case 5: “rash judgment”. questions to be answered 1.how are rashes classified? 2.what infectious...
TRANSCRIPT
Questions to be answered
1. How are rashes classified?2. What infectious conditions are to be entertained in
Michelle’s case?3. Are there non-infectious conditions that may present
with rashes?4. In view of the general presentation, what is the most
likely diagnosis of Michelle’s case?5. Discuss the possible complications of her condition6. Discuss the treatment of Michelle’s case7. Discuss the measure/s necessary to prevent infection
with the viral exanthems that present with maculopapular rash
“RASH JUDGMENT”
• Michelle is a 10-year old girl with fever for the last five days. Associated symptoms include brassy cough and coryza, watery diarrhea and decreased appetite. Two days later, she was noted to have “sore eyes” and irritability.
• The mother could not recall the child’s immunizations except that she was given the last vaccines at the health center at age 4 months
“RASH JUDGMENT”
• On examination, she looked tired and ill, and had a temperature of 390C; CR 88/min. and RR 26/min.. She had a rash that started 8 – 12 hrs. earlier behind the ears and on the face then spread down the body. The rash was erythematous with fine macules and papules. Conjunctivitis was prominent. On examination of the buccal mucosa, small 1-mm.white papules were seen opposite the 2nd molars.
“RASH JUDGMENT”
• 2 days later, the white spots disappeared and the palms and soles were involved in the erythematous rash which later became brownish. This was later followed by a fine branny desquamation first occurring in the face later involving the body.
RASH JUDGMENT
• A exanthem is a skin eruption occurring as an integral part of an infectious disease. The corresponding changes in the mucous membranes is an enanthem
• Accurate diagnosis not always possible on preliminary examination- judgment should be deferred until rash develops
Morphologic types or Components of a rash
• Macule is a circumscribed discoloration of the skin. Often evolve into papules. Papules are small nodular elevations of the skin
• Vesicles are small blisters containing clear fluid. Pustules are small elevations of the skin containing pus
Maculopapular rash
Vesiculopustular rash
Morphologic types or Components of a rash
• Petechiae are small hemorrhages beneath the epidermis. Ecchymoses are larger areas of hemorrhage
Color Atlas of Infectious Diseases, Emond & Rowland
Other components
• Crust/scab – congealed exudate on the skin
• Wheal – localised effusion of fluid into the skin causing a raised, white or pinkish-white zone with a halo of erythema
• Erythema – a diffuse or localised red ness of the skin
Vital information necessary in the diagnosis of exanthematous
illnesses
Exposure Season Incubation period Age Previous
exanthem Relation of rash to
fever Adenopathy
Type of rash Distribution of
rash Progression of
rash Exanthems Other associated
symptoms or Prodrome
Laboratory testsFeigin and Cherry Textbook of Pediatric Infectious Diseases
Basis for Rash Judgment:
1. Prodromal period
2. Rash
3. Presence of pathognomonic or other diagnostic signs
4. Laboratory diagnostic tests
Conditions that present with Maculopapular rash
1. Measles• Prodromal period:
– The rash is preceded by a 3 or 4 day period of fever, conjunctivitis, coryza and cough
• Rash:– reddish brown, appears on the
face first and progresses downward to involve the trunk and extremities in sequence
Measles
• Rash (cont.): The eruption fades by the 5th or 6th day with brownish staining first followed by branny desquamation. The hands and feet do not desquamate
Brownish discoloration
Measles
• Pathognomonic sign: Koplik’s spots– Detected on the mucosa of the
cheeks opposite the molars, where they resemble coarse grains of salt on the surface of the inflamed membrane.
• Histologically are small necrotic patches in basal layers of the mucosa with serum exudation and mononuclear cell infiltration
Conditions that present with Maculopapular rash
2. Rubella (Postnatal)• Prodromal period:
– In children there are no prodromal period. The appearance of the rash and preceding lymphadenopathy may be the first obvious sign of disease.
