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Viral Exanthems

Ordonez, Jeff Crimson

Objectives

To define the term exanthem vs.


enanthem

To differentiate the different primary skin


lesions

To present a case and identify exanthem


based on the clinical signs and symptoms

To discuss briefly the common viral


infections that would present with an
exanthem

Definition

Exanthem

- Greek origin exanthema meaning to


bloom or break out.
- a rash that appears abruptly and affects
several areas of the skin simultaneously.

Enanthem
- An eruption of the mucous membrane

Primary Skin Lesions

Macule- flat <1cm

Papule- elevated
<1cm

Primary Skin Lesions

Plaque- similar to
papule, >1cm,
flat and broad

Nodule- similar to
papule, >1cm,
round

Primary Skin Lesions

Vesicle- fluidfilled, <1cm

Bullaesimilar to
vesicle,
>1cm

Primary Skin Lesions

Pustule- pusfilled, initial


papular phase,
surrounded by
erythema

Wheal (hive)edematous
papules and
plaques

CASE
ID: Chloe, 12 month old baby
girl
CC: High grade fever and
seizure

HPI

1 day PTA

high grade fever (39.8 C)

clear nasal discharge

good suck and playful

given Paracetamol at 10mkdose- temporary


relief

fever reappear after 4-5 hours (39.2-39.5)

HPI

Few hours PTA

still with HGF (40.1)

irritable but still feeding

Few minutes PTA

upward rolling of eyeballs

stiffening of extremities

lasted for 5 seconds then returned to normal

FHx: older 2 siblings having febrile seizures

PE: unremarkable

Dx: Benign Febrile Convulsions etiology to


be determined

COURSE AT THE
WARDS

Given Para q 4 for fever

admitted for observation of recurrence of


seizure

Temp: 39 C every 3-4 hours -> TSB done

COURSE AT THE
WARDS

1st HD, Day 3 of illness

fever disappeared

playful

After 12 hours

Rose-colored rashes appeared on trunk

Discrete, approximately 3-5 mm, slightly raised

Eventually spread to the neck and face at the end of


the day

COURSE AT THE
WARDS

2nd HD

most rashes were in the proximal


extremities

none on the trunk and face

rashes eventually disappeared by the end


of the day

COURSE AT THE
WARDS

absence of fever

non-repetition of seizure

disappearance of rash

improved well-being
DISCHARGED!

Based on Chloes history and


PE, what is most likely the
diagnosis?
A. Rubella
B. Measles
C. Varicella
D. Erythema infectiosum
E. Erythema subitum

RUBELLA

Synonyms : German Measles or 3 day measles

The disease is commonly a mild childhood


diseases; however, infection in early pregnancy
may cause fetal death, or serious birth defects
known as congenital rubella syndromes (CRS).

CRS is an important cause of hearing, visual


impairment and mental retardation in countries
where rubella is endemic.

Rubella

Etiology: Rubella virus, member of Family


Togaviridae, genus Rubivirus

Pathogenesis: virus replicates in the respiratory


epithelium then spreads to regional lymph nodes

MOT: direct or droplet contact from nasopharyngeal


secretions

Period of communicability: 5 days before to 6 days


after the appearance of rash

Incubation period:14-21 days

Epidemiology

Based on available data from 2008 2010,


over 80% of reported rubella cases
occurred in the persons under 20 years old.

Clinical Manifestation

Many cases of non-congenital rubella are


subclinical

Prodrome: low grade fever, sore throat, red


eyes with or without eye pain, headache,
malaise, anorexia, and lymphadenopathy (SO,
PA, AC LN)

Exanthem: pruritic, small, irregular pink to red


macules and papules which begin on the face
and neck that coalesce, then it spreads
centrifugally to involve the torso and
extremities, occur as discrete macules over 24
hours

Exanthem

Enanthem

Tiny rose-colored
lesions on the
oropharynx or
petechial
haemorrhages on the
soft palate and uvula
(Forchheimer spots)20%

Clinical Course

Adults tend to have more prodromal


symptoms and complications compare to
children

Arthritis sometimes accompanies exanthem


(more common in teenagers and adult
women)

Duration of rash is 3 days and resolves


without desquamation. Clears the head and
neck first

Encephalitis and thrombocytopenia are


potential complications

Evaluation

Leukopenia, neutropenia and mild


thrombocytopenia

Dx is usually made using serology to detect


rubella-specific IgM antibody or to
document a 4-fold rise in antibody tiger in
acute and convalescent phase serum

Should be reported to local health


departments

Treatment

No specific treatment

Supportive care

Control measures for rubella includes


droplet precautions and exclusion from
school or child care for 7 days after onset
of rash

Vaccine: MMR 2 dose regimen (12-15


months and 4-6 years of age)

