1. Pediatric ExanthemsPediatric Exanthems Deborah J BostockDeborah J Bostock Col, USAF, MCCol, USAF, MC Family Medicine and GeriatricsFamily Medicine and Geriatrics

2. Classic ReferenceClassic Reference Exanthems and Drug EruptionsExanthems and Drug Eruptions Habif: Clinical Dermatology, 4thHabif: Clinical Dermatology, 4th ed.ed., Copyright 2004 Mosby, Inc., Copyright 2004 Mosby, Inc. 3. Review article:Review article: Pediatric exanthemsPediatric exanthems Clinics in Family PracticeClinics in Family Practice Volume 5 Number 3 SeptemberVolume 5 Number 3 September 20032003 Copyright 2003 W. B. SaundersCopyright 2003 W. B. Saunders CompanyCompany Jeffrey D. Wolfrey, MDJeffrey D. Wolfrey, MD William H. Billica, MDWilliam H. Billica, MD Scott H. Gulbranson, MDScott H. Gulbranson, MD Alaina B. Jose, MDAlaina B. Jose, MD Mark Luba, MDMark Luba, MD Andrew Mohler, MDAndrew Mohler, MD Cheryl Pagel, MDCheryl Pagel, MD Jarrett K. Sell, MDJarrett K. Sell, MD 4. Pediatric ExanthemsPediatric Exanthems In antiquity, these illnesses were allIn antiquity, these illnesses were all lumped together.lumped together. Eventually, a distinction was madeEventually, a distinction was made between measles and pox (withbetween measles and pox (with growing clarity over about agrowing clarity over about a millennium).millennium). 5. Pediatric ExanthemsPediatric Exanthems Six separate childhood exanthemsSix separate childhood exanthems were defined from what was oncewere defined from what was once called the measles.called the measles. In the early part of the 20th century,In the early part of the 20th century, these were often referred to bythese were often referred to by numbernumber 6. PoxesPoxes Chickenpox and SmallpoxChickenpox and Smallpox the other two classic childhoodthe other two classic childhood exanthemsexanthems recognized as separate from eachrecognized as separate from each other in the 18th century.other in the 18th century. These both had blisters, or pox,These both had blisters, or pox, that set them apart from the redthat set them apart from the red rashes of the other grouprashes of the other group 7. Classic ChildhoodClassic Childhood ExanthemsExanthems 1.1. MeaslesMeasles 2.2. Scarlet feverScarlet fever 3.3. RubellaRubella (German measles)(German measles) 4.4. Atypical scarlet feverAtypical scarlet fever 5.5. Erythema InfectiosumErythema Infectiosum 6.6. RoseolaRoseola 8. Today, dozens of exanthemsToday, dozens of exanthems are recognized:are recognized: AdenovirusAdenovirus AnthraxAnthrax MononucleosisMononucleosis Colorado tickColorado tick feverfever MumpsMumps Cat-scratchCat-scratch feverfever Rat-bite feverRat-bite fever Rocky MountainRocky Mountain spotted feverspotted fever Relapsing feverRelapsing fever MeningococcemiaMeningococcemia TyphusTyphus Hand-foot-mouthHand-foot-mouth diseasedisease 9. #1- Measles#1- Measles VirusVirus: Rubeola: Rubeola DemographicsDemographics Winter or springWinter or spring Infancy to young adulthood 8- to 12-Infancy to young adulthood 8- to 12- day incubation Epidemics until 96%day incubation Epidemics until 96% immunizedimmunized ProdromeProdrome 24 days. High fever,24 days. High fever, cough, coryza, conjunctivitis,cough, coryza, conjunctivitis, photophobia, Koplik spots, lethargy,photophobia, Koplik spots, lethargy, sneezing.sneezing. 