This slide describes common exanthems found in children and this knowledge is important in our everyday life

1. Common Childhood Exanthem
Enukora Jason Chukwunonso
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2. OUTINE
• INTRODUCTION
• MEASLES
• RUBELLA
• HAND-FOOT-MOUTH SYNDROME
• VARICELLA
• ERYTHEMA INFECTIOSUM
• ROSEOLA INFANCTUM
• CONCLUSION
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3. INTROUCTION
• An exanthem is any eruptive skin rash that may be associated with
fever or other systemic symptoms. Causes include infectious
pathogens, medication reactions and occasionally combination of
both.
• Over 100 years ago, a group of characteristic childhood eruptions
were described and numbered from one to six: measles, varicella,
hand-foot-mouth disease, rubella, erythema infectiosum and roseola
infantum. The origin of the fourth classic childhood eruption, formerly
referred to as Dukes’ diseases is controversial. It may represent
misdiagnosed cases of rubella or scarlet fever rather than a distinct
illness.
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4. Cont.
• In children, exanthems are most often related to infection and of
these viral infections are the most common.
• Determining the cause of an exanthem is based on the characteristic
morphology, distribution and time course of the eruption as well as a
careful assessment of infectious contacts, immunization status and
aspects of the physical examination.
• The most common viral exanthems is varicella more commonly
referred to as chickenpox.
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5. Measles
• Measles virus is a single-stranded, lipid-enveloped RNA virus in the family
Paramyxoviridae and genus Morbillivirus.
• The portal of entry of measles virus is through the respiratory tract or
conjunctivae following contact with large droplets or small-droplet aerosols
in which the virus is suspended. Patients are infectious from 3 days before
to up to 4-6 days after the onset of rash
• Measles infection causes necrosis of the respiratory tract epithelium and
an accompanying lymphocytic infiltrate. Measles produces a small-vessel
vasculitis on the skin and on the oral mucous membranes. Histology of the
rash and exanthem reveals intracellular edema and dyskeratosis associated
with formation of epidermal syncytial giant cells with up to 26 nuclei
• Warthin-Finkeldey giant cells that are pathognomonic for measles
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6. Pathology, Clinical features and Lab findings
• Measles consists of 4 phases: incubation period, prodromal illness, exanthematous
phase, and recovery.
• CLINICAL MANIFESTATIONS Measles is a serious infection characterized by high fever, an
enanthem, cough, coryza, conjunctivitis, and a prominent exanthem. After an incubation
period of 8-12 days, the prodromal phase begins with a mild fever followed by the onset
of conjunctivitis with photophobia, coryza, a prominent cough, and increasing fever.
Koplik spots represent the enanthem and are the pathognomonic sign of measles,
appearing 1-4 days prior to the onset of the rash
• INAPPARENT MEASLES INFECTION The rash may be indistinct, brief, or, rarely, entirely
absent
• LABORATORY FINDINGS The diagnosis of measles is almost always based on clinical and
epidemiologic findings. Laboratory findings in the acute phase include reduction in the
total white blood cell count, with lymphocytes decreased more than neutrophils.
Absolute neutropenia has been known to occur, however. In measles not complicated by
bacterial infection, the erythrocyte sedimentation rate and C-reactive protein level are
normal.
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8. Diagnosis, Differential Diagnosis
• In the absence of a recognized measles outbreak, confirmation of the clinical
diagnosis is often recommended. Serologic confirmation is most conveniently
made by identification of immunoglobulin (Ig) M antibody in serum. IgM antibody
appears 1-2 days after the onset of the rash and remains detectable for about 1
month.
• Erythematous immune-mediated illnesses and infections, including rubella,
adenovirus infection, enterovirus infection, and Epstein-Barr virus infection.
