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Exanthematous D iseases of C hildhood

Exanthematous D iseases of C hildhood. Dr. Abdullah ALAKEEL Assistant Professor & Consultant, KKUH Head of D ermatology Unit , KAUH. Exanthematous diseases of childhood. What are exanthems ? Localized or generalized skin eruptions . Enanthems ?

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Exanthematous D iseases of C hildhood

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  1. Exanthematous Diseases of Childhood Dr. Abdullah ALAKEEL Assistant Professor & Consultant, KKUH Head of Dermatology Unit , KAUH

  2. Exanthematous diseases of childhood • What are exanthems ? • Localized or generalized skin eruptions. • Enanthems ? • Eruption of the mucus membrane. • The majority of childhoodexanthems are caused by viruses, lesscommon by bacterial or rickettsial agents.

  3. Measles • Rubeola (Measles) : • ssRNA in the familyParamyxoviridae. • Infection begins in the nasopharyngealepithelium, & lesscommonly the conjuctivae. • Enterslymphnodes, multiplies within the RES, with a subsequentviremia. • Thendisseminated to multiple lymphoid tissues & otherorgans  (skin,liver, & GI ).

  4. Measles • Classicallypresentswithfeverand the three Cs : • Cough, Coryza, Conjuctivitis. • The pathognomonicenanthemKoplik spots, usuallyoccurduring the prodromalperiod. • Punctuate , gray-white to erythematous papules on the buccal mucosa.

  5. Measles • The cutaneouseruptionusuallybegins 2-4 daysfollowing the prodrome. • Begins on face (esp. forehead), hairline, behind the ears & spreadsdownward onto to the trunk & extremities. (cepahalocaudedspread).

  6. Measles • Complications: • Pneumonia, bronchitis, otitis, gastroenteritis, myocarditis & encepahlitis. • Modifiedmeasles : • Measlesoccuring in a previouslyvaccinatedindividual, in such cases, the prodrome ismilder & of shorter duration, exanthemislessprominent & Koplikmaybe absent.

  7. Measles • Diagnosisisclinical. • Lab confirmation if necessary. • A fourfoldincrease in titerconfirm the diagnosis of measles. • PCR & semi-quantative real-time PCR assays have been developed, the latter being sensitive & specific & useful in situations whereearly & rapiddiagnosisis vital.

  8. Measles • Treatment : • Supportive • Specific antiviral Rxdon’texist. • Ribavirin has been used in severelyill/ immunocompromised patients * • Antibios? • Vitamin A ? Protective action on epitheliallining of GI, increased mucus secretion & enhanced local barriers to infection. • Isolation for 4 daysfrom the onset of rash. • Sequelae ?

  9. Scarlet Fever • Type of exanthem: • Bacterial • Cause: • GABHS • Age: 1-10 years, rarely in infants. • Transmission: respiratorysecretions.

  10. ScarletFever • Whatis the primary distinction betweenstreptococcalpharyngitis & scarletfever? • The accompanyingexanthem in SF. • Oropharyngeal inspection reveals: • Tonsillopharyngealerythema, exudates & petechial macules of palate.

  11. Scarlet Fever • During 1st few days of illness: • Tongue mayreveal a white coating, withred & edematouspapillaeprojecting(white strawberrytongue). • 4th-5th day: coatingpeels off, leavingbehind a red, glisteningtonguewithprominentpapillae(redstrawberrytongue). • DDx of streptococcalpharyngitis: • Mononucleosis, mycoplasma, Chlamydia,..

  12. Scarlet Fever • Tender anterior cervical adenopathy . • Rhinorrhea& cough are usually absent. • Resolves over 4-5 days& mayhealwithsheets of desquamation (over hands, feet, toes & fingers).

  13. Scarlet Fever • Diagnosis: • Based on the clinicalpresentation. • The gold standard lab: • Throat culture. • Rapidstreptestingwhenproperlyperformed has a highsensitivity & specificity. • Antistreptococcalserologiesmaybeuseful.