– Adults and adolescents may have a variable period of malaise and low-grade fever before the rash appears
Rubella course
Rubella rash
Postnatal Rubella
• Rash: – Not distinctive; initially
discrete, delicate pink macules beginning on face and neck and progresses downward to the trunk & extremities more rapidly than measles. On the third day the face is usually clear
– Does not desquamate
Postnatal Rubella
• Forchheimer spots – red spots are often seen on the palate – Exceptionally profuse
in this patient
Rubella
• Diagnostic sign:– lymphadenopathy (particularly postauricular
and occipital) is a common manifestation, but it also occurs in other diseases
• Laboratory diagnosis:– positive throat culture for rubella virus and rise
in antibody level are helpful diagnostic aids
Congenital Rubella Syndrome
• “Blueberry muffin” rash: a purpuric rash may present at birth or develop within 48 hrs.
• May be accompanied by bleeding from the mucosal surface
Conditions that present with Maculopapular rash
3. Roseola infantum• Prodromal period:
– a 3 or 4 day period of high fever and irritability precedes the rash which appears as the temperature falls to normal
Roseola infantum (HHV 6)
• Rash:– typically discrete rose-red
maculopapules that frequently appear on the chest and trunk first and then spread to involve the face and extremities.
– The eruption usually disappears within 2 days. Occasionally within several hours
Roseola infantum
• Diagnostic sign: – The coincidental appearance of the rash with
defervescence in an infant is distinctive
• Laboratory diagnostic test: – none locally commercially available
Conditions that present with Maculopapular rash
4. Erythema infectiosum:
Rash: erupts in 3 stages1. Red, flushed cheeks with
circumoral pallor (“slapped check” appearance)
2. Maculopapular eruption over upper and lower extremities (the rash assumes a lacelike appearance as it fades)
Erythema infectiosum
• Rash (cont.)3. An evanescent stage characterized by subsidence of
the eruption followed by recurrence precipitated by a variety of skin irritants
• Diagnostic sign: – suggested by the slapped-face appearance in a well
child
• Laboratory diagnosis: – future serologic tests to confirm parvovirus B19
Conditions that present with Maculopapular rash
5. Infectious mononucleosis
• Rash – pinkish maculopapular, often mistaken for rubella– Tends to be patchy and
heavier on the limbs
Infectious mononucleosis
• Diagnostic signs:– a triad of membranous tonsillitis,
lymphadenopathy and splenomegaly suggests this
• Laboratory diagnostic test:– blood smear positive for abnormal
lymphocytes. – Monospot test and heterophil
agglutination (Paul-Bunnell) test are positive
6. Enteroviral Infections
• Prodrome:– Echovirus 16 (Boston
exanthem) prodrome resemble exanthem subitum but fever lower
– Fever & constitutional symptoms in Echovirus 4, 6 & 9 may precede but usually coincide with rash appearance
• Rash:– May be maculopapular,
petechial and vesicular eruptions with Coxsackie A9, A16,A10, A5,B3 and B5
Cochsackievirus infection
ECHOvirus type 19 infection
7. Mucocutaneous Lymph Node Syndrome (Kawasaki disease)
• Prodrome:– A nonspecific febrile illness
with sore throat precedes the rash by 2 – 5 days
• Rash:– Generalized,
erythematous, maculopapular. The palms and soles are swollen and reddened, eventually peeling after several days or weeks.