10. #1 Measles#1 Measles Rash and DiseaseRash and Disease EnanthemEnanthem: Koplik spots=gray: Koplik spots=gray pinheads, ring of erythema, buccalpinheads, ring of erythema, buccal mucosa. 0.52d.mucosa. 0.52d. ExanthemExanthem: erythematous blanching: erythematous blanching macules.macules. Starts forehead, spreads downwardStarts forehead, spreads downward Confluent by 72 hrConfluent by 72 hr Spares palms, and soles, 46 days.Spares palms, and soles, 46 days. Toxic appearance.Toxic appearance. 11. #1- Measles#1- Measles DiagnosisDiagnosis Leukopenia, IgG and IgMLeukopenia, IgG and IgM serologies, acute and convalescentserologies, acute and convalescent titerstiters TreatmentTreatment Symptomatic.Symptomatic. Antipyretics.Antipyretics. In severe disease, vitamin A.In severe disease, vitamin A. 12. #1- Measles#1- Measles ComplicationsComplications Otitis media,Otitis media, diarrhea, pneumonia (common indiarrhea, pneumonia (common in atypical rubeola).atypical rubeola). Rarely, laryngo-tracheobronchitis,Rarely, laryngo-tracheobronchitis, myocarditis, encephalitis. Subacutemyocarditis, encephalitis. Subacute sclerosing panencephalitissclerosing panencephalitis 13. #1- Measles#1- Measles PreventionPrevention Vaccinate all at 1218 mo.Vaccinate all at 1218 mo. Two doses for 13 years and older.Two doses for 13 years and older. Post-exposure vaccine if immuno-Post-exposure vaccine if immuno- compromisedcompromised VZIG if pregnant, premature, orVZIG if pregnant, premature, or immunocompromisedimmunocompromised 14. #2- Scarlet Fever#2- Scarlet Fever Streptococcal, erythrogenic toxin.Streptococcal, erythrogenic toxin. DemographicsDemographics 1 to 10 yr1 to 10 yr ProdromeProdrome 2 to 4 days2 to 4 days 15. #2- Scarlet Fever#2- Scarlet Fever Rash and DiseaseRash and Disease Strawberry tongueStrawberry tongue Exudative pharyngitisExudative pharyngitis Generalized; spares palms and solesGeneralized; spares palms and soles Pinpoint papulesPinpoint papules Desquamation of the tips of the fingers andDesquamation of the tips of the fingers and toestoes 16. #2 Scarlet Fever#2 Scarlet Fever DiagnosisDiagnosis Group A streptococcal positive throatGroup A streptococcal positive throat cultureculture Elevated WBC count and ESRElevated WBC count and ESR TreatmentTreatment : penicillin,: penicillin, cephalosporins, erythromycin,cephalosporins, erythromycin, ofloxacin, rifampin, or the newerofloxacin, rifampin, or the newer macrolidesmacrolides 17. #3- Rubella#3- Rubella VirusVirus: Rubivirus (Rubella): Rubivirus (Rubella) DemographicsDemographics 514 yr before vaccines514 yr before vaccines Now teens and young adults 2- to 3-wkNow teens and young adults 2- to 3-wk ProdromeProdrome Mild catarrhal symptoms, oftenMild catarrhal symptoms, often overlooked.overlooked. Marked tender lymphadenopathy seen 24Marked tender lymphadenopathy seen 24 hr before rashhr before rash 18. #3 Rubella#3 Rubella Rash and DiseaseRash and Disease ExanthemExanthem:: Starts face, spreads by 24 hr to trunk,Starts face, spreads by 24 hr to trunk, extremities.extremities. Day 1: 1- to 4-mm macules, usuallyDay 1: 1- to 4-mm macules, usually distinct, sometimes reticular.distinct, sometimes reticular. Day 2: pinpoint papules.Day 2: pinpoint papules. Day 3: clears. Sometimes mildDay 3: clears. Sometimes mild desquamation.desquamation. Low-grade fever, pruritus possible.Low-grade fever, pruritus possible. 