FEVER AND RASHES

IN CHILD

Sarmin Sultana
BMS15091648
 CONTENTS
• German Measles (Rubella): Rubella virus
• Measles (Rubeola): Measles virus
• Chicken Pox / Shingles: Varicella-Zoster virus
• Erythema Infectiosum (Fifth Disease): Human Parvovirus B19
• Exanthema Subitum (Sixth Disease): Human Herpes virus 6
• Hand-Foot-Mouth Disease: Coxsackievirus
• Dengue
• Kawasaki Disease
• Scarlet Fever
• Impetigo
• Meningitis
 German Measles (Rubella)
• Rubella (German measles) is an acute, mild febrile illness characterized by
a rash and lymphadenopathy that affects children and young adults.
• Following an incubation period of 14-21 days, a prodrome consisting of
low-grade fever, sore throat, red eyes with or without eye pain, headache,
malaise anorexia, and lymphadenopathy begins. Suboccipital,
postauricular, and anterior cervical lymph nodes are most prominent.
• In children, the first manifestation of rubella is usually the rash, which is
variable and not distinctive. It begins on the face and neck as small,
irregular pink macules that coalesce, and it spreads centrifugally to involve
the torso and extremities, where it tends to occur as discrete macules.
About the time of onset of the rash, examination of the oropharynx may
reveal tiny, rose-colored lesions (Forchheimer spots) or petechial
hemorrhages on the soft palate. The rash fades from the face as it extends
to the rest of the body so that the whole body may not be involved at any
one time. The duration of the rash is generally 3 days, and it usually
resolves without desquamation.
A rash due to rubella on a child's back. The area affected is
similar to that of measles but the rash is less intensely red
 Treatment
• Rubella is a self-limited illness hence no specific
treatment is indicated. Live-attenuated rubella
vaccines is available as a single antigen or
combined with measles & mumps vaccine (MMR)
• The primary purpose of rubella vaccination is to
prevent congenital rubella infections . The vaccine
confers lifelong immunity in all recipients. The
vaccine is safe and causes few side effects in
children.
 Measles (Rubeola)
• Measles is highly contagious infectious disease.
• Transmission of the causative virus occurs mainly via the respiratory
route (by inhalation of large droplets of infected secretions) .
• Measles consists of 4 phases: incubation period, prodromal illness,
exanthematous phase, and recovery phase.
• The virus gains access to humans via the respiratory tract where it
multiplies locally; the infection then spreads to regional lymphoid
tissue.
• A primary viremia disseminates the virus, which then replicates in
the reticuloendothelial system .
• A secondary viremia seeds the epithelial surfaces of the body,
including skin, respiratory tract and conjunctiva, where replication
occurs .
 Measles (Rubeola)
CLINICAL MANIFESTATIONS:
• Measles has an incubation period of 8–12 days from exposure to
the onset of rash. The prodromal phase (early symptom) is
characterized by fever, sneezing, coughing, redness of the eyes and
Koplik spots.
• Koplik spots are pathognomonic for measles are small, bluish white
ulcerations on the buccal mucosa opposite the lower molars .
These spots contain giant cells & viral antigens and appear before
the rash.
• The rash, which starts on the head and then spreads progressively
to the chest, trunk and limbs, appears as light pink maculopapules .
• With the onset of the rash, symptoms begin to subside. The rash
fades over about 7 days in the same progression as it evolved,
often leaving a fine desquamation of skin in its wake.
Measles (Rubeola)

