Fever with a maculopapular skin rash in children Measles Rubella Dengue Roseola Infantum Scarlet fever

1. Fever with a Skin Rash
Diagnosis and Differential Diagnosis
Prof. Imran Iqbal
Fellowship in Pediatric Neurology (Australia)
Prof of Paediatrics (2003-2018)
Prof of Pediatrics Emeritus, CHICH
Prof of Pediatrics, CIMS
Multan, Pakistan

2. (God speaking to Prophet Muhammad (PBUH)
This is the Book (the Quran), whereof there is no doubt;
a guidance for those who are conscious of Allah (the pious persons
who love Allah and abstain from His disobedience)
Al Quran surah Al-Baqara 2:2
Al- Quran

3. Fever with a Skin Rash
• Rash – widespread areas of altered skin
• Macule – an area of skin that is altered in color
• Papule – elevated solid palpable lesion < 1 cm
• Vesicle – fluid-filled lesion < 1 cm
• Purpura – bleeding into skin

4. Maculopapular Skin Rash
with or without Fever
Viral Infections
• Measles
• Rubella
• Roseola infantum
• Fifth disease
• Dengue fever
• Entero viruses
• Infectious
mononucleosis (EB virus)
Other causes
• Bacterial infections
• Scarlet fever
• Staphylococcal scalded
skin syndrome
• Immune-mediated
• Allergic Rash
• Drug Rash
• Erythema multiforme

5. Papular or Vesicular Skin Rash
with or without fever
Viral infections
• Varicella
• Herpes simplex / zoster
• Hand-foot-mouth
disease
• Molluscum contagiosum
• Small pox (eradicated)
Others
• Impetigo
• Scabies

6. Purpuric Skin Rash
with or without fever
Infections
• Meningococcal infection
• Infective endocarditis
• DIC
Blood / Vascular disorders
• ITP - thrombocytopenia
• Hemophilia
• Acute leukemia
• HSP
• Vasculitis

7. Measles
Epidemiology, Etiology
Clinical Features, Complications, Management
Prognosis and Prevention
Prof. Imran Iqbal
Fellowship in Pediatric Neurology (Australia)
Prof of Paediatrics (2003-2018)
Prof of Pediatrics Emeritus, CHICH
Prof of Pediatrics, CIMS
Multan, Pakistan

8. Case scenario
• Parents bring their 9 month old baby to your clinic.
• He is having fever and cough for the last 5 days
• When you examine the baby, you find that he is having
red eyes and runny nose
• Dark Red colored macular rash is can be seen on the
face and trunk.
1. What is the most likely diagnosis ?
2. Differential diagnosis ?

9. MEASLES (Rubeola)
A contagious disease
with fever and a characteristic
maculopapular rash
caused by measles virus
Etiology
Measles virus
RNA virus - Paramyxovirus

10. EPIDEMIOLOGY
• Usual age = 1 to 5 years
• Range = 3 months to adults
• Very common in unvaccinated children and adults
• Can occur in vaccinated children 5 – 10 years after
vaccination when antibody levels decline
• Measles comes in epidemics when a collection of
susceptible children is present

11. Transmission of Measles
• DROPLET INFECTION
• Highly contagious
• Human to human is the only method of transmission
• INCUBATION PERIOD: 7 – 14 days
• Infectivity Period:
Onset of illness to 8 days
OR
4 days before to 4 days after onset of rash

12. Clinical Features

13. CLINICAL FEATURES – 3 phases
• Prodromal phase – before the onset of Rash
• Exanthematous phase – after the rash appears
• Recovery phase – fever and rash subside

14. Prodromal Phase
• Initial 3 to 5 days
• Continuous high fever
• Conjunctivitis with red eyes
• Rhinitis with Runny nose,
• Bronchitis with dry cough
• Koplik’s spots – white spots like grains of salt seen on
buccal mucosa opposite first molar teeth
• Koplik’s spots appear one day before onset of skin rash
and persist for 1 – 2 days

15. Exanthematous Phase (maculopapular rash)
• Rash first appears on forehead
• Appears in a head-to-feet direction
• Progresses to feet in two days
• Fever increases as rash appears
• Fever starts to decrease when rash has appeared upto
feet
• Rash remains for 6 to 7 days

