Dr.

De Los Reyes

Pedia 250 Case Conference: Rashes

ICC I in Pediatrics

General Data: Agnes is a 7-year old female from Makati who sought consult last October 28, 2005 Chief Complaint: Rashes History of Present Illness: Five days PTC, the patient has moderate grade undocumented fever associated with dry nonproductive cough, runny nose, slightly red eyes, and mild abdominal pain. No consult was done. The mother gave the patient paracetamol for the fever. Three days PTC, high-grade fever was noted and documented at 40C. Mother also noted apperance of maculopapular rash on the upper lateral parts of the neck. Two days prior to consult, there was a note of fever at 40C. The rash progressed to the chest, abdomen and back. Persistence of symptoms prompted consult. Guide Questions: 1. What are the possible ddx in a patient with rashes? 2. How is the diagnosis of measles in children made? What are the diagnostic work-ups which you will request for Agnes which could suggest measles? 3. What is the pathophysiology of Measles infection? What are its complications? 4. How will you treat the patient? 5. What are the preventive measures for measles?

Scarlet Fever URTI associated with a characteristic rash, which is caused by an infection with pyrogenic exotoxin (erythrogenic toxin)producing GAS in individuals who do not have antitoxin antibodies. R Rash appearing 12-48 after onset of fever R Rash starting on the neck R Abdominal pain S Scarlet macules over generalized erythema (boiled lobster appearance) S Sore throat Rubella Caused by togavirus R Low-grade fever R Maculopapular rash R Red eyes with or without pain R Stuffy or runny nose

DIFFERENTIAL DIAGNOSES Classical Infectious Childhood Exanthems 1. Measles (Rubeola) 2. Scarlet Fever 3. Rubella 4. Filatov Duke disease 5. Erythema Infectiosum 6. Roseola Infantum Dengue Fever Kawasaki Disease Infectious Mononucleosis Enteroviral Infection Drug Eruption

S S

In children, a prodrome may not be present As opposed to Measles, fever in Rubella rarely rises above 38 C Rash is usually the first manifestation in children

The exanthem begins as discrete macules on the face that spread to the neck, trunk, and the extremities. The macules may coalesce on the trunk. This lasts 1-3 days (3 day measles), first leaving the face, and may be followed by desquamation. The hallmark of rubella is the generalized, tender lymphadenopathy that involves all nodes, but which is most striking in the suboccipital, postauricular, and anterior and posterior cervical nodes. Most prevalent at the time of appearance of the rashes but may precede it by a week

Measles Acute viral infection caused by paramyxovirus Transmission occurs via droplet spray during the prodromal period which makes it highly contagious Prodrome: Classic triad R Cough R Coryza R Conjunctivitis Fever of increasing grade Kopliks spots

Erythema Infectiosum Also known as fifth disease

R S

Caused by parvovirus B19 Fever Headache Mild URTI symptoms Slapped-cheek appearance

R Central maculopapular rash First apparent on the face and upper neck Pruritus is not a common symptom Spreads, reaching the hands and feet, for about three days Lasts for five to six days, and then fades.

Roseola Infantum R Fever (up to 40C) R Maculopapular or eythematous rash

MJ and Dana

August 8, 2011 MONDAY

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Dr. De Los Reyes

Pedia 250 Case Conference: Rashes

S Rash appears after resolution of fever

ICC I in Pediatrics

Rash appears after resolution of fever

S Typically beginning on the trunk progressing to the

neck and extremities. Drug Eruption B-Lactams Amoxicillin rash in EBV infection

S Irritability S Abrupt onset of high fever

S More than 95% of roseola cases occur in children younger than 3 yr, with a peak at 615 mo of age.

Sulfonamides Anticonvulsants NSAIDs

Dengue Fever R High grade fever

R Abdominal pain
S Maculopapular rash that appears after defervescence

(Refer to the ppt for the pictures of rashes ) PATHOPHYSIOLOGY One of the most contagious infectious diseases 90% secondary attack rate

Kawasaki Disease KD is the leading cause of heart disease in children, occurs more often in boys than in girls and usually affects those younger than 5. R High and persistent fever Characteristic Features R Conjunctivitis (?) Mucositis with strawberry tongue and dry, cracked lips (?) Edema and erythema of the hands and feet R Erythematous rash

Acute viral infection caused by paramyxovirus

Measles Virus Single-stranded lipid enveloped RNA virus

Family Paramyxoviridae and genus Morbillivirus Structural proteins hemagglutinin (H) protein Target of neutralizing antibodies

(?) nonsuppurative CLAD R Abdominal pain S S Cough is not severe 80% of potients are <5 y.o.

fusion (F) protein antibodies to the F protein limit proliferation of the virus during infection

Infectious Mononucleosis Caused by EBV R R Rash Abdominal pain

Humans are the natural hosts and only reservoir of the infection.