Exanthem subitum (in infants) and erythema infectiosum (in older children) may
also be confused with measles. Mycoplasma pneumoniae and group A
streptococcus may also produce rashes similar to that of measles. Kawasaki
syndrome can cause many of the same findings as measles but lacks discrete
intraoral lesions (Koplik spots) and a severe prodromal cough, and typically leads
to elevations of neutrophils and acute-phase reactants. In addition, the
characteristic thrombocytosis of Kawasaki syndrome is absent in measles. Drug
eruptions may occasionally be mistaken for measles.
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9. Complications and Treatment
• Pneumonia is the most common cause of death in measles.
• Croup, tracheitis, and bronchiolitis are common complications in infants and toddlers
with measles
• Acute otitis media is the most common complication of measles
• Febrile seizures occur in >3% off children with measles.
• Subacute Sclerosing Panencephalitis
• Management of measles is supportive. Antiviral therapy is not effective in the treatment
of measles in otherwise normal patients. Maintenance of hydration, oxygenation, and
comfort are goals of therapy. Antipyretics for comfort and fever control are useful. For
patients with respiratory tract involvement, airway humidification and supplemental
oxygen may be of benefit. Respiratory failure from croup or pneumonia may require
ventilatory support. Oral rehydration is effective in most cases, but severe dehydration
may require intravenous therapy. Prophylactic antimicrobial therapy to prevent bacterial
infection is not indicated. Measles infection in immunocompromised patients is highly
lethal. Ribavirin is active in vitro against measles virus.
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10. Prevention
• Susceptible individuals exposed to measles may be protected from
infection by either vaccine administration or immunization with
immune globulin. The vaccine is effective in prevention or
modification of measles if given within 72 hr of exposure. Immune
globulin may be given up to 6 days after exposure to prevent or
modify infection.
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11. Rubella (3rd Disease)
• Rubella (German measles or 3 day measles) is a mild, often exanthematous
disease of infants and children that is typically more severe and associated
with more complications in adults
• Rubella virus is a member of the family Togaviridae and is the only species
of the genus Rubivirus. It is a single-stranded RNA virus. The virus is
sensitive to heat, ultraviolet light, and extremes of pH but is relatively
stable at cold temperatures. Humans are the only known host
• The viral mechanisms for cell injury and death in postnatal or congenital
rubella are not well understood.
• Following infection, the virus replicates in the respiratory epithelium and
then spreads to regional lymph nodes. The period of highest
communicability is from 5 days before to 6 days after the appearance of
the rash.
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12. Clinical Features
• Postnatal infection with rubella is a mild disease not easily discernible from other
viral infections, especially in children. Following an incubation period of 14-21
days, a prodrome consisting of low-grade fever, sore throat, red eyes with or
without eye pain, headache, malaise, anorexia, and lymphadenopathy begins.
• In children, the first manifestation of rubella is usually the rash, which is variable
and not distinctive. It begins on the face and neck as small, irregular pink macules
that coalesce, and it spreads centrifugally to involve the torso and extremities,
where it tends to occur as discrete macules. About the time of onset of the rash,
examination of the oropharynx may reveal tiny, rose-colored lesions
(Forchheimer spots) or petechial hemorrhages on the soft palate. The rash fades
from the face as it extends to the rest of the body so that the whole body may
not be involved at any one time. The duration of the rash is generally 3 days, and
it usually resolves without desquamation.
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14. Lab Findings, Diagnosis and Differentials
• LABORATORY FINDINGS: Leukopenia, neutropenia, and mild
thrombocytopenia have been described during postnatal rubella.
• The most common diagnostic test is rubella immunoglobulin (Ig) M
enzyme immunosorbent assay.
• It is similar to other viral exanthematous diseases. In severe cases, it
may resemble measles. The absence of Koplik spots allow for
differentiation from measles. Other diseases frequently confused with
rubella include infections caused by adenoviruses, parvovirus B19
(erythema infectiosum), Epstein-Barr virus, enteroviruses, and
Mycoplasma pneumoniae.
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15. Complication, Treatment and Prevention
• Complications include: arthritis, encephalitis. Other neurologic syndromes
rarely reported with rubella include Guillain-Barré syndrome and
peripheral neuritis. Myocarditis is a rare complication.
