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CHAPTER
35
History
234
Physical examination
234
235
Erythema toxicum
235
Staphylococcal skin infection
235
Localized herpes simplex virus (HSV) infection
Varicella zoster virus infection
236
Petechiae 236
Clinical problem
235
236
History
243
Physical examination
Be sure to examine:
234
Table 35.1
Description
Common causes
Vesicles
Petechiae
Pustules
Urticaria
Macules
Plaques
Type of lesion
Papules
235
Erythema toxicum
This appears as red macules with overlying small
yellow or white pustules. The condition is idiopathic
and non-infective. It can be mistaken for infection: a
Gram stain of the lesion shows multiple eosinophils.
The rash often appears during the first few days of life
and may persist up to a fortnight.
236
Chickenpox is caused by primary infection with varicella zoster virus (VZV). Classically, there is a short
prodrome of about a day of sore throat and fever, after
which varicella commences as crops of itchy, circumscribed, vesicular lesions on the scalp and trunk. These
become pustular before becoming crusted and then
resolve without scarring, if not superinfected. A range
of lesions at different stages is usually seen at any one
time. Mucous membranes may be involved. There is
often only a mild prodromal illness of fever and mild
lethargy. When varicella occurs in the context of significantly damaged skin, such as eczema, the risk of
serious illness is much higher, and careful monitoring
and treatment are indicated.
237
Enteroviruses
Non-polio enteroviruses are a common cause of
vesicular rashes, especially in summer and autumn.
Hand, foot and mouth disease is caused by different
enteroviruses, most commonly Coxsackievirus type
A16. It often occurs in epidemics in daycare centres or
schools. It is associated with a papulovesicular eruption on the palms, soles, mucous membranes and
sometimes the buttocks. There may be mild associated
respiratory or gastrointestinal symptoms, but the clinical course is benign.
Enterovirus 71 can cause hand, foot and mouth
disease, but differs from the other enteroviruses in that
infections may be accompanied by significant neurological manifestations, such as aseptic meningitis,
brainstem encephalitis with neurogenic pulmonary
oedema, and acute flaccid paralysis.
Impetigo
Impetigo is the most common skin infection encountered in infants and school-aged children. It is caused
by Streptococcus pyogenes or Staphylococcus aureus. The
early lesion is an erythematous papule, which
progresses to transient vesicles and then becomes a
shallow ulcer with surrounding honey-coloured
crusted exudate. The lesions are often found in an area
of traumatized skin, and are commonly around the
nose, mouth and extremities. It is spread among individuals through close physical contact.
Maculopapular rashes
Many virus infections, especially enteroviruses,
produce maculopapular exanthems. These are often
non-specific and generalized in distribution (Fig.
35.3). They can be difficult to differentiate from allergic drug reactions. Features that favour a viral aetiology are:
Measles
Measles is rare in countries with high levels of immunization. While the diagnosis should be considered in
a child with a blotchy, geographical, erythematous
exanthem, other causes are usually more likely in an
immunized child. Characteristic features of measles
are:
238
Rubella
Rubella virus infection results in an erythematous, discrete exanthem that is often faint but may be morbilliform (measles-like) and spreads down from the face.
Occipital and/or post-auricular lymphadenopathy is
typically (but not exclusively) associated, and arthritis
and conjunctivitis can occur. There are relatively few
systemic symptoms in children. It is important to trace
and investigate pregnant contacts of a case.
Kawasaki disease
This is an important differential diagnosis of a child
with rash and fever. Clinical features include persistent
high fever with characteristic marked irritability,
rash, cervical lymphadenopathy (sometimes unilateral
resembling abscess), non-exudative conjunctivitis,
stomatitis, and swelling or redness of hands and feet.
The rash is not specific and can take many forms. It
may resemble erythema multiforme, scarlet fever,
measles, urticaria or a drug reaction. It is usually nonpruritic, and may be transient or evanescent (comes
and goes).
Roseola infantum
Roseola is a condition that affects infants and young
children. Children initially have 35 days of high fever
and mild systemic symptoms, before the rash then
appears with simultaneous defervescence. The rash
consists of small rose-pink macules or papules, which
may be morbilliform and are most prominent on the
trunk and face. The most common aetiological agent
is human herpesvirus 6 (HHV-6). Children with
measles are febrile and miserable when the rash is
present; in contrast, the child with roseola becomes
afebrile and well as the rash appears.
