COMMON EXANTHEMS IN CHILDREN

PEDIATRICS 2 – DR. CHRISTINE BERNAL

EXANTHEM   o Koplik   spots   are   rarely   present   and   rashes  

• Greek  word  “exanthema”  =  a  breaking  out   begins  distally  and  progresses  in  a  cephalad  
• Widespread  rash  usually  occurring  in  children  caused   direction,   with   little   involvement   of   the   face  
by   toxins   or   drugs,   microorganisms,   or   can   result   and  upper  part  of  the  trunk  
from  autoimmune  disease   o Not   seen   anymore   due   to   the   eradication   of  
Higher during summer
  the  killed  vaccine  
COMMON  INFECTIOUS  EXANTHEMS  IN  CHILDREN   • Diagnosis:  Clinical  
1. Rubeola   • Treatment  
2. Rubella   o Supportive   Anti-pyretics, hydration
3. Roseola  Infantum   o Vitamin  A  (immunomodulator)  
4. Erythema  Infectiosum   § 100,000  IU  6  mos  –  1  yr  
5. Varicella   § 200,000  IU  >  1  yr  
6. Infectious  Mononucleosis   § Given   orally   via   capsule   that   is  
7. Scarlet  Fever   pricked  with  a  needle  
  § Prevents   complications:   diarrhea  
RUBEOLA   and  pneumonia  
• Measles   Infants, older children • Complications  
• Mode   of   transmission:   droplet   spray   during   the   o Superimposed  bacterial  infection  
prodromal  period  (highly  contagious)   o Otitis  media  
• Incubation  period:  8-­‐12  days   o Pneumonia  
• Prodromal  –  3-­‐5  days   o Encephalitis   /   SSPE   –   severe   complication,  
Colds/ continuous nasal discharge
• 3   C’s   (Cough,   Coryza,   Conjunctivitis)   –   presence   in   may   occur   many   years   after   the   onset   of  
prodromal  period  +  high  grade  fever   measles,  progressive  type),    
• High  grade  fever  –  first  4-­‐5  days  then  it  drops   o May  exacerbate  latent  PTB  
• May  co-­‐infect  with  bacteria  -­‐>  bacterial  conjunctivitis   o GI  symptoms   Malabsorption
-­‐>  yellowish  discharge  of  the  eyes   • Prevention   MMR
Pathognomonic During the prodromal period
Blue,greyish white Upper molar
• Koplik  spots  –  white  spots  on  the  buccal  mucosa   Before the rash o Active  immunization:  9  mos,  15  mos  and  4-­‐6  
• Only  exanthema  that  the  patient  is  ill-­‐looking   yr  (booster)  
• Distribution  of  rash  (typical):   Typical rash- head to toe § Outbreak:   maybe   given   as   early   as  
o Starts   behind   the   ears   along   the   hairline,   6  mo  
face  then  spreads  downward  over  the  body   § MMR  
rd th
o Appears  on  the  3  and  peaks  on  the  5  day   o Passive   immunization:   Gammaglobulin:  
of  illness   0.25mL/kg   (max  15mL)    Modified measles
During prodromal period- best time but can be given even when
o Confluence   of   maculo-­‐papular   rash   over   the   rash is present. § For  patients  exposed  
head   and   trunk   area   and   it   becomes    
discrete   maculo-­‐papular   rash   on   the   lower   RUBELLA   3-day measles
extremities   • German  measles  
• Branny  Desquamation  –  typical  finding   • Age:  Children  and  young  adults  
o Seen  in  the  later  part  of  the  disease  course   o Mostly  teens  
as  the  rashes  start  to  disappear   o Peak  incidence  –  5  –  14  yrs  old  
• Modified  Measles   • Mode   of   transmission:   oral   droplets   or  
o Attenuated   form   of   infection   that   may   transplacental  
occur   in   individuals   who   have   received   • Low  grade  fever  
immune  globulin  after  exposure  to  measles   • Incubation  period:  14  –  21  days  
o Clinical   manifestations   are   milder   than   • Prodromal  period:  shorter  and  milder  
those  of  typical  infection  and  the  incubation   • Tender   retroauricular,   post-­‐cervical   and   post-­‐
period  is  prolonged  from  14  to  20  days   occipital  lymphadenopathy  (most  common)  
• Atypical  Measles   o Classic  finding  
o Occurs   in   individuals   infected   with   natural   o Present  on  the  day  1  of  illness  
virus   and   who   previously   received   killed    
measles  vaccines    
Infective 3-4 days before up to 4-6 days after rash
Cough and diarrhea due to rashes in larynx and intestinal wall respectively
Given anti-Koch because may reactivate latent PTB
Coxsackie and enterovirus- common viral exanthem in infant and children
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 COMMON EXANTHEMS IN CHILDREN
PEDIATRICS 2 – DR. CHRISTINE BERNAL

