Razan Abu Khaizaran
The basic of skin Rash Loading...
Description of Rashes
Description of Rashes Loading...
Approach to Rash of acute onset Ø Ø Ø Ø Ø Ø Ø
History : how the symptoms started ? Suspected prodrome symptoms Is he ill/febrile Are there associated symptoms ? Purpuric conditions Past medical history Immunization Contact with anyone ill
Approach to Rash of acute onset Physical examination : Ø general examination Ø Rash : • Characteristic : blench with pressure or not • Distribution • The presence of an enanathem
Rash characteristic
Definitions Exanthem – a skin eruption occurring as a symptom of a general disease
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Enanthem – eruptive lesions on the mucous membranes
Classic Childhood Exanthems q “1st Disease”-Measles q “2nd Disease” – scarlet fever q “3rd Disease – Rubella q “5th Disease- Erythema Infectiosum q 6th Disease- Rosolea infantum q Varicella-Zoster
“1st Disease”-Measles • • • • • •
Rubeola- 9 day measles RNA Paramyxovirus … very contagious At risk : - preschool age children unvaccinated Season : late winter/spring Incubation: 10-12 days before prodrome symptoms Infectious : 1-days before prodrome to 4 days after onset of rash .
Pathophysiology
2-3 days
4-7 days
7-11 days
Clinical manifestation Ø Ø Ø Ø
Four phases : incubation 10-12 d prodrome (catarrhal) exanthematous (rash) Recovery
3d Maculopapular eryth. Descending, 4-7 d
Prodrome phase After 10 days of incubation lasts for 3 days Prodrome symptoms: v 3Cs : cough , coryza , conjunctivitis, fever
enanthem v Koplik spots.. Pathogonomic Then after 12- 24 hours of enanthem the rash phase
Koplik Spots
Buccal mucosa
Rash phase
• After 14 days of incubation period/ after 3 days of prodrome
symptoms . • Rash + fever
• Fever : high grade ( 40 c)/ baby looks ill • Rash : maculopapular erythematous rash • Starts on the back of ears spreads to the head and neck before
spreading to cover most of the body in 24 hours in a descending fasion • Lasts for 4-7 days .. Disappear in the same manner • as it disappears( in stains )changing color from red to dark brown and desquamate • The rash could be petechial or hemmoragic ( black measles)
Measles Rash
Diagnosis Clinically serology : IGM within 1-2 days after rash and to 1 -2 months
Treatment Ø Ø Ø
Supportive : Vitamin A : improve outcome highly recommended in children btw 6 months and 2 years requiring hospitalization immunocompromised
Complications: Pneumonia : Ø bacterial pneumonia : the most common complication & the most common cause of morbidity Ø interstitial pneumonia Ø Giant cell (Hecht) pneumonia cell mediated immunity compromised Otitis media
Complications: Encephalomyelitis: Early : due to direct viral infection Late : demyelinating due to immunologic process Subacute sclerosing panencephalitis after 8 to 10 years
MMR vaccine • Live attenuated vaccine • For children at 12-15 months • • • • •
5% not covered in first one so give another
4-6 years ( not a booster dose) CI: immunocompromised states conginetal immunodefieciency sever HIV infection ( but recommended in those who do not have evidence of sever immunosuppressant ) leukemia lymphoma
• cancer therapy ( but recommended in those in remission
who did not receive chemotherapy in last 3 months • Immunosuppressive course of corticosteroids (>= 2 mg/kg/day for >= 14 days ( in those who toke these doses after one months recommended) • Pregnancy • Recent administration of IG(3 to 11 months ) modified measles
“2nd Disease”-Scarlet fever Due to erythrogenic exotoxin-producing group A beta-hemolytic streptococci At risk: <10 years old Peak 4-8 years old
Season: late fall, winter, spring Likely due to close contact indoors in school
Incubation period: 2-4 days Infectious period: during acute infection, gradually diminishes over weeks by large respiratory droplets and infected nasal secretions
Clinical features Abrupt onset fever, headache, vomiting, malaise, sore throat Develop during any GABHS infection (impetigo, cellulitis, pharyngitis) Enanthem Bright red oral mucosa Palatal petechiae Tongue changes (Strawberry Tongue) Differential dx: kawazaki
Strawberry Tongues
Scarlet fever – exanthem Begins on the trunk & moves peripherally Sandpaper rash ( erythematous skin with tiny skin colored papules and has the texture of sand paper. The rash blenches with pressure. Pastia’s lines (petechiae localized within skin creases in a linear distribution. Desquamation of dry skin occurs as infection resolves.
Scarlet fever – exanthem Loading...
Diagnosis )
Clinically Positive throat culture for Strep.pyogenes (gold standard
Positive rapid streptococcal tests that detect GABHS antigens.
Treatment
• • • •
The goal is to prevent development of RF Oral Penicillin VK IM Benzathine Penicillin Penicillin allergic pts .. Erythromycin or Macrolides
Complications Purulent Otitis media Sinusitis Peritonsillar/retropharyngeal abscesses Cervical adenitis
Nonsuppurative sequalae Rheumatic Fever Acute glomerulonephritis …. AB doesn’t prevent this Arthritis .. AB doesn’t prevent this also
“3rd Disease”-Rubella German measles - 3 day measles RNA Tagovirus … very contagious through air droplet At risk : unvaccinated adolescent Season : late winter/spring Incubation:14-21 days Infectious : 5-7-days before rash to 3 to 5 days days after onset of rash .
Clinical manifestation • Milder than measles can be asymptomatic in up to 50%. • Prodrome symptoms :
non specific ( low grade fever , malaise, sore thraot ..etc) painful lymphadenopathy ( suboccipital, posterior auricular, cervical nodes) • Enanthem : Forscheimer spots (nonpruritic , maculopapular
rash on soft palate
Forscheimer spots
Clinical manifestation Exanthem with low grade fever : morbilliform rash ( begins on the face and then spreads to the body ) lasts 3 days . Polyarthritis could occur especially in women.
