Pediatric Exanthems -Part II-

1. Pediatric Exanthems-Part II-

2. Objectives • Be able to identify the rashes of: • Varicella, Zoster, & Ramsey Hunt • Coxsackie and Enteroviruses: Hand Foot Mouth Disease and Herpangina • Named exanthems including Gianotti Crosti, Unilateral Laterothoracic Exanthem, and Pityriasis Rosea • Know the general clinical features accompanying each of the above rashes

3. Varicella (Chicken Pox) • Varicella zoster virus • At risk: • Unvaccinated, young children • 2nd attack rate within household=80-95% • Season: sporadic • Incubation: 10-21 days • Infectious period: • via respiratory drops and vesicular fluid • 2 days before to 5 days after onset of rash

4. Varicella • Prodrome • Ranges from asymptomatic to fever, malaise, cough, coryza, and sore throat • Pruritis • Variable from mild to severe

5. Varicella - Exanthem Atypical – after vaccine Typical Disease

6. Varicella - Complications • Secondary bacterial infection: 5-10% • Otitis media: 5% • Higher risk for adults, neonates, immune compromised: pneumonitis, encephalitis, cerebellar ataxia, hepatitis • Rare complications: Reye Syndrome, Guillain-Barre, nephritis, carditis, arthritis, orchitis, uveitis

7. Herpes Zoster • Reactivation of latent varicella in dorsal root ganglia (sensory) • At risk: elderly, immune compromised, children who had varicella in utero or in 1st year of life • Prodrome: unusual in children, in adults dull ache for up to a week before rash

8. Varicella Zoster - Exanthem Dermatomal clusters of uniform 2 mm red papules with central vesicles and crusts Unilateral, dermatomal, grouped vesicles

9. Cephalic Herpes Zoster – Ramsey Hunt Syndrome Acute facial paralysis that occurs in association with herpetic blisters of the skin of the ear canal, auricle, or both is referred to as the Ramsay Hunt syndrome, or herpes zoster oticus.

10. Varicella Zoster - Complications • Post-herpetic neuralgia: uncommon in kids • Disseminated disease: immune compromised • Widespread cutaneous lesions • Visceral disease • Ulcerations • Secondary Infection

11. Enterovirus Rashes Hand Foot Mouth Herpangina Nonspecific

12. Hand-Foot-Mouth Disease • Hand-foot-and-mouth disease (HFMD) is a viral illness with a distinct clinical presentation of oral and characteristic distal extremity lesions • Usually Coxsackie A16 • At risk: preschool children • Incubation period • Prodrome: 1-2 days before rash • Low grade fever, anorexia, malaise, sore mouth

13. Hand-Foot-Mouth: Enanthem

14. Hand-Foot-Mouth: Exanthem

15. Herpangina • Herpangina - acute febrile illness associated with small vesicular or ulcerative lesions on the posterior oropharyngeal structures • Various enteroviruses cause the condition, most commonly Coxsackie A

16. Herpangina: Enanthem

17. Nonspecific Enteroviral Exanthems • Multitude of presentations – these will frustrate you! • Morbilliform or rubelliform • Vesicular • Petechial (often echovirus 9) • Urticarial • Involvement of other organ systems is rare

18. Enterovirus or Rubella? RUBELLA!

19. Named Exanthems Gianotti-Crosti Syndrome Unilateral Laterothoracic Exanthem Pityriasis Rosea

20. Gianotti-Crosti Syndrome • Most commonly due to EBV, but also Hepatitis B and other viruses • At risk: 6 months-14 years (mean = 2 yo) • Season: spring and early summer • Constitutional symptoms: mild • Low grade fever, malaise, lymphadenopathy, mild pruritis, mild hepatitis

21. Gianotti-Crosti Syndrome AKA – Papular Acrodermatitis of Childhood

22. Unilateral Laterothoracic Exanthem • Viral etiology supported by patient's history (eg, age at presentation, multiple affected children in a family), lack of efficacy of antibiotics, serologic findings, & presentation during spring and winter • At risk: 1-5 years old (mean 2 years old) • Prodrome: 60-75% • Rhinitis, pharyngitis, bronchitis, conjunctivitis, gastroenteritis • Fever in 40-65%

23. Unilateral Laterothoracic Exanthem

24. Pityriasis Rosea • Viral etiology suggested by seasonality, mild prodromal symptoms, associated URI, clustering of cased • Season: spring, autumn, winter • At risk: 10-35 years old • Prodrome: very mild if present • Malaise, nausea, anorexia, headache, low fever

25. Pityriasis Rosea Herald Patch

26. GOOD LUCK!