“Your living is determined not so much by what life brings to you as

1. “Your living is determined not so much by what life brings to you as by the attitude you bring to life; not so much by what happens to you as by the way your mind looks at what happens.” Kahlil Gibran

2. Dr. NehalDraz Viral Exanthems

3. Definition • Exanthem is the medical name given to a widespread rash that is usually accompanied by systemic symptoms such as fever, malaise and headache. • It is usually caused by an infectious condition such as a virus, and represents either a reaction to a toxin produced by the organism, damage to the skin by the organism, or an immune response. • Exanthems may also be due to a drug (especially antibiotics).

4. exanthems during childhood are very common and are usually associated with the following viral skin infections: • Common winter and summer viruses including respiratory and enteroviruses respectively • Chickenpox (varicella) • Measles (morbilli) • German measles (rubella) • Roseola • Fifth disease (erythemainfectiosum) • Laterothoracicexanthem

5. signs and symptoms of exanthems Most non-specific rashes appear as spots or blotches and may or may not be itchy. The rash is usually widespread and may be more extensive on the trunk and extremities. In most cases, prior to the rash appearing, patients may have symptoms of general unwellness (prodroma) that include: • Fever • Malaise • Headache

6. Loss of appetite • Abdominal pain • Irritability • Muscular aches and pains These signs and symptoms may vary depending on the cause of the exanthem.. Viral exanthems often occur in small epidemics so there may be other children effected at the same time.

7. Varicella (Chicken Pox) • Mild, highly contagious disease chiefly affecting children • Mode of transmission: - airborne droplets and direct contact from varicella patients - Vesicular fluid of Zoster patients can be the source of Varicella in susceptible children

8. Pathogenesis: • VZV infects the mucosa of the upper respiratory tract • Multiplies in the regional LNs • Primary viremia and spread to liver and spleen • Secondary viremia follows with viral spread to the skin • Typical rash occurs • VZV remains latent in the dorsal root ganglia for life

9. Clinical Picture: • Incubation period: 10-21 days • Symptoms: mild fever & rash • Rash: first appears on the trunk, then face and limbs • Flat macules become papules then vesicles • Followed by crust formation • The crust is often shed off and heals without scarring • Cropping is a characteristic feature of varicella rash: fresh vesicles appear in crops, so that all stages of macules, papules, vesicles & crusts are seen at the same time • More severe in adults

11. Complications • 1- pneumonia especially in adults, may be fatal • 2- rarely: fulminant encephalitis, which may be a manifestation of Reye’s syndrome that occurs as a consequence of salicylates intake during infection

12. Congenital Varicella Syndrome & Neonatal Varicella • Primary maternal infection during the 1st trimester may lead to congenital varicella syndrome ( serious & fatal): skin lesions, hypoplasia of limbs, chorioretinitis & CNS defects • Primary maternal infection near the time of birth can lead to widely disseminated infection in the new born with mortality rate of 35% • If rash began a week or more before delivery, maternal Abs transferred via placenta – baby gets the infection but escapes clinical disease

13. Treatment Acyclovir • Inhibits viral DNA polymerase enzyme • Used in immunocompromised patients with chicken pox, zoster, or varicella complicated with pneumonia, keratitis, & neonatal Varicella Doesn’t affect latency

14. Zoster (shingles) • Sporadic disease in adults or immunocompromised patients • Results from reactivation of latent VZV • Rash similar to varicella but limited to a nerve distribution to the skin innervated by a dorsal root ganglion (dermatom)

15. Complications: • If affecting the eye via trigeminal nerve: keratitis, conjunctivitis & iritis • It can affect the brain via the cranial nerve leading to Bell’s palsy • Post Herpetic neuralgia: Very painful, Likely due to nerve damage from zoster outbreak, Lasts for months after zoster resolves & Does not respond to antiviral treatment

16. Diagnosis • Depends mainly on clinical picture & serology: Specific VZV Abs using CFT, Nt, or ELISA

17. Prevention 1- Active immunization 2- Passive immunization • Live attenuated varicella vaccine Single dose, age: 1-12 yrs • Varicella zoster immunoglobulins (VZIG) Given to: • Immunocompromised children exposed to infection • Mothers infected near term(before delivery) and their infants ( immediately after delivery)

