EXANTHEMATOUS FEVERS

DEFINITION
An infection that causes the skin rash covering most of the body is called an exanthem.

EXANTHEMATOUS FEVERS
Following are traditionally included in pediatric exanthems:
First Disease - MEASLES (RUBEOLA) Second Disease - RUBELLA (GERMAN MEASLES, 3 Day Measles) Third Disease - VARICELLA (CHICKEN POX) Fourth Disease Atypical Scarlet Fever Fifth Disease - ERYTHEMA INFECTIOSUM (SLAPPED CHEEK DISEASE) Sixth Disease - EXANTHEMA SUBITUM (ROSEOLA INFANTUM, 3 Day Fever)

MORPHOLOGY OF LESION
TYPE OF RASH
Macule Papule

DESCRIPTION
Change in normal skin color with no skin elevation or depression Solid raised lesion up to 0.5 cm in greatest diameter

Morbilliform
Vesicle Bullous Pustular

Measles like rash (maculo papular erythematous rash, i.e blanching)

Circumscribed elevated fluid containing lesion less than 0.5 cm Same as vesicle except lesion is more than 0.5 cm in greatest diameter Circumscribed elevation of skin containing purulent fluid

Purpura < 1 cm Small red or purple tiny, caused by a minor hemorrhage, Ecchymoses > 1 cm Petechiae very, pin head sized spot

HOW TO APPROACH
HISTORY EXAMINATION MANAGEMENT

HISTORY
Time spent on history and examination is worthwhile, lab test are of little help in the initial phase
Onset distribution and progression of rash Associated symptoms Fever, itching, pain or bleeding Immunization history Chicken Pox, Measles Is it the season for Dengue? Any contacts with similar illness? Drug history Any serious symptoms?

EXAMINATION
Life threatening features altered level of consciousness, respiratory distress, shock Description of rashes:
Number Morphology Distribution Site & Spread Any desquamation

Are mucous membrane affected?

MEASLES (RUBEOLA)
Epidemiology:
Agent RNA Virus- morbilli Genus, Paramyxoviridae Family

Reservoir- Man

Transmission: Droplet Spread

Period Of Infectivity - 4 Days Before & 5 Days After Onset
Of Rash

Secondary Attack Rate - 90% Age 6 Months To 5 Years

CLINICAL FEATURES
Incubation Period:

10 to 14 Days Prodromal Phase Fever, cough, coryza, Conjuncivitis. Koplik Spots - 2nd Day Of Fever, Inner Side Of Cheek

Eruptive Phase Rash On 4th Day Starts On Face & Spreads Downward. Rash- Confluent, Erythematous, Macular. Disappears In 4-5 Days With Brawny Desquamation

Rash of Measles
Erythematous confluent rash that blanches on pressure seen on the face and neck

VARIANTS OF MEASLES
1. Modified Measles Occurs In Partially Immune Children Milder Illness

2. Atypical Measles In Recipients Of Killed Vaccine More Severe Hepatosplenomegaly Not Contagious

3. Hemorrhagic Measles High Fever, Bleeding, convulsions

1.

2.

3.

4. 5. 6.

Respiratory Otitis Media Tracheitis, Bronchiolitis (common in infants and toddlers) Laryngitis Pneumonia Giant cell pneumonia, secondary bacterial pneumonia Flaring Up Of Primary T B Neurological Acute Encephalitis SSPE 7 13 yrs after primary measles infection (M>F) Gastro Intestinal Chronic Diarrhea Acute Appendicitis Malnutrition& Vitamin A Deficiency Myocarditis, Bacteremia Febrile Seizures < 3 %

COMPLICATIONS

DIAGNOSIS
Mainly Clinical Serology Viral Culture

DIFFERENTIAL DIAGNOSIS
Rubella - Mild, Discrete Rash Infectious Mononeucleosis Miliaria Pruritis Drug Rash Roseola Infantum - Fever Subsides After The Rash Appears

TREATMENT
Symptomatic Antipyretics, Hydration Maintain Hygiene Good Nutrition Vitamin A - 2 Lakh Units 2 days for more than 1 yr child &1 Lakh unit for 6 months 1 yr child. Repeat 4 weeks later for children with ophthalmic evidence of Vit A deficiency

PREVENTION
Active Immunization:
Vaccine With In 3 Days Of Exposure

Passive Immunization:
IM Gamma Globulin With In 6 Days

RUBELLA - GERMAN MEASLES - 3 DAY MEASLES

Epidemiology:
Agent- RNA Virus - Togaviridae Natural Host - Humun Transmission - Droplet Transplacental Subclinical - Clinical- 2:1 Infectivity- 1wk Before & 1wk After

Clinical Features:
Incubation Period - 14 to 21 Days Prodrome - Fever,catarrh, Post Auricular Lymphadenopathy Eruptive Discrete & Lasts For 3days

Rash in Rubella Discrete maculo papules confluent with large areas of flushing

CONGENITAL RUBELLA SYNDROME

Infection during 1st Trimester Microcephaly, Mental Retardation, Sensorineural Deafness, Cataracts, Retinopathy Cardiac Defects - PDA, PS Highly Infectious up to 18 Months Others IUGR, Retinopathy, Micropthalmia, Meningoencephalitis, Hepatosplenomegaly, Thrombocytopenia, Hypotonia Risk of Congenital Rubella: Gestation Risk <11 Weeks 90% 11-12 Weeks 33% 13-14 Weeks 11% 14- 15 Weeks 24%

PREVENTION
Immunization Active
MMR 1st dose at 15 Months followed by 2nd at 4 6 yrs of age Rubella to adolescents

