VIRAL EXANTHEMS

Sahara Tuazan Abonawas

Class 2013

EXANTHEM
A widespread rash that is usually accompanied by systemic symptoms usually caused by an infectious condition represents either a o reaction to a toxin produced by the organism o damage to the skin by the organism o an immune response
Enanthem - Discrete lesions found at the buccal mucosa

Most common childhood viral exanthems:

Rubeola (Measles or First disease) Rubella (German Measles or Third disease) Erythema infectiosum (Fifth disease) Roseola infantum (Exanthem subitum or Sixth disease) Varicella (Chickenpox)

Viral Exanthem

Etiology

Incubation period (days) 10-12

Prodromal period (days) 3-5

Rash

Complications

Rubeola (Measles) Rubella (German Measles) Erythema infectiosum (Fifth disease) Roseola infantum (Sixth disease)

Measles virus Rubella virus Parvovirus

Maculopapular, starts on head and progresses caudally Discreet maculopapular rash that begins on the face and spreads quickly Slapped cheeks then reticular erythematous macupapular rash beginning on arms then to the trunk and legs Discreet maculopapular that starts on trunk and spreads to extremities

Otitis media, Pneumonia, Encephalitis Relatively uncommon to children

14-21

shorter than that of measles

4-28

HHV-6 HHV-7

5-15

Varicella (Chickenpox)

Varicella virus

10-21

Pruritic teardrop shaped vesicles that break and crust over beginning on face or trunk and spreading to extremities

Bacterial superinfection, Pneumonia, Encephalitis, Bleeding disorders, Congenital infection, Lifethreatening perinatal infection

RUBEOLA
(Measles)

Definition
An acute viral infection characterized by a

final stage with maculopapular rash erupting over the neck and face, trunk, arms and legs accompanied by high fever

Etiology
Measles virus

- an RNA virus of genus Morbillivirus, family Paramyxoviridae - only one serotype is known - shed in nasopharyngeal secretions, blood, and urine during the prodromal period and for a short time after the rash appears - can remain viable for at least 34 hr at room temperature.

Epidemiology
Endemic throughout the world

Peak age incidence = 5-10 y/o

But now occurs most often in unimmunized preschool-aged children

Transmission
Highly contagious approximately 90% of susceptible family

contacts acquire the disease Maximal dissemination of virus - occurs by droplet spray during the prodromal period (catarrhal stage)

Pathogenesis
Essential lesion of measles

- found in the skin, conjunctivae, and the mucous membranes of the nasopharynx, bronchi, and intestinal tract Serous exudate and proliferation of mononuclear cells and a few polymorphonuclear cells - occur around the capillaries Hyperplasia of lymphoid tissue - usually occurs, particularly in the appendix, where multinucleated giant cells of up to 100 m in diameter (Warthin-Finkeldey reticuloendothelial giant cells) may be found

 Particularly notable about the sebaceous glands and hair follicles in the skin Koplik spots - consist of serous exudate and proliferation of endothelial cells similar to those in the skin lesions A general inflammatory reaction of the buccal and pharyngeal mucosa - extends into the lymphoid tissue and the tracheobronchial mucous membrane

Clinical Manifestations
Three clinical stages:

Incubation stage Prodromal stage with an enanthem (Koplik spots) and mild symptoms Final stage with a maculopapular rash accompanied by high fever

Incubation stage
lasts approximately 10-12 days to the first prodromal symptoms and another 2-4 days to the appearance of the rash may be as short as 6-10 days Body temperature - may increase slightly 9-10 days from the date of infection and then subside for 24 hr or so Patient - may transmit the virus by the 9th-10th day after exposure and occasionally as early as the 7th day, before the illness can be diagnosed

Prodromal stage
Lasts 3-5 days characterized by o low-grade to moderate fever o dry cough o coryza o conjunctivitis o an enanthem (Koplik spots) o Usually with photophobia May be severe with sudden high fever and

pneumonia An enanthem or red mottling is usually present on the hard and soft palates