19. #3 Rubella#3 Rubella DiagnosisDiagnosis Acute and convalescent titersAcute and convalescent titers rubella IgM antibody (esp. for exposedrubella IgM antibody (esp. for exposed pregnant women)pregnant women) TreatmentTreatment Symptomatic.Symptomatic. NSAIDs for arthritis.NSAIDs for arthritis. 20. #3 Rubella#3 Rubella ComplicationsComplications Self-limiting polyarthritis in girls, youngSelf-limiting polyarthritis in girls, young women. Hands and wrists, large jointwomen. Hands and wrists, large joint effusions.effusions. Fetuses of nonimmune women infectedFetuses of nonimmune women infected may have deafness, eye, cardiac andmay have deafness, eye, cardiac and endocrine anomalies, and retardation.endocrine anomalies, and retardation. 21. #3 Rubella#3 Rubella PreventionPrevention Vaccine at 1215 moVaccine at 1215 mo Second dose at 1112 yr.Second dose at 1112 yr. Immune globulin not indicated.Immune globulin not indicated. 22. #4- Atypical Scarlet#4- Atypical Scarlet FeverFever 23. #5-#5- Erythema InfectiosumErythema Infectiosum VirusVirus: Parvovirus B19: Parvovirus B19 Demographics:Demographics: SpringSpring 517 yr517 yr 4- to 21-d incubation4- to 21-d incubation ProdromeProdrome Low-grade fever, headache,Low-grade fever, headache, malaise.malaise. 24. #5-#5- Erythema InfectiosumErythema Infectiosum Rash and DiseaseRash and Disease Slapped cheeks facial erythemaSlapped cheeks facial erythema with abrupt onsetwith abrupt onset Circumoral and perioral pallor,Circumoral and perioral pallor, sparing of nasal bridge.sparing of nasal bridge. Body develops pale maculopapularBody develops pale maculopapular exanthem; may involve palms andexanthem; may involve palms and soles. Lasts 35 dayssoles. Lasts 35 days Atypically, Papular-PurpuricAtypically, Papular-Purpuric Gloves andGloves and Socks syndrome (onlySocks syndrome (only hands and feet affected)hands and feet affected) 25. #5-#5- Erythema InfectiosumErythema Infectiosum DiagnosisDiagnosis IgM and IgG serologies, acute andIgM and IgG serologies, acute and convalescent antibody titers, DNAconvalescent antibody titers, DNA hybridizationhybridization TreatmentTreatment Symptomatic.Symptomatic. IVGG and transfusions if hematologicIVGG and transfusions if hematologic complicationscomplications 26. #5-#5- Erythema InfectiosumErythema Infectiosum ComplicationsComplications In anyone:In anyone: Henoch-Schonlein purpura,Henoch-Schonlein purpura, Polyarteritis nodosaPolyarteritis nodosa Infectious mononucleosis.Infectious mononucleosis. In HIV+ or those with hemolyticIn HIV+ or those with hemolytic anemia:anemia: aplastic anemia.aplastic anemia. In pregnancy: fetal hydrops orIn pregnancy: fetal hydrops or stillbirth.stillbirth. 27. #5-#5- Erythema InfectiosumErythema Infectiosum No vaccine.No vaccine. No isolation once symptomaticNo isolation once symptomatic (not(not contagious);contagious); Pregnant women should avoidPregnant women should avoid outbreak sites for 3 wk and getoutbreak sites for 3 wk and get serologic testing.serologic testing. 