High grade
• Distribution  of  rash:   From head going to feet • Three  day  fever  followed  by  rash  at  defervescence  of  
o Similar   to   measles   but   they   are   discrete   and   fever   Patient is not irritable anymore. Patient is well-looking.
Disappears in 2-3 days. not  associated  with  desquamation   o Clue:   see   the   rash   only   when   the   patient   is  
No scarring.
o Appear  4  –  5  days  of  the  fever   afebrile  
• Prominence  of  muscle  aches  and  pains   • Treatment:  Supportive  
• Forchheimer  spots  –  red  spots  seen  on  the  palate   o Give  Paracetamol  for  the  fever  
• Diagnosis:  Clinical   • Complications:  None  
• Treatment:  Supportive    
• Complication     ERYTHEMA  INFECTIOSUM  
o None   • Fifth  disease  –  fifth  described  viral  exanthem  
o Benign  viral  exanthem   • Age:  school  aged  children  and  adults  
o The  most  important  consequence  of  rubella   • Etiologic  agent:  Parvovirus  B19  
is   in   the   pregnant   woman   “Congenital   • Mode   of   transmission:   respiratory   route   thru   large  
Rubella  Syndrome”   Give vaccine during 1st trimester droplets  
• Prevention   • Incubation  period:  4  –  28  days  
o Active   immunization   –   15   mos,   4   –   6   yrs   • Mild  prodromal  period  
(booster)   o Low-­‐grade   fever,   headache,   mild   upper  
§ MMR     respiratory  symptoms  
o Passive   immunization   –   Gammaglobulin   –   o Not  ill-­‐looking  
for  exposed  pregnant  woman   • Primary   target   is   the   erythroid   cell   line   –   Transient  
nd
• Congenital  Rubella  Syndrome   Aplastic   Crisis   –   seen   on   the   2   week   –   not   all  
o General:   IUGR,   hepatosplenomegaly,   patients  have  this  
chemical  evidence  of  hepatitis   o Drop  in  all  three  cell  lines  seen  in  CBC  
o CNS:   mental   retardation,   behavioral   • Slapped   cheek   –   malar   area   but   does   not   cross   the  
disorders,  hypotonia,  seizures,  CSF  protein   nasal  bridge  and  sparing  of  alar  area  
o Cardiac:   PDA,   peripheral   and   valvular   • Lace-­‐like  pattern  rash  –  livido  reticularis  (also  seen  in  
pulmonary  stenosis,  aortic  stenosis,  VSD   lupus)  
o EENT:   cataracts,   “salt   and   pepper”   • Diagnosis:  Clinical  
retinopathy,   corneal   clouding,   glaucoma,   • Treatment:  Supportive  
nerve   deafness   (single   most   common   • Prevention:  None   No vaccine
finding,   it   can   be   isolated   without   all   other   • Self  limiting  disease  
manifestations)    
o Orthopedic:  radiolucencies  in  long  bones   VARICELLA  –  ZOSTER  INFECTIONS   More severe symptoms for
o Hematologic:   transient   thrombocytopenia   • Etiology:  
adolescents and older adult vs
during childhood
with  purpura   Not pathognomonic o Varicella   –   Zoster   virus   (member   of   herpes  
o Dermatologic:   “blueberrymuffin”   spots   virus  family)  
(petechiae   and   purpuric   rash),   o Primary  infection  –  Varicella  (chickenpox)  
dermatoglyphic   o Latency  in  the  dorsal  root  ganglia  
nd rd
o Endocrine:  Diabetes  in  2  or  3  decade   o Reactivation  -­‐>  Zoster  
 
