Rashes and Fevers

Question 1

What is roseola infantum?

Answer 1

Roseola infantum (also known as exanthem subitum, occasionally sixth disease) is a common disease of infancy caused by the human herpes virus 6 (HHV6). It has an incubation period of 5-15 days and typically affects children aged 6 months to 2 years.

Question 2

What are the clinical features of roseola infantum?

Answer 2

High fever: lasting a few days, followed later by a maculopapular rash
Nagayama spots: papular enanthem on the uvula and soft palate
Febrile convulsions occur in around 10-15%
Diarrhoea and cough are also commonly seen

Question 3

What is the management of roseola infantum and what complications can occur?

Answer 3

Management
None – just supportive treatment and ruling out dangerous differentials
School exclusion is not needed.

Compilations
Aseptic meningitis
Hepatitis

Question 4

What is slapped cheek disease?

Answer 4

Slapped Cheek Disease (Fifth disease, Erythema Infectiosum, Erythrovirus)
Infection of parvovirus B19 most commonly in the spring.

Question 5

What are the 3 distinct phases of slapped cheek disease?

Answer 5

1. 2-4 days bright red erythema appears over cheeks that spares the nose and eyes
2. 4-8 days erythematous macular to morbilliform rash on extensor surfaces
3. Days to weeks following rash fades leaving reticulated lacy pattern
   Complications uncommon in children but in adults causes arthralgia and arthritis

Question 6

What is rubella?

Answer 6

Caused by the Rubella virus, respiratory transmission that causes a communicable erythematous disease. Half of those infected are asymptomatic. Incubation period of 14-21 days.

Question 7

How does rubella present?

Answer 7

Prodromal symptoms last 1-5 days and include eye pain on eye movement, conjunctivitis, sore throat, head and body aches, low grade fever and tender lymphadenopathy particularly posterior auricular and sub-occipital.

Typically termed 3 days measles – exanthem starts on neck and spreads to trunk and extremities within 24 hours. Begins to fade on second day and disappears by day 3.

Question 8

What is measles?

Answer 8

Caused by the measles virus, very contagious disease with each infected individual infecting someone else in 90% of cases. Incubation period of 7-10 days.

Question 9

What is the typical presentation of measles?

Answer 9

Prodrome of cough, coryza, kolpik spots (white spots) in the mouth, high fever and sore red eyes. Main rash develops 2-4 days after initial symptoms it is morbilliform (rose red and extensive) and starts behind the ears.

Question 10

What complications can occur from measles infection?

Answer 10

Complications include otitis media, diarrhoea, bacterial pneumonia, tracheitis, encephalitis, corneal ulceration, hepatitis, convulsions, ITP, myocarditis and death.

Question 11

What is scarlet fever?

Answer 11

Group A Beta haemolytic strep in children between 5-15 years. Spread by aerosol or skin to skin contact. Incubation period 1-4 days

Question 12

How does scarlet fever present and how is it managed?

Answer 12

Presents with typical viral symptoms with flushed cheeks and bright red, swollen tongue with strawberry appearance. Fine red rough rash that feels like sandpaper appears up to 3 days after fever starts. Rash fades after 3-4 days and then peeling begins. Complications include rheumatic fever, Glomerulonephritis and erythema nodosum.

Treat with oral penicillin, notify local infection control centre and school exclusion for the next 24 hours.

Question 13

What complications can occur from scarlet fever?

Answer 13

Complications include rheumatic fever, Glomerulonephritis and erythema nodosum.

Question 14

How does kawasaki’s disease present?

Answer 14

Unknown cause, thought to be post viral infection.

Fever for 5 days persistently (resistant to paracetamol and NSAIDs plus 4/5 of the following:
1. Bilateral conjunctival infection
2. Polymorphous rash
3. Non purulent lymphadenopathy especially cervical
4. Redding or cracked lips, strawberry tongue and diffuse infection of mucosa
5. Reddening of palms or soles and desquamation of hands
CRASH (Conjunctivitis, Rash, Adenopathy, Strawberry tongue and Hands and feet)

Question 15

How does herpes simplex virus 1 present?

Answer 15

Usually passed on via mucous membranes or skin. Clinical manifestations include: Asymptomatic, Gingivostomatitis (vesicles on lips, gums and tongue and hard palate). Difficult to eat or drink with progress to painful ulcers and child will be miserable. Can also present with cold sores, conjunctivitis, meningitis and encephalitis. Treat with oral or IV aciclovir, analgesia and fluids (oral or IV).

Question 16

What is chicken pox?

Answer 16

Caused by primary infection with varicella zoster virus (herpes virus 3) whilst shingles is a secondary reactivation of the virus. It is highly contagious and spread via respiratory route. A child is infective from 4 days before the rash until all lesions are crusted over. Its incubation period is roughly 10-21 days.

Question 17

How does chicken pox present?

Answer 17

Fever, itchy rash starting on head and spreading. Initially macular then papular and then vesicular and a systemically upset child. Rash concentrated on the trunk

Question 18

What are the complications from chicken pox?

Answer 18

Secondary bacterial infection (NSAIDs increase risk). Usually only one lesions affected but rarely may get group-A strep soft tissue infection resulting in necrotising fasciitis.
Pneumonia – rare
Encephalitis – most commonly associated cerebellitis but resolves within a month
Disseminated haemorrhage chicken pox
Arthritis, nephritis and pancreatitis – again rare

Question 19

How should chicken pox be managed?