18. Measles (robeola) • One of the most contagious respiratory infections • It can nearly affect every person (in a given population) by adolescence, in the absence of immunization programs Mode of transmission: - Large repiratory droplet -airborne Most infectious in the early stage Before the rash appears

19. Pathogenesis & clinical picture • Replication initially in the upper & lower respiratory tract • Followed by LNs replication • Viremia & growth in a variety of epithelial tissue • Incubation period: 1-2 wks • In 2-3 days, no rash but fever, running nose, cough & conjunctivitis

20. Koplick spots: slightly raised white dots, 2-3 mm in diameter are seen on the inside of the cheek shortly before rash onset persist for 1-3 days • A characteristic maculopapular rash extending from face to extremities involving palms & soles : this seems to be associated with T-cells attacking virally infected endothelial cells in small blood vessels • The rash lasts from 3-7 d & may be followed by skin exfoliation

22. 1-Respiratory symptoms 2-3 days 2-Koplick spots 3-Maculopapular rash Persist 1-3 days Disappear after the rash onset Lasts for 3-7 days 4-Skin exfoliation Long life immunity due to IgG neutralizing Abs

23. Diagnosis • Depends mainly on clinical picture & serology: • ELISA is used for detection of IgM or IgG • For IgM single serum specimen 1-2 wks after the rash onset • For IgG, paired acute & convalescent sera are necessary • Four fold or more rise in IgG titer indicates infection

24. complications I- Respiratory • Otitis media & bacterial pneumonia: common • Giant cell pneumonia in patients with impaired CMI ( rare but fatal) II- Neurological • Postinfectious encephalitis. Few days after the rash (1:1000) • Subacutesclerosingpanencephalitis (SSPE) (1:100.000)

25. Passive immunization Measles IGs Prevention • - For immunocompromised patients • Intramuscular within 6 days of exposure • Prevent measles symptoms in 80% of cases Active immunization Measles vaccine • Live attenuated • Given by subcutaneous injection • Long term immunity • Monovalent form or MMR vaccine

26. Rubella • 1- German measles: acute febrile illness with rash & lymphadenopathy affecting children & young adults • 2- Congenital Rubella Syndrome: Serious abnormalities of the fetus as a consequence of maternal infection during early pregnancy

27. Postnatal rubella (German measles)Pathogenesis & clinical picture • Mode of transmission: droplet • Initial viral replication occurs in the respiratory mucosa followed by multiplication in the cervical lymph nodes • Viremia develops with spread to other tissues. As a result the disease symptoms develop in 50% of cases after an incubation period of 12-23 days • Possibly 50% of infections are apparently subclinical

28. Fever & malaise (prodromal symptoms) for 1-2 days • Maculopapular rash appears on the face,then the trunk, then the extremities and disappears within 3 days • Suboccipital and postauricularlymphadenopathy • Extremely rare complications, self limiting encephalopathy

29. complications • Extremely rare (1/6000) • Rubella encephalopathy • 6 days after the rash appears • Complete recovery with no sequalae

30. Diagnosis • Depends mainly on clinical picture & serology: • ELISA is used for detection of IgM or IgG • For IgM single serum specimen 1-2 wks after the rash onset • For IgG, paired acute & convalescent sera are necessary • Four fold or more rise in IgG titer indicates infection

31. Congenital rubella • Congenital rubella is a group of physical problems that occur in an infant when the mother is infected with the virus that causes German measles.

32. Congenital rubella is caused by the destructive action of the rubella virus on the fetus at a critical time in development. • The most critical time is the first trimester (the first 3 months of a pregnancy). After the fourth month, the mother's rubella infection is less likely to harm the developing fetus. • The rate of congenital rubella has decreased dramatically since the introduction of the rubella vaccine.

33. Risk factors for congenital rubella include: • Not getting the recommended rubella immunization • Contact with a person who has rubella (also called the 3-day measles or German measles) • Pregnant women who are not vaccinated and who have not had rubella risk infection to themselves and damage to their unborn baby.

