5. Scarlet fever
Group A streptococci (s.pyogenes)
Initially sore throat and fever
Followed by rash
Rash comprises of:
- Diffuse erythema all over trunk, neck and axilla, initially flat but then
studded with tiny papules giving it a ‘’sandpaper texture’’
- Linear petechial along skin folds, termed ‘’pastia’s lines’’
- Pallor around mouth
- Strawberry tongue, with faint erythema and hypertrophy of pappilae
- Palmoplantar peeling 7-10 days after rash
6.
7. Scarlet fever
If not treated, may progress to glomerulonephritis, and rarely to rheumatic
fever
Treatment is oral Abx that cover gram +ve organisms (e.g. amoxicillin,
erythromycin) for 10-14 days
8. Staphylococcal scalded skin syndrome
Caused by staph. Aureus
Not a form of septicemia
Organism infects/colonises a locus in the skin (e.g. impetigo, conjunctivitis,
throat/nasal colonization) produces exfoliating toxin (same toxin that
locally produces the blister in bullous impetigo) toxin enters bloodstream
generalized peeling of the skin
Blood and skin cultures negative as a result
Initially starts with fever and erythema, rash is mainly in the skin folds
rash generalizes later evolves into desquamation
Notable facial feature: peri-orificial edema and later fissuring/furrowing
9.
10.
11. SSSS
Good prognosis in children
Worse prognosis in adults (usually seen in immunocompromised patients and
patients with CRF)
Treatment includes IV fluid support with IV Abx targeting S.aureus (preferably
b-lactamase resistant, such as dicloxacillin)
12. Toxic shock syndrome
Staphylococcal or streptococcal
Previously associated with tampon use, now mainly associated with wound
infections, abscesses, nasal packing (staphylococcal) and distant sites of skin
infection (streptococcal)
High fever
Hypotension
Multi-organ involvement (including hepatic, renal, hematologic, pulmonary etc…)
Staphylococcal TSS more commonly associated with diffuse rash than
Streptococcal TSS
Rash is generalized scarletiniform or maculopapular, associated with conjunctivitis
and palmoplantar erythema and edema (palms/soles later desquamate)
13.
14. TSS
High mortality rate in streptococcal TSS (50%), compared to staphylococcal
TSS (5%)
Treatment is with clindamycin with or without IV penicillinase resistant
penicillin
15. Meningococcemia
Caused by gram negative diplococcus N.meningitides, carried in nasopharynx
High fever
Toxic appearing
Rash starts as dusky erythematous macules and papules later evolve into
stellate purpuric lesions with a central gunmetal grey color (culture of deep
tissue has high chance of being positive) later develop large necrotic areas
with diffuse purpura/ecchymoses if DIC develops
16.
17. Meningococcemia
High mortality rate if not recognized early
Treatment with IV antibiotics (e.g. third generation cephalosporin)
18. Rocky mountain spotted fever
Due to transmission of Rickettsia rickettsia by the bite of a tick, most
commonly Dermacentor spp.
the incubation period is 2–14 days (mean, 7 days) following the bite.
High fever, myalgias, headache (often for 2–5 days prior to rash)
Rash begins on wrists/ankles spreads centripetally (± palms/soles)
Petechiae within erythematous macules/papules
Complications include acute renal failure, hypotension, and coma
Mortality rate of up to 25% if not treated
Doxycycline is treatment of choice (chloramphenicol if pregnant)
19.
20. Hints towards bacterial infections in
pediatrics
High fever
Neutrophils high
Sore throat preceding rash
Patient appears unwell (compared with viral/drug induced rash)
21. Viral infections
MANY!
Most commonly:
- Measles (now uncommon due to vaccine)
- Rubella (now uncommon due to vaccine)
- Enteroviruses
- EBV/CMV
- Parvovirus (fifth disease)
- HHV 6 (roseola infantum)
- Varicella
22. Measles
Paramyxovirus
Rash starts in head/face progress downwards
Maculopapular ‘’morbilliform’’ rash
3 C’s: cough, coryza, conjunctivitis
Oral feature: koplik spots
Complications include pneumonia, otitis, encephalitis, Subacute sclerosing
panencephalitis
Treatment is supportive, but new evid
23.