MEASLES

Synonyms: Rubeola

Etiology: Measles virus, member of Family


Paramyxoviridae, genus Morbillivirus

MOT: contact with large droplets or small-droplet


aerosols

Period of communicability: 3 days before to 4-6 days


after the appearance of rash

Incubation period: 8-12 days

Immunocompromised patients can be contagious for the


duration of the illness

Pathogenesis
Incubation (8-12 days)

Virus migrates to regional LN

Primary viremia - virus goes to RES

Secondary viremia- virus goes to body surfaces

Prodromal illness

Epithelial necrosis and giant cell formation in body tissues

Viral shedding

Cells are killed by cell-to-cell fusion

Exenthematous Phase

Antibody production

Viral replication and symptoms begin to subside

Epidemiology

Most common in children 3-5 years old

Incidence has decreased substantially


where measles vaccine has been instituted

Still common in many developing countries


(parts of Africa and Asia)

Clinical Manifestation

Prodrome: fever, malaise, 3C (cough,


coryza, conjunctivitis), Koplik spots

Enanthem: Koplik spots (pathognomonic)


appears 1-4 days prior to onset of rash,
discrete red lesions with bluish white spots
in the center on the inner aspects of the
cheeks at the level of premolar

Koplik Spots

Clinical Manifestation

Exanthem: red maculopapular eruption that


begins on the forehead (around the
hairline), behind the ears , and on the
upper neck which spreads downward to
torso and extremities, reaching the palms
and soles. It becomes confluent on face
and upper trunk

Exanthem

Clinical Manifestation

Recovery: Clinical improvement begins


within 2 days of appearance of the rash.
Rash fades over about 7 days leaving fine
desquamation

Cough lasts the longest often up to 10 days

Evaluation

Based on clinical and epidemiological


findings

Serology: Anti measles IgM and IgG,


isolation of measles virus or identification
of measles RNA

Histologic evaluation of skin lesions or


respiratory secretions may show syncytial
keratinocytic giant cells (Warthin-Finkeldey
Giant cells)

Complications

Pneumonia is the most common cause of


death in measles. (GIANT CELL
PNEUMONIA)

Acute otitis media is the most common


complication of measles.

Groups at increased risk for complications


of measles include immunocompromised
hosts, pregnant women, malnourished
individuals, and persons at extremes of age

Management

Uncomplicated measles is self-limiting,


lasting 10-12 days

Supportive

Maintenance of hydration, oxygenation


and comfort are the goals of therapy.

Vitamin A is indicated for all patients with


measles.

ERYTHEMA
INFECTIOSUM

Synonyms: Fifth disease

Etiology: Parvovirus B19, Parvoviridae family,


Erythrovirus genus

MOT: respiratory route via large-droplet spread from


nasopharyngeal viral shedding, percutaneous exposure
to blood and blood products and vertical transmission
from mother to foetus.

Period of communicability: most infectious before onset


of rash

Incubation period: 4-28 (16-17) days

Pathogenesis

Primary target of B19 infection is the


erythroid cell line (erythroid precursors)

Produces cell lysis, leading to progressive


depletion of erythroid precursors and
transient arrest of erythropoiesis

Transient aplastic crisis or Post infectious


phenomena

Epidemiology

Most common in children, 4-10 years old,


but can affect all ages

Tends to occur in epidemics

Seroprevalence increases with age, 40-60%


of adults having evidence of prior infection

Clinical
Manifestations
Prodrome: low grade fever, headache, malaise,

pruritus, myalgia and joint pain

Exanthem: 3 stages

1.)erythematous facial flushing slapped cheek


appearance

2.) rash spreads rapidly or concurrently to the


trunk and proximal extremities as diffuse macular
erythema

3.) Central clearing of macular lesions, giving


rash a lacy, reticulated appearance

Exanthem

Clinical
Manifestations

Rash tends to be more prominent on


extensor surfaces, sparing the palms and
soles

Rash resolves spontaneously without


desquamation

Evaluation

Based on clinical presentation

Anti-B19 IgM is the best marker of


recent/acute infection (w/n 2-4 months)

Anti-B19 IgG serves a marker of past


infection or immunity

Treatment

No specific antiviral therapy for B19


infection

Recur with exposure to sunlight, heat,


exercise, and stress

Supportive therapy

Transfusion in transient aplastic crisis

Varicella

Synonyms: Chickenpox

Etiology: VZV

MOT: Contact with oropharyngeal secretions and


fluid of skin lesions of infected individuals, either
by airborne spread or through direct contact

Period of communicability: 2 days before to 7


days after the onset of the rash, when all lesions
are crusted

Incubation period: 10-21 days

Pathogenesis

VZV infects via conjunctivae or upper respiratory tract and


tonsillar lymphoid tissue

During the early part of I.P., virus replicates in local lymphoid


tissue.

