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RASHES IN CHILDREN Rashes in Children 1.Viral Exanthems 2.Vesiculobullous Lesions 3. Purpura/Petechiae 4. Diffuse Erythemas with Desquamation 2 Rashes in Children Viral Exanthems MACULOPAPULAR RASH (red areas of the skin with small bumps) VESICULAR RASH (blisters/fluid-filled) 4 Rashes i...

RASHES IN CHILDREN Rashes in Children 1.Viral Exanthems 2.Vesiculobullous Lesions 3. Purpura/Petechiae 4. Diffuse Erythemas with Desquamation 2 Rashes in Children Viral Exanthems MACULOPAPULAR RASH (red areas of the skin with small bumps) VESICULAR RASH (blisters/fluid-filled) 4 Rashes in Children Maculopapular Rashes CHILDHOOD VIRAL DISEASES Medical history A mother presents a child with coryza, cough, conjunctivitis, fever. Patient also has a rash which began from the face to the chest. Tiny grayish white dots are seen on the buccal mucosa next to the 3rd molar. Rubeola (Measles) Virus PARAMYXOVIRUS (RNA) 7 Rashes in Children Measles: Disease Review > Highly contagious virus > Respiratory transmission2 > Incubation period: 10-12 days2 > Replication in nasopharynx and regional lymph nodes2 1. www.nfid.org, National Foundation for Infectious Disease (accessed Aug 2005) 2. Measles in: William Atkinson, Charles Wolfe eds. Epidemiology & Prevention of Vaccine Preventable Diseases. Dept of Health & Human Services CDC;7th Edition;2003;96-113 8 Rashes in Children Measles: Disease Review > Primary viremia 2-3 days after exposure2 > Secondary viremia 5-7 days after exposure with spread to tissues2 > Morbidity and mortality of measles are greatest in patients <5y/o and those >20 y/o 1. www.nfid.org, National Foundation for Infectious Disease (accessed Aug 2005) 2. Measles in: William Atkinson, Charles Wolfe eds. Epidemiology & Prevention of Vaccine Preventable Diseases. Dept of Health & Human Services CDC;7th Edition;2003;96-113 9 Rashes in Children Transmission and Immunity Transmission > Droplet infection > Direct contact > Period of communicability: 4 days before and after rashes appear Immunity > Long lasting > Passive immunity lasts for 5 – 6 months > Live attenuated vaccine confers lifelong immunity > Inactivated vaccine 6 – 18 months 1 0 Rashes in Children Pathogenesis Upper respiratory passage – nasopharynx or conjunctiva Epithelial cells infected and virus multiplies Extension to regional lymphoid tissue Primary viremia Multiplication in respiratory epithelium, RES, distant sites Secondary viremia Infection in skin and other sites Virus in blood, respiratory tract, skin and other organs Viremia, virus in organs 11 Rashes in Children Measles: Clinical Features Prodrome O > Stepwise increase in fever to >39.5 C or higher > Cough, coryza, conjunctivitis * Koplik spots – pathognomonic > 1 – 2 days before the rash > grayish white pinpoint dots ,red border, opposite lower molars > Transient Rash > 2-4 days after prodrome, 14 days after exposure > Maculopapular, becomes confluent > Begins on face and head > Persists 5-6 days > Fades in order of appearance > Leaves brawny desquamation Measles in: William Atkinson, Charles Wolfe eds. Epidemiology & Prevention of Vaccine Preventable Diseases. Dept of Health & Human Services CDC;7th Edition;2003;96-113 12 Rashes in Children Rash begins around hairline, on face and neck, behind ears Rash spreads downward to chest and abdomen Rash affects arms and legs last 13 Rashes in Children Measles manifestation on the skin Measles (rubeola) pharyngitis in an adult showing striking inflammation © Copyright American Academy of Pediatrics Rashes in Children © Copyright American Academy of Pediatrics Erythematous, maculopapular rash with areas of confluence Rashes in Children Measles: Diagnosis > Clinical picture > Isolation of measles virus from clinical specimens > Serology – IgG, IgM > Decreased WBC during prodrome and rash 16 Rashes in Children Common Complications Life-threatening : 1. Bronchopneumonia 2. Otitis media 3. Laryngotracheobronchitis 4. Diarrhea 5. Blindness 6. Flare up of existing TB 17 Rashes in Children Uncommon/Rare Complications Myocarditis /Pericarditis – rare ITP Mesenteric lymphadenitis Encephalitis – occurs during rashes, within 8 days from onset Convulsions, lethargy, irritability, coma 20 – 40% with brain damage Hemorrhagic/Black measles Subacute Sclerosing Panencephalitis (SSPE) 18 Rashes in Children Differential Diagnosis 1. Miliaria with acute URTI 2. Rubella 3. Roseola infantum 4. Allergic dermatitis 5. Infectious mononucleosis 19 Rashes in Children Inapparent Measles Infection > Subclinical