24. Rubella
Togavirus
Rash similar to measles
Lymphadenopathy (occipital, cervical, pos-auricular)
Complications include arthritis, hepatitis, pneomonia
25. Enteroviruses
Mainly coxsackie virus
Wide range of presentations
Most commonly a herpangina or hand foot mouth disease
Now also recognized as a cause of morbilliform exanthems
26.
27. EBV ‘’infectious mononucleosis’’
Human herpes virus 4
Starts out as a pharyngitis with sore throat
Rash classically very faint and unrecognizable, accentuated upon
administration of Abx to form a maculopapular rash mainly on the trunk
NOT AN ALLERGIC REACTION
Patient can safely use the same antibiotic in the future
EBV mononucleosis could also cause urticaria or erythema multiforme
Other systemic features include fever, fatigue, headache, lymphadenopathy
(generalized or cervical), Hepatosplenomegaly
28.
29. CMV ‘’Mononucleosis-like’’ syndrome
Usually asymptomatic in children
If symptomatic, Rash similar to EBV
No pharyngitis
Negative monospot test
30. Parvovirus B19 ‘’fifth disease’’
Starts as a macular rash in the cheek resembling a ‘’slapped cheek’’
progresses to involve the extremeties > trunk with a reticulated distribution
Very mild prodrome of mild fever and possibly arthralgia
31. HHV6 ‘’roseola infantum’’
Starts with a high fever
Rash starts as fever subsides
Circular or elliptical ‘’rose red’’ macules and papules, mainly on the trunk
Lesions usually surrounded by white halo
Main complication in immunocompetent children is febrile seizures
32.
33. Varicella ‘’chicken pox’’
HHV3
Usually mild infection in immunocompetent children
Comprises of papules that progress to vesicles erosion crust and dry
Usually rapid progress of individual lesions, so you see multiple different
phases of each lesion at any one location
Rash starts in the head/neck and then progresses downwards to the trunk
Child is infectious 2 days before onset of the rash until all the lesions crust
and dry, which is usually 5 days after the onset
Rarely have any systemic complications in children and treatment is mainly
supportive (control pruritus and fever, prevent secondary skin infections)
Vaccine now part of child vaccine schedule
34. Hints to viral infection
Maculopapular rash
Onset after Abx
Lymphocytosis
Child usually appears well (compared to bacterial infections)
Urticarial lesions
35. Fungal infections
Mainly congenital candidiasis
Usually occurs in premature infants or with mothers who have vaginal
candidosis or foreign body in uterus/cervix
Presents with widespread pustules or burn-like erythema and peeling
More severe in premature neonates
Treated with IV antifungals in severe cases (especially in premature neonates)
or with topical antifungals in mild cases
36.
37. Kawasaki disease
Etiology remains unknown; factors include a genetic predisposition to immune
activation and possibly an infectious trigger.
Most common cause of pediatric acquired heart disease
Diagnostic criteria includes fever >39 for 5 days plus 4 of the 5 following criteria:
- Bilateral nonpurulent bulbar conjunctival injection
- Oropharyngeal changes such as ‘chapped’/ fissured lips , a ‘strawberry’ tongue,
and diffuse hyperemia
- Cervical lymphadenopathy (>1.5 cm; usually unilateral)
- Erythema, edema, and (eventually) desquamation of the hands and feet
- Polymorphous exanthem – morbilliform or urticarial > erythema multiforme-like
,scarlatiniform or pustular
38.
39.
