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Pediatric Exanthems

Sarah Stein, MD
Sections of Dermatology and Pediatrics
University of Chicago

Definitions
• Exanthem: A skin eruption occurring as a
symptom of a general disease.
• Enanthem: Eruptive lesions on the mucous
membranes.

“Classic Childhood Exanthems”
I.
II.
III.
IV.
V.
VI.

Measles (Rubeola)
Scarlet Fever
Rubella (German measles)
Filatow-Dukes Disease
Erythema Infectiosum
Roseola Infantum

“1st Disease”=Measles
• Paramyxovirus
• At risk: preschool-age children who escaped
vaccination; school-age children/adolescents in
whom vaccination failed
• Season: late winter/spring
• Incubation period: 8-12days
• Infectious period: 1-2d before prodrome to 4d
after onset of rash

Measles: clinical features
• Prodrome: day 7-11 after exposure
– Fever, cough, coryza, conjunctivitis

• Enanthem: Koplik’s spots appear 2 days
before the rash, last 2 days into the rash

Measles:
“morbilliform
exanthem”
Presents day 14

after exposure

Measles: complications





Otitis media
Bronchopneumonia
Encephalitis
Myocarditis
Pericarditis
Subacute sclerosing panencephalitis—late
sequellae due to persistent infx of the CNS

“2nd Disease”=Scarlet Fever
• Due to erythrogenic exotoxin-producing
group A beta-hemolytic streptococci
• At risk: <10yo, peak 4-8yo
• Season: late fall, winter, spring
– Likely due to close contact indoors in school

• Incubation period: 2-4 days
• Infectious period: during acute infection,
gradually diminishes over weeks

Scarlet Fever: clinical features
• Abrupt onset fever, headache, vomiting,
malaise, sore throat
• Enanthem
– Bright red oral mucosa
– Palatal petechiae
– Tongue changes

Strawberry tongues

Scarlet Fever: exanthem
(12-48hrs after fever onset)

Scarlet Fever: complications
• Purulent
complications
– Otitis media
– Sinusitis
– Peritonsillar/retropharyngeal abscesses
– Cervical adenitis

• Nonsuppurative
sequalae
– Rheumatic fever
– Acute
glomerulonephritis

Scarlet Fever and a negative strep
culture?
• Scarlet fever-like syndrome in a young
adult
• Arcanobacterium haemolyticum (aka
corynibacterium haemolyticum)
– Gram positive rod
– Grows on 5% human blood agar
– More sensitive to erythromycin

“3rd Disease”=Rubella




Togavirus
At risk: unvaccinated adolescents
Season: late winter/early spring
Incubation period: 14-21 days
Infectious period: 5-7d before rash to 3-5d
after rash

Rubella: clinical features
• Asymptomatic infection in up to 50%
• Prodrome
– Children: absent to mild
– Adol and Adult: Fever, malaise, sore throat,
nausea, anorexia, painful occipital LAD

• Enanthem
– Forschheimer’s spots = petechiae on the hard
palate

Rubella: exanthem

Rubella: complications
• Arthralgias/arthritis in older patients
• Peripheral neuritis, encephalitis,
thrombocytopenic purpura—rare
• Congenital rubella syndrome
– Infection during first trimester
– IUGR, eye findings, deafness, cardiac defects,
anemia, thrombocytopenia, skin nodules

“4th Disease”=Filatow-Dukes
Disease
• Obsolete
• Probably now better defined as another
clinical entity

“5th Disease”=Erythema
Infectiosum




Human Parvovirus B19
At risk: school-age children
Season: sporadic
Incubation period: 4-14 days
Infectious period: up until onset of the rash

EI: clinical features
• Over 50% of infections are asymptomatic
• Prodrome
– Mild fever (15-30%), sore throat, malaise

• Adults—flu-like symptoms, arthralgias/arthritis
(potentially chronic), rash in up to 40%
• Hematological changes–proerythrocyte tropic
virus
– Drop in RBC count

Erythema
Infectiosum:
slapped cheek
appearance

EI: complications
• Immunocompromised—chronic infection
with severe, persistent, relapsing and
remitting anemia, prolonged viral shedding
• Patients with decreased RBC survival time
(hemoglobinopathies, hemolytic dis)—
aplastic crises, prolonged viral shedding
• Fetal infection—hydrops fetalis (overall
risk of fetal death 1-9%)

Papular purpuric glove and sock
syndrome
• 2nd syndrome ascribed to Parvovirus B19,
other viruses may be possible causes
• Spring/summer; young adults
• Rash, LAD, fever, anorexia, arthralgias
• Self-limited over 7-14 days
• Viremia clears after rash

Papular purpuric glove and sock
syndrome

th
“6

Disease”=Roseola infantum
(aka Exanthem subitum)