Koplik's spots seen as minute white dots on

the inflamed buccal mucosa of a patient with
measles
 Measles (Rubeola)
• The vaccine is available in three forms :
1. In combination with rubella vaccine (MR).
2. In combination with mumps & rubella vaccines (MMR).
3. In combination with mumps, rubella, varicella vaccines
(MMRV).
• Vitamin A treatment has decreased mortality & morbidity
• Postexposure Prophylaxis Susceptible individuals exposed to
measles may be protected from infection by either vaccine
administration or immunization with immune globulin. The
vaccine is effective in prevention or modification of measles if
given within 72 hr of exposure. Immune globulin may be given
up to 6 days after exposure to prevent or modify infection.
 Chicken pox
• Varicella (chickenpox) is a mild, highly contagious
disease, characterized by a generalized vesicular
eruption of the skin and mucous membranes.
• Varicella-zoster virus (VZV) causes primary, latent, and
recurrent infections. The primary infection is
manifested as varicella (chickenpox) and results in
establishment of a lifelong latent infection of sensory
ganglion neurons. Reactivation of the latent infection
causes herpes zoster (shingles).
• Varicella-zoster virus (VZV) is a fast-growing cytolytic
virus that belongs to the herpesvirus family. VZV
establish latent infections in neurons
 Chicken Pox
• The illness usually begins 14-16 days after exposure, although the incubation period
can range from 10-21 days.
• Almost all exposed, susceptible persons experience a rash, albeit so mild in some
cases that it may go unnoticed. Prodromal symptoms may be present, particularly in
older children and adults. Fever, malaise, anorexia, headache, and occasionally mild
abdominal pain may occur 24-48 hr before the rash appears. Fever and other
systemic symptoms usually resolve within 2-4 days after the onset of the rash.
• Varicella lesions often appear first on the scalp, face, or trunk. The initial exanthem
consists of intensely pruritic erythematous macules that evolve through the papular
stage to form clear, fluid-filled vesicles. Clouding and umbilication of the lesions
begin in 24-48 hr. While the initial lesions are crusting, new crops form on the trunk
and then the extremities; the simultaneous presence of lesions in various stages of
evolution is characteristic of varicella. The distribution of the rash is predominantly
central or centripetal with the greatest concentration on the trunk and proximally
on the extremities.
• The exanthem may be much more extensive in children with skin disorders, such as
eczema or recent sunburn. Hypopigmentation or hyperpigmentation of lesion sites
persists for days to weeks in some children, but severe scarring is unusual unless the
lesions were secondarily infected.
Breakthrough varicella lesions are predominantly maculopapular, and vesicles
are less common; the illness is most commonly mild with <50 lesions
 Chicken Pox
• Varicella and herpes zoster have been diagnosed primarily by their
clinical appearance. Laboratory evaluation has not been considered
necessary for diagnosis or management.

Treatment & Prevention:

• Acyclovir, valacyclovir, famciclovir are used in the treatment.
Acyclovir prevents the development of systemic disease and halts
the progression of zoster however it doesn’t prevent post-herpetic
neuralgia. To be most effective, treatment should be initiated as
early as possible, preferably within 24 hr of the onset of the
exanthem. There is less clinical benefit if treatment is initiated more
than 72 hr after onset of the exanthem.
• Previous infection with varicella confer lifelong immunity. A single
dose of the live attenuated varicella vaccine is highly effective at
inducing protection from varicella in children .
 Erythema Infectiosum (Fifth Disease)
• The most common manifestation of parvovirus B19 is erythema
infectiosum, also known as fifth disease, which is a benign, self-limited
exanthematous illness of childhood.
• The incubation period for erythema infectiosum is 4-28 days (average: 16-
17 days).
• The prodromal phase is mild and consists of low-grade fever in 15-30% of
cases, headache, and symptoms of mild upper respiratory tract infection.
The hallmark of erythema infectiosum is the characteristic rash, which
occurs in 3 stages that are not always distinguishable.
• The initial stage is an erythematous facial flushing, often described as a
“slapped-cheek” appearance . The rash spreads rapidly or concurrently to
the trunk and proximal extremities as a diffuse macular erythema in the
2nd stage. The rash tends to be more prominent on extensor surfaces,
sparing the palms and soles. Affected children are afebrile and do not
appear ill. Some have petechiae. The rash resolves spontaneously without
desquamation, but tends to wax and wane over 1-3 wk. It can recur with
exposure to sunlight, heat, exercise, and stress.
Erythema Infectiosum (Fifth Disease)
•The rash associated with erythema
infectiosum is immune complex mediated
(type III hypersensitivity)
•The illness is short-lived, with the rash
fading after 2–4 days.

Treatment & Prevention:

Fifth disease and transient aplastic crisis
are treated symptomatically. The latter
may require transfusion therapy. There is
no antiviral drug therapy and no vaccine
for parvovirus infections
A “slapped-cheek” appearance is
typical of the rash for erythema
Infectiosum [3].
 Exanthema Subitum (Sixth Disease)
• Human herpesvirus 6 (HHV-6A and HHV-6B) and human herpesvirus 7
(HHV-7) cause ubiquitous infection in infancy and early childhood. HHV-6B
is responsible for the majority of cases of roseola infantum (exanthema
subitum or sixth disease) and is associated with other diseases, including
encephalitis, especially in immunocompromised hosts.
• Roseola infantum (exanthem subitum, or sixth disease) is an acute, self-
limited disease of infancy and early childhood. It is characterized by the
abrupt onset of high fever, which may be accompanied by fussiness. The
fever usually resolves acutely after 72 hr (“crisis”) but may gradually fade
over a day coincident with the appearance of a faint pink or rose-colored,
nonpruritic, 2-3 mm morbilliform rash on the trunk .
• The rash usually lasts 1-3 days, spreading from the trunk to the face and
extremities. Because the rash is variable in appearance, location, and
duration, it is not distinctive.
Erythema Infectiosum (Fifth Disease)
Additional symptoms and signs include irritability,
inflamed tympanic membranes, rhinorrhea and
congestion, gastrointestinal complaints, and
encephalopathy.

