COmmon childhood exanthems by Jason Enukora.pptx

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

1. Common Childhood Exanthem Enukora Jason Chukwunonso 1

2. OUTINE INTRODUCTION MEASLES RUBELLA HAND-FOOT-MOUTH SYNDROME VARICELLA ERYTHEMA INFECTIOSUM ROSEOLA INFANCTUM CONCLUSION 2

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. 3

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. 4

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 5

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. 6

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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. 8

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. 9

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. 10

11. Rubella (3 rd 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. 11

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. 12

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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. 14

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. 15

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 16

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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 18

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. 19

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 20

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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. 22

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. 23

24. 5 th 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 24

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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. 26

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 . 27

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. 28

29. Roseola infantum-6 th 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 29

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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. 31

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. 32

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 33

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. 34

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. 35

36. References Nelson textbook of pediatrics Clevelaand clinic Medscape Osmosis.com 36