28. #6- Roseola#6- Roseola VirusVirus: HHV-6 /HHV-7: HHV-6 /HHV-7 DemographicsDemographics 03 yr03 yr Prodrome:Prodrome: 35 d intermittent fever to 40.5C.35 d intermittent fever to 40.5C. Child appears well.Child appears well. 29. #6- Roseola#6- Roseola Rash and DiseaseRash and Disease ExanthemExanthem:: 02 d after defervesces02 d after defervesces 1- to 5-mm rose macules with pale areola1- to 5-mm rose macules with pale areola densest on neck and trunk.densest on neck and trunk. Can get confluent.Can get confluent. Lasts 13 d.Lasts 13 d. EnanthemEnanthem: pinpoint papules or streaks on: pinpoint papules or streaks on uvula, soft palate. LAD, periorbital edema,uvula, soft palate. LAD, periorbital edema, cough, headache, coryza, abdominal pain.cough, headache, coryza, abdominal pain. 30. #6- Roseola#6- Roseola DiagnosisDiagnosis Clinical.Clinical. Specific IgM and IgG for acute andSpecific IgM and IgG for acute and convalescent titers not widelyconvalescent titers not widely available.available. TreatmentTreatment Symptomatic. Antipyretics for fever.Symptomatic. Antipyretics for fever. 31. #6- Roseola#6- Roseola ComplicationsComplications Febrile seizures.Febrile seizures. More rarely:More rarely: mononucleosismononucleosis neonatal hepatitisneonatal hepatitis fatal hemophagocytic syndromefatal hemophagocytic syndrome encephalitisencephalitis thrombotic thrombocytopenic purpurathrombotic thrombocytopenic purpura Prevention: nonePrevention: none 32. Hand, Foot, and Mouth diseaseHand, Foot, and Mouth disease aka Papular-purpuric gloves and socks syndromeaka Papular-purpuric gloves and socks syndrome VirusVirus: Enteroviruses: Enteroviruses DemographicsDemographics Summer (less pronouncedinSummer (less pronouncedin tropics)tropics) 6 mo to 13 yr6 mo to 13 yr ProdromeProdrome Brief. Sore throat,Brief. Sore throat, anorexia, malaise, low-grade fever.anorexia, malaise, low-grade fever. 33. Hand, Foot, and MouthHand, Foot, and Mouth disease Rash and Diseasedisease Rash and Disease EnanthemEnanthem:: Oral mucosal vesicles that erode to formOral mucosal vesicles that erode to form ulcers 2 mm to 2 cm in diameter.ulcers 2 mm to 2 cm in diameter. Painful!Painful! ExanthemExanthem:: 3- to 7- mm vesicles on dorsal hands,3- to 7- mm vesicles on dorsal hands, feet, and sometimes palms, sole.feet, and sometimes palms, sole. Tender, pruritic, or asymptomaticTender, pruritic, or asymptomatic 34. B19 35. Hand, Foot, and MouthHand, Foot, and Mouth diseasedisease DiagnosisDiagnosis ClinicalClinical Specific serotype testing should clinicianSpecific serotype testing should clinician suspect a particular enterovirussuspect a particular enterovirus TreatmentTreatment Symptomatic. Analgesia to helpSymptomatic. Analgesia to help childchild with oral intake, steroids for itchwith oral intake, steroids for itch 36. Hand, Foot, and MouthHand, Foot, and Mouth disease Complicationsdisease Complications Rare with Coxsackie A and B.Rare with Coxsackie A and B. CNS or pulmonary complicationsCNS or pulmonary complications possible with enterovirus-71.possible with enterovirus-71. 37. DDx of an ErythematousDDx of an Erythematous Maculopapular RashMaculopapular Rash RubellaRubella RubeolaRubeola Scarlet feverScarlet fever Kawasaki diseaseKawasaki disease Secondary syphilisSecondary syphilis Drug eruptionDrug eruption Coxsackie virusCoxsackie virus ECHO virusECHO virus AdenovirusAdenovirus InfectiousInfectious mononucleosismononucleosis ParvovirusParvovirus MeningococcemiaMeningococcemia ToxoplasmosisToxoplasmosis Serum sicknessSerum sickness Rickettsial disease (eg,Rickettsial disease (eg, Rocky MountainRocky Mountain Spotted fever)Spotted fever) RoseolaRoseola