Pediatric ExanthemsPediatric Exanthems

بيماران مبتال به تب و راش جلدي به توجه فوري بيماران مبتال به تب و راش جلدي به توجه فورينيازمند مي باشند . علل اين تظاهرات ممكن نيازمند مي باشند . علل اين تظاهرات ممكن

است عوامل كشنده و حياتي باشند و تشخيص است عوامل كشنده و حياتي باشند و تشخيص هاي افتراقي فراواني كه براي آن مطرح مي هاي افتراقي فراواني كه براي آن مطرح مي

باشند درخواست تستهاي باليني زيادي را توسط باشند درخواست تستهاي باليني زيادي را توسط پزشكان متخصص ايجاب مي نمايد . گرفتن شرح پزشكان متخصص ايجاب مي نمايد . گرفتن شرح

حال باليني كامل ، مسافرت اخير بيمار ، سابقه حال باليني كامل ، مسافرت اخير بيمار ، سابقه تماس با حيوان يا انسان مبتال به عفونت ، يا تماس با حيوان يا انسان مبتال به عفونت ، يا

مصرف ماده خاصي نكات كليدي مهمي براي مصرف ماده خاصي نكات كليدي مهمي براي كشف علت بيماري مي باشند .كشف علت بيماري مي باشند .

مشخصه راش جلدي نيز در معاينه فيزيكي بسيار مشخصه راش جلدي نيز در معاينه فيزيكي بسيار ارزشمند است از آنجائيكه معموالً قبل از آماده ارزشمند است از آنجائيكه معموالً قبل از آماده شدن جواب كشت ها و آزمايشات اين بيماران شدن جواب كشت ها و آزمايشات اين بيماران

( درمان مي گيرند لذا ( درمان مي گيرند لذا empiricempiric ) )بطور تجربيبطور تجربيمحدود كردن دامنه تشخيص هاي افتراقي كمك محدود كردن دامنه تشخيص هاي افتراقي كمك

به . .كننده مي باشدكننده مي باشد جلدي هاي راش شايع و مختلف انواع بندي طبقه ترتيب درپتشي و ، انواع بولوس ، ماكولوپاپولر

بندي تقسيم كهير ، اريتماتوس ، زيكولرشود . مي

Pediatric ExanthemsPediatric ExanthemsSix separate childhood exanthems were Six separate childhood exanthems were

defined from what was once called the defined from what was once called the “measles“measles ”. ”.

In the early part of the 20th century, these In the early part of the 20th century, these were often referred to by numberwere often referred to by number

Classic Childhood ExanthemsClassic Childhood Exanthems.1.1MeaslesMeasles.2.2Scarlet feverScarlet fever .3.3RubellaRubella (“German measles”) (“German measles”).4.4Atypical scarlet feverAtypical scarlet fever.5.5Erythema InfectiosumErythema Infectiosum .6.6RoseolaRoseola

Today, dozens of exanthems Today, dozens of exanthems are recognizedare recognized::

AdenovirusAdenovirusAnthraxAnthraxMononucleosisMononucleosisColorado tick feverColorado tick feverMumpsMumpsCat-scratch feverCat-scratch feverRat-bite feverRat-bite fever

Rocky Mountain Rocky Mountain spotted feverspotted fever

Relapsing feverRelapsing feverMeningococcemiaMeningococcemiaTyphusTyphusHand-foot-mouth Hand-foot-mouth

diseasedisease

#1#1 - -MeaslesMeasles

VirusVirus: Rubeola: Rubeola DemographicsDemographics Winter or spring Infancy to Winter or spring Infancy to

young adulthood 8- to 12-day incubation young adulthood 8- to 12-day incubation Epidemics until 96% immunizedEpidemics until 96% immunized

ProdromeProdrome 2–4 days. High fever, cough, 2–4 days. High fever, cough, coryza, conjunctivitis, photophobia, Koplik coryza, conjunctivitis, photophobia, Koplik

spots, lethargy, sneezingspots, lethargy, sneezing..

