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DR. FAZAL ASLAM
www.dnbpediatrics.com
Age of child.
Temporal relation of fever with rash.
Site of onset—distribution—direction—
progression
Morphology of rash
A...
Immunisation status.
Contacts
Immunocompromised ?
Drug/food allergy
Travel to endemic areas
Animal/insect bite
Joint pain
...
Full exposure in natural light.
MORPHOLOGY-colour, size,
consistency,margins, surface characteristics.
DISTRIBUTION-flexor...
Kopliks spot
Forchheimer spots
Palatal petechiae
Pharyngitis.
Strawberry tongue
Fissuring of lips.
Circumoral pallor.
Coat...
Lymph nodes.
Joints.
CNS involvement.
Hepatosplenomegaly.
Heart.
Eyes
www.dnbpediatrics.com
Hb,TLC,DLC,ESR,Platelet count.
Chest xray.
Blood culture.
Tourniquet test.
Viral serology.
TORCH screening.
Urine analysis...
Maintenance of vitals.
Temperature control.
Isolation of patient
Bed rest
Nutritious diet
Stop offending drugs (if any).
O...
MORPHOLOGY SMALL <0.5 CM LARGE >0.5CM
FLAT LESIONS
Normal texture macule patch
Indurated plaque plaque
ELEVATED LESIONS
so...
MACULOPAPULAR PURPURIC /PETECHIAL
Measles (rubeola) Infectious mononucleosis
Rubella Malaria
Roseola infantum (exanthema
s...
VESICOBULLOUS NODULAR SCARLITINIFORM
Varicella Erythema nodosum Scarlet fever
Impetigo. Fungal Kawasaki ds
Enterovirus Pse...
www.dnbpediatrics.com
www.dnbpediatrics.com
Paramyxovirus.
IP—8 to 12 days.
Period of communicability.
4—Rash—5.
Rash starts from face &
behind ears.
KOPLIKS SPOTS.
D...
www.dnbpediatrics.com
www.dnbpediatrics.com
- mild measles in people with partial
protection
◦ Usually children vaccinated prior to age
12 months +/- coadministered
i...
Respiratory infections-otitis media
(mc),croup,tracheitis,bronchiolitis.
Abdominal pain – appendicitis due to swelling of
...
No specific treatment
Hydration, antipyretics
Avoid intense light (for photophobia)
IV ribavirin .
Vitamin A .
single dose...
INDICATIONS.
-6 m to 2yrs hospitalised with measles &
complications
- >6 m not received vit A & with risk factors.
immunod...
www.dnbpediatrics.com
German measles/3 day
measles—RNA Togavirus
IP—2 to 3 weeks.
Most contagious-2 days
prior to 6 days after rash
Winter-sprin...
Thrombocytopenia (1/3000)
Arthritis-clasically small hand joints
Encephalitis(1/5000).
Progressive rubella panencephalitis...
Infection in utero: congenital rubella
syndrome (CRS)
◦ If infection in 1st trimester – 90% of fetuses
infected.
◦ After 1...
Features of congenital rubella syndrome:
1-Intrauterine growth retardation
small for gestational age and
failure to thrive...
Exanthema subitum.
HHV-6,7.
IP-5 to 15 days
Children >6 months.
NO PRODROME.
Abrupt high fever.
Fever resolution by CRISIS...
Begins on trunk & spreads out
www.dnbpediatrics.com
Febrile seizure (10% of pts)
HHV-6 can cause meningoencephalitis or
aseptic meningitis
Multiorgan disease can occur in
imm...
www.dnbpediatrics.com
Herpes virus varicellae
IP- 10 to 21 days
Papulesvesicles crusting.
Pleomorphic,flexor surface.
Spreads centripetally,sy...
www.dnbpediatrics.com
Secondary infections (staph/strep) most
common; may be life threatening with toxic
shock syndrome/necrotizing fasciitis
Va...
Primary varicella in pregnant woman  fetal
varicella infection
◦ Low birthweight, cortical atrophy, seizures, mental
reta...
◦ Occurs in newborns of mothers
with varicella (not shingles) 5 days
before or 2 days after delivery
◦ Child born prior to...