• Treatment: There is no specific treatment available for either acquired
rubella or Congenital Rubella Syndrome. SUPPORTIVE CARE Postnatal
rubella is generally a mild illness that requires no care beyond antipyretics
and analgesics. Intravenous immunoglobulin or corticosteroids can be
considered for severe, nonremitting thrombocytopenia
• PREVENTION Patients with postnatal infection should be isolated from
susceptible individuals for 7 days after onset of the rash. Standard plus
droplet precautions are recommended for hospitalized patients. Rubella
vaccine is administered in combination with measles and mumps (MMR) or
also with varicella (MMRV) in a 2 dose regimen at 12-15 mo and 4-6 yr of
age.
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16. Hand-Foot-Mouth disease
• Hand-foot-and-mouth disease, one of the more distinctive rash syndromes,
is most frequently caused by coxsackievirus A16, sometimes in large
outbreaks, and can also be caused by enterovirus 71; coxsackie A viruses 5,
6, 7, 9, and 10; coxsackie B viruses 2 and 5; and some echoviruses.
• It is usually a mild illness, with or without low-grade fever. The oropharynx
is inflamed and contains scattered vesicles on the tongue, buccal mucosa,
posterior pharynx, palate, gingiva, and/or lips.
• These may ulcerate, leaving 4-8 mm shallow lesions with surrounding
erythema. Maculopapular, vesicular, and/or pustular lesions may occur on
the hands and fingers, feet, and buttocks and groin; the hands are more
commonly involved than the feet
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18. CONT.
• Lesions on the hands and feet are usually tender, 3-7 mm vesicles that occur more
commonly on dorsal surfaces but frequently also on palms and soles. Vesicles resolve in
about 1 wk.
• Buttock lesions do not usually progress to vesiculation. Disseminated vesicular rashes
may complicate preexisting eczema.
• Hand-foot-and-mouth disease caused by enterovirus 71 is frequently more severe than
coxsackievirus A16 disease, with high rates of neurologic and cardiopulmonary
involvement, especially in young children.
• Coxsackie virus A16 also can occasionally be associated with complications such as
encephalitis, acute flaccid paralysis, myocarditis, pericarditis, and shock. Coxsackievirus
A6 is also responsible for atypical hand-foot and-mouth disease (and herpangina),
notable for affecting adults and children and causing relatively severe disease, including
fever, generalized rash (face, proximal extremities, and trunk, in addition to hands, feet,
and buttocks), pain, dehydration, and desquamation of palms and soles. Onychomadesis
(nail shedding) has been observed following coxsackievirus A6 and other coxsackievirus
infections
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19. Varicella
• Varicella-zoster virus (VZV) causes primary, latent, and recurrent
infections. The primary infection is manifested as varicella (chicken
pox).
• VZV is a neurotropic human herpesvirus with similarities to herpes
simplex virus.
• VZV is transmitted by contact with oropharyngeal secretions and the
fluid of skin lesions of infected individuals, either by airborne spread
or through direct contact.
• Primary infection (varicella) results from inoculation of the virus onto
the mucosa of the upper respiratory tract and tonsillar lymphoid
tissue.
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20. Clinical Features
• Varicella in Unvaccinated Individuals
• susceptible persons experience a rash, Fever, malaise, anorexia, headache,
and occasionally mild abdominal pain may occur 24-48 hr before the rash
appears. Varicella lesions often appear first on the scalp, face, or trunk.
• Varicelliform Rashes in Vaccinated Individuals
• Varicelliform rashes that occur after vaccination could be a result of wild-
type VZV.
• Breakthrough varicella is disease that occurs in a person vaccinated more
than 42 days before rash onset and is caused by wild-type virus. One dose
of varicella vaccine is >97% effective in preventing moderate and severe
varicella and is 85% (median; range: 44-100%) effective in preventing all
disease after exposure to wild-type VZV
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22. CONT.