• Mode  of  transmission  
ROSEOLA  INFANTUM  
o Person  to  person  
• Exanthem  subitum   § Direct   contact   with   patients   with  
• Age:  6  mos  –  2  yr   varicella  or  herpes  zoster  
• Etiologic  agent:  HHV  6  and  7   § Airborne   from   respiratory   tract  
• Mode  of  transmission:  Adult  saliva   secretions  
• No  prodromal  period   § Rarely,  from  zoster  lesions  
• Mild   upper   respiratory   signs   (cough   and   colds),   o Transplacental  
irritability   and   anorexia,   sometimes   seizures   and   • Age  of  incidence:  mostly  <10  yrs  (Varicella)  
high  fever   • Incubation   period:   14   to   16   days   (occasionally   as  
• Nagayama   spots   –   ulcers   at   the   uvulopalatoglossal   early  as  10  days  or  as  late  as  21  days)  
junction  commonly  observed  in  Asian  children   • Period  of  contagiousness  
Complications- Croup, tracheolaryngobronchitis, myocarditis

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 COMMON EXANTHEMS IN CHILDREN
PEDIATRICS 2 – DR. CHRISTINE BERNAL

From   1   to   2   days   before   until   shortly   after  

o (Maternal  
the  onset  of  the  rash   Varicella)  
o May  persist  until  crusting  of  the  lesions   Cicatricial  skin  
• Clinical  manifestations   scarring  
o Macules  -­‐>  vesicles  -­‐>  crust  -­‐>  shallow  pock   Clinical  features   Skin  lesions   Limb  hypoplasia  
marks   Neurologic,  Renal,  
o Rashes   usually   start   from   trunk   and   spread   ANS  abnormalities  
centrifugally   Anti-­‐viral  
o Pruritus   Treatment   (Acyclovir)   None  
§ Give   antihistamine   to   prevent   VZIg  
superinfection  of  the  skin  lesions    
o Celestial   map   –   different   kind   of   lesions   in   • Neonatal  Varicella  
one  area  (typical  for  varicella)   o Baby  is  delivered  with  the  lesions  
• Benign  viral  infectious  disease   o Up  to  28  days  
• Complications   • Congenital  Varicella  
o Staphylococcal   and/or   streptococcal   super   o More  of  systemic  involvement  
infection  of  skin  lesions   o Irreversible  thus  no  treatment  
o Invasive  group  A  streptococcal  disease   o Cicatricial   skin   scarring   (zoster   like  
o Pneumonia   distribution,   only   on   1   dermatome  
o Arthritis   level)  
o Central  nervous  system   o Limb  hypoplasia  
§ Stroke   o Neurologic   (microcephaly,   cortical  
§ Aseptic  meningitis   atrophy,  seizures,  mental  retardation)  
§ Progressive  encephalopathy   o Eye   (chorioretinitis,   micropthalmia,  
§ Post-­‐infectious  encephalitis   cataract)  
§ Cerebellitis   o Renal  (hydroureter,  hydronephrosis)  
§ Reye’s  syndrome   o ANS  abnormalities  (neurogenic  bladder,  
§ Transverse  myelitis   swallowing  difficulties)  
§ Guillain  Barre  syndrome    
• Treatment:   Before   getting   pregnant   you   must   have   the   vaccines   3  
o No  Aspirin  (risk  of  Reye’s  syndrome)   months  in  advance!!!  
o Decision  to  use  antiviral  agents  depends  on    
§ Specific  host  factors   INFECTIOUS  MONONUCLEOSIS  
§ Extent  of  infection   • Kissing’s  disease  
§ Initial  response  to  therapy   • Age:  any  age  group  
o Limitation:   o 90&   of   children   contract   EBV   infection  
Only works if given within 24hrs of
appearance of the rash- shorten§ Immunocompetent:   no   need   for   by  6  years  of  age  
the course of the disease and less Acyclovir   o 40%   -­‐   50%   of   adolescents   have  
lesions § Immunocompromised:   give   previously  experienced  EBV  infection  
Acyclovir   • Etiologic  agent:  Epstein  barr  virus  
• Prevent   disseminated   • Mode   of   transmission:   saliva   (close   contact  
Varicella   (kissing),   mothers   fondling   their   children,  
§ Immunocompetent   hosts:   virus   toddlers  sharing  toys)  
replication   has   stopped   by   72   • Incubation  period:  30  –  50  days   Longest incubation
hours  after  onset  of  rash   • Prodromal  period:  1  –  2  weeks  
• Duration   extended   in   • Infection   is   heralded   by   3   to   5   days   of   mild  
immunocompromised   headache,   malaise,   myalgia   and   fatigue  
hosts   (prominent  in  adolescents)  
  • Followed   by   the   onset   of   fever,  
  NEONATAL   CONGENITAL   lymphadenopathy   and   severe   sore   throat  
Period  of   5  days  before  to  2   (enlarged  tonsils)  
First  trimester  
Pregnancy   days  after  delivery  