Oral acyclovir- indications
◦ Healthy nonpregnant teenagers and adults
◦ Children > 1 yr with chronic cutaneous or
pulmona...
VZIG (1 vial/5 kg IM) :
◦ Pts on high dose steroids
◦ Immunocompromised without a history of CP
◦ Pregnant women
◦ Newborn...
www.dnbpediatrics.com
Human parvovirus B19.
IP-4 to 14 days.
Preschool and young
school age children.
Prodrome minimal or absent
Slapped cheek s...
www.dnbpediatrics.com
Complications
◦ Arthritis: F>M, older>younger
◦ Aplastic crisis: usually not noticed in patients
with normal erythrocyte h...
Vasculitis of unknown etiology
Multisystem involvement and inflammation of
small and medium sized arteries with
aneurysm f...
www.dnbpediatrics.com
www.dnbpediatrics.com
www.dnbpediatrics.com
www.dnbpediatrics.com
www.dnbpediatrics.com
www.dnbpediatrics.com
Coronary artery thrombosis and coronary artery aneurysm(25%)
Myocardial infarction
Myocarditis(50%).
Congestive heart fail...
ACUTE STAGE.
IV Immunoglobulin (mechanism unknown)
◦ Single dose of 2 g/kg over 12 hours
Aspirin 80-100 mg/kg/day divided ...
Aedes aegyptii-daytime,urban,collections of
water.
Dengue like disease-chikungunya, o’nyong-
nyong, westnile fever.
IP-1 t...
Multiple types of dengue virus.
Dengue 3 virus- severe clinical syndrome..
Relatively mild 1st phase with rapid clinical
d...
DENGUE HEMORRHAGIC FEVER.
1. Fever.
2. minor/major hemorrhagic manifestations.
3. thrombocytopenia ( <1lac).
4. objective ...
GRADE 1- Fever + positive tourniquet test.
GRADE 2- Spontaneous bleeding.
GRADE 3-Circulatory failure.
GRADE 4- Profound s...
DF.
Bed rest, supportive treatment, Aspirin C/I.
 DHF.
1. IVF NS>RL.
2. If pulse pressure <10mm Hg/elevn of
hematocrit pe...
IP-7 to 14 days.
Stepladder rise of fever (rare).
Abdominal pain
Hepatosplenomegaly m
Relative bradycardia.
Coated tongue....
Acute, self limited illness,oral
transmission
Epstein-Barr virus.
IP-30 to 50 days.
Clinical features
Atypical lymphocytos...
Ampicillin rash.
Gianotti crosti syndrome.
www.dnbpediatrics.com
Major jones criteria.
Trunk, upper arms,legs
never on face
Maculopapular, raised edges
central clearing,circular shape
Not...
Erythrogenic toxin producing
group A -hemolytic
streptococci
1 to 2 days after pharyngitis
Rash from neck- trunk- extremi...
www.dnbpediatrics.com
Neisseria meningitides.
Usually sudden onset of
fever,chills, myalgia, and arthralgia
Rash is macular, nonpruritic,
erythe...
www.dnbpediatrics.com
Superficial infection
of the dermis
Two types:
◦ Impetigo contagiosa
◦ Bullous impetigo
Etiology
◦ Group A ß hemolytic str...
Multiple crusted
lesion with
erythematous halo
with polycyclic edges.
Spreads without healing.
www.dnbpediatrics.com
< 5 yrs.
Staphylococcal exfoliatin
Bullous lesions.
Easy peeling of skin in
thin sheets.
Positive Nikolsky’s sign
Diagnosi...
www.dnbpediatrics.com
www.dnbpediatrics.com
Most common rickettsial infection in US
Abrupt fever, headache, and myalgia
Rash from extremities towards trunk
Maculespe...
www.dnbpediatrics.com
Enteroviruses
◦ coxsackieviruses A and B
◦ echoviruses
Vesicular lesions, may be petechial
Associated with aseptic meningi...
www.dnbpediatrics.com
www.dnbpediatrics.com
YOU
www.dnbpediatrics.com
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  • To get an idea of how similar the rashes could present in all these disease states, examples are given. This is one example of a drug reaction.
  • …and one can readily see how similar they are. Rashes associated with a general viral illness (viral exanthem) also appear like this.