#1#1 MeaslesMeaslesRash and DiseaseRash and Disease

EnanthemEnanthem: Koplik spots  =  gray : Koplik spots  =  gray pinheads, ring of erythema, buccal pinheads, ring of erythema, buccal

mucosa. 0.5–2dmucosa. 0.5–2d..ExanthemExanthem: erythematous blanching : erythematous blanching

maculesmacules . .Starts forehead, spreads downwardStarts forehead, spreads downwardConfluent by 72 hrConfluent by 72 hr Spares palms, and soles, 4–6 daysSpares palms, and soles, 4–6 days . .Toxic appearanceToxic appearance . .

#1#1 - -MeaslesMeaslesDiagnosisDiagnosis Leukopenia, IgG and IgM Leukopenia, IgG and IgM

serologies, acute and convalescent titersserologies, acute and convalescent titers TreatmentTreatment Symptomatic. Antipyretics Symptomatic. Antipyretics . .

In severe disease, vitamin AIn severe disease, vitamin A . .

#1#1 - -MeaslesMeaslesComplicationsComplications Otitis media, diarrhea, Otitis media, diarrhea,

pneumonia (common in atypical rubeola)pneumonia (common in atypical rubeola)..Rarely, laryngo-tracheobronchitis, Rarely, laryngo-tracheobronchitis,

myocarditis, encephalitis. Subacute sclerosing myocarditis, encephalitis. Subacute sclerosing panencephalitispanencephalitis

#1#1 - -MeaslesMeaslesPreventionPrevention

Vaccinate all at 12–18 moVaccinate all at 12–18 mo . .Two doses for 13 years and olderTwo doses for 13 years and older . .Post-exposure vaccine if immuno-Post-exposure vaccine if immuno-

compromisedcompromised VZIG if pregnant, premature, or VZIG if pregnant, premature, or

immunocompromisedimmunocompromised

#2#2 - -Scarlet FeverScarlet Fever Streptococcal, erythrogenic toxinStreptococcal, erythrogenic toxin.. DemographicsDemographics 1 to 10 yr 1 to 10 yr ProdromeProdrome 2 to 4 days 2 to 4 days

#2#2 - -Scarlet Fever Scarlet Fever Rash and DiseaseRash and Disease

Strawberry tongueStrawberry tongueExudative pharyngitisExudative pharyngitis Generalized; spares palms and solesGeneralized; spares palms and soles Pinpoint papulesPinpoint papulesDesquamation of the tips of the fingers and toesDesquamation of the tips of the fingers and toes

http://www.dermatlas.org/derm/IndexDisplay.cfm?ImageID=-19962688

Pastia line

#2#2 Scarlet FeverScarlet Fever

DiagnosisDiagnosis Group A streptococcal positive throat cultureGroup A streptococcal positive throat cultureElevated WBC count and ESRElevated WBC count and ESR

TreatmentTreatment : penicillin, cephalosporins, : penicillin, cephalosporins, erythromycin, ofloxacin, rifampin, or the erythromycin, ofloxacin, rifampin, or the

newer macrolidesnewer macrolides

#3#3 - -RubellaRubellaVirusVirus: Rubivirus (Rubella): Rubivirus (Rubella) DemographicsDemographics

55––1414 yr before vaccinesyr before vaccinesNow teens and young adults 2- to 3-wkNow teens and young adults 2- to 3-wk

ProdromeProdrome Mild catarrhal symptoms, often overlookedMild catarrhal symptoms, often overlooked . .Marked tender lymphadenopathy seen 24 hr Marked tender lymphadenopathy seen 24 hr

before rashbefore rash

#3#3 Rubella Rubella Rash and DiseaseRash and Disease

ExanthemExanthem : :Starts face, spreads by 24 hr to trunk, Starts face, spreads by 24 hr to trunk,

extremitiesextremities . .Day 1: 1- to 4-mm macules, usually distinct, Day 1: 1- to 4-mm macules, usually distinct,

sometimes reticularsometimes reticular . .Day 2: pinpoint papulesDay 2: pinpoint papules . .Day 3: clears. Sometimes mild desquamationDay 3: clears. Sometimes mild desquamation..

