasmosis 
Serum sickness 
Rickettsial disease (eg, 
Rocky Mountain Spotted
fever)
Roseola 
 Impetigo
- this usually takes the form of
itchy lesions with macules, vesicles,
bullae, pustules and gold-coloured crusts
caused by Staphylococcus aureus or
group A beta-haemolytic streptococci.2
Staphylococcal scalded skin
syndrome(appears as scalded skin, due to
focal staphylococcal infection – eg phage
type 71 – releasing an exotoxin).3
Pediatric Exanthems
In antiquity, these illnesses were all lumped 
together.
Eventually, a distinction was made between 
measles and pox (with growing clarity over
about a millennium).
Poxes
Chickenpox and Smallpox 
the other two classic childhood exanthems
recognized as separate from each other in
the 18th century.
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These both had blisters, or pox, that set 
them apart from the red rashes of the
other group
Varicella (chickenpox) - vesicles (initially 
papules, often not noticed), appearing as 'drops
of water'. Superficial, thin-walled with
surrounding erythema rapidly changing to
pustules and crusts. Appears in crops with all
stages represented. First appears on face and
scalp then spreads to trunk and extremities.
Crusts fall off in 1-3 weeks leaving pink base.
Initial fever is classically high before becoming
low grade. Beware of dyspnoea/cough which
may indicate varicella zoster virus (VZV)
pneumonitis.1
 Herpes
simplex virus infection (HSV) eczema herpeticum (HSV infection
superimposed on pre-existing, often mild,
eczema causing an eruption of crusty
vesicles and eczematous patches).
Lesions in DIFFERENT stages of 
development 
• Rapid evolution of lesions 
• Centripetal (central) distribution 
• Lesions rarely on palms or soles 
• Patient rarely toxic or moribund 
 Erythema
multiforme, classically
appearing as target lesions (erythematous
ring with central bulla)2
 Stevens-Johnson syndrome4
 Toxic epidermal necrolysis4
 Pompholyx (on hands/feet)5
Is it red but not scaly (and NOT
purpuric)?
Consider:
 Cellulitis
Kawasaki's disease
 Scarlet fever and the viral exanthemas e.g.:
Roseola infantum – (Sixth Disease)
Primary human herpes viral (HHV6 & 7) infection. Most common age is under
two years, frequent cause of infantile febrile seizures. Small blanchable pink
macules and papules found on trunk and neck. Associated with high fever prior
to defervescence or fifth disease) caused by Parvovirus B19
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Measles - presents as erythematous & appearance of rash on fourth day. Often asymptomatic.
Erythema infectiosum - (slapped cheek syndrome
macules and papules, initially discrete may
become confluent on face, neck and shoulders. On mucous membranes, Koplik's spots (tiny
bluish-white papules with erythematous areola) may develop. Also, upper respiratory tract
infection with cough, malaise and fever subsiding as rash increases (measles prodrome =
the 4 C's - cough, coryza, conjunctivitis and cranky++!)
Rubella (German measles) pink macules and papules starting on forehead and spreading to
face, trunk and extremities on first day

Fades from face on second day and rest of body by third day. Petechiae on

soft palate before rash. Low fever.
Scarlet fever (=scarlatina) exotoxin mediated
rash (Group A Streptococcus) - sore throat
then general erythema (classically with
perioral sparing), followed by confluent
petechiae in skin folds (Pastia sign) due to
increased capillary fragility. Strawberry tongue
(initially white, then red). Skin desquamation
(peeling) frequently follows rash

Is it red and purpuric?
 Meningococcal
meningitis (not common but should be
excluded) Early, in 75% cases 2-10mm macular or maculopapular
rash that blanches on pressure becomes apparent within first 24
hours of disease; sparsely distributed on face, trunk and lower
extremities.18 Use 'glass test' to assess 'blanchability' of rash by
placing glass tumbler against lesions and applying pressure. Later
the petechiae in centre of macules become haemorrhagic.
 Henoch-Schonlein purpura
 Idiopathic
thrombocytopaenic purpura (ITP),
leukaemia and other haematological disorders20
 Trauma, non-accidental Injury
 Enterovirus infections21
 Miscellaneous conditions:
Warts2
Verrucas
Head lice7
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Classic Reference
Exanthems and Drug Eruptions
Habif: Clinical Dermatology, 4th ed.,
Copyright © 2004 Mosby, Inc.


Review article:
Pediatric exanthems
Clinics in Family Practice 
Volume 5 • Number 3 • September 2003
Copyright © 2003 W. B. Saunders
Company
Jeffrey D. Wolfrey, MD *
William H. Billica, MD
Scott H. Gulbranson, MD
Alaina B. Jose, MD
Mark Luba, MD
Andrew Mohler, MD
Cheryl Pagel, MD
Jarrett K. Sell, MD