  • Transcript of "Frsh"

    1. 1. DR. FAZAL ASLAM www.dnbpediatrics.com
    2. 2. Age of child. Temporal relation of fever with rash. Site of onset—distribution—direction— progression Morphology of rash Associated symptoms Is patient in shock ? PAST HISTORY www.dnbpediatrics.com
    3. 3. Immunisation status. Contacts Immunocompromised ? Drug/food allergy Travel to endemic areas Animal/insect bite Joint pain Pica www.dnbpediatrics.com
    4. 4. Full exposure in natural light. MORPHOLOGY-colour, size, consistency,margins, surface characteristics. DISTRIBUTION-flexor/extensor, sym/asymmetrical,centrifugal/centripetel. If only exposed areas involved? Involvement of genitals/mucous membrane. Nikolsky sign www.dnbpediatrics.com
    5. 5. Kopliks spot Forchheimer spots Palatal petechiae Pharyngitis. Strawberry tongue Fissuring of lips. Circumoral pallor. Coated tongue. www.dnbpediatrics.com
    6. 6. Lymph nodes. Joints. CNS involvement. Hepatosplenomegaly. Heart. Eyes www.dnbpediatrics.com
    7. 7. Hb,TLC,DLC,ESR,Platelet count. Chest xray. Blood culture. Tourniquet test. Viral serology. TORCH screening. Urine analysis. Lumbar puncture. ECG, 2D echo. www.dnbpediatrics.com
    8. 8. Maintenance of vitals. Temperature control. Isolation of patient Bed rest Nutritious diet Stop offending drugs (if any). Oral hygiene. Vit A. Antibiotics. Antihistaminics Specific treatment acc to etiologies www.dnbpediatrics.com
    9. 9. MORPHOLOGY SMALL <0.5 CM LARGE >0.5CM FLAT LESIONS Normal texture macule patch Indurated plaque plaque ELEVATED LESIONS solid papule nodule Fluid filled vesicle bulla Pus filled pustule pustule LESIONS D/T EXTRAVASATION OF BLOOD petechiae ecchymosis www.dnbpediatrics.com
    10. 10. MACULOPAPULAR PURPURIC /PETECHIAL Measles (rubeola) Infectious mononucleosis Rubella Malaria Roseola infantum (exanthema subitum/6th disease) Rickettsial Erythema infectiosum (5th disease) Meningococcal Kawasaki disease Infective endocarditis Infectious mononucleosis Viral hemorhagic fever Early meningococcemia Typhoid Dengue Erythema marginatum Typhus www.dnbpediatrics.com
    11. 11. VESICOBULLOUS NODULAR SCARLITINIFORM Varicella Erythema nodosum Scarlet fever Impetigo. Fungal Kawasaki ds Enterovirus Pseudomonas Toxic shock syndrome Meningococcal Atypical mycobacteria Staphylococcal scalded syndrome www.dnbpediatrics.com
    12. 12. www.dnbpediatrics.com
    13. 13. www.dnbpediatrics.com
    14. 14. Paramyxovirus. IP—8 to 12 days. Period of communicability. 4—Rash—5. Rash starts from face & behind ears. KOPLIKS SPOTS. Diagnosis mostly clinical www.dnbpediatrics.com
    15. 15. www.dnbpediatrics.com
    16. 16. www.dnbpediatrics.com
    17. 17. - mild measles in people with partial protection ◦ Usually children vaccinated prior to age 12 months +/- coadministered immune serum globulin or ◦ Persons receiving immunoglobulin. ATYPICAL MEASLES -Rash begins peripherally and moves centrally in persons receiving formalin inactivated measles. www.dnbpediatrics.com
    18. 18. Respiratory infections-otitis media (mc),croup,tracheitis,bronchiolitis. Abdominal pain – appendicitis due to swelling of Peyer patches/hepatitis/gastroentritis Pneumonia,Hecht’s pneumonia. Myocarditis,g’nephritis,thrombocytopenic purpura Encephalitis (most serious) Late onset: subacute sclerosing pan encephalitis (autoimmune phenomenon) Activation of a tubercular focus. Diarrhoea, malnutrition. Febrile seizures (<3%). BLACK MEASLES. www.dnbpediatrics.com