Low-grade fever, pruritus possibleLow-grade fever, pruritus possible . .

#3#3 RubellaRubellaDiagnosisDiagnosis

Acute and convalescent titersAcute and convalescent titersrubella IgM antibody (esp. for exposed rubella IgM antibody (esp. for exposed

pregnant women)pregnant women) TreatmentTreatment

SymptomaticSymptomatic . .NSAIDs for arthritisNSAIDs for arthritis . .

#3#3 RubellaRubellaComplicationsComplications

Self-limiting polyarthritis in girls, young Self-limiting polyarthritis in girls, young women. Hands and wrists, large joint women. Hands and wrists, large joint

effusionseffusions . .Fetuses of nonimmune women infected may Fetuses of nonimmune women infected may

have deafness, eye, cardiac and endocrine have deafness, eye, cardiac and endocrine anomalies, and retardationanomalies, and retardation . .

#3#3 RubellaRubellaPreventionPrevention

Vaccine at 12–15 moVaccine at 12–15 moSecond dose at 11–12 yrSecond dose at 11–12 yr . .Immune globulin not indicatedImmune globulin not indicated . .

#5#5 - -Erythema InfectiosumErythema Infectiosum VirusVirus: Parvovirus B19: Parvovirus B19 DemographicsDemographics : :

SpringSpring55––1717 yryr44 - -to 21-d incubationto 21-d incubation

ProdromeProdrome Low-grade fever, headache, malaiseLow-grade fever, headache, malaise..

#5#5 - -Erythema InfectiosumErythema Infectiosum Rash and Disease Rash and Disease

““Slapped cheeks” facial erythema with Slapped cheeks” facial erythema with abrupt onset –conjunctivitisabrupt onset –conjunctivitis--

Circumoral and perioral pallor, sparing of Circumoral and perioral pallor, sparing of nasal bridgenasal bridge . .

Body develops pale maculopapular Body develops pale maculopapular exanthem; may involve palms and soles. exanthem; may involve palms and soles.

Lasts 3–5 daysand can be brought by Lasts 3–5 daysand can be brought by stresses 2-39 Daysstresses 2-39 Days

Gloves andGloves and Socks syndrome (only hands and Socks syndrome (only hands and feet affected)-also hemorrhagicAtypically, feet affected)-also hemorrhagicAtypically,

Papular-PurpuricPapular-Purpuric

#5#5 - -Erythema InfectiosumErythema InfectiosumDiagnosisDiagnosis

IgM and IgG serologies, acute andIgM and IgG serologies, acute and convalescent antibody titers, DNA hybridization convalescent antibody titers, DNA hybridization

ANA-RF-Aplastic Anemia Fetal HydropsANA-RF-Aplastic Anemia Fetal HydropsTreatmentTreatment

SymptomaticSymptomatic . .IVGG and transfusions if hematologic IVGG and transfusions if hematologic

complicationscomplications

#5#5 - -Erythema InfectiosumErythema InfectiosumComplicationsComplications

In anyoneIn anyone : :Henoch-Schonlein purpuraHenoch-Schonlein purpura , ,Polyarteritis nodosaPolyarteritis nodosaInfectious mononucleosisInfectious mononucleosis . .

In HIV+ or those with hemolytic anemiaIn HIV+ or those with hemolytic anemia::aplastic anemiaaplastic anemia . .

In pregnancy: fetal hydrops or stillbirthIn pregnancy: fetal hydrops or stillbirth..

#5#5 - -Erythema InfectiosumErythema Infectiosum

No vaccineNo vaccine.. No isolation once symptomaticNo isolation once symptomatic (not (not

contagious)contagious) ; ;Pregnant women should avoid Pregnant women should avoid

outbreak sites for 3 wk and get outbreak sites for 3 wk and get serologic testingserologic testing..