40. Kawasaki disease
Laboratory findings of acute disease include leukocytosis with neutrophilia,
anemia, elevated ESR/CRP and hepatic transaminase levels, hypoalbuminemia
and sterile pyuria
Treatment is with IVIG and aspirin, in recalcitrant cases steroids and
infliximab are considered
Main complication is coronary artery aneurism
Other complications include ther cardiac (e.g., myo-/pericarditis, valvular
abnormalities), CNS (e.g., irritability, aseptic meningitis), musculoskeletal
(e.g., arthritis), gastrointestinal, and genitourinary involvement
41. Drug reactions
Morbilliform drug reaction
SJS/TEN
DRESS syndrome
Serum sickness/serum sickness-like reactions
42. Morbillifrom reaction
Common culprits include Aminopenicillins, Sulfonamides, Cephalosporins,
Anticonvulsants, Allopurinol
Onset 7-21 days after taking medication
Fever low grade
Maculopapular rash mainly over the trunk, and more pruritic than other
causes
Dusky red colour
Treatment is with discontinuing drug and antihistamines, steroids reserved for
more severe cases
43. SJS/TEN
Common culprits are Sulfonamides, Anticonvulsants, NSAIDs, Allopurinol,
Penicillins
Onset 7 to 21 days after taking medications
Preceded by flu-like symptoms
Rash starts as dusky erythematous macules/papules in
trunk/face/palms/soles confluence to larger patches/plaques
desquamate leaving erosions and severe mucous membrane involvement
SJS/TEN is a spectrum based on body surface area involvement
44.
45.
46.
47. SJS/TEN
Mortality is much higher for TEN than SJS
Treatment is with admission to ICU or burn unit and withdrawal of the likely
drug and any other unnecessary drugs
IV fluid and electrolyte support
Monitoring for any GI or respiratory complications
Monitoring for any secondary skin infection during the desquamation phase
No good evidence for corticosteroids, some evidence for IVIG and cyclosporine
48. Other rare types of drug induced fever
and rash
DRESS syndrome (drug reaction with eosinophilia and systemic symptoms)
CCC is edematous morbilliform rash with facial edema plus systemic
involvement, and longer history of drug intake (2-6 weeks), common culprits
are allopurinol, anticonvulsants, sulpha drugs
Serum sickness CCC is urticaria with joints pains and renal involvement,
common culprits are Anti-thymocyte globulin, Tositumomab, Infliximab
Serum sickness-like reaction similar to serum sickness but without renal
disease or vasculitis, common culprits are Cefaclor, Bupropion, Minocycline,
Penicillins, Propranolol
49. Hints for drug induced fever and rash
Recent administration of a medication
Eosinophilia
Rash mainly over trunk
50. Still’s disease
Systemic-Onset Juvenile Idiopathic Arthritis
daily spiking fevers (especially in the late afternoon/early evening)
accompanied by an evanescent eruption of salmon-pink macules and slightly
edematous papules and plaques, mainly at sites of pressure or trauma
Additional features include arthralgias/myalgias, arthritis (usually
polyarticular), lymphadenopathy, hepatosplenomegaly, and serositis
Leukocytosis with neutrophilia, thrombocytosis, anemia, elevated ESR/CRP,
and extremely high serum ferritin levels (e.g. >4000 mg/ml) are common
laboratory findings, whereas ANA and RF are usually absent.
51.
52. Still’s disease
Treatment includes NSAIDs (for mild disease), systemic CS, methotrexate,
antagonists of IL-1 (e.g. anakinra, canakinumab) or IL-6 (e.g. tocilizumab),
and TNF inhibitors (the latter especially for arthritis).
53. Hereditary periodic fever syndromes
Group of hereditary autoinflammatory disorders that feature recurrent
episodes of fever and rash
Examples include FMF, TRAPS, HIDS, CAPS
Cutaneous findings, which range from erysipeloid erythema (FMF) to urticarial
eruptions (CAPS), represent clues to the underlying diagnosis
Acute inflammation in other organ systems can lead to manifestations such as
arthritis, serositis, and conjunctivitis; over time, secondary systemic
amyloidosis may develop