    19. 19. No specific treatment Hydration, antipyretics Avoid intense light (for photophobia) IV ribavirin . Vitamin A . single dose of 2 lacs iu oral- >1 yr. 1 lac iu oral -6 m to 1 yr. if opthalmologic evidence –repeat dose next day & 4 wks later. www.dnbpediatrics.com
    20. 20. INDICATIONS. -6 m to 2yrs hospitalised with measles & complications - >6 m not received vit A & with risk factors. immunodeficiency,clinical e/o vit A def,impaired intestinal absorption,moderate to severe malnutrition,migration from endemic areas. www.dnbpediatrics.com
    21. 21. www.dnbpediatrics.com
    22. 22. German measles/3 day measles—RNA Togavirus IP—2 to 3 weeks. Most contagious-2 days prior to 6 days after rash Winter-spring Prodrome Face  neck  trunk. Lymphadenopathy. Forchheimers spots(20%) www.dnbpediatrics.com
    23. 23. Thrombocytopenia (1/3000) Arthritis-clasically small hand joints Encephalitis(1/5000). Progressive rubella panencephalitis. Others – GBS, peripheral neuritis,myocarditis. www.dnbpediatrics.com
    24. 24. Infection in utero: congenital rubella syndrome (CRS) ◦ If infection in 1st trimester – 90% of fetuses infected. ◦ After 16 wks of gestation –defects uncommon even if fetal infection occurs. Infants with CRS may shed virus in nasopharyngeal secretions and urine for more than 1 year – can easily transmit virus www.dnbpediatrics.com
    25. 25. Features of congenital rubella syndrome: 1-Intrauterine growth retardation small for gestational age and failure to thrive 2-Nerve deafness 3- Microcephaly and mental retardation 4- Congenital heart disease (PDA, VSD) 5- Cataract, glaucoma, and cloudy cornea 6- Thrombocytopenic purpura. 7- Hepatosplenomegaly,osteopathy,interstitial nephritis, pneumonitis. www.dnbpediatrics.com
    26. 26. Exanthema subitum. HHV-6,7. IP-5 to 15 days Children >6 months. NO PRODROME. Abrupt high fever. Fever resolution by CRISIS & LYSIS. Febrile seizures. Rash develops after fever dissipates-rainbow following the storm Mainly on trunk-rash fades within 3 days. NAGAYAMA’S SPOTS Good prognosis www.dnbpediatrics.com
    27. 27. Begins on trunk & spreads out www.dnbpediatrics.com
    28. 28. Febrile seizure (10% of pts) HHV-6 can cause meningoencephalitis or aseptic meningitis Multiorgan disease can occur in immunocompromised patients ◦ Pneumonia ◦ Hepatitis ◦ Bone marrow suppression ◦ Encephalitis www.dnbpediatrics.com
    29. 29. www.dnbpediatrics.com
    30. 30. Herpes virus varicellae IP- 10 to 21 days Papulesvesicles crusting. Pleomorphic,flexor surface. Spreads centripetally,symmetrical,mucosa & axilla involved,spares palm & soles,diminishes centrifugally. Scab formation after 4-7 days. Fever rises with each fresh crop of rash Period of communicability is 2 days before and 7 days after lesions crusted over www.dnbpediatrics.com
    31. 31. www.dnbpediatrics.com
    32. 32. Secondary infections (staph/strep) most common; may be life threatening with toxic shock syndrome/necrotizing fasciitis Varicella gangrenosa – thrombocytopenia with hemorrhagic lesions Pneumonia,Myocarditis/pericarditis. Hepatitis,Glomerulonephritis,Orchitis Arthritis Ulcerative gastritis Encephalitis (cerebellar ataxia may occur without encephalitis) Reyes syndrome www.dnbpediatrics.com
    33. 33. Primary varicella in pregnant woman  fetal varicella infection ◦ Low birthweight, cortical atrophy, seizures, mental retardation, chorioretinitis, cataracts, intracranial calcifications Children exposed in utero to VZV may develop zoster without varicella www.dnbpediatrics.com