34. Clinical picture • Transient symptoms: • growth retardation, anemia & thrombocytopenia • Permanent defects: congenital heart diseases, total or partial blindness, deafness & mental retardation • Progressive rubella panencephalitis: Extremely rare slow virus disease, develops in teens with death within 8 yrs

35. Laboratory Diagnosis • Detection of maternal IgM or rising IgG in serum • Then, detection of rubella Ag in the amniotic fluid by DIF • Live newborn: detection of IgMantirubella Abs in the serum of the baby by ELISA • Stillbirth: virus isolation on MKTC During Pregnancy After Birth

36. Prevention of congenital rubella vaccinate • Women in the childbearing age • School age children Pregnancy should be avoided 3 months after vaccination Maternal rubella infection confirmed during the first trimester???? Therapeutic abortion

37. MMR • Contains 3 live attenuated viruses: mumps, measles and rubella • Given in 2 doses • The first dose: to children 12-15 months of age by subcutaneous injection Why not before that? When is the second dose? Contraindications?

38. Roseola(Roseolainfantum or exanthemsubitum.) • a disease caused by at least two viruses, human herpes virus type 6 (HHV-6) and possibly type 7 (HHV-7). These viruses are in the same family as the cold sore virus (causing herpes simplex and genital herpes) and the varicella zoster virus (causing chickenpox and shingles). • These viruses have only been identified in recent years and we are still learning about the full range of diseases caused by them.

39. Modes of transmission • Roseola is spread from person to person via respiratory fluids or saliva of infected individuals. • The incubation period for roseola is approximately 9-10 days after exposure. • The exact period an infected person is contagious for is unclear but it is most likely spread during the febrile phase of the illness when there are no outward signs that the child is infected with the virus.

40. Disease • In many cases of roseola, the child appears well with few or no signs or symptoms. Typical cases are characterised by the following: • High fever (often up to 40 degC) for 3-5 days • Upper respiratory symptoms such as sore throat, cough, runny nose or congestion • Irritability and tiredness

41. Rash appears around days 3 to 5 as fever subsides • Typically small pink or red raised spots (2-5 mm in diameter) that blanch (turn white) when touched • Some spots may be surrounded by a lighter halo of pale skin • Starts on trunk and may spread to involve the neck, face, arms and legs • Non-itchy, painless and does not blister • May fade within a few hours or persist for as long as 2-3 days

42. In some cases, a child may be infected with the virus and never develop the rash. • Less commonly, the rash may appear without a preceding fever. • In most cases, particularly if fever is low, the child is well. • In about 5-15% of young children, high fevers may trigger febrile seizures.

43. In some cases, a child may be infected with the virus and never develop the rash (subclinical). • Less commonly, the rash may appear without a preceding fever. • In most cases, particularly if fever is low, the child is well. • In about 5-15% of young children, high fevers may trigger febrile seizures.

44. Complications • Complications are rare with roseola in most children. • The most common complication is febrile seizures/convulstionsthat may occur in 5-15% of children. These are triggered by the high fevers of roseola and may be alarming when seen for the first time. Signs of a febrile seizure include: • Loss of consciousness • Jerking or twitching movements in the arms, legs or face for 2 to 3 minutes • Wet or soiled pants in an unconscious, toilet-trained child • Irritability • These seizures are brief and not dangerous

45. Treatment • There is no specific treatment for roseola. The disease is usually mild and self-limiting. • Rest, maintaining fluid intake and paracetamol for fever is all that is usually required. • warm baths or sponges can also be used to help reduce fever. • No treatment is necessary for the rash as it does not itch or hurt and fades spontaneously.

46. ErythemaInfectiosum(5th disease) • It is caused by human B19 Parvovirus • Affects mainly children, occasionally adults • Mode of transmission: respiratory secretions, blood & vertical

47. Fifth Disease is a common childhood exanthema, characterized by "slapped cheek" facial erythema, as well as a maculopapular rash over the trunk and the extremities

48. During the viremic phase of the infection, excess antibodies lead to the formation of immune complexes, which induce these characteristic childhood rashes.

49. In adults, B19 infection leads to more severe symptoms of polyarthropathy, or inflammatory polyarthritis, rather than a rash (as in children). • These symptoms often resemble those or rheumatoid arthritis in the distribution of the joints affected and the characteristics of the inflammation