Passive
Immune Serum Globulin with in 7 days of exposure

VARICELLA(CHICKEN POX)
Epidemiology: AGENT - VARICELLA ZOSTER VIRUS RESERVOIR - MAN TRANSMISSION - DIRECT CONTACT AIRBORNE PERIOD OF INFECTIVITY - 1DAY BEFORE & 5DAYS AFTER
ONSET OF RASH

SECONDARY ATTACK RATE - 90% AGE - 5-9YRS SEASON - JAN-MAY

CLINICAL FEATURES
INCUBATION PERIOD - 14 to 21 DAYS PRODROMAL PHASE - MILD FEVER ERUPTIVE PHASE RASH ON 1st DAY Macule - papule- tear drop vesicles cloudy & crusting Crops of lesions, Pleomorphism Centripetal distribution Intensly pruritic Lesions also occur on mucosae recovery in one week

Skin lesions of chicken pox Note the varying stages of development (Macules, papules, vesicles) present at the same time

Dew drop on a rose petal

Scab formation

COMPLICATIONS
1. Cutaneous - Secondary Infection, Purpura Fulminans

2. Systemic - Encephalitis, Gbsyndrome, Pneumonia, Arthritis, AGN, Reyes Syndrome

3. Late Complication - Herpes Zoster Varicella During Pregnancy1st Trimester Embryopathy Cutaneous Scarring Limb Hypoplasia Chorioretinitis, seizures

Near Birth - Disseminated Varicella

Hemorrhagic Chicken pox

Diagnosis:
Mainly Clinical ELISA - detects Antibodies Viral Isolation PCR

Treatment:
Antipruritic Agents AntipyreticsNo Asprin Acyclovir-severe Cases 20 mg/kg/dose max 800mg/dose. 4 doses/day for 5 days. Start within 24 hrs of the onset of examthen

Prevention:
Active Immunization- Vaccine Passive Immunization-VZIg 125 u/kg Newborns Pregnant Women Immunocompromised Patients

ERYTHEMA INFECTIOSUM
Etiology: Human Parvovirus b19 Transmission: Respiratory Secretions Incubation Period: 7 - 14 Days Prodromal Illness Minimal/Absent Characteristic Skin Lesions in 3 Stages

ERYTHEMA INFECTIOSUM Contd..

First Phase
Erythematous Slapped Cheeks

Second Phase Itchy Erythematous Or Maculopapular Rash On Trunk And Extremities. Palms And Soles Spared

Third Phase
Fades From Centre Giving A Reticular Pattern Disappears In 2 Weeks without Desquamation

FIRST PHASE

SECOND PHASE

ERYTHEMA INFECTIOSUM Contd..

Complications: Arthrits Thrombocytopenia, transient aplastic crisis Aseptic meningitis Myocarditis Treatment: Symptomatic

EXANTHEM SUBITUM (ROSEOLA INFANTUM )

Etiology:
Human Herpes Virus 6

Age Group :
6 months To 3 Years (Peak 6 to 15 months) Occurs In Spring and Autumn Months

Incubation Period:
5-15 Days

Clinical Manifestations:
Abrupt Onset, high Fever, Coryza, Pharyngitis. Temperature Comes Down When Rash Appears Macular Or Maculopapular Starting on Trunk extending to Extremities and Face.

EXANTHEM SUBITUM Contd..

Rash Lasts for 24 - 48 Hours Occipital and Post Auricular Lymphadenopathy Edema of Eyelids occur Ulcers at uvulopalutoglossal junction (Nagayama spots in Asian Infants)

Complications
Febrile convulsions

Lab
Leukopenia, Relative Lymphocytosis.

Prognosis
Good

Treatment
Symptomatic
immunocompromised children with severe disease - antiviral therapy for 2 to 3 weeks with Ganciclovir and Cidofovir

Roseola infatum. Evolution of signs and symptoms

Differential Diagnosis of Fever with Rash

Disease
Measles

Incubation Period
10 14 Days

Prodromal Illness
3 4 Days Coryza, Conjunctivities, Photophobia etc..

Rash
Top to toe rash, profuse on day 5, starts to disappear from day 7 onwards Same distribution as in measles but progresses more rapidly in 1 to 2 days fades quickly from 3 rd day Rash appears at the end of the disease from 3 / 4th day, starts in the trunk spreads to extremities. Sparse over face & legs. Fades in few hrs

Other Signs
Kopliks spots

Rubella

14 21 Days

None in infants and children Adolescents Fever & malaise 1- 4 days, no photophobia 3-4 days of high fever with no localizing signs

Red blush over the face Lymph adenopathy, occipito posterior, cervical and posterior auricular Lymph adenopathy esp cervical Child is often well occasional febrile convulsions

Roseola Infantum

7 14 Days

Differential Diagnosis of Fever with Rash Cond..

Disease
Erythema Infectiosum Enterovirus Infection Chicken Pox

Incubation Period
7 14 Days

Prodromal Illness
None

Rash
Lace like rashes in extremities. Lasts 7 14 days May be petechial

Other Signs
Slapped cheek appearance

Variable

Variable

Epidemics of gastroenteritis may be present Secondary bacterial infections (cellulites, abscess, impetigo) Encephalitis usually 4 7 days after rash Pneumonia often transient, severe cases occur in neonates those on immuno suppressive agents Rare AGN, HUS, nephrotic syndrome

14 21 Days

Often absent. Older children may have fever, headache, malaise

Rash appears on day 1 start as macules, develops quickly into papules and vesicles. Superficial polymorphic dew drop appearance Centripetal distribution

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