    34. 34. ◦ Occurs in newborns of mothers with varicella (not shingles) 5 days before or 2 days after delivery ◦ Child born prior to maternal antibody response develops ◦ Treat infants ASAP with varicella zoster immunoglobulin www.dnbpediatrics.com
    35. 35. Oral acyclovir- indications ◦ Healthy nonpregnant teenagers and adults ◦ Children > 1 yr with chronic cutaneous or pulmonary conditions ◦ Patients on chronic salicylate therapy ◦ Patients receiving short or intermittent courses of aerosolized corticosteroids Dose: 80 mg/kg/day in four divided doses for 5 days www.dnbpediatrics.com
    36. 36. VZIG (1 vial/5 kg IM) : ◦ Pts on high dose steroids ◦ Immunocompromised without a history of CP ◦ Pregnant women ◦ Newborns exposed 5 days prior to birth and 2 days after delivery ◦ Neonates born to nonimmune mothers ◦ Hospitalized premature infants < 28 weeks’ gestation www.dnbpediatrics.com
    37. 37. www.dnbpediatrics.com
    38. 38. Human parvovirus B19. IP-4 to 14 days. Preschool and young school age children. Prodrome minimal or absent Slapped cheek syndrome with circumoral pallor. Lacy reticular pattern on fading. Rash lasts for 1 to 3 weeks. Waxing and waning course. Spread is respiratory Initial viremia at 7-10 days; mild flu-like illness Patients are only contagious up to presence of rash www.dnbpediatrics.com
    39. 39. www.dnbpediatrics.com
    40. 40. Complications ◦ Arthritis: F>M, older>younger ◦ Aplastic crisis: usually not noticed in patients with normal erythrocyte half-life BUT results in severe anemia in those with any chronic hemolytic anemia (rash follows hemolysis) ◦ Pregnancy: early miscarriage, late hydrops fetalis ◦ GLOVES & SOCKS SYNDROME- Papular/purpuric www.dnbpediatrics.com
    41. 41. Vasculitis of unknown etiology Multisystem involvement and inflammation of small and medium sized arteries with aneurysm formation More common among children of Asian decent Usually children <5 years; peak 2-3 years. 3 CLINICAL PHASES-acute, subacute,convalescent. www.dnbpediatrics.com
    42. 42. www.dnbpediatrics.com
    43. 43. www.dnbpediatrics.com
    44. 44. www.dnbpediatrics.com
    45. 45. www.dnbpediatrics.com
    46. 46. www.dnbpediatrics.com
    47. 47. www.dnbpediatrics.com
    48. 48. Coronary artery thrombosis and coronary artery aneurysm(25%) Myocardial infarction Myocarditis(50%). Congestive heart failure Hydrops of gall bladder Aseptic meningitis Arthritis Sterile pyuria (urethritis) Thrombocytosis Diarrhea Pancreatitis Peripheral gangrene www.dnbpediatrics.com
    49. 49. ACUTE STAGE. IV Immunoglobulin (mechanism unknown) ◦ Single dose of 2 g/kg over 12 hours Aspirin 80-100 mg/kg/day divided q 6hrs until day 14.  CONVALESCENT STAGE. Aspirin 3-5 mg/kg od until 6-8 wks after illness onset.  CORONARY ABNORMALITIES (long term therapy) Aspirin 3-5 mg/kg od +/- clopidrogel 1mg/kg max upto 75 mg/day,  ACUTE CORONARY THROMBOSIS. prompt fibrinolytic therapy. www.dnbpediatrics.com
    50. 50. Aedes aegyptii-daytime,urban,collections of water. Dengue like disease-chikungunya, o’nyong- nyong, westnile fever. IP-1 to 7 days. Sudden onset of high grade fever. Frontal/retroorbital pain. Back break fever. C/F in first 2 days ,2-6 days,after 1-2 days of fever. www.dnbpediatrics.com
    51. 51. Multiple types of dengue virus. Dengue 3 virus- severe clinical syndrome.. Relatively mild 1st phase with rapid clinical deterioration & collapse after 2-5 days. Hepatomegaly may be seen. Positive tourniquet test. 20-30% - Dengue shock syndrome. 10%-gross ecchymosis/gastrointestinal bleed www.dnbpediatrics.com
