childhood exanthemata dr. philip g. murphy consultant microbiologist, amnch,tallaght
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Childhood Exanthemata
Dr. Philip G. MurphyConsultant Microbiologist,
AMNCH,Tallaght.
Aetiology• Exanthem = exterior rash
Measles
Rubella
Varicella (chickenpox)
Scarlet fever
Parvovirus
HH6
(Kawasaki Disease)Other childhood fevers:Mumps, Whooping cough, Diphtheria
NSROC
MeaslesMeaslesRubeola (RNA morbillivirus)Rubeola (RNA morbillivirus)
• Incubation: 7-14 d
• Prodrome: 4 -5 d before rash
fever, malaise, coryza, sneezycough,
Koplik spots1-3 d before rash
• Rash: day 4-7 of illness
starts behind ears, forehead, around mouth
dusky red, florid maculopapular rash spreads over trunk and limbs. Lasts 5 d.
• Infectivity: prodrome to 4 d after the rash
• Transmission: respiratory droplet or direct contact
• Complications: ears & OM,
lungs & pneumonia
conjunctivitis
CNS encephalitis at d 10, SSPE after several years
MeaslesMeasles• Highly contagious acute viral illness caused by a
paramyxovirus, genus Morbillivirus
• One of the leading causes of child mortality in developing countries - 10% of all deaths of children < 5 years.
• Measles eradication possible – no longer endemic in U.S.
• Europe: Outbreaks reported in Germany 1996, 1999 and 2000, Netherlands 1999 (2600 cases and 3 deaths).
Measles vaccinationMeasles vaccination• Measles vaccination in Ireland since 1985
• Vaccination rates of 95% necessary to eliminate spread
• Vaccination coverage of 70 – 80% at 24 months of age in the Eastern Regional Health Authority
• Outbreak of measles occurred between December 1999 and July 2000. Majority of cases in TCH catchment area.
Notifications of measles, January 1991-September 2000, Dublin, Wicklow and Kildare
0
500
1000
1500
2000
2500
3000
91 92 93 94 95 96 97 98 99 00
year
No
case
s
Measles by week of notification Area Health Boards
1 January-28 October 2000
0
10
20
30
40
50
60
70
80
90
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43
Week of notification
No
case
s no
tifie
d
Northern AHB
South Western AHB
East Coast AHB
Eastern Regional Health Authority
Number (%)
Total number attending TCH 355Number admitted to TCH 111 Underlying chronic or acute illnesses 29 (26)Number admitted to ICU 13 (11)Mortality 3
Range Median
Inpatient stay 1 - 43 5
ICU stay 1 - 28 6
12.00%
27.00%
61.00%
Yes No Record No
MMR Status of Measles Cases in Northern MMR Status of Measles Cases in Northern Area Health Board (n=567):Area Health Board (n=567):
0
10
20
30
40
50
60
70
80
90
Deh
ydra
tion
Pn
eum
onit
isan
dP
neu
mon
ia
Tra
chei
tis
Indication for admissionIndication for admission
Symptoms and Signs
0
20
40
60
80
100
120
Number
Of
Patients
Exanthem
Pyrexia
Cough
Conjunctivitis
Vomiting
Diarrhoea
Otitis Media
Febrile Seizure
Apnoea
95% 95% 84%
54% 40% 39% 33%
8%
Control
• Public Health– Outbreak Control Team set up by NDSC– Measles/Mumps/Rubella (MMR) vaccination
• Brought forward to 12 months of age• Given at 6 months in our area• Repeated at 15 months• Second MMR brought forward to 4 years of age• Opportunistic vaccination in schools and creche
– Recalled non-attenders– Press releases
FutureFuture
• Oireachtais Committee Report– Co-ordinator to oversee vaccine program– Dedicated administrative and nursing staff– Modernisation of Civil Registration Service
• Personal public service number– Improved IT at health board level– Vaccine information statements to parents– Continuous immunisation campaigns in media until rate >
95%• Guidelines for future outbreaks
Varicella (chickenpox, shingles)Varicella (chickenpox, shingles)• Incubation: 12-21 d
• Prodrome: 1 d before rash
fever, malaise
• Rash: oval macule progressing to macule and then pustules which heal and crust. Appears as crops centrally
then peripherally
• Other: may be marked fever for 2-3 d., then settles
• Infectivity: 5d before to 5 d after the rash
• Transmission: respiratory droplet or direct contact
• Complications:Rare:encephalitis after 10d
pneumonia especially immune suppressed
20 bacterial skin infection
Shingles
• Diagnosis: EM, CFT
• Treatment: aciclovir, topical disinfectants, ZIG if immune suppressed
RubellaRubella• Incubation: 14-23 d
• Prodrome: none or mild fever1d before rash
• Rash: none or for 1-3 d a pink macular rash on face and trunk
otherwise well
sub-occipital lymphadenopathy
arthralgia /polyarthritis in older child or adult
rarely thrombocytopaenia
• Infectivity: 7d before to 5 d after the rash
• Transmission: respiratory droplet or direct contact
• Complications: in utero - congenital rubella syndrome,
deafness,cataracts, cardiac abnormalities hepatomegaly, splenomegaly, purpura. 30% mortality.
25% if exposure in first 4months, 60-80% in 1st month
rarely encephalitis at 10d
Kawasaki DiseaseKawasaki Disease
• Unknown aetiology ?? Infective
• fever, rash,
• conjunctivitis, hand/feet dorsae induration
• stomatitis, strawberry tongue, lymphadenopathy
• coronary artery narrowing - aneurysm, thrombosis and MI
• desquamation in recovery
• Rx: Immuneglobulin
Erythema infectiosum Erythema infectiosum (Fifth Disease, Slapped ckeek syndrome)(Fifth Disease, Slapped ckeek syndrome)
• Parvovirus B19, ssDNA, 22 nm diameter
• Rash on cheeks, flitting and later lace-like on trunk
• More severe in adults with arthritis and lymphadenopathy
• benign course and rare complications
• transient marrow depression and rarely aplastic crisis
Exanthem subitumRoseola infantum;Sixth Disease
• Human Herpes virus 6
• commonly seroconversion by 2 years
• 3-5 d fever, urti
• 20% exanthem: classic maculopapular rash
• common in CNS – but ? Role in multiple sclerosis
Scarlet feverScarlet fever• Aetiology; Streptococcus pyogenes (Group A)• Pathogenesis: erythrogenic toxin• Incubation: 1-3 d • Prodrome: 1-2 d fever,sorethroat,headache,flushed
cheeks• Rash: punctate erythematous central and blanches• Signs: circumoral palor, strawberry tongue, desquamation post rash• Infectivity: up to 3 weeks or 24h after pen• Transmission: respiratory• Complications: septicaemia, endocarditis, OM, Quinsy
rheumatic fever, acute nephritis
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