form of measles > Individuals with passively acquired antibody: infants, recipients of blood products, some individuals who received the vaccine when exposed to Measles virus develop some symptoms > Does not shed the virus and does not transmit the infection to household contacts 20 Rashes in Children Atypical Measles > More severe type of measles > Due to circulating immune complexes that formed due to an abnormal immune response to the vaccine > Occurs in persons vaccinated with an Inactivated/Killed vaccine (1963-1967) exposed to natural virus 21 Rashes in Children Treatment and Prevention > Treatment No specific treatment Supportive measures – antipyretic, bed rest, fluids Vitamin A – reduces morbidity and mortality in children with severe measles in the developing world Antibiotics for complications > Prevention Live attenuated measles vaccine Immune globulin (Ig) 22 Rashes in Children Prevention > Isolation of patients: from 7th day after exposure until 5 days after the rash appeared > Measles vaccine: 9 months old > MMR vaccine: (2 doses): 12-15 months old, then 4-6y/o (minimum interval 4 weeks) * May be given to 9 months old > Post-exposure prophylaxis Passive immunization with Ig – within 6 days of exposure (<6 months old or those who are pregnant) Vaccine alone within 72 hours from exposure: exposed children 6 mos. of age or older 23 Rashes in Children Underutilization of Measles Vaccine The high measles disease burden, despite an increase in routine measles immunization coverage, is attributed mainly to the underutilization of measles vaccine These deaths are unacceptable because measles vaccine is safe, highly effective and cost-effective WHO/UNICEF Joint Report: Measles Mortality Reduction And Regional Strategic Plan 2003-2005 24 Rashes in Children Why do we need a 2nd dose of MMR? Eradication of measles cannot be achieved with a single-dose strategy alone A second dose of vaccine such as MMR is recommended by the WHO, to: Ensure individuals receive at least one dose Ensure immunity to individuals in whom no immunogenic response occurred with the first dose Restore immunity in those whose immunity has waned World Health Organization, Pan American Health Organization and CDC.MMWR 1997;46(RR-II) 25 Rashes in Children MEASLES OUTBREAK IN PH - Feb. 2019 > 12,7000 cases, 203 deaths ( 2-5 yo. ) > Mortality: 63% unvaccinated > NCR, Centarl Luzo, Calabarzon, Western Visayas, Central Visayas > Mindanao: Davao, Zamboanga, Taguig, Neg. Or “Vaccine confidence has also decreased in the Philippines following the dengue vaccine (Dengvaxia) issue. A recent study from the London School of Hygiene and Tropical Medicine documented that those believe “that vaccines are important, are safe and are effective” dropped from close to 100% in 2015 to 60-80% in 2018. This reveals a critical need to combat misinformation and improve public understanding of the critical importance and safety of vaccines.” 26 Roseola Infantum 27 Rashes in Children Roseola Infantum > 6th disease, Exanthem subitum > Etiology = Human herpesvirus 6 (most cases) = Human herpesvirus 7 = Echovirus 16 > Transmission > Probably acquired from saliva of healthy persons and enter the host through oral, nasal or conjunctival mucosa 28 Rashes in Children Roseola Infantum Children < 3 yrs. of age (esp. 6-15mos.) Peak incidence Mar – Apr Incubation period: 10 -16 days Fever – sudden onset, high grade subsides after 2 – 3 days With lysis of fever – rash appears on face and trunk disappears in 1 – 2 days 29 Rashes in Children Roseola Infantum Clinical manifestation > Prodrome period: rhinorrhea, pharyngeal inflammation, slight conjunctival redness, mild lymphadenopathy High-grade fever 3-5 days, may have febrile seizures > With defervescence :maculopapular rash Trunk, neck, face and proximal extremities for 1 – 3 days Diagnosis > Clinical picture > Rashes appear as fever disappears 30 Rashes in Children Roseola Infantum > PE – normal findings, child active, alert and playful Occasionally with full and tense anterior fontanel > Differential diagnosis 1. Measles 2. Meningitis > Treatment Symptomatic – antipyretics to lower temperature Sedatives or anticonvulsants for seizures 31 Rashes in Children Rose-pink, macular lesions of Roseola infantum 32 Rashes in Children Erythema Infectiosum > Fifth disease > Etiology Parvovirus B19 > Transmission Respiratory, blood transfusion 33 Rashes in Children Stages of Rash Erythematous and macular – “slapped cheek” appearance with circumoral pallor and sparing of nasal bridges Maculopapular rash + pruritus – lacey or reticular pattern Rash waxes and wanes in 1-3 weeks – rash recurrence due to heat, cold, exercise, stress 1. 