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  • However, what people called the “pox” and what was then called the “measles” are now known to each include a variety of distinct diseases.
  • However, what people called the “pox” and what was then called the “measles” are now known to each include a variety of distinct diseases.
  • However, what people called the “pox” and what was then called the “measles” are now known to each include a variety of distinct diseases.
  • Measles and scarlet fever were the first two to be separated. Rubella (German measles) was called “third disease”; atypical scarlet fever was “fourth disease”; erythema infectiosum was (and is) “fifth disease,” and roseola was “sixth disease.”
  • However, what people called the “pox” and what was then called the “measles” are now known to each include a variety of distinct diseases.
  • Fig. 81.6 Measles. Pink macules and minimally elevated papules with confluence
  • Scarlet fever was a feared disease in the nineteenth and early twentieth centuries, when it was more virulent, but presently scarlet fever is usually benign. Virulent strains may appear in the future. New waves of scarlet fever are associated with an increase in frequency of Streptococcus pyogenes clones carrying variant gene alleles encoding streptococcal pyrogenic exotoxin A (scarlet fever toxin).[14] Previous exposure to the toxin is required for expression of disease. Streptococcal pyrogenic exotoxin A causes disease by enhancing delayed-type hypersensitivity to streptococcal products.
  • Scarlet fever was a feared disease in the nineteenth and early twentieth centuries, when it was more virulent, but presently scarlet fever is usually benign. Virulent strains may appear in the future. New waves of scarlet fever are associated with an increase in frequency of Streptococcus pyogenes clones carrying variant gene alleles encoding streptococcal pyrogenic exotoxin A (scarlet fever toxin).[14] Previous exposure to the toxin is required for expression of disease. Streptococcal pyrogenic exotoxin A causes disease by enhancing delayed-type hypersensitivity to streptococcal products.
  • Strawberry tongue: red tongue with prominent papillae
  • diffuse red sandpaper-like
  • Scarlet fever was a feared disease in the nineteenth and early twentieth centuries, when it was more virulent, but presently scarlet fever is usually benign. Virulent strains may appear in the future. New waves of scarlet fever are associated with an increase in frequency of Streptococcus pyogenes clones carrying variant gene alleles encoding streptococcal pyrogenic exotoxin A (scarlet fever toxin).[14] Previous exposure to the toxin is required for expression of disease. Streptococcal pyrogenic exotoxin A causes disease by enhancing delayed-type hypersensitivity to streptococcal products.
  • Rubella
  • Fig. 81.7 Erythema infectiosum. Lacy, reticulated skin eruption over the arm during the second stage of the exanthem. Courtesy of Yale Residents Slide Collection.
  • Fig. 81.8 Papular-purpuric gloves and socks syndrome. Erythematous patches with petechiae on the palms. This patient also had superficial erosions of the palate and pharynx
  • Fig. 81.4 Hand-foot-and-mouth disease. Note the oval or football-shaped vesicle on an erythematous base centrally.
  • Fig. 81.5 Enteroviral exanthem. Note prominent petechial component of the exanthem in this 10-year-old boy.
  • Fig. 81.9 Unilateral laterothoracic exanthem. Erythematous macules and papules involving the left axilla, lateral trunk and flank. The exanthem progressed to a bilateral distribution, but maintained left-sided predominance.
  • Fig. 81.13 Kawasaki disease. A Strawberry tongue and cheilitis. Courtesy of Robert Hartman, M.D. B Perineal eruption of Kawasaki disease. Accentuation of erythema in the genital or perineal region is a characteristic cutaneous finding.
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    1. 1. Pediatric ExanthemsPediatric Exanthems Deborah J BostockDeborah J Bostock Col, USAF, MCCol, USAF, MC Family Medicine and GeriatricsFamily Medicine and Geriatrics
    2. 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. 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. 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. 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. 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. 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. 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. 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 2–4 days. High fever,2–4 days. High fever, cough, coryza, conjunctivitis,cough, coryza, conjunctivitis, photophobia, Koplik spots, lethargy,photophobia, Koplik spots, lethargy, sneezing.sneezing.
    10. 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. 0.5–2d.mucosa. 0.5–2d.  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, 4–6 days.Spares palms, and soles, 4–6 days. – Toxic appearance.Toxic appearance.
    11. 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. 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. 13. #1- Measles#1- Measles PreventionPrevention  Vaccinate all at 12–18 mo.Vaccinate all at 12–18 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. 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. 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. 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. 17. #3- Rubella#3- Rubella  VirusVirus: Rubivirus (Rubella): Rubivirus (Rubella)  DemographicsDemographics – 5–14 yr before vaccines5–14 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. 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. 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. 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. 21. #3 Rubella#3 Rubella PreventionPrevention  Vaccine at 12–15 moVaccine at 12–15 mo  Second dose at 11–12 yr.Second dose at 11–12 yr.  Immune globulin not indicated.Immune globulin not indicated.
    22. 22. #4- Atypical Scarlet#4- Atypical Scarlet FeverFever
    23. 23. #5-#5- Erythema InfectiosumErythema Infectiosum  VirusVirus: Parvovirus B19: Parvovirus B19  Demographics:Demographics: – SpringSpring – 5–17 yr5–17 yr – 4- to 21-d incubation4- to 21-d incubation  ProdromeProdrome – Low-grade fever, headache,Low-grade fever, headache, malaise.malaise.
    24. 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 3–5 dayssoles. Lasts 3–5 days  Atypically, Papular-PurpuricAtypically, Papular-Purpuric  Gloves andGloves and Socks syndrome (onlySocks syndrome (only hands and feet affected)hands and feet affected)
    25. 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. 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. 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. 28. #6- Roseola#6- Roseola  VirusVirus: HHV-6 /HHV-7: HHV-6 /HHV-7  DemographicsDemographics 0–3 yr0–3 yr  Prodrome:Prodrome: – 3–5 d intermittent fever to 40.5°C.3–5 d intermittent fever to 40.5°C. – Child appears well.Child appears well.
    29. 29. #6- Roseola#6- Roseola Rash and DiseaseRash and Disease  ExanthemExanthem:: – 0–2 d after defervesces0–2 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 1–3 d.Lasts 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 pain.cough, headache, coryza, abdominal pain.
    30. 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. 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. 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. 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. 34. B19
    35. 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. 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. 37. DDx of an ErythematousDDx of an Erythematous Maculopapular RashMaculopapular Rash  Rubella   Rubella     Rubeola   Rubeola     Scarlet fever   Scarlet fever     Kawasaki disease   Kawasaki disease     Secondary syphilis   Secondary syphilis     Drug eruption   Drug eruption     Coxsackie virus   Coxsackie virus     ECHO virus ECHO virus   Adenovirus    Adenovirus      InfectiousInfectious mononucleosis   mononucleosis     Parvovirus   Parvovirus     Meningococcemia   Meningococcemia     Toxoplasmosis   Toxoplasmosis     Serum sickness   Serum sickness     Rickettsial disease (eg,Rickettsial disease (eg, Rocky MountainRocky Mountain Spotted fever)   Spotted fever)     RoseolaRoseola

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