Roseola infantum. Erythematous, blanching macules

and papules in an infant who had high fever for 3
days preceding development of the rash.

TREATMENT:
Supportive care is usually all that is needed for
infants with roseola.
 Hand-Foot-Mouth Disease
• Hand-foot-and-mouth disease is characterized by oral and
pharyngeal ulcerations and a vesicular rash of the palms
and soles that may spread to the arms and legs. Vesicles
heal without crusting, which clinically differentiates them
from the vesicles of herpesviruses and poxviruses.
• This disease has been associated particularly with
coxsackievirus A16 but also with B1 (and enterovirus 71).
Hand-Foot-Mouth Disease

Vesicular lesions on the foot in hand, foot

and mouth disease
 Dengue
• Dengue fever is a benign syndrome caused by several arthropod-
borne viruses and is characterized by biphasic fever, myalgia or
arthralgia, rash, leukopenia, and lymphadenopathy. Dengue
hemorrhagic fever is a severe, often fatal, febrile disease caused by
1 of 4 dengue viruses.
• Dengue Fever The incubation period is 1-7 days. In infants and
young children, the disease may be undifferentiated or
characterized by fever for 1-5 days, pharyngeal inflammation,
rhinitis, and mild cough. A majority of infected older children and
adults experience sudden onset of fever, with temperature rapidly
increasing to 39.4-41.1°C (103106°F), usually accompanied by
frontal or retroorbital pain, particularly when pressure is applied to
the eyes. Occasionally, severe back pain precedes the fever (back-
break fever).
 Dengue
• A transient, macular, generalized rash that
blanches under pressure may be seen during
the 1st 24-48 hr of fever. Myalgia and
arthralgia occur soon after the onset of fevers
and increase in severity over time.
• Approximately 1-2 days after defervescence,
a generalized, morbilliform, maculopapular
rash appears that spares the palms and soles.
It disappears in 1-5 days; desquamation may
occur. About the time this second rash
appears, the body temperature, which has
previously decreased to normal, may become
slightly elevated and demonstrate the
characteristic biphasic temperature pattern.
 Kawasaki Disease
• Kawasaki disease (KD) is an acute febrile illness of childhood seen worldwide with
the highest incidence occurring in Asian children. KD is a vasculitis with a
predilection for the coronary arteries.
• Fever is characteristically high (≥38.3°C [101°F]), unremitting, and unresponsive to
antibiotics. The duration of fever without treatment is generally 1-2 wk, but may
persist for 3-4 wk.
• KD can be divided into 3 clinical phases. The acute febrile phase is characterized by
fever and the other acute signs of illness and usually lasts 1-2 wk. The subacute
phase is associated with desquamation, thrombocytosis, the development of CAA,
and generally lasts about 3 wk. The convalescent phase begins when all clinical
signs of illness have disappeared and continues until the erythrocyte
sedimentation rate (ESR) returns to normal, typically about 6-8 wk after the onset
of illness.
• Cardiac involvement is the most important manifestation of KD. Myocarditis occurs
in most patients with acute KD and manifests as tachycardia disproportionate to
fever, along with diminished left ventricular systolic function. Persistence of high
fever, unresponsive to antibiotics and the eventual development of other signs of
KD result in the diagnosis
 Kawasaki Disease
In addition to fever, the 5 principal
clinical criteria of KD are:
bilateral nonexudative conjunctival
injection with limbal sparing;
erythema of the oral and pharyngeal
mucosa with strawberry tongue and
red, cracked lips; edema and
erythema of the hands and feet; rash
of various forms (maculopapular,
erythema multiforme, or
scarlatiniform); and nonsuppurative
cervical lymphadenopathy . Perineal
desquamation is common in the
acute phase and begins 2-3 wk after
the onset of illness and may progress
to involve the entire hand and foot.
 Kawasaki Disease
• COMPLICATIONS
• The patient with KD who has had a small solitary
aneurysm should continue aspirin indefinitely.
• Acute thrombosis may occasionally occur in an
aneurysmal or stenotic coronary artery;
thrombolytic therapy may be lifesaving in this
circumstance.
• Long-term follow-up of patients with coronary
artery aneurysms should include periodic
echocardiography with stress testing and possibly
angiography if large aneurysms are present.
 Scarlet Fever
• Scarlet Fever Scarlet fever is an upper respiratory tract infection
associated with a characteristic rash, which is caused by an infection
with pyrogenic exotoxin (erythrogenic toxin)–producing Group A
streptococcus in individuals who do not have antitoxin antibodies.
• The rash appears within 24-48 hr after onset of symptoms,
although it may appear with the first signs of illness . It often begins
around the neck and spreads over the trunk and extremities. The
rash is a diffuse, finely papular, erythematous eruption producing
bright red discoloration of the skin, which blanches on pressure. It is
often accentuated in the creases of the elbows, axillae, and groin.
The skin has a goose-pimple appearance and feels rough.
 Scarlet Fever
• The cheeks are often erythematous with pallor around the mouth.
After 3-4 days, the rash begins to fade and is followed by
desquamation, initially on the face, progressing downward, and
often resembling a mild sunburn. Occasionally, sheet-like
desquamation may occur around the free margins of the
fingernails, the palms, and the soles. Examination of the pharynx of
a patient with scarlet fever reveals essentially the same findings as
with pharyngitis.
• In addition, the tongue is usually coated and the papillae are
swollen. After desquamation, the reddened papillae are prominent,
giving the tongue a strawberry appearance .
• Typical scarlet fever is not difficult to diagnose; the milder form
with equivocal pharyngeal findings can be confused with viral
exanthems, Kawasaki disease, and drug eruptions.
 Scarlet Fever