  14. Scarlet Fever • Complications: • Pneumonia, pericarditis, meningitis, hepatitis, GN, & rheumaticfever( prevailingtheory ARF preventionis to startantimicrobialRxwitihin 9 days of onset of Sx of GABHS). • Treatment: • Penicillin V • Erythromycin or another macrolide if allergic to penicillin. • 1st generationcephalosporins.

  15. Rubella (GermanMeasles) • Type of exanthem: • Viral • Incidence has greatlydecreasedsincewidespread vaccination began in th US in 1969. • Beforethat, epidemicsevery 6-9 years& major epidemics or pandemicsevery 10-20 years. • The primary goal of the vaccination was to preventfetal infection, ( miscarriage, stillbirth, & congenitalrubellasyndrome).

  16. Rubella (GermanMeasles) • Cause : • RNA virus in the Togaviridaefamily. • Humans are the only source of infection. • Postnatal diseaseisspreadthrough direct or droplet contact from NP secretions. • Upto 50% asymptomatic, & mild, self-limiteddiseaseiscommon. • Incubation period: • 14-23 days

  17. Rubella (GermanMeasles) • Clinical manifestations: • Prodromalsymptomsmayoccur(esp. adolescents & adults): • Low grade fever, headache, malaise, eye pain, sore throat, rhinorrhea & cough. • Prodrome presents 2-5 daysbefore the exanthem.

  18. Rubella (GermanMeasles) • Cutaneous manifestations: • Erythematous to « rose-pink » macules & papules, tends to become confluent & commonlyinvolves the face & trunk. • Spreads in a cephalocaudadmanner. • Involution in 1-3 days fading the sameorder in whichitappeared.

  19. Rubella (GermanMeasles) • Generalizedlymphadenopathy : • Suboccipital, postauricular & cervical regions. • Arthralgias & arthritis are common, mostcommon joints affected are those of the fingers, wrists& knees. Resolutionmaytakeseveralweeks & chronicarthritisoccasionallydevelops.

  20. Rubella (GermanMeasles) • Other complications of rubella: • Encephalitis, myocarditis, pericarditis & hepatitis. Anemia, neutropenia & thrombocytpeniaamyalsooccur. • Clinical diagnosisisdifficult. • Labs : • Rubella specificIgMantibodyindicatesrecent infection. • The virus canbeisolatedfrom nasal specimens.

  21. Rubella (GermanMeasles) • Treatment: • Of postnatal rubellaisgenerallysupportive. • Requires contact isolation if hospitalized. • And non-hosptalizedchildrenshouldbeexcusedfromschool for 7 daysfollowingonset of rash.

  22. Erythema infectiosum • Alsocalled : fifthdisease. • Cause : • Parvovirus B19. • B19 iscommon in most countries , 60% of adults are seropositive for the virus in the US. • Most common in school-agechildren. • Transmission: respiratory tract followed by viremiathat ends after 5-7 dayswith production of IgMantibody.

  23. Erythema infectiosum • ProdromalSx: • Headaches, fever& chills. Respiratorysymptomsmaybepresent. • IgGantibodyappearsduring the 3rd week of illness & coincideswith the appearance of the rash & arthralgias. • Patients withcutaneousfindings of EI are NOT consideredinfectious. • Outbreaksprimarilyduringwinter & spring.

  24. Erythema infectiosum • Alsoknown as « slappedcheek ». • Occurs 2-3 daysafter the prodromalSx. • This phase has been termed the 1st stage, with the DDx ; phototoxicreaction, SLE. • Stage 2 : reticulatederuption on trunk & extremities 1-4 daysfollowing facial rash, maybepruritic, palm & soles usuallyspared. • Tends to fade 2-3 weeks.

  25. Erythema infectiosum • Intermittent recur in response to environmental stimuli e.g sunlight, or physicalactivity. • This intermittent waxing & waningrepresents the 3rd stage. • Duration 1-3 weeks. • Joint Sx in 8-10 %, but up to 60% of adultswithprimary B19.

  26. Erythema infectiosum • The mostcommoninvolved joints (MCP, PIP,knees,wrists & ankles), mostlytransient & self-limited. • Some experts have suggested a potential association between B19 & rheumaticarthritis or other CTD, stillremainsunclear.