• The differential diagnosis of varicella includes: vesicular rashes caused by other
infectious agents, such as herpes simplex virus, enterovirus, monkey pox,
rickettsial pox, and S. aureus; drug reactions; disseminated herpes zoster; contact
dermatitis; and insect bites (especially for breakthrough varicella). Severe
varicella was the most common illness confused with smallpox before the
eradication of smallpox.
• The complications: mild varicella hepatitis is relatively common, mild
thrombocytopenia occurs in 1-2% of children with varicella and may be
associated with transient petechiae. Purpura, hemorrhagic vesicles, hematuria,
and gastrointestinal bleeding are rare complications that may have serious
consequences. Other complications of varicella, some of them rare, include acute
cerebellar ataxia, encephalitis, pneumonia, nephritis, nephrotic syndrome,
hemolytic-uremic syndrome, arthritis, myocarditis, pericarditis, pancreatitis,
orchitis, and acute retinal necrosis.
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23. Diagnosis, Treatment and Prevention
• Varicella and herpes zoster have been diagnosed primarily by their
clinical appearance. Laboratory evaluation has not been considered
necessary for diagnosis or management. Varicella The only antiviral
drug available in liquid formulation that is licensed for treatment of
varicella for pediatric use is acyclovir
• Varicella is a vaccine-preventable disease. Varicella vaccine contains
live, attenuated VZV (Oka strain) and is indicated for subcutaneous
administration.
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24. 5th disease-Erythema infectiosum
• Fifth disease (erythema infectiosum) is a childhood condition that
appears as a bright red rash on your child’s cheeks. It’s nicknamed
“slapped cheek disease” because of this rash. A virus
called parvovirus B19 causes fifth disease. This virus is common and
very contagious. Infected people can spread it through coughing or
sneezing.
• In most cases, fifth disease isn’t a serious medical condition. It often
goes away with minimal or no treatment.
• Why is it called fifth disease?
• Fifth disease got its name because it was the fifth viral skin rash
known to affect children in a list of six conditions
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26. Clinical Features
• A parvovirus B19 infection often starts with flu-like symptoms, which are usually
mild. During this time, the virus is most contagious. These symptoms include:
Fatigue, Headaches, Achiness, Low-grade fever, Runny nose, Sore throat.
• About 20% of children who have a parvovirus B19 infection don’t have these
symptoms. Still, they can pass the virus to others.
• It can take several days after the onset of flu-like symptoms for the raised, bright
red rash (fifth disease) to show up on your child’s face. The rash may be itchy.
Children typically no longer have flu-like symptoms once the rash appears.
• In some cases, you may see a second rash that develops after the cheek rash. It
usually looks “lacey” and may appear on your child’s: Arms, Legs, Trunk (chest
and back), Buttocks.
• About 10% of children with fifth disease also experience joint pain and swelling.
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27. Complications
• In healthy children and adults, fifth disease very rarely causes
complications.
• But the condition can cause problems for people who have a blood
disorder or weakened immune system. This is because the virus can affect
the way your body makes red blood cells. It can cause your child’s red
blood cell count to drop so low that they need a blood transfusion.
• Children (and adults) with the following conditions are at increased risk of
complications:
• Cancer, such as leukemia.
• HIV.
• Certain types of anemia, such as sickle cell anemia and thalassemia.
• A transplanted organ.
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28. Diagnosis, Treatment and Prevention
It is diagnosed based on the child’s symptoms.
• The “slapped cheek” rash is a strong sign of this condition. When it’s accompanied by flu-like symptoms, it
can be diagnosed without any other tests. In very rare cases, blood tests are done to confirm fifth disease.
• Fifth disease symptoms typically go away in a few weeks with minimal or no treatment. Your child’s
healthcare provider may recommend over-the-counter (OTC) pain relievers that can treat fever, headaches
and joint pain. These medicines include:
• Acetaminophen.
• Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen.
