Razan Abu Khaizaran

Loading...
The basic of skin Rash

Loading...
Description of Rashes
Description of Rashes
Loading...
Approach to Rash of acute onset Approach to Rash of acute onset
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 :
general examination

Rash :
Characteristic : blench with pressure or not
Distribution
The presence of an enanathem



Rash characteristic


Loading...
Definitions
Exanthem a skin eruption occurring as a
symptom of a general disease

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 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 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

Four phases :
incubation
prodrome (catarrhal)
exanthematous (rash)
Recovery

10-12 d
3 d
Maculopapular eryth. Descending, 4-7 d
Prodrome phase 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 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
Supportive :
Vitamin A :
improve outcome
highly recommended in children btw 6 months and 2 years
requiring hospitalization requiring hospitalization
immunocompromised
Complications:
Pneumonia :
bacterial pneumonia : the most common complication
& the most common cause of morbidity
interstitial pneumonia
Giant cell (Hecht) pneumonia cell mediated
immunity compromised

Otitis media Otitis media



Complications:
Encephalomyelitis:
Early : due to direct viral infection
Late : demyelinating due to immunologic process

Subacute sclerosing panencephalitis
after 8 to 10 years after 8 to 10 years

MMR vaccine
Live attenuated vaccine
For children at 12-15 months
4-6 years ( not a booster dose)
CI: immunocompromised states
conginetal immunodefieciency
sever HIV infection ( but recommended in those sever HIV infection ( but recommended in those
who do not have evidence of sever immunosuppressant )
leukemia
lymphoma


5% not covered in
first one so give
another

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 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 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 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.

Pastias lines (petechiae localized within skin creases in a
linear distribution.

Desquamation of dry skin occurs as infection resolves.

Loading...
Scarlet fever exanthem
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 Penicillin allergic pts .. Erythromycin or Macrolides


Complications
Purulent
Otitis media
Sinusitis
Peritonsillar/retropharyngeal abscesses
Cervical adenitis
Nonsuppurative sequalae
Rheumatic Fever
Acute glomerulonephritis . AB doesnt prevent this
Arthritis .. AB doesnt prevent this also Arthritis .. AB doesnt 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 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 . days .

Polyarthritis could occur especially in women.
Rubella Exanthem

Diagnosis :
Clinically ??
Confirmed by serology and culture

Treatment : supportive
Msh kter specific
Complications 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

Neurologic :
Heart:

Neurologic :
Microcephaly
Meningoencephalitis
Behavioral disorder
Mental retardation
Heart:
PDA
Peripheral
pulmonary artery
stenosis


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-
Erythema Infectiosum
Human 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 : 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 Season: sporadic
Incubation period: 9 days
Infectious period: virus is intermittently shed into saliva
throughout life; asymp persistent infection

E2lebu el 6
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 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 :
pruritic rash in variuos stages
Macules Papules Vesicle Pustules
Lesion maybe hemorrhagic
Crops .. Trunk then face & head .. Less commonly
extremities ..
Lasts For 3 to 4 days
Various stages
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 .. Viral culture .. HSV cultured ..

Treatment
Supportive .. Antipyritic
antibiotic for secondary infection
Anti histamine
Consider acyclovir in immunocompromised or risk for 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 : 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 neuralgiauncommon in kids
Infection during pregnancy
Primary infection rare in pregnancy .
If it happens in the first 20 weeks of 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 Chickenpox infected child .. Isolated
Live attenuated varicella vaccine ..
At age 12 to 18 months

VZIG : within 96 hrs :
Immunocmpromised
Neonates
Premature