Mucocutaneous Lymph Node Syndrome (Kawasaki disease)
• Rash (cont.)– Dryness with erythema
of the lips (red strawberry tongue), mouth and tongue accompanies bilateral conjunctival injection
Mucocutaneous Lymph Node Syndrome (Kawasaki disease)
• Conjunctivitis– Bilateral, bulbar,
generally nonpurulent
• Cervical lymphadenopathy– Usually unilateral– Not explained by other
known disease process
Mucocutaneous Lymph Node Syndrome (Kawasaki disease
• Periungual desquamation or
• Perianal desquamation may follow in the subacute phase
Diagnostic Criteria for Kawasaki Disease
• Fever lasting for at least 5 days• Presence of at least 4 of the ff. 5 signs:
– Bilateral bulbar conjunctival injection, generally nonpurulent– Changes in the mucosa of the oropharynx, including injected
pharynx, injected and/or dry fissured lips, strawberry tongue– Changes of the peripheral extremities, such as edema and/or
erythema of the hands or feet in the acute phase; or periungual desquamation in the subacute phase
– Rash, primarily truncal; polymorphous or nonvesicular– Cervical adenopathy, > 1.5 cm., usually unilateral
lymphadenopathy illness not explained by other known disease process
8. Staphylococcal Scalded Skin Syndrome
• Prodrome:– None– Fever and irritability occur
at the time of onset of the rash
• Rash:– Generalized,
erythematous, scarlatiniform eruption with sandpaper-like texture
Staphylococcal Scalded Skin Syndrome
• Rash (cont)– The erythema is
accentuated in the skin folds.
– The skin is tender and within 1-2 days, bullae appear and the epidermis separate into large sheets, revealing a moist, red, shiny surface underneath (Nikolsky sign)
Ritter’s disease
Staphylococcal Scalded Skin Syndrome variants
Lyell’s disease
+ Nikolsky sign
Lyell’s disease
Toxic Epidermal Necrolysis
Staphylococcal Scalded Skin Syndrome variants
Newborns – Ritters disease or Newborns – Ritters disease or Pemphigus neonatorumPemphigus neonatorum
Older children and adults – Older children and adults – Lyell’s disease or Toxic Lyell’s disease or Toxic Epidermal NecrolysisEpidermal Necrolysis– TEN differentiated from SSS TEN differentiated from SSS
by intraepithelial splitting at by intraepithelial splitting at the dermoepidermal junctionthe dermoepidermal junction
– TEN usually drug-induced TEN usually drug-induced from phenytoin, from phenytoin, phenobarbital, phenobarbital, sulfonamides,sulfonamides,
penicillinpenicillin
Toxic epidermal Necrolysis
Staphylococcal Scalded Skin Syndrome variants
• Diagnostic sign:– An associated staphylococcal infection e.g.
Impetigo or purulent conjunctivitis may be present
• Laboratory diagnostic tests:– Culture of skin positive for phage group II
9. Staphylococcal Toxic Shock Syndrome
• Prodrome:– High fever, headache
confusion, sore throat, vomiting, diarrhea and shock may precede or may be associated with the rash
• Rash– There are no characteristic
features of the rash– Occurs most prominently in the
trunk & extremities– Associated with edema and
desquamation
Poor capillary refill in TSS
Staphylococcal Toxic Shock Syndrome
• Diagnostic signs:– The scarlatiniform eruption is associated with
high fever, toxicity and a shock-like state
• Laboratory tests:– Cultures of various mucosal surfaces or
purulent lesions should be positive for Staphylococcus aureus
10. Typhoid fever
• Rash:– Rose spot
• Typically appear towards the end of the 1st week
• Present in 50% of adults but less common in children
• Difficult to detect on dark skin• Districuted over abdomen, chest
and back but rarely seen in face, hands or feet
– Step-ladder temperature chart
Noninfectious conditions
• Drug eruptions/toxic erythemas• Sunburn• Miliaria
– No prodromal periods– Sunburn rashes confined to the areas not protected
by clothing– Miliaria: fine punctiform lesions are chiefly confined to
the flexor areas. Rash not usually generalized and does not desquamate
Drug Eruptions…Others
Erythema multiforme
from
sulphonamide
Urticariacaused byPenicillin
Malar “butterfly Rash” of SystemicLupus erythematosus
Task 7:Discuss the measure/s
necessary to prevent infection with the viral exanthems that present with maculopapular
rash