Transmission Through droplets or aerosols of infected secretions from nose, mouth or pharynx Portal of entry: respiratory tract or conjunctivae Patients are infectious from 3 days before the rash up to 46 days after its onset ~ 90% of exposed susceptible individuals develop measles

Classic presentation R Low grade fever S Pharyngitis (?) LAD Enteroviral Infection Usually caused by echoviruses No significant adenopathy

Phases A. Incubation Period ~10-12 days to first prodromal symptoms Last 6-10 days

R Pink, maculopapular, blanching rash

MJ and Dana

August 8, 2011 MONDAY

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Dr. De Los Reyes

Pedia 250 Case Conference: Rashes

ICC I in Pediatrics

Measles virus migrates to regional lymph nodes Primary viremia virus disseminates to the RES

Complications more likely in:

<5 years of age (esp. <1 year old) >20 years old Severe malnutrition

Secondary viremia virus spreads to body surfaces replicates in skin, respiratory tract, conjunctiva and other distant organs

Acute Otitis Media most common complication Pneumonia most common cause of death Croup, tracheitis, bronchiolitis in infants Diarrhea, vomiting Seizures, encephalitis Myocarditis

B. Prodromal Phase Lasts 3-5 days Epithelial necrosis Giant cell formation in body tissues

Virus shedding begins

Subacute Sclerosing Panencephalitis (SSPE) Rare, delayed onset Prodrome Malaise Cough Coryza Conjunctivitis with lacrimation Nasal discharge Fever Virus regains virulence after 710 yr the virus and attacks the cells in the CNS that offered the virus protection Slow virus infections Fatal outcome M>F Result from a persistent infection with an altered measles virus that is harbored intracellularly in the CNS for several years

C. Exanthematous Phase In response to the invasion of the virus, the body throws cell-mediated responses. Cell-mediated responses are the main line of defense against measles, as evidenced by the fact that people with cell-mediated deficiencies develop severe measles infection. This leads to hypersensitivity reaction leading to rash.

Measles at an early age favors the development of SSPE Begin insidiously 713 yr after primary measles infection Massive myoclonus Choreoathetosis, immobility, dystonia, lead pipe rigidity

Rashes usually become first apparent on the face and upper neck. Pruritus is not a common symptom. Over about three days, the rash spreads, reaching the hands and feet. The rash lasts for five to six days, and then fades. On average, the rash occurs 14 days after exposure to the virus. Antibody production begins Viral replication and accompanying symptoms begin to subside Rash fades after over 7 days (desquamation of the skin) Cough can last 10 days

DIAGNOSIS

diagnosis is mostly clinical with most common symptoms of o high grade fever o 3 Cs cough, coryza, conjunctivitis o Characteristic central maculopapular rash Laboratory confirmation or rarely needed but serelogic testing can be done o Antibody investigation IgM antibodies or seroconversion to IgG is the quickest method to confirm acute measles; positive if serum levels are >20ul

Complications

MJ and Dana

August 8, 2011 MONDAY

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Dr. De Los Reyes

Pedia 250 Case Conference: Rashes

o o

ICC I in Pediatrics

Molecular investigation detection of measles RNA through PCR/genotyping Virus isolation done through throat swab, nasopharyngeal aspirate, conjunvtival swab, urine TREATMENT

Entirely supportive o Antipyretics for fever o Bed rest o Adequate fluid intake No specific antiviral therapy Treat complications

PREVENTION

Isolate patient from 7th day after exposure to 5 days after rash appearance Vaccine MMR (measles-mumps-rubella) vaccine is recommended at 12-15 months of age o Second immunization recommended at 4-6 years of age o Adolescents entering college should have received second measles immunization Post exposure prophylaxis passive immunization with immune globulin within 6 days of exposure o

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August 8, 2011 MONDAY

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