• There isn’t a vaccine to prevent fifth disease.
• Because the virus spreads easily through nasal and mouth droplets, good hygiene is the best way to prevent
the disease. Child risk of infection can be reduced by:
• Washing of hands frequently and thoroughly.
• Sneezing or coughing into the crook of the elbow.
• Avoiding close contact with an infected person.
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29. Roseola infantum-6th disease
• Human herpesvirus 6 (HHV-6A and HHV-6B) and human herpesvirus 7
(HHV-7) cause ubiquitous infection in infancy and early childhood.
HHV-6B is responsible for the majority of cases of roseola infantum
(exanthema subitum or sixth disease) and is associated with other
diseases, including encephalitis, especially in immunocompromised
hosts. A small percentage of children with roseola have primary
infection with HHV-7.
• HHV-6A, HHV-6B, and HHV-7 are the sole members of the Roseolo
virus genus in the Betaherpesvirinae subfamily of human
herpesviruses
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31. CONT.
• Roseola infantum is an acute, self-limited disease of infancy and early
childhood.
• It is characterized by the abrupt onset of high fever, which may be
accompanied by fussiness. The fever usually resolves acutely after 72
hr (“crisis”) but may gradually fade over a day (“lysis”) coincident with
the appearance of a faint pink or rose-colored, nonpruritic, 2-3 mm
morbilliform rash on the trunk.
• The rash usually lasts 1-3 days but is often described as evanescent
and may be visible only for hours, spreading from the trunk to the
face and extremities.
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32. Diagnosis
• The most characteristic laboratory findings noted in children with primary
HHV-6B infection are lower mean numbers of total white blood cells,
lymphocytes and neutrophils, than in febrile children without primary
HHV-6B infection. Similar hematologic findings have been reported during
primary infection with HHV-7.
• Thrombocytopenia, elevated serum transaminase values, and atypical
lymphocytes have also been noted sporadically in children with primary
HHV-6B infection.
• Results of CSF analyses reported in patients with encephalitis thought to be
caused by HHV-6 have been normal or demonstrated only minimal CSF
pleocytosis with mild elevations of protein, especially early in the course of
the disease, which may progress with time.
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33. Differential Diagnosis and Complications
• A history of 3 days of high fever in an otherwise nontoxic 10 month old
infant with a blanching maculopapular rash on the trunk suggests a
diagnosis of roseola. Likewise, a specific diagnosis of HHV-6 is not usually
necessary except in situations in which the manifestations of the infection
are severe or unusual and might benefit from antiviral therapy.
• Convulsions are the most common complication of roseola and are
recognized in up to one third of patients.
• Case reports have additional complications in children with primary HHV-
6B infection, including encephalitis, acute disseminated demyelination,
autoimmune encephalitis, acute cerebellitis, hepatitis, and myocarditis.
Late-developing long-term sequelae, including developmental disabilities
and autistic-like features, are reported rarely in children who have central
nervous system symptoms during primary HHV-6B infection
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34. Treatment, Prognosis and Prevention
• Supportive care is usually all that is needed for infants with roseola.
Parents should be advised to maintain hydration and may use
antipyretics
• Specific antiviral therapy is not recommended for routine cases of
primary HHV-6B or HHV-7 infection.
• Primary infections with HHV-6 and HHV-7 are widespread throughout
the human population with no current means of interrupting
transmission.
• Roseola is generally a self-limited illness associated with complete
recovery. The majority of children with primary infections with HHV-
6B and HHV-7 also recover uneventfully without sequelae.
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35. Conclusion
• Viral exanthems of childhood are skin rashes that often affect children
and include varicella, hand-foot-mouth disease, roseola infantum,
measles, rubella and erythema infectiosum. Each has distinct
symptom and is caused by a different virus.
• Many viral diseases such as measles, rubella and varicella are now
preventable with vaccination.
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36. References
• Nelson textbook of pediatrics
• Clevelaand clinic
• Medscape
• Osmosis.com
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