Common Exanthems

1. Common Exanthems Adam Goldstein, MD Associate Professor UNC Department of Family Medicine Chapel Hill, NC aog@med.unc.edu

2. Understand nomenclature for common exanthems Know an appropriate differential dx for most exanthems Improved ability to diagnose: Measles (rubeola) German Measles (Rubella) Chicken Pox (Varicella) Fifth Disease (Erythema infectiosum) Roseola (exanthem subitum) Hand, foot & mouth disease Pityriasis rosea Asymmetric periflexural exanthem of childhood (APEC) Kawasaki disease Smallpox Scarlet fever Drug eruptions Unknown exanthems Objectives

3. Exanthems • Anyone of a number of systemic processes giving generalized eruption • Usually not isolated • Caused by: • Viruses • Bacteria • Fungal • Drugs • Idiopathic

5. Exanthems (Historical) • 1 Measles • 2 Scarlet fever • 3 Rubella • 4 "Dukes' disease”- ? measles, rubella, scarlet fever, Staph infection, or one of several unspecified enteroviral infections; • 5 Erythema Infectiosum • 6 Roseola.

6. Measles (Rubeola) • Diff Dx • S/S’s: Fever, conjunctivitis, cough • Characteristic Koplik spots 24-48 hours before rash • Rash: • Days 4-5, red & blotchy • begins on face & behind ears • usually with onset high fever • spreads to body • Usually spares palms/soles • Rash coalesces on trunk/face

7. Rubella (German measles) • "little red”; 3rd Disease • Schoolchildren highest infectivity in unvaccinated populations • Congenital Rubella Syndrome • deafness, eye lesions, heart malformations & mr • 24 cases 1997-1999, mostly immigrant • 25-50,000 cases Mexico 1998 • Higher suspicion cases in patients immigrating from countries with higher rates • Vaccination contraindicated pregnancy (MMWR, 2001)

9. Rubella • Diffuse rash, LN enlargement, h/a, malaise, mild cough and conjunctivitis • Pink rash appears on face and spreads to body www.info.gov.hk/dh/diseases/ CD/rubella.htm

10. Chicken Pox- Varicella • caused by varicella-zoster virus • blister-like rash, itching, fatigue & fever • 250-500 itchy blisters, 3 stages at same time (papule, vesicle, scab) • 1 in 10 complications: bacterial, pneumonia, encephalitis

11. Chicken Pox- Varicella

12. Fifth Disease (Erythema infectiosum) • Parvovirus B19 • S/S’s: low fever, cold, mildly ill • Skin: • "slapped-cheek" rash on face • lacy red rash trunk & limbs • infected adults may develop joint pains hands, wrists, knees • kids may return to school- no longer infectious • pregnant women exposed- refer to guidelines (Crane J, J Obstet Gynaecol Can, 2002)

13. Roseola/Exanthem Subitum • Human Herpes Virus 6>7 • spread via saliva • 72-95% sero + in US early age • S/S’s: irritable, diarrhea, cough, fever 102-105F, for 3-7 days; 10% seizure • Skin: • As fever resolves, faint macules develop on trunk and extremities that blanch upon pressure • Rash resolves 1-2 days

14. Roseola/Exanthem Subitum • Skin: • As fever resolves, faint macules develop on trunk and extremities that blanch upon pressure • Rash resolves 1-2 days

16. Hand Foot and Mouth Disease • Common acute febrile illness of children • Group A coxsackie viruses • 2-7 days resolves • Hand washing • Rare complications

17. HFM Disease • hand • foot • mouth

18. Pityriasis rosea • Unknown cause • Lasts 6-12 weeks • Herpes viruses 6 & 7 associated • Herald patch 1-20 days before rash • Sometimes confused with T. Corporis or psoriasis

19. Pityriasis rosea • Oval patches follow line of ribs like fir tree • Erythromycin may be effective tx (Sharma, JAAD, 2000)