    52. 52. DENGUE HEMORRHAGIC FEVER. 1. Fever. 2. minor/major hemorrhagic manifestations. 3. thrombocytopenia ( <1lac). 4. objective evidence of increased capillary permeability (hematocrit increased by >20%). 5.serosal effusion(by CXR/USG). 6.hypoalbuminemia.  DENGUE SHOCK SYNDROME. ABOVE + Hypotension/narrow pulse pressure(<20mm Hg) www.dnbpediatrics.com
    53. 53. GRADE 1- Fever + positive tourniquet test. GRADE 2- Spontaneous bleeding. GRADE 3-Circulatory failure. GRADE 4- Profound shock with undetectable BP www.dnbpediatrics.com
    54. 54. DF. Bed rest, supportive treatment, Aspirin C/I.  DHF. 1. IVF NS>RL. 2. If pulse pressure <10mm Hg/elevn of hematocrit persists-plasma/colloid. 3. avoid overhydration. 4. serial hematocrit determin & vitals monitoring www.dnbpediatrics.com
    55. 55. IP-7 to 14 days. Stepladder rise of fever (rare). Abdominal pain Hepatosplenomegaly m Relative bradycardia. Coated tongue. Maculopapular rashes/rose spot in 25% cases. Rose spot difficult to appreciate in dark skinned. www.dnbpediatrics.com
    56. 56. Acute, self limited illness,oral transmission Epstein-Barr virus. IP-30 to 50 days. Clinical features Atypical lymphocytosis. www.dnbpediatrics.com
    57. 57. Ampicillin rash. Gianotti crosti syndrome. www.dnbpediatrics.com
    58. 58. Major jones criteria. Trunk, upper arms,legs never on face Maculopapular, raised edges central clearing,circular shape Not itchy/painful. www.dnbpediatrics.com
    59. 59. Erythrogenic toxin producing group A -hemolytic streptococci 1 to 2 days after pharyngitis Rash from neck- trunk- extremities,blanches on pressure. Petechiae in linear form. More intense along elbow,axilla,groin creases. Fade in 4 to 5 days with desquamation 1st face progressing downwards. Warm Sandpaper like skin White and red strawberry tongue Treatment –penicillin or erythromycin www.dnbpediatrics.com
    60. 60. www.dnbpediatrics.com
    61. 61. Neisseria meningitides. Usually sudden onset of fever,chills, myalgia, and arthralgia Rash is macular, nonpruritic, erythematous lesions,usually on extremities,relative sparing of child’s body surface. Petechial rash develops in 75% of cases • Complications: permanent CNS damage, deafness, seizures, paralysis, cognitive deficits,fever, rash, hypotension, shock, DIC Treatment: Pen G/ Cefotaxime/ ceftriaxone. www.dnbpediatrics.com
    62. 62. www.dnbpediatrics.com
    63. 63. Superficial infection of the dermis Two types: ◦ Impetigo contagiosa ◦ Bullous impetigo Etiology ◦ Group A ß hemolytic streptococcus ◦ Coagulase positive S. aureus Treatment : Erythromycin. www.dnbpediatrics.com
    64. 64. Multiple crusted lesion with erythematous halo with polycyclic edges. Spreads without healing. www.dnbpediatrics.com
    65. 65. < 5 yrs. Staphylococcal exfoliatin Bullous lesions. Easy peeling of skin in thin sheets. Positive Nikolsky’s sign Diagnosis: Tzanck test, bacterial culture Treatment www.dnbpediatrics.com
    66. 66. www.dnbpediatrics.com
    67. 67. www.dnbpediatrics.com
    68. 68. Most common rickettsial infection in US Abrupt fever, headache, and myalgia Rash from extremities towards trunk Maculespetechiae Treatment ◦ Tetracycline ◦ Doxycycline ◦ Chloramphenicol www.dnbpediatrics.com
    69. 69. www.dnbpediatrics.com
    70. 70. Enteroviruses ◦ coxsackieviruses A and B ◦ echoviruses Vesicular lesions, may be petechial Associated with aseptic meningitis, myocarditis www.dnbpediatrics.com
    71. 71. www.dnbpediatrics.com
    72. 72. www.dnbpediatrics.com
    73. 73. YOU www.dnbpediatrics.com
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