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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.
  • Frsh

    1. 1. DR. FAZAL ASLAM
    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
    3. 3. Immunisation status. Contacts Immunocompromised ? Drug/food allergy Travel to endemic areas Animal/insect bite Joint pain Pica
    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
    5. 5. Kopliks spot Forchheimer spots Palatal petechiae Pharyngitis. Strawberry tongue Fissuring of lips. Circumoral pallor. Coated tongue.
    6. 6. Lymph nodes. Joints. CNS involvement. Hepatosplenomegaly. Heart. Eyes
    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.
    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
    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
    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
    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
    12. 12.
    13. 13.
    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
    15. 15.
    16. 16.
    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.
    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.
    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.
    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.
    21. 21.
    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%)
    23. 23. Thrombocytopenia (1/3000) Arthritis-clasically small hand joints Encephalitis(1/5000). Progressive rubella panencephalitis. Others – GBS, peripheral neuritis,myocarditis.
    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
    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.
    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
    27. 27. Begins on trunk & spreads out
    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
    29. 29.
    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
    31. 31.
    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
    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
    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
    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
    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
    37. 37.
    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
    39. 39.
    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
    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.
    42. 42.
    43. 43.
    44. 44.
    45. 45.
    46. 46.
    47. 47.
    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
    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.
    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.
    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
    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)
    53. 53. GRADE 1- Fever + positive tourniquet test. GRADE 2- Spontaneous bleeding. GRADE 3-Circulatory failure. GRADE 4- Profound shock with undetectable BP
    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
    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.
    56. 56. Acute, self limited illness,oral transmission Epstein-Barr virus. IP-30 to 50 days. Clinical features Atypical lymphocytosis.
    57. 57. Ampicillin rash. Gianotti crosti syndrome.
    58. 58. Major jones criteria. Trunk, upper arms,legs never on face Maculopapular, raised edges central clearing,circular shape Not itchy/painful.
    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
    60. 60.
    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.
    62. 62.
    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.
    64. 64. Multiple crusted lesion with erythematous halo with polycyclic edges. Spreads without healing.
    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
    66. 66.
    67. 67.
    68. 68. Most common rickettsial infection in US Abrupt fever, headache, and myalgia Rash from extremities towards trunk Maculespetechiae Treatment ◦ Tetracycline ◦ Doxycycline ◦ Chloramphenicol
    69. 69.
    70. 70. Enteroviruses ◦ coxsackieviruses A and B ◦ echoviruses Vesicular lesions, may be petechial Associated with aseptic meningitis, myocarditis
    71. 71.
    72. 72.
    73. 73. YOU