20. Asymmetric periflexural exanthem of childhood (APEC) • Laterothoracic exanthem • Uncommon, G > B • Viral symptoms can occur • Often mistaken for eczema, fungal • Skin: • Usually starts in armpit or groin and extends outwards, on one side of body • May spread to face, genitalia, hands or feet • Patches are net-like or in rings • Pruritic • Resolves within 3 months

21. Kawasaki disease • 80% in children < 4 years • Self-limiting & resolves spontaneously without treatment 4-8 weeks • 15-20% have damage to coronary arteries and 2% of patients die from heart attack (Brogan PA, Arch Dis Child, 2002)

22. Kawasaki disease

23. Kawasaki disease

24. Kawasaki disease http://www.dermnetnz.org/index.html

26. Smallpox • Classic generalized exanthem • Latin word for “spotted” referring to the raised bumps on the face and body • Rash, high fever & mortality rate 30% • Last natural case Somalia in 1977 http://www.bt.cdc.gov/agent/smallpox/overview/disease-facts.asp

27. Smallpox • Exanthem from vaccination • 1/100,000 • Vaccinia rash or outbreak of sores • Generalized vaccinia • Erythema multiforme http://www.bt.cdc.gov/agent/smallpox/

28. Smallpox • From Vaccination • 1/50,000 • Eczema vaccinatum • Progressive vaccinia • Postvaccinal encephalitis

29. Scarlet fever • Group A streptococcus toxin • children aged 4-8 • contagious by coughing/sneezing or touching the infected skin • sudden fever with sore throat, swollen LN’s, h/a, n, v, loss of appetite, swollen and red strawberry tongue, abdominal pain, body aches, and malaise

30. Scarlet fever • Skin: • rash 12-48 hours after fever • ears, neck, chest, armpits, groin, then rest of body over 24 hours • scarlet spots or blotches, often the first sign • starts to look like sunburn with goose pimples • skin may have a rough sandpaper-like feel • as rash fades, it peels similar to that of sunburned skin

31. Drug eruptions • Almost all drugs

32. Drug eruptions • Dilantin

33. Drug eruptions • Minocycline

34. Drug eruptions • Fixed drug eruption

36. Unknowns 1

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46. BONUS

47. BONUS

48. BONUS

49. References • Trizna Z. Viral diseases of the skin: diagnosis and antiviral treatment. Pediatr Drugs 2002;4:9-19. • http://home.mdconsult.com/das/guideline/view/26827010/N/11196820?sid=166362089&source=MI • Crane J. Parvovirus B19 infection in pregnancy. J Obstet Gynaecol Can 2002; 24: 727-43. • Glatman-Freedman A. Rubella vaccine. Pediatr Rev 2002; 23(3): 106-7. • Smallpox Vaccine. Pediatrics 2002. American Academy of Pediatrics, Committee on Infectious Diseases; 110: 4. • Bromberg K. Group A beta-hemolytic streptococcal pharyngitis. Am Fam Physician 2001; 63(8): 1486-7. • Bisno AL. Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Infectious Diseases Society of America. Clin Infect Dis 2002; 35(2): 113-25.

50. References • Gable EK. Pediatric exanthems. Prim Care 2000; 27: 353-69. • Brogan PA. Kawasaki disease: an evidence based approach to diagnosis, treatment, and proposals for future research. Arch Dis Child 2002; 86: 286-90. • Hairston BR. Viral diseases of the oral mucosa. Dermatol Clin 2003; 21(1): 17-32. • De Araujo T. Human herpesviruses 6 and 7. Dermatol Clin 2002; 20(2): 301-6. • Sharma PK. Erythromycin in pityriasis rosea: A double-blind, placebo-controlled clinical trial. J Am Acad Dermatol 2000; 42: 241-4. • MMWR. Control and prevention of rubella: evaluation and management of suspected outbreaks, rubella in pregnant women, and surveillance for congenital rubella syndrome. July 13, 2001; 50: 1-23.