#6#6 - -RoseolaRoseolaVirusVirus: HHV-6 /HHV-7: HHV-6 /HHV-7DemographicsDemographics 0–3 yr 0–3 yr ProdromeProdrome::

33––55 d intermittent fever to 40.5°Cd intermittent fever to 40.5°C . .Child appears wellChild appears well . .

#6#6 - -RoseolaRoseola Rash and DiseaseRash and Disease

ExanthemExanthem : :00––22 d after defervescesd after defervesces11 - -to 5-mm rose macules with pale areola densest on to 5-mm rose macules with pale areola densest on

neck and trunkneck and trunk . .Can get confluentCan get confluent . .Lasts 1–3 dLasts 1–3 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 paincough, headache, coryza, abdominal pain . .

#6#6 - -RoseolaRoseolaDiagnosisDiagnosis

ClinicalClinical . .Specific IgM and IgG for acute and Specific IgM and IgG for acute and

convalescent titers not widely availableconvalescent titers not widely available.. TreatmentTreatment

Symptomatic. Antipyretics for feverSymptomatic. Antipyretics for fever . .

#6#6 - -Roseola Roseola ComplicationsComplications

Febrile seizuresFebrile seizures . .More rarelyMore rarely::

mononucleosismononucleosis neonatal hepatitisneonatal hepatitisfatal hemophagocytic syndromefatal hemophagocytic syndromeencephalitisencephalitisthrombotic thrombocytopenic purpurathrombotic thrombocytopenic purpura

Prevention: nonePrevention: none

Hand, Foot, and Mouth diseaseHand, Foot, and Mouth diseaseaka Papular-purpuric gloves and socks syndromeaka Papular-purpuric gloves and socks syndrome

VirusVirus: Enteroviruses: EnterovirusesDemographicsDemographics

Summer (less pronouncedin tropics)Summer (less pronouncedin tropics) 66 mo to 13 yrmo to 13 yr

ProdromeProdrome Brief. Sore throat, anorexia, Brief. Sore throat, anorexia, malaise, low-grade fevermalaise, low-grade fever . .

Hand, Foot, and Mouth Hand, Foot, and Mouth disease Rash and Diseasedisease Rash and Disease

EnanthemEnanthem : :Oral mucosal vesicles that erode to form Oral mucosal vesicles that erode to form

ulcers 2 mm to 2 cm in diameterulcers 2 mm to 2 cm in diameter . .PainfulPainful!!

ExanthemExanthem : :33 - -to 7- mm vesicles on dorsal hands, feet, to 7- mm vesicles on dorsal hands, feet,

and sometimes palms, soleand sometimes palms, sole . .Tender, pruritic, or asymptomaticTender, pruritic, or asymptomatic

B19

Hand, Foot, and Mouth Hand, Foot, and Mouth diseasedisease

DiagnosisDiagnosis ClinicalClinical Specific serotype testing should clinician Specific serotype testing should clinician

suspect a particular enterovirussuspect a particular enterovirus TreatmentTreatment

Symptomatic. Analgesia to help Symptomatic. Analgesia to help childchild with with oral intake, steroids for itchoral intake, steroids for itch

Hand, Foot, and Mouth Hand, Foot, and Mouth disease Complicationsdisease Complications

Rare with Coxsackie A and BRare with Coxsackie A and B . .CNS or pulmonary complications possible CNS or pulmonary complications possible

with enterovirus-71with enterovirus-71 . .