2. 3. 34 Rashes in Children Erythema Infectiosum © MEDLibes Online Medical Library 35 Erythematous and macular ”slapped cheek” appearance Rashes in Children Complications 1. Arthropathy – arthritis/arthralgia 2. Transient aplastic crisis - arrest in production of red blood cells may occur in the following conditions: Sickle cell disease Thalassemia Hereditary spherocytosis Pyruvate kinase deficiency 3. Fetal infection: results in hydrops because of severe anemia cardiac failure, fetal death, and miscarriage 36 Rashes in Children Erythema Infectiosum Diagnosis > Clinical picture > Serology > PCR Treatment > Supportive 37 Rashes in Children Rubella Virus TOGAVIRUS (RNA) www.med.sc.edu:85/ mhunt/rub1.jpg; accessed in Aug 2005 38 Rashes in Children Rubella Virus: 3-day Measles Etiology Rubella virus belongs to Rubivirus genus of family Togaviridae Epidemiology Worldwide In RP, sporadic Highest attack rate in 5 – 9 yrs No sex difference Transmission Respiratory route – droplet infection Contact with infected individuals Contaminated linen and articles – nasopharyngeal secretion, stool or urine 39 Rashes in Children German Measles (Rubella) Reservoir Humans Transmission Respiratory – person-to-person Communicability 7 days before to 5-7 days after rash onset 40 Rashes in Children German Measles: Pathogenesis Respiratory transmission of the virus Replication in the nasopharynx and regional lymph nodes Viremia (5-7 days) Includes placenta and fetus 41 Rashes in Children Signs and Symptoms > Symptoms (if present) usually mild: inflammation of the lymph nodes maculopapular rash mild catarrhal symptoms > Adults may feel unwell with fever and loss of appetite > Approximately two-thirds of rubella cases not clinically evident © Copyright American Academy of Pediatrics www.vaccineinformation.org/photos/rubeaap001.jpg Accessed Aug 2005 Rubella rash (face) in a previously unimmunized young woman. Rashes in Children Clinical features Retroauricular, posterior cervical and post-occipital lymphadenopathy = most characteristic sign appear 24 hours before the rash appears up to the neck > Rash begins on the face and spreads quickly. > Evolution is so rapid that the rash may be fading on the face by the time it appears on the trunk 43 Rashes in Children Rash begins as red spots on the face Rash spreads quickly to trunk and extremities Rash is highly variable; often there is no rash 44 Rashes in Children Clinical Features Rash clears by the 3rd day, minimal desquamation Fever is low-grade or absent for 1-3 days Source: Centers for Disease Control and Prevention 45 © Copyright Dr. CW Leung, Department of Paediatrics and Adolescent Medicine, Princess Margaret Hospital, Hong Kong Rashes in Children Rubella rash © Copyright Dr. CW Leung, Department of Paediatrics and Adolescent Medicine, Princess Margaret Hospital, Hong Kong 46 Rashes in Children Rubella: Complications > Rare in childhood or adulthood > Arthritis or arthralgia in 2% of cases Mainly females > CNS complications (i.e., post-infectious encephalitis) occur in adults at a rate of 1/6000 cases > Congenital Rubella Syndrome (CRS) 47 Rashes in Children Congenital Rubella Syndrome > Up to 85% of infants affected if infection acquired in-utero during first trimester > Infection may affect all organs > May lead to fetal death or premature delivery > Severity of damage to fetus depends on gestational age Rubella in: William Atkinson, Charles Wolfe eds. Epidemiology & Prevention of Vaccine Preventable Diseases. Dept of Health & Human Services CDC;7th Edition;2003;169-188 48 Rashes in Children Congenital Rubella Syndrome > Deafness > Cataracts > Heart defects > Microcephaly > Mental retardation > Bone alterations > Liver and spleen damage Infant with congenital rubella syndrome Source: Centers for Disease Control and Prevention Rubella in: William Atkinson, Charles Wolfe eds. Epidemiology & Prevention of Vaccine Preventable Diseases. Dept of Health & Human Services CDC;7th Edition;2003;124-137 49 Rashes in Children CRS:Time of infection Time of infection Risk of congenital abnormalities Most common abnormalities 40–60% Multiple congenital defects and/or spontaneous abortion 9–12 weeks 30–35% Single defect e.g. congenital heart disease or deafness 12–16 weeks 10% Up to 8 weeks Single defect, usually deafness Mandell G, Douglas R, Bennett J eds. Principles and Practice of Infectious Diseases, third edition, 1990 50 Rashes in Children