  27. Erythema infectiosum • B19 can cross the placenta, fetal infection is possible in nonimmunefemaleswith acute infections. • Fetaleffect of B19 infection mayincludeanemia, high-output congestive heartfailure, hydropsfetalis& IU fetaldemise. • The majority of pregnantwomenwith B19 are asymptomatic, whichmakes the true incidence of fetalinvolvementdifficult to determine.

  28. Erythema infectiosum • It isestimatedthat 30-66% of adultfemales are immune to B19 & therefore no fetalrisk. • The majority of fetuseswhoacquire acute infection in utero, itis self limited & they are deliveredasymptomatic & atterm. • The greaterriskiswhen infection isacquiredbefore 20 weeks’ gestation, & mostfetallossesoccurbetween 9-28 weeks. • The overallrisk of B19 relatedfetalloss in pregnanciescomplicated by B19 is 1-9%.

  29. Erythema infectiosum • Surviving infants tend to behealthy, with normal development & neurologicoutcome. • B19 relatedteratogenicity has onlyrarely been reported. • The Dxduringpregnanycanbeconfirmed by maternal B19 IgM & IgGantibodies or PCR assay. • Thesestudies are corroboratedwithfindings of prenatal US (fetalanemia & hydrops).

  30. Erythema infectiosum • Management of severlyaffectedfetuseswith B19 by in utero blood transfusions.

  31. Papular-Purpuric Gloves & Socks Syndrome • Many (but not all) cases has been documented to becaused by B19. • Diagnosedduringspring & summer. • Acute onset & rapidly progressive, symmetricswelling & erythema of hands & feetwith a petechial or purpuric component. • A papularexanthemmayoccurelsewhere on the body. • Enanthem : petechiae & erosions of hard & soft palate, pharynx, tongue & innerlips.

  32. Papular-Purpuric Gloves & Socks Syndrome • AssociatedSx: • Fever, arthralgias, malaise, & respiratory or GI complaints. • Hemato(leukopenia, thrombocytpenia) are RARE.

  33. Papular-Purpuric Gloves & Socks Syndrome • The diagnosisisoften made clinically. • In immunocompetentchildren, labs are unnecessary. • If not the case, enzyme immunoassays & radioimmunoassay are useful in detecting anti-B19 IgM & IgG.

  34. Papular-Purpuric Gloves & Socks Syndrome • In a pregnantfemaleexposed to B19, serologictesting for IgM & IgG ab shouldbeperformed. • IF acute infection isdocumented, serial fetal US isindicated. • Maternal & fetalserum PCR techniques maybeuseful, esp. Whenserologicstudies are unclear(). • B19 antigendetection in amnioticfluidsamples has been described.

  35. Erythematous, blanchable macules & papules, displayingoccasionally a peripheral halo of vasoconstriction.

  36. Roseola Infantum • Exanthemsubitum, sixthdisease. • Cause : • Viral, HHV-6 & 7. • Serologicalstudies have demonstratedthatmostchildren have been infectedwith HHV6 before 3 yrs , & with HHV7 by 6-10 yrs. • Transmission: primarily by saliva, & horizontal transmissoniswelldocumented.

  37. Roseola Infantum • Clinical presentation : • High fever, lasting for 3-5 days in an otherwisehealthy infant. • The exanthemappearsafter the normalization of the temperature, on the trunk& eventually to the extremities , neck and face. • The exanthemusuallyresolves in 1-3 days.

  38. Roseola Infantum • Associatedsigns: • Irritability, diarrhea, bulging fontanelle, cough, cervical lymphadenopathy & edematouseyelids. • Periorbitaledemaiscommon & couldbe a useful clue whenpresent in a febrile but otherwisewellappearingchild. • Enanthem of erythematous papules occur up to 2/3 of patients.

  39. Roseola Infantum • Primary HHV6 infection couldbeasymptomatic. • HHV6 associatedencephalitis has occured in bothimmunocompetent & immunocompromised patients. • Solid organ & bonemarrow transplant are atrisk of reactivation. • It couldmimicthat of acute GVH disease in some patients.

  40. Roseola Infantum • Rxisunnecessary and itusuallyspontaneouslyresolveswithout long-termsequelae

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