Meningococcal infection
A transient macular rash, mimicking an enteroviral
rash, can occur early in infection with Neisseria meningitidis in up to 20% of cases. It typically disappears in
less than a day, and purpura may then appear.
Bacterial infections
Other causes
Neisseria meningitidis
infection
Staphylococcus aureus
sepsis
Streptococcus pneumoniae
sepsis
Listeria monocytogenes
sepsis
Group A streptococcal
pharyngitis
239
Papular rashes
Molluscum contagiosum
Molluscum is a poxvirus infection, which causes multiple, 25 mm diameter, flesh-coloured papules with
a central dimple (umbilication). Initially firm, the
lesions become softer and waxier with time. Some
lesions have a mildly erythematous base and lesions
may become superinfected. The lesions can occur on
all parts of the body, but are least common on the
palms or soles. Auto-inoculation and spread to others
via close contact can occur. In the vast majority of
cases, the condition will resolve over some months
without specific treatment. Immunodeficiency, e.g.
HIV, predisposes to severe molluscum.
Leukaemia
Children with marrow infiltration by malignant cells,
particularly leukaemia, may present with a petechial
240
Generalized erythroderma
Staphylococcal scalded skin syndrome
StevensJohnson syndrome
An important differential of EM, this eruption differs
in that two or more mucosal surfaces are involved,
lesions are more widespread, and there is progression
to bulla formation and haemorrhagic crusting (Fig.
35.8). Mucosal ulceration of the mouth and genitalia
may occur and is severely painful. There is often significant internal organ involvement and a prodrome
of flu-like upper respiratory tract illness. The most
common infectious agent implicated is Mycoplasma
pneumoniae; the other major causal agent is drugs.
241
ances and secondary infection are common complications. The split in the skin layers is superficial, so that
with antibiotic treatment complete recovery occurs
with no scarring.
Scarlet fever
Scarlet fever is a systemic manifestation of Streptococcus pyogenes infection, resulting from exotoxin production. It affects mainly children aged 312 years and
is rare in infancy. Scarlatina is the name given to a
milder illness in which streptococcal infection causes
scarlatiniform rash alone, without the systemic features. True scarlet fever causes an erythematous, fine,
punctate rash which characteristically has a sandpaper
texture. It appears initially on the trunk and spreads
rapidly. Petechiae may be found on major skin folds.
Other distinctive features are glossal inflammation,
with prominent papillae (a strawberry tongue) and
circumoral pallor, with the rash sparing the skin
around the mouth. There is often desquamation of
fingers and toes on resolution.
Erythema marginatum
The rash associated with rheumatic fever (RF) is a
form of urticaria. It manifests in around 10% of
patients with RF, and is considered one of the major
diagnostic criteria for RF when present. The rash has
an erythematous macular component and a raised
edge (Fig. 35.10). It is non-pruritic and non-painful,
and the lesions coalesce to form a serpiginous pattern.
Urticaria
It is important to appreciate that, while classically
associated with hypersensitivity reactions, urticaria
in children under 5 years of age is most commonly
caused by a viral illness. In this situation, there is often
less associated pruritus than would be expected with
an allergic reaction. Severe lesions may be associated
with a purple discoloration due to bruising (purple
urticaria; see Fig. 35.9). Viral urticaria differs from
erythema multiforme because the position of the
lesions changes, and the erythema disappears from
individual lesions over a 24-hour period.
242
The rash may be fleeting and may reappear intermittently over weeks.
Drug reactions
Cutaneous manifestations are the most common form
of adverse drug reaction in children. While classically
drug reactions are urticarial in nature, almost all morphological variants are possible. Angioedema related
to drug ingestion is more significant, as it implies an
IgE-mediated pathway for the reaction and hence possible risk of anaphylaxis on re-exposure.
Clinical problem
243
Clinical problem
A 3-year-old girl was brought by ambulance to
the emergency department after a seizure at home.
On the day of presentation, she had been nonspecifically unwell. In the afternoon she complained
of a few non-specific aches and pains, and was
anorexic. Her mother thought she felt hot. She had
vomited once during the evening. She had no
rhinorrhoea, cough or rash. Just after midnight she
had a brief generalized tonicclonic seizure and
was brought to hospital.
Her only significant medical history was of a
febrile convulsion at 18 months of age, from which
she had recovered uneventfully. She had been born
at term, with no perinatal complications. Her
immunizations were up to date. She had no
siblings.
On examination in the emergency department
Questions
Discussion
244