Koplik spots
grayish white dots, usually as

small as grains of sand, that have slight, reddish areolae occasionally they are hemorrhagic tend to occur opposite the lower molars but may spread irregularly over the rest of the buccal mucosa found within the midportion of the lower lip, on the palate, and on the lacrimal caruncle rarely appear and disappear rapidly, usually within 12-18 hr

Transverse line of conjunctival inflammation - sharply demarcated along the eyelid margin - may be of diagnostic assistance in the prodromal stage - disappears as the entire conjunctiva becomes involved

Final stage
The temperature rises abruptly as the rash appears

and often reaches 40C (104F) or higher

Symptoms - subside rapidly as the rash appears on

the legs and feet within about 2 days, usually with an abrupt drop in temperature to normal
Within 24 hr after the temperature drops:

Patients appear well

1 40
T E M

3 4

8 9

39
38 37
Fever Dry cough Coryza Conjunctivitis

Rash Koplik spots

Rash - starts as faint macules in the upper lateral parts of the neck, behind the ears, along the hairline, posterior parts of the cheek

First 24 hour: Maculopapular rash -spreads rapidly over the entire face, neck, upper arms, & upper part of the chest

2nd day : Rash spreads over the back, abdomen, entire arm, & thighs
2nd-3rd day: Rash - reaches the feet and concomitantly rash begins to fade on the face Branny desquamation & brownish discoloration as the rash fades and disappears within 7 days

Diagnosis
Based on clinical features
Measles IgM antibodiesdetected for 1 month

after illness

Multinucleated giant cells can be demonstrated

in smears of nasal mucosa during prodromal stage

WBC-with Leukopenia & a relative lymphocytosis

CSF - increase in protein, small increase in

lymphocytes, and normal level of glucose

Treatment
NO specific antiviral therapy

Treatment is primarily supportive Antipyretics for fever Bed rest Maintenance of adequate fluid intake Appropriate antimicribial therapy

Prognosis
Case fatality rate = 1-3/1000 cases (USA) Deaths 10 due to pneumonia or 20 bacterial

infections Developing countries: frequently occurs in infants; possibly because of concomitant malnutrition disease - very severe and has a high mortality

Prevention
Isolation precautions 7th day after exposure until 5 days

after the rash has appeared

Active immunization

1ST dose recommended at 12-15 mo af age 2ND dose at 4-6yrs of age or after 4 wks of 1st dose Contraindications: pregnant women, children with primary

immunodeficiency, untreated tuberculosis, cancer, or organ transplantation, those receiving long-term immunosuppressive therapy, or severely immunocompromised HIV-infected children

Passive immunization

Effective for prevention within 6days of exposure Immune globulin - <12 mo of age: 0.25mL/kg max. 15 ml Immunocompromised: 0.5mL/kg max 15 ml

RUBELLA
(German or Three-day measles)

Definition
An acute viral infection characterized by mild

constitutional symptoms, a rash similar to mild rubeola or scarlet fever, enlargement of postoccipital, retroauricular and posterior cervical lymph nodes

Etiology
Rubella virus

- an RNA Virus of genus Rubivirus in the family Togaviridae

Epidemiology
Humans - the only natural host Virus

- spread by oral droplet or transplacentally - present in nasopharyngeal secretions, blood, feces, and urine - shed in nasopharyngeal secretions, blood, feces, and urine - has been recovered from the nasopharynx 7 days before exanthem and 7-8 days after its disappearance Distributed worldwide Affects both sexes equally Peak incidence in children: 5-14 yrs old But most cases now occur among susceptible teenagers and young adults

Clinical Manifestations
Incubation period : 14-21 days
Prodromal phase
characterized by mild catarrhal symptoms shorter than that of measles Most characteristic sign: retroauricular, post

cervical, postoccipital lymphadenopathy - evident at least 24 hr before the rash appears and may remain for 1 wk or more

Forchheimer spots
- enanthem - appears just before the onset of skin rash - discrete rose spots on the soft palate which coalesce into red bluish & extend over the fauces

1
T e m p e r a t u r e

3 4

8 9 10

40

39
38

37
Adenitis

Rash

Exanthem
More variable Begins on the face and spreads quickly within 24 hrs: Discreet maculopapules

present in large number Large areas of flushing spread rapidly over entire body usually mild itching