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 COMMON EXANTHEMS IN CHILDREN
PEDIATRICS 2 – DR. CHRISTINE BERNAL

Other   symptoms   –   abdominal   pain,   edema   of  

• o Clinical  
the  eyelids  (Hoagland  sign),  jaundice,  rash   o Throat  swab  Culture  
• Triad:   sore   throat   or   pharyngitis,   o Rapid  Strep  test  
lymphadenopathy,  splenomegaly   • Treatment:  
• 80%  of  infected  patients  treated  with  ampicillin   o Penicillin  x  10  days  
or  amoxicillin  experienced  “Ampicillin  Rash”   § For   complete   eradication   of   the  
• Diagnosis:   disease  =>  10  days  
o Clinical   triad:   exudative   pharyngitis,   § Prevent   the   non   suppurative  
cervical   lymphadenopathy   and   complications  of  strep  
splenomegaly   • Rheumatic  fever  
o Presents   with   prolonged   fever   (fever   • Post   streptococcal  
for  more  than  2  weeks)   glomerulonephritis  
§ Check  for  serology    
§ Usual  viral  fever  –  3  –  5  days   PATTERN  OF  THE  DISEASE  
o EBV  IgM  positive    
o Presence   of   atypical   lymphocytes   in   the   RUBEOLA  
Looks like macrophage
peripheral  blood  smear  (Downey  cell)  
o Serologic   test   -­‐   +   heterophile   antibody  
st nd
Burkitt's lymphoma
(appears   during   1   or   2   week   of  
illness)  
o Monospot  test  –  done  in  the  ER  to  tell  if  
there  is  the  presence  of  the  virus  
• Treatment:   bed   rest   and   symptomatic  
management    
• Complications:  Rare   RUBELLA  
o Airway  obstruction  
o Subcapsular  splenic  hemorrhage  
o Splenic  rupture  
§ If   the   patient   is   into   contact  
sports,   tell  them  to  avoid   it   for  
2  –  3  weeks  
 
SCARLET  FEVER    
• Age:  School-­‐age  children   ROSEOLA  INFANTUM  
• Etiologic   agent:   Group   A   Streptococcus   producing  
erythrogenic  toxin  A,  B  &  C  
• Mode   of   transmission:   Respiratory   route   (close  
contact)  
• Incubation  period:  3  –  4  days  
• Clinical  characteristics:  
o Fever    
SCARLET  FEVER  
o Pharyngitis  
Desquamates also o Cervical  lymphadenitis  
o Rash   Like Kawasaki
o Strawberry  tongue  (prominent  and  very  red  
tongue  papillae)  
o Sandpaper  /  Goose  pimple  like  rash  
o Pastia’s  line  (red  lines  seen  on  skin  creases,  
axillary,  antecubital,  inguinal  areas,  appears    
prior  to  the  onset  of  the  rash)    
• Diagnosis:   *Transcribed  from  the  lecture  slides  and  discussion  of  Dr.  Christine  Bernal,  for  
3D  2016.  

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