DDx of an Erythematous DDx 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        

Infectious Infectious mononucleosismononucleosis      

ParvovirusParvovirus      MeningococcemiaMeningococcemia      ToxoplasmosisToxoplasmosis      Serum sicknessSerum sickness      Rickettsial disease (eg, Rickettsial disease (eg,

Rocky Mountain Spotted Rocky Mountain Spotted fever)fever)      

RoseolaRoseola

Impetigo - this usually takes the form of - this usually takes the form of itchy lesions with macules, vesicles, itchy lesions with macules, vesicles,

bullae, pustules and gold-coloured crusts bullae, pustules and gold-coloured crusts caused by caused by Staphylococcus aureusStaphylococcus aureus or or

group A beta-haemolytic streptococci.group A beta-haemolytic streptococci.2 Staphylococcal scalded skin syndrome(appears as scalded skin, due to focal (appears as scalded skin, due to focal

staphylococcal infection – eg phage type staphylococcal infection – eg phage type 71 – releasing an exotoxin).71 – releasing an exotoxin).3

Pediatric ExanthemsPediatric ExanthemsIn antiquity, these illnesses were all lumped In antiquity, these illnesses were all lumped

togethertogether . .Eventually, a distinction was made between Eventually, a distinction was made between

measles and pox (with growing clarity over measles and pox (with growing clarity over about a millennium)about a millennium) . .

PoxesPoxesChickenpox and SmallpoxChickenpox and Smallpox

the other two classic childhood exanthemsthe other two classic childhood exanthemsrecognized as separate from each other in recognized as separate from each other in

the 18th centurythe 18th century . .These both had blisters, or pox, that set These both had blisters, or pox, that set

them apart from the red rashes of the them apart from the red rashes of the other groupother group

Varicella) ) chickenpoxchickenpox - ( - (vesicles (initially vesicles (initially papules, often not noticed), appearing as 'drops papules, often not noticed), appearing as 'drops

of water'. Superficial, thin-walled with of water'. Superficial, thin-walled with surrounding erythema rapidly changing to surrounding erythema rapidly changing to

pustules and crusts. Appears in crops with all pustules and crusts. Appears in crops with all stages represented. First appears on face and stages represented. First appears on face and

scalp then spreads to trunk and extremities. scalp then spreads to trunk and extremities. Crusts fall off in 1-3 weeks leaving pink base. Crusts fall off in 1-3 weeks leaving pink base.

Initial fever is classically high before becoming Initial fever is classically high before becoming low grade. Beware of dyspnoea/cough which low grade. Beware of dyspnoea/cough which

may indicate may indicate varicella zoster virus (VZV) virus (VZV) pneumonitispneumonitis..1

Herpes simplex virus infection (HSV) - virus infection (HSV) - eczema herpeticum (HSV infection (HSV infection

superimposed on pre-existing, often mild, superimposed on pre-existing, often mild, eczema causing an eruption of crusty eczema causing an eruption of crusty

vesicles and eczematous patches).vesicles and eczematous patches).

Lesions in DIFFERENT stages ofdevelopment •Rapid evolution of lesions •Centripetal (central) distribution •Lesions rarely on palms or soles •Patient rarely toxic or moribund

Erythema multiforme, classically , classically appearing as target lesions (erythematous appearing as target lesions (erythematous

ring with central ring with central bulla))2 Stevens-Johnson syndrome4

Toxic epidermal necrolysisToxic epidermal necrolysis4 Pompholyx (on hands/feet) (on hands/feet)5

Is it red but not scaly (and NOT Is it red but not scaly (and NOT purpuric)?purpuric)? CoConsider: nsider: CellulitisCellulitis

Kawasaki's disease Scarlet fever and the viral exanthemas e.g.: Scarlet fever and the viral exanthemas e.g.:

Roseola infantum – (Sixth Disease) – (Sixth Disease) Primary human herpes viral (HHV6 & 7) infection. Most common age is under two Primary human herpes viral (HHV6 & 7) infection. Most common age is under two

years, frequent cause of infantile febrile seizures. Small blanchable pink macules years, frequent cause of infantile febrile seizures. Small blanchable pink macules and papules found on trunk and neck. Associated with high fever prior to and papules found on trunk and neck. Associated with high fever prior to

defervescence defervescence or fifth disease) caused by or fifth disease) caused by Parvovirus B19 B19 Measles - presents as erythematous & appearance of rash on fourth day. Often asymptomatic. - presents as erythematous & appearance of rash on fourth day. Often asymptomatic.

