Dr(Mrs) M.S.PanapitiyaConsultant Paediatrician

Fever & rashes

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

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

Mobilliform rash

• Has the pattern of scarlet fever

• has innumerable small red papules

• Patients with other conditions such as

Kawasaki disease viral infections drug reaction

Scarlatiniform rash

• VIRAL INFECTIONS• BACTERIAL INFECTIONS• NONINFECTIVE

Aetiology

Chicken poxHand foot mouth diseaseMeaslesRubellaFifth diseaseSixth diseaseDengue fever

Viral infections

Erythema infectiousum

Fifth Disease

Parvovirus B19

The preceding four exanthems were1. Measles2. Scarlet fever3. Rubella 4. Atypical Scarlet fever ( Filatov-Dukes disease) 6. Roseola infantum (sixth disease)

Benign, self-limited exanthematous illness of childhood.

The prodromal phase• low-grade fever• headache• mild upper respiratory tract infection

Fifth Disease

Characteristic rash

occurs in three stages

1.erythematous facial flushing

"slapped-cheek" appearance.

Fifth Disease

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

3. Central clearing of macular lesions occurs

giving the rash a lacy, reticulated appearance.

Palms and soles are spared,

more prominent on extensor surfaces

rash resolves spontaneously without desquamation

Fifth Disease

Exanthem subitumSixth disease

Roseola infantum

Human herpes virus 6 (HHV-6)

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.

Roseola infantum

Fever persists for 3-5 days, and then typically resolves rather abruptly (crisis)

A rash appears within 12-24 hr of fever resolution

Roseola infantum

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.

(rubeola)

Measles

Measles has three clinical stages

Measles

Incubation stage 10-12 days

Prodromal stage 2- 4 days

Disease stage 6-10 days

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

Measles

prodromal phase

The pathognomonic sign of measles, appear by 2-3 days

Grayish white dots, usually as small as grains of sand

Opposite the lower molars

Koplik spots

They appear and disappear rapidly, usually within 12-18 hr.

Measles

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

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

Measles

• Mx• admit• iv fluids• vit A• antiotics• NUTRITION

Measles

• Complictions pneumonia diarrhoea malnutrition blindness encephalitis death

(German or three-day measles)

RUBELLAThe 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.

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

RUBELLALymphadenopathy.

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.

RUBELLA

CHICKEN POX

Hand foot and mouth disease

Vesicular exanthum

Hand foot and mouth disease

Coxsackievirus A

Coxsackie B viruses

Enterovirus 71

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

Hand, foot, and mouth disease

MxSymptomaticNo specific therapy

Vricella-Zoster Virus CHICKEN POX

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

• Blisters on a pink base • Dry brown crusts

• New waves of blisters often spring up as the illness progresses

CHICKEN POXVricella-Zoster Virus The initial exanthem

The initial exanthem • Intensely pruritic • Erythematous macules• Papular stage

Varicella is a more serious disease with higher rates of complications and deaths among infants, adults, and immunocompromised patients.

CHICKEN POXVricella-Zoster Virus

The initial infection is intrauterine, although the newborn often develops clinical chickenpox postpartum.

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

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

Stigmata of Varicella-Zoster Virus Fetopathy

Cicatricial skin lesions Hypopigmentation

Microphthalmia Cataracts Chorioretinitis Optic atrophy

Microcephaly Hydrocephaly Calcifications Aplasia of brain

Hypoplasia of an extremity Motor and sensory deficits Absent deep tendon reflexes

SkinEyeBrainLimbs

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

Usually very mild

Breakthrough varicella

2-6 weeks after vaccination

Could be due to either the wild or vaccine strains

Potentially infectious

Scarlet fever

Upper respiratory tract infection associated with a characteristic rash

Infection with pyrogenic exotoxin producing group A streptococcus

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

Scarlet feverDiffuse, finely papular, erythematous eruption producing a bright red discoloration

Blanches on pressure

More intense along the creases of the elbows, axillae, and groin

Scarlet fever

P

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

Scarlet fever

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

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

Very ill

Alteration in the level of consciousness

Oliguria, hypotensionprogress to shock

Disseminated intravascular coagulation

Toxic shock syndrome

Toxic shock syndrome

• Exanthum A diffuse erythematous macular rash

(scarlatiniform) appears within 24 hr

Hyperemia of pharyngeal& conjunctival, mucous membranes

Strawberry tongue is common

Fever lasting for at least 5 days

Presence of at least four of the following five signs:

Kawasakie disease

Diagnostic criterias

Fever lasting for at least 5 days

1. Bilateral bulbar conjunctival injection, generally nonpurulent

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

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.

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.

Dengue fever rash

Thank you

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

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.

C0NGENITAL INFECTION(PARVOVIRUS B19)

The second trimester seems to be the most sensitive period, but fetal losses are reported at every stage of gestation

• 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

ORAL HSV PRIMARY INFECTION

reatmentAny 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 pressureIntravenous gamma globulin may help in severe cases

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

Signs and testsNo 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