2nd day : pinpoint appearance with 3rd day : eruption with minimal desquamation

 No

photophobia Fever is low grade or absent during the rash and persist for 1-3 days Anorexia, headache, and malaise - not common

Diagnosis
Evident at clinical symptoms and history Confirmed by serology, virus culture from

nasopharyngeal secretions and blood WBC = normal or decreased IgM antibodies are detected in first few days of illness

Treatment
No

specific antiviral therapy Treatment is entirely supportive Antipyretics (acetaminophen or Ibuprofen) are indicated for fever

Prognosis

Excellent

Prevention

MMR vaccine 1st dose: 12-15 mos 2nd dose: anytime at childhood (4-6yr) orafter 4 wks of first dose Pregnant patients should not be given rubella vaccine and females should avoid becoming pregnant for 3 months after vaccination

ROSEOLA INFANTUM
(Exanthem subitum)

Definition
A mild febrile, exanthematous illness

occuring almost exclusively during infancy (peak: 6-15 months of age)

Etiology
Herpesvirus-6 (HHV-6)and Herpesvirus-7

(HHV-7) - herpes virus subfamily of herpes virus

Epidemiology
Primary infection with HHV-6 occurs early in life
> 90% of newborn infants are (+) HHV-6
By 4-6 months old prevalence drops to 0-60% Peak acquisition is at 6-15 months old

Primary infection with HHV-7 occurs later

90% at 7-10 yrs old

Transmission
Virus - probably acquired from the saliva of healthy persons and enters the host through the oral, nasal, or

conjunctival mucosa Most adults excrete HHV6 and HHV7 in saliva and women excrete them in genital tract HHV6 can be transmitted in utero NO evidence that infection can be transmitted in breastmilk

Clinical Manifestations
Incubation Period - averages 10 days (5-15 days) Prodromal Period - usually asymptomatic but may include mild upper respiratory tract signs * minimal rhinorrhea

* slight pharyngeal inflammation * mild conjunctival redness

 Clinical Illness is heralded by a febrile stage:

(37.9-400C) for 3-5 days then typically resolves abruptly (crisis) or occasionally gradually over 24-36 hrs (lysis) Irritable and anorexic Seizures occur (5-10%)
Temperature

Nagayama spots - ulcers at uvulopalataoglossal

junction common in infants in Asian countries

1
T e m p e r a t u r e

3 4

8 9 10

40

39
38
Febrile Stage

37

Rash

Rash o appears 12-24 hrs of resolution of fever o rose colored, fairly distinctive o discrete, small (2-5mm), slightly raised pink lesions on the trunk which spreads to the neck, face, and proximal extremities o not usually pruritic o no vesicles or pustules develops o fades after 1-3 days

Diagnosis
Can be established based on age, history and

clinical findings Lab findings: WBC = 8,000-9,000 during first few days and then decreases with appearance of rash May perform specific HHV6 serologic testing IgM develops by 5th to 7th day of illness and resolves within 2 months Seroconversion 4x = positive result

Treatment
HHV-6 - inhibited by ganciclovir, cidofovir,

foscarnet
HHV-7 - inhibited by cidofovir, foscarnet
Supportive treatment

Children at pre-eruptive stage may benefit from Acetaminophen and Ibuprofen

Prognosis
Excellent

Prevention
No vaccine has been developed

Erythema infectiosum
(Fifth disease)

Definition
A benign, self-limited exanthematous

illness of childhood

Etiology
Caused by Parvovirus B19, which are

small DNA viruses of the genus Erythrovirus in the family Parvoviridae

Replicate in mitotically active cells

Epidemiology
Common and worldwide Clinically

apparent infections are most prevalent in school-aged children (5 and 15 years of age) with 70% of cases occurring between 5-15 yrs old

Transmission
Via exposure to fluid from the nose (respiratory

secretions)
Also transmissible in blood and blood products

Transmission rate in household contacts is from15-30%

Mothers more commonly affected than fathers

Children no longer infectious by the time they have

developed a rash

Clinical Manifestations
Incubation period
Ranges from 4 to 28 days (average 16-17 days)