16. Maculopapular Skin Rash in Measles

17. Profuse Maculopapular Rash of Measles

18. Measles in Older Child

19. Recovery
• After rash has fully erupted, fever subsides
• Respiratory symptoms decrease
• Rash shows branny desquamation
• Rash leaves brown discoloration on skin
• Child remains in a state of illness for many days
• Child gets better gradually
• Appetite returns slowly

20. Diagnosis
and
Differential Diagnosis

21. DIAGNOSIS
• DIAGNOSIS of measles is clinical diagnosis
• High Fever
• Koplik’s spots on buccal mucosa before skin rash
• Characteristic Maculopapular Rash
• Conjunctivitis with red eyes
• Rhinitis with Runny nose,
• Bronchitis with dry continuous cough
• Diagnosis of Measles is strengthened by presence of
cases of measles in the community (epidemiological
evidence)

22. DIAGNOSIS – Case Definition
• Measles can be diagnosed in the presence of following
clinical signs:
1. A generalized maculopapular rash
AND
2. Fever (101 F or greater) for 3 or more days
AND
3. One of the following three clinical signs:
• Runny nose
• Red eyes
• Cough

23. Diagnosis of Measles – Lab confirmation
• Measles is a clinical diagnosis and lab confirmation is
not needed
• Investigations to confirm measles may be needed for
epidemiological or research studies
• Measles virus infection may be confirmed by:
-- Measles virus isolation and culture
-- Measles virus IgM antibody in serum

24. DIFFERENTIAL DIAGNOSIS
(Before rash appears)
• Measles can be diagnosed in febrile children with cough
before onset of skin rash if frequent cases are occurring
in the community
Differential Diagnosis
• Viral bronchitis
• Bacterial bronchitis
• Bacterial pneumonia

25. DIFFERENTIAL DIAGNOSIS
(After rash appears)
• Roseola infantum
• Rubella
• Scarlet fever
• Infectious mononucleosis
• Other viral illnesses
• Drug rash

26. Other Maculopapular
Skin Rashes

27. Roseola infantum (Exanthem subitum)
• Caused by Human Herpes virus 6 (HHV-6)
• Usual age – 6 to 15 months
• Clinical features:
• Febrile phase – moderate fever in a well-looking child for
3 days
• Exanthematous phase – fever falls suddenly and a
maculopapular rash appears on all the body which
remains for 2 -3 days

28. Roseola infantum (Exanthem subitum)
• Baby had fever for 4 days. Today no fever and a maculopapular rash
is visible on all body

29. Rubella (German Measles)
• Caused by Rubella virus
• Usual age – 4 to 10 years
• Clinical features:
• Low grade fever
• A maculopapular rash remains for 3 days
• Suboccipital and postauricular lymph nodes enlarged for
7 days

30. Rubella (German Measles)
• Five year old child with pink macular rash on all body
and palpable occipital lymph nodes. T = 99.8 F

31. CONGENITAL RUBELLA SYNDROME
• First trimester Rubella infection of mother - (Fetus
affected - 25 – 75 %)
• Last trimester Rubella infection (Fetal infection - 25 %)
• Clinical features of CRS:
• Microcephaly
• Congenital cataract
• Hearing loss
• Cardiac anomalies (PDA)
• Mental handicap
• Growth retardation (IUGR)
• Hepato-splenomegaly (last trimester infection)

32. Scarlet Fever
• Associated with Acute tonsillitis (in 10 % of patients)
• Caused by Streptococcus pyogenes
• Erythrogenic exotoxin produced by Streptococcus
pyogenes bacteria causes generalized skin rash
• Usual age – 5 to 15 years
• Clinical features:
• High grade fever
• Acute tonsillitis
• Sandpaper like rash on all body

33. Dengue Fever
• Caused by Dengue virus (RNA virus)
• Transmitted by Aedes egypti mosquito
• Incubation Period: 1 – 7 days
• Pathology:
• Increased vascular permeability
• Thrombocytopenia
• Clinical Presentations:
• Dengue Fever
• Dengue Hemorrhagic Fever (DHF)
• Dengue Shock Syndrome (DSS)

34. Dengue Fever – symptoms and signs
Dengue (suspected) diagnostic criteria (3 or more)
• Fever (2 to 10 days) ESSENTIAL
• Headache
• Retro-orbital pain
• Myalgia
• Backache
• Rash
• Bleeding
• Abdominal pain
• Decreased urine output
• Irritability (infants)