Scarlet fever.
A, Punctate, erythematous rash (2nd day).
B, White strawberry tongue (1st day). C, Red
strawberry tongue (3rd day).
 Impetigo
Impetigo (or pyoderma) has traditionally been classified into 2
clinical forms: bullous and nonbullous.
 Impetigo
• Nonbullous impetigo is the more common form and is a superficial infection
of the skin that appears first as a discrete papulovesicular lesion surrounded
by a localized area of redness. The vesicles rapidly become purulent and
covered with a thick, confluent, amber-colored crust that gives the
appearance of having been stuck onto the skin. The lesions may occur
anywhere but are most common on the face and extremities. If untreated,
nonbullous impetigo is a mild but chronic illness, often spreading to other
parts of the body, but occasionally self-limited.
• Bullous impetigo is less common and occurs most often in neonates and
young infants. It is characterized by flaccid, transparent bullae usually <3 cm
in diameter on previously untraumatized skin. The usual distribution involves
the face, buttocks, trunk, and perineum. Although Staphylococcus aureus has
traditionally been accepted as the sole pathogen responsible for bullous
impetigo, there has been confusion about the organisms responsible for
nonbullous impetigo. In most episodes of nonbullous impetigo, either GAS or
S. aureus, or both, is isolated.
• Culture of the lesions is the only way to distinguish nonbullous impetigo
caused by S. aureus from that caused by GAS
 Impetigo
• Bullous impetigo is less common and occurs most often in
neonates and young infants. It is characterized by flaccid,
transparent bullae usually <3 cm in diameter on previously
untraumatized skin. The usual distribution involves the
face, buttocks, trunk, and perineum. Although
Staphylococcus aureus has traditionally been accepted as
the sole pathogen responsible for bullous impetigo, there
has been confusion about the organisms responsible for
nonbullous impetigo. In most episodes of nonbullous
impetigo, either GAS or S. aureus, or both, is isolated.
• Culture of the lesions is the only way to distinguish
nonbullous impetigo caused by S. aureus from that caused
by group A streptococcus.
 Meningitis
• Meningitis is an inflammation of the membranes (meninges) surrounding the
brain and spinal cord.
• Typical nonspecific early symptoms include fever, irritability, lethargy,
respiratory symptoms, refusal to drink, and vomiting. Less commonly,
diarrhea, sore throat, and chills/shivering are reported. A fine maculopapular
rash, which is indistinguishable from rashes seen after viral infections, is
evident in approximately 7% of cases early in the course of infection.
• As disease progresses, cold hands or feet and abnormal skin color may be
important signs, capillary refill time becomes prolonged, and a nonblanching
or petechial rash will develop in more than 80% of cases. In fulminant
meningococcal septicemia, the disease progresses rapidly over several hours
from fever with nonspecific signs to septic shock characterized by prominent
petechiae and purpura (purpura fulminans) with poor peripheral perfusion,
tachycardia (to compensate for reduced blood volume resulting from capillary
leak), increased respiratory hypotension (a late sign of shock in young
children), confusion, and coma (resulting from decreased cerebral perfusion).
 Meningitis
As disease progresses, cold hands or feet and abnormal skin color may be
important signs, capillary refill time becomes prolonged, and a nonblanching or
petechial rash will develop in more than 80% of cases. Coagulopathy, electrolyte
disturbance (especially hypokalemia), acidosis, adrenal hemorrhage, renal failure,
and myocardial failure, may all develop.

Most children with meningococcal disease can be managed with

antibiotics and simple supportive care and will improve rapidly