Rubella – Exanthem
Diagnosis : Clinically ?? Msh kter specific Confirmed by serology and culture Treatment : supportive
Complications Meningoencephalitis Polyarthritis Congenital Rubella syndrome: If in the 1st 4 weeks ..85% congenital defects From 13 to 16 week .. 35% will have anomalies After 4 months gestation seems no disease
Heart: PDA Peripheral pulmonary artery stenosis
Neurologic : Microcephaly Meningoencephalitis Behavioral disorder Mental retardation
Auditory: Sensoneural hearing loss Blueberry muffin appearance ( dermal erthropoiesis) Hepatosplenomegaly Thrombocytopenia
• Diagnosis : my detecting IGM antibody in baby. • Infants with CRS continues to have virus in urine , stool ,
respiratory secretions up to one year .
• Prevention : MMR vaccine • All pregnant woman should have prenatal serology testing for
rubella. • Susceptible pregnant mothers should have vaccine after delivery. • Susceptible pregnant woman exposed to rubella should have IG if elective abortion not an option. •
“5thDisease”Infectiosum HumanErythema Parvovirus B19/DNA At risk: school-age children Season: sporadic Incubation period: 4-14 days Infectious period: up until onset of the rash Y3ne el rash msh contagious
Clinical features •Over 50% of infections are asymptomatic • Prodrome ( upper respiratory symptoms) • After 1-2 weeks (Slapped cheeck appearance) • After facial rash , lacy reticular rash on extremities sparing of palms and soles lasts for 3-5 days . • Arthralgia
Erythema Infectiosum
Diagnosis : Clinically Serology Treatment : supportive Complications : Aplastic anemia in pts with hemolytic anemia Erythroblastosis fetalis in neonates during maternal infection
“6th Disease”-Roseola infantum • Exanthem subitum
Human Herpes Virus6(and 7)/dsDNA/hepesvirus family • At risk: 6-36 mo (peak age 6-7mo) • Season: sporadic • Incubation period: 9 days E2lebu el 6 • Infectious period: virus is intermittently shed into saliva throughout life; asymp persistent infection
Clinical manifestation •High fever for 3-4 days •Abrupt defervescencewith appearance of rash (rose coloured papular rash fades in 1-3 days ) •Associated seizures likely due to infection of the meningesby the virus Not all HVP 6 infection cause rash GI & respiratory symptoms may be present
Roseola infantum
Diagnosis : Clinically Serology Treatment : Suppotrive
Varicella-Zoster (chickenpox and zoster)
• Varicella –zoster virus / dsDNA/Herpesvirus family • Primary infection (chickenpox) , secondary infection
(zoster,shingles).
• • • • • • • • •
Chickenpox ( childhood disease (4-10 years)/endemic disease) Season : late winter/spring Transmission : highly communicable .. Direct contact , droplet & air. Incubation: 10-21 days after contact Infectious : 2-days before to 7 days after onset of rash . Zoster 10/20% of individuals .. 75% after 45 years Sporadically , evenly throughout the year Immunocompromised.
Pathophysiology Infects upper respiratory tract replicate there . Primary viremia .. Regional LNs . Liver spleen Secondary viremia .. Skin cutaneous manifestation Resolution Remains latent in dorsal root ganglion .. Reactivate in the ganglion ,, tracks down the sensory nerve .. Dermatome
Clinical manifestation/Chickenpox • Prodrome symptoms:
before 1 day of rash nonspecific ( fever , anorexia , malaise ) • Exanthem : Ø pruritic rash in variuos stages Various stages • Macules Papules Vesicle Pustules • Lesion maybe hemorrhagic • Crops .. Trunk then face & head .. Less commonly
extremities .. • Lasts For 3 to 4 days
Chickenpox
Clinical manifestation/Zoster intense localized pain and tenderness over a dermatome .. Acure neuritis Eruption of papules .. 1 to 7 days Dorsal and lumber .. It can affect cranial nerve 8 .. Ramsay Hunt syndrome Ophthalmic nerve ,, ipsilateral cerebral angiitis & stroke.
Diagnosis Clinically .. Lab not needed Consider : eczema herpeticum / Kaposi Varicelliform eruption .. HSV infection in eczematous or traumatic skin Viral culture .. HSV cultured ..
Treatment Supportive .. Antipyritic antibiotic for secondary infection Anti histamine Consider acyclovir in immunocompromised or risk for sever disease . Decrease complications such as pneumonia & Encephalitis
Complications • Mild disease but complicated in neonates, adults &
immunocompromised.
• Skin : • Secondary infection of skin by staph or strep : • Impetigo … to necrotizing fascitis Toxic shock syndrom .. Vericella
gangrenosa
• Reye syndrome • CNS : encephilitis ,acute cerebellar ataxia, Guillain Baree, transvere
myelitis • Pneumonia • Hepatitis
•Post-herpetic neuralgia—uncommon in kids
Infection during pregnancy • Primary infection rare in pregnancy . • If it happens in the first 20 weeks of pregnancy :
congenital varicella syndrom • Low birth weight .. Zigzag scarring of skin … hypoplasia of limbs ,CNS damage ( cortical atrophy , seizures , mental retardation ) eye abnormalities ( cataract , chorioretinitis, • Infection 5 days before or 2 days after delievery .. Neonatal varicella .. Maternal immunity not developed .. Need urgent IG
Prevention • Chickenpox infected child .. Isolated • Live attenuated varicella vaccine .. • At age 12 to 18 months • • • •
VZIG : within 96 hrs : Immunocmpromised Neonates Premature