Human Herpes Virus 6 (and 7)
At risk: 6-36 mo (peak age 6-7mo)
Season: sporadic
Incubation period: 9 days
Infectious period: virus is intermittantly
shed into saliva throughout life; asymp
persistent infection

Roseola: clinical features
• High fever for 3-4 days
• Abrupt defervescence with appearance of
rash
• Associated seizures likely due to infection
of the meninges by the virus

Roseola: exanthem

The rest of the herpes family





Herpes simplex virus 1 and 2
Varicella-zoster virus
Cytomegalovirus
Epstein-Barr virus
Human Herpes virus 6 and 7
Human Herpes virus 8

Chicken Pox=Varicella
• Varicella zoster virus, family herpesviridae
• At risk: young children, nonimmune inds
– Second attack rate within households is 80-95%

• Season: sporadic
• Incubation period: 10-21 days
• Infectious period: via resp drop and vesicle
fluid, 2d before to 5d after onset of rash

Chicken Pox: clinical features
• Prodrome
– Ranges from asymp to fever, malaise, cough,
coryza, sore throat

• Pruritus
– Variable from mild to severe

Chicken Pox: exanthem

Chicken Pox: complications
• Secondary bacterial infection—5-10%
• Otitis media—5%
• Higher risk for adults, neonates, immunocomp.



Pneumonitis
Encephalitis
Cerebellar ataxia
Hepatitis

• Other rare comps—Reye syn, Guillain-Barre,
nephritis, carditis, arthritis, orchitis, uveitis

Smallpox
(variola):
exanthem

Herpes Zoster: clinical features
• Reactivation of latent VZV in sensory
ganglia
• At risk: elderly, immunocomp., children
who had chicken pox in utero or in 1st year
• Prodrome
– Unusual in children
– In adults, dull ache for up to a week before rash

Varicella Zoster:
exanthem

Cephalic herpes zoster: RamseyHunt Syndrome

Varicella Zoster: complications
• Post-herpetic neuralgia—uncommon in kids
• Disseminated dis—immunocompromised
– Widespread cutaneous lesions
– Visceral disease

• Ulcerations
• Secondary infection

Infectious Mononucleosis

Infectious Mononucleosis: and
ampicillin/amoxicillin

Enterovirus rashes
• Hand-foot-mouth disease
• Herpangina
• Nonspecific eruptions

Hand-foot-mouth disease
• Typically due to Coxsackie A16
• At risk: preschool-school aged children
– Highly contagious

• Incubation period: 4-6 days
• Prodrome: 1-2 days before rash
– Low-grade fever, anorexia, malaise, sore mouth

HFMD: enanthem

HFMD: exanthem

Nail matrix arrest and HFMD

Herpangina
• Coxsackie A viruses
• At risk: young children
• Prodrome
– Fever, sore throat

Herpangina: enanthem

Nonspecific enteroviral
exanthems
• Multitude of presentations



Morbilliform or rubelliform
Vesicular
Petechial (typical of echovirus 9)
Urticarial

• Involvement of other systems-rare, but not
to be ignored
– CNS, pulmonary, GI, muscular, cardiac

Enterovirus:
nonspecific
exanthem

“Named” exanthems
• Gianotti-Crosti Syndrome, aka papular
acrodermatitis of childhood
• Unilateral Laterothoracic Exanthem, aka
asymmetric periflexural exanthem of
childhood (APEC)
• Pityriais Rosea

Gianotti-Crosti syndrome:
clinical features
• Most often due to EBV, also Hep B and all
other viruses
• At risk: 6mo-14yrs, mean 2yrs
• Season: spring and early summer
• Constitutional symptoms: mild
– Low grade fever, malaise, LAD, rare pruritus,
mild hepatitis (except in Hep B-associated case)

Gianotti-Crosti Syndrome

Gianotti-Crosti Syndrome

Gianotti-Crosti Syndrome

Unilateral Laterothoracic
Exanthem
• aka Asymmetric Periflexural Exanthem
• ?viral: suggested by age, clustering, resp
symptoms
• At risk: 1-5yos, mean 2yo
• Prodrome: 60-75%
– Rhinitis, pharyngitis, bronchitis, conjunctivitis,
gastroenteritis
– Fever in 40-65%

Unilateral
Laterothoracic
Exanthem

Pityriasis Rosea
• ?viral: suggested by seasonality, mild
prodromal symptoms, assoc URI, clustering
of cases
• Season: spring, autumn, winter
• At risk: 10-35yos, can be seen in younger
• Prodrome: very mild, if any
– Malaise, nausea, anorexia, headache, low fever

Pityriasis Rosea

Pityriasis Rosea

Pityriasis Rosea