Prodromal phase
mild Consist of low-grade fever, headache and symptoms of

URTI

Final Stage
Hallmark : characteristic rash

Initial stage : erythematous facial flushing, described as "slapped-cheek appearance

Rash
spreads rapidly or concurrently to

the trunks and proximal extremities as diffuse macular erythema

Central clearing of macular lesions

- occurs promptly, giving the rash a lacy, reticulated appearance Characteristic sparing of palms and soles

resolves spontaneously without

desquamation but tends to wax and wane over 1-3 weeks

can recur with exposure to

sunlight, heat, exercise and stress

Diagnosis
Usually based on clinical presentation of the typical rash

and exclusion of other conditions

Serologic test for B19 B19 specific IgM develops rapidly after infection and persist for 6-8wks

Treatment
No specific antiviral therapy

Prognosis
EXCELLENT

VARICELLA (Chicken Pox)

Definition
an acute febrile rash illness, common in children who have not been immunized variable severity but is usually self-limited

Etiology
Varicella-zoster virus (VZV) a neurotropic human herpes virus with Etiology. similarities to herpes simplex virus also an -herpesvirus enveloped with double-stranded DNA genomes that encode more than 70 proteins, including proteins that are targets of cellular and humoral immunity

Epidemiology
Most children were infected by 15 yr of age, with fewer than 5% of adults Epidemiology. remaining susceptible Higher rates of complications and deaths among infants, adults, and immunocompromised persons Transmission of VZV to susceptible individuals occurs at a rate of 65-86% Patients with varicella are contagious from 24-48 hr before the rash appears and until vesicles are crusted, usually 3-7 days after onset of rash

Pathogenesis
Transmitted in respiratory secretions and in the fluid of skin lesions either by airborne spread or through direct contact Pathogenesis.
Primary infection (varicella) results from the respiratory inoculation of virus Replicates in the respiratory tract followed by a brief subclinical viremia during the early part of the 10-21-day incubation period Widespread cutaneous lesions occur during a second viremic phase

Peripheral blood mononuclear cells carry infectious virus, generating new crops of vesicles for 3-7 days Also transported back to respiratory mucosal sites during the late incubation period, permitting spread to susceptible contacts before the appearance of rash Establishes latent infection in sensory ganglia cells in all individuals who experience primary infection

Clinical Manifestation
Illness - usually begins 14-16 days after exposure Incubation period - can range from 10-21 days Clinical Manifestations. 24-48 hr before the rash appears: Fever, malaise, anorexia, headache, and occasionally mild abdominal pain Temperature elevation - usually moderate, usually from 100102F but may be as high as 106 Fever and other systemic symptoms - persist during the first 2-4 days after the onset of the rash

 Varicella lesions - often appear first on the scalp, face, or trunk 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 Distribution of the rash - predominantly central or centripetal Ulcerative lesions involving the oropharynx and vagina are also common; many children have vesicular lesions on the eyelids and conjunctivae, but corneal involvement and serious ocular disease is rare

 About 300 - average number of varicella lesions Healthy children - may have fewer than 10 to more than 1,500 lesions Hypopigmentation or hyperpigmentation of lesion sites - persists for days to weeks in some children Severe scarring - unusual unless the lesions were secondarily infected

Complications
Bacterial super-infection Pneumonia Encephalitis Bleeding disorders Congenital infection Life-threatening perinatal infection

Treatment
Oral therapy with acyclovir (20 mg/kg/dose; maximum: 800 mg/dose) given as 4 doses per day for 5 days should be used to treat uncomplicated varicella in nonpregnant individuals 13 yr of age or older and children 12 mo of age or older with chronic cutaneous or pulmonary disorders; receiving short-term, intermittent, or aerosolized corticosteroids; receiving long-term salicylate therapy; and possibly second cases in household contacts Intravenous acyclovir (500 mg/m2 q 8 hr IV) therapy initiated within 72 hr of development of initial symptoms decreases the likelihood of progressive varicella and visceral dissemination in high-risk patients. Treatment is continued for 7 days or until no new lesions have appeared for 48 hr

THANK YOU