Erythema infectiosum - (- (slapped cheek syndrome macules and papules, initially macules and papules, initially discrete may become discrete may become confluent on face, neck and shoulders. On mucous membranes, Koplik's spots (tiny bluish-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 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 - with cough, malaise and fever subsiding as rash increases (measles prodrome = the 4 C's -

cough, coryza, conjunctivitis and cranky++!) cough, coryza, conjunctivitis and cranky++!) Rubella (Rubella (German measles) pink macules and papules starting on forehead and spreading to ) pink macules and papules starting on forehead and spreading to

face, trunk and extremities on first dayface, trunk and extremities on first day Fades from face on second day and rest of body by third day. Petechiae onFades from face on second day and rest of body by third day. Petechiae on

soft palate before rash. Low fever. soft palate before rash. Low fever.

Scarlet fever (=scarlatina) exotoxin mediated Scarlet fever (=scarlatina) exotoxin mediated rash (Group A Streptococcus) - sore throat rash (Group A Streptococcus) - sore throat

then general erythema (classically with then general erythema (classically with perioral sparing), followed by confluent perioral sparing), followed by confluent

petechiae in skin folds (Pastia sign) due to petechiae in skin folds (Pastia sign) due to increased capillary fragility. Strawberry tongue increased capillary fragility. Strawberry tongue

(initially white, then red). Skin desquamation (initially white, then red). Skin desquamation (peeling) frequently follows rash(peeling) frequently follows rash

Is it red and purpuric?Is it red and purpuric? Meningococcal Meningococcal meningitis (not common but should be meningitis (not common but should be excluded) Early, in 75% cases 2-10mm macular or maculopapular excluded) Early, in 75% cases 2-10mm macular or maculopapular

rash that blanches on pressure becomes apparent within first 24 rash that blanches on pressure becomes apparent within first 24 hours of disease; sparsely distributed on face, trunk and lower hours of disease; sparsely distributed on face, trunk and lower

extremities.extremities.1818 Use 'glass test' to assess 'blanchability' of rash by Use 'glass test' to assess 'blanchability' of rash by placing glass tumbler against lesions and applying pressure. Later placing glass tumbler against lesions and applying pressure. Later

the petechiae in centre of macules become haemorrhagic. the petechiae in centre of macules become haemorrhagic. Henoch-Schonlein purpuraHenoch-Schonlein purpura

Idiopathic thrombocytopaenic purpura (Idiopathic thrombocytopaenic purpura ( ITP), ITP), leukaemia and other haematological disordersleukaemia and other haematological disorders2020

Trauma, non-accidental Injury Trauma, non-accidental Injury Enterovirus infectionsEnterovirus infections2121

Miscellaneous conditions: Miscellaneous conditions: WartsWarts22

Verrucas Verrucas Head liceHead lice77

Classic ReferenceClassic ReferenceExanthems and Drug EruptionsExanthems and Drug Eruptions Habif: Clinical Dermatology, 4th ed.Habif: Clinical Dermatology, 4th ed., ,

Copyright © 2004 Mosby, IncCopyright © 2004 Mosby, Inc . .

Review article:Review article:Pediatric exanthemsPediatric exanthems

Clinics in Family PracticeClinics in Family PracticeVolume 5 • Number 3 • September 2003Volume 5 • Number 3 • September 2003

Copyright © 2003 W. B. Saunders Copyright © 2003 W. B. Saunders CompanyCompany

Jeffrey D. Wolfrey, MD * Jeffrey D. Wolfrey, MD * William H. Billica, MDWilliam H. Billica, MD

Scott H. Gulbranson, MDScott H. Gulbranson, MDAlaina B. Jose, MDAlaina B. Jose, MD

Mark Luba, MDMark Luba, MDAndrew Mohler, MDAndrew Mohler, MD

Cheryl Pagel, MDCheryl Pagel, MDJarrett K. Sell, MDJarrett K. Sell, MD