35. Complications
of
Measles

36. COMPLICATIONS - EYES
• Conjunctivitis
• Keratitis (common)
• Corneal ulcer
• Blindness

37. COMPLICATIONS - CHEST
• Post Measles Pneumonia (common)
• Empyema
• Otitis media
• Laryngitis
• Activation of quiescent TUBERCULOSIS

38. COMPLICATIONS - GIT
• Oral Thrush
• Mouth ulcers
• Post Measles Diarrhea (common)
• Persistent diarrhea (malabsorption)

39. COMPLICATIONS - CNS
• Post Measles Encephalitis
- occurs after measles
- high mortality
• SSPE (subacute sclerosing panencephlitis)
- occurs after many years
- very high mortality

40. COMPLICATIONS - systemic
• Malnutrition (loss of weight by ½ to 1 kg during measles)
• Immunodeficiency (low immunity for 3 months)

41. Management

42. MANAGEMENT
• Antipyretics – Paracetamol / Ibuprofen
• Hydration – extra fluids – Oral / IV
• Nutrition – small frequent feeds
• Relieve cough and cold – tea, soup, steam inhalation
-- Anti-tussive medicines (pholcodine / dextrometarphan)
• Vitamin A –
-- measles virus infection increases Vitamin A requirements
-- Vitamin A needed for repair of damage to epithelia
-- Vitamin A reduces complications in measles

43. Vitamin A in Measles
• Give Vitamin A
First dose on diagnosis – day 1
Second dose – day 2
Third dose – (if corneal ulceration) – day 14
• DOSE of Vitamin A –
– Less than 6 months = 50000 units
– 6 to 12 months = 100,000 units
– More than 12 months = 200,000 units

44. Prognosis of Measles
Depends upon
• Age
• Nutritional status
• Complications of disease
• Medical care available
• Deaths – pneumonia, encephalitis, malnutrition

45. Prevention of Measles

46. MEASLES VACCINE
• MEASLES VACCINE (EPI schedule)
(live attenuated virus)
• DOSE - 0.5 ml given SC at upper arm
• First dose -- at 9 months of age
• Second dose -- at 15 months of age
• Measles Vaccine can be given as MMR (Measles,
Mumps, Rubella vaccine)

47. Measles Vaccine – age of administration
• Why Measles Vaccine is given at 9 -12 months of age ?
• Previous studies had shown that trans-placental
immunity given by mother to fetus persists till 9 months
of age ?
• Measles Vaccination before 9 months was not
considered to be effective due to interference by the
measles antibodies already present in the infant

48. Measles Antibodies in infants – Recent data
• Recent studies have shown that Measles antibodies in infants born
to present generation of mothers may decline by 3 months of age
• A study in Canada recently found that most infants were susceptible
to measles by 3 months of age
Michelle Science et al.
Measles Antibody Levels
in Young Infants.
PEDIATRICS Volume
144, number 6, December
2019:e20190630

49. Measles cases in infants – Pakistan
• Recent studies in Pakistan have shown that Measles cases
are frequent in infants between 3 to 9 months of age
• A study of measles in children was done in Multan in 2018.
Out of all recorded cases of measles, 51 % were 3 - 9 months
of age.
• These infants were unvaccinated against measles vaccine
because they were less than 9 months of age.
• Imran Iqbal. Changing Epidemiology of Measles in Children Presenting to Children’s
Hospital and the Institute of Child Health, Multan - Pak Pediatr J 2019; 43(1): 21-24

50. Measles Vaccine – age of administration ?
• The present generation of mothers and their infants do
not have adequate antibody levels against Measles
• First dose of Measles Vaccination given at 6 months of
age may protect many more infants against measles
• Age of administration of measles Vaccine may be shifted
to six months during epidemics of Measles (WHO)

51. Health Education about Measles

52. History of
Diagnosis of Measles

53. Muhammad bin Zakariya RAZI (860 – 932 AD)
The first scientific description of the disease
MEASLES
and its distinction from smallpox
is attributed to the
Persian physician Ibn Razi (Rhazes) 860-932
who published a book entitled
"The Book of Smallpox and Measles"
(in Arabic: Kitab fi al-jadari wa-al-hasbah).

54. Muhammad bin Zakariya RAZI (860 – 932 AD)
• Born in RAE, Iran
• Worked as chief physician in
Baghdad
• Wrote 224 books
• His book on Pediatrics:
“Booklet on Ailments of
children and their care”
• Western physicians translated
his works in Latin and learned
medicine from him

55. Muhammad bin Zakariya RAZI (860 – 932 AD)