Disseminates by a primary viremia and infects regional


lymph nodes. the liver, spleen and other organs

Secondary viremia follows, resulting in cutaneous infection


with the typical vesicular rash that lasts 3-7 days

VZV is also transported back to the mucosa of upper


respiratory tract and oropharynx during the late incubation
period permitting spread to susceptible contacts 1-2 days
before the appearance of rash

Epidemiology

Post vaccine era- peak incidence in children


10-14 years of age

Clinical
Manifestations

Prodrome: fever, malaise, anorexia, headache and


occasionally mild abdominal pain 24-48 hours before
the rash appears

Fever and other systemic symptoms usually resolve


within 2-4 days after the onset of rash

Exanthem: Lesions first appear on the scalp, face, or


trunk. Initial exanthem, intensely pruritic
erythematous macules that evolve through papular
stage to form nonumbilicated oval clear, fluid-filled
vesicles tear drop

Clouding and umbilication of the lesions begin 24-48


hours

Exanthem

Clinical
Manifestations

While the initial lesions are crusting, new crops


form on the trunk followed by the head, the
face, and then extremities. (CENTRIPETAL)

Total of 100-500 lesions, with all forms present


at the same time

Lesions may also be found on mucous


membranes

Pruritus is universal and marked

Lymphadenopathy may be generalized

Evaluation

Based on clinical history and examination

PCR is the current diagnostic method of


choice

Treatment

Symptomatic therapy of varicella includes


antipyretics, cool baths and careful hygiene.

Oral Acyclovir

not recommended routinely in healthy children

Given within 24 hours of rash -> modest


decrease in signs and symptoms

80 mg/kg/day divided in 4 doses x 5 days


(max 3200mg/day)

Treatment

Considered in healthy people at increased risk:

>12 years of age unvaccinated

chronic cutaneous or pulmonary disorders

Long term salicylate therapy

Short, intermittent, or aerosolized steroids

Secondary household cases

Pregnant women in 2nd/3rd trimester

Complications

Secondary infection of skin lesions by


streptococci or staphylococci is the most
common complication

Reye syndrome may follow varicella; thus,


salicylate use is contraindicated during
varicella infection

Primary varicella usually resolves


spontaneously.

ROSEOLA INFANTUM

Synonyms: Exanthema subitum, Sixth disease

Etiology: Human herpesvirus-6 and less


commonly HHV 7

MOT: saliva or respiratory droplets of


asymptomatic adults or older children

Period of communicability: Adults develop


lifelong latent infection and intermittent viral
shedding

Incubation period: 5-15 days

Pathogenesis

HHV 6 infect mature mononuclear cells and


caused a relatively prolonged verifier
during primary infection

Epidemiology

Children 6 months-4 years

Most common exanthema before age 2

Transplacental antibody protects most


infants until 6 months of age

Clinical
Manifestations

Acute febrile illness, lasting approximately 3 to 7 days, often


followed by the characteristic rash of roseola (in ~ 20% of
infected children)
Prodrome: High fever (39-40C), palpebral edema, cervical
lymphadenopathy, mild upper respiratory symptoms. Child
appears well. As fever subsides, exanthem appears (exanthema
subitum means sudden rash).
Exanthem: faint pink or rose-colored, nonpruritic, 2-3 mm
macules and papules surrounded by white halos. Begins on
trunk, spreads to neck and proximal extremities. Lasts 1-3 days.
Enanthem: Nagayama spots- ulcers at the uvulopalatoglossal
junction

Exanthem

Enanthem

Evaluation

Most characteristic lab findings are lower


mean numbers of WBC, lymphocytes and
neutrophils

Viral culture is the gold standard method to


document active viral replication.

Treatment

Benign, self-limited disease

Supportive care

Maintain hydration

Antipyretics

Complications

Convulsions are the most common


complication of roseola

Viral
Syndrome

Rubeola

Rubella

Varicella
Erythema
Infectiosum

Associated
signs and
Epidemiology
symptom

Causative
Virus

Exanthem/
Enanthem

Measles

Erythematous macules
and papules; spread
from head down. White
erosions on buccal
mucosa (Koplik spots)

Rubella

Pruritic pink macules


and papules, spread
from head down over 24
Any age, under 20
hrs. Petechial lesions on
soft palate (Forsheimers
sign)

Low grade fever and


occipital/ retroauricular
nodes
STAR complex (sore
throat, arthritis, rash)

VZV

Generalized pruritic
macules, papules that
rapidly progress to
Any age, MC; 10-14
vesicles (clear to cloudy years old
fluid) which then
ulcerates, crust and heal.

Significant pruritus

Parvovirus
B19

Erythematous slapped
cheeks, followed by
Any age, MC: 4-10 years
reticulate erythema on
old
body.

Low grade fever (7-10


days)
STAR complex

Erythematous macules

Any age, MC: 3-5 years


old

3C (cough, coryza,
conjunctivitis)
Desquamation