Answer 19

Supportive
Keep cool and trim nails
Avoid NSAIDS
Calamine lotion
Children should be excluded from school until all lesions are dry and have crusted over which is usually 5 days after the first onset.
Immunocompromised patients and new-borns with peripartum exposure should receive VZ immunoglobulin and if chicken pox develops treated with Aciclovir.

If bacterial superinfection then give flucloxacillin

Question 20

What is impetigo?

Answer 20

Superficial bacterial infection of the skin either from S.Aureus or Strep pyogenes. Can be primary or a complication of eczema or chicken pox or other condition. This occurs particularly during warm weather and is very contagious.

Question 21

How does impetigo present?

Answer 21

Lesions tend to appear on face, flexures and limbs not covered by clothing. Gives a typical golden crusted skin lesion around the mouth.

Question 22

How should impetigo be managed?

Answer 22

If limited and localised then hydrogen peroxide 1% cream first line,
2nd line topical fusidic acid or mupirocin if MRSA and resistant to fusidic acid
If extensive then oral flucloxacillin, or oral erythromycin
Exclusion from school until lesions crusted and healed or 48 hours after commencing antibiotic treatment

Question 23

What causes hand foot and mouth disease?

Answer 23

Infection of Coxsackie A16 virus usually in children under 10 years old.

Question 24

How does hand, foot and mouth disease present?

Answer 24

Symptoms include high fever, cough, sore throat and stomach ache. Oral red lesions on tongue, inside mouth which progress to yellow-grey ulcers. After these ulcers disappears spots develop on the hands and soles and turn into blisters. Lasts about 7-10 days.

Question 25

What is HSP?

Answer 25

Acute IgA mediated disorder causing a vasculitis like reaction following a viral infection.

Question 26

How does HSP present?

Answer 26

Can often involve joints, kidneys and rarely the lung and CNS. Typically: rash especially in legs, abdominal pain and vomiting, joint pain, oedema and haematuria.

Question 27

What are milia?

Answer 27

Small raised pearly white or yellow bumps on the skin. Found on half of babies – regarded as normal. Found on the face and chest mainly but can be found anywhere. Usually clears spontaneously after a few weeks. – Keratin deposit in in forming sweat glands.

Question 28

What is erythema toxicum neonatorum?

Answer 28

Harmless rash appearing on day 2-3 and disappears a few days later. Small firm yellow or white raised bumps filled with pus on a erythematous area of skin. Begins on the face and concentrated on the trunk. Does not appears on soles and palms.

Question 29

What is a naevus complex or stork bite marks?

Answer 29

Affects almost half of children, found on the face and back of head due to distention of dermal capillaries. Fade eventually except those on the back of the head though these are usually covered by hair.

Question 30

What is cradle cap?

Answer 30

Large greasy yellow or brown scales on the scalp that is not itchy. Can also affect ears, face, neck, nappy area, and skin folds. Clears on its own but baby oil can help. Also known as seborrheic dermatitis. May develop in the first few weeks of life. It is characterised by an erythematous rash with coarse yellow scales. Seborrhoaeic dermatitis in children tends to resolve spontaneously by around 8 months of age

Management depends on severity
Mild-moderate: baby shampoo and baby oils
Severe: mild topical steroids e.g. 1% hydrocortisone

Question 31

What is a strawberry naevus?

Answer 31

Also known as cavernous haemangioma, most common tumour in infancy affecting 10% of Caucasians and a 3:1 F:M. Common with low birth weight, prematurity and multiple gestations. Present from birth or develop within the first week. Often not there at birth then start in the first month as a red flat area but develops raised red dimples. Grow with the child till 3-15 months then begin to regress. Majority are found on the head and neck but some can be internal.

Question 32

What is a port-wine stain?

Answer 32

Pink to purple vascular flat patches due to vascular malformation with ectasia of the superficial dermal capillaries. Most commonly affect the face and are unilateral with a distinct cut off. Lesions tend to persist, darken and thicken with age. Can be improved with laser surgery.

Question 33

What are mongolian spots?

Answer 33

Black/blue pigmented lesions usually on the buttocks or base of the spine. Caused by entrapment of melanocytes during migration. Most often found in afro-Caribbean and Asian babies. Fade over the first few weeks and may be mistaken for bruises.

Question 34

What does nappy rash (irritant contact dermatitis) look like and how should it be treated?

Answer 34

W shape lesion affecting convex areas and sparing folds. Areas worsens with baby wipes and cloth nappies. Avoid by keeping area clean and dry and treat with zinc oxide ointments.

Question 35

What is molluscum contagiosum?

Answer 35

Skin infection due to a large DNA pox virus. Raised pearly white papules/nodules with a central depression. They can painless or purpuric and tender. Focally located or widely distributed vary in colour and range from 1-100. Usually affects face, neck, armpits, arms and hands. Usually improves after a few months.

Question 36

How does perineal thrush present?

Answer 36

Vivid red, sharply bordered erythema with satellite papules or vesicles. Usually anterior perineum. Commonly due to systemic antibiotic treatment. Use antifungal agents such as nystatin or miconazole and gentle cleansing of the perineum but no oral antifungals.

Question 37

How does ringworm present and how is it treated?

Answer 37

Fungal infection that causes a red or silvery ring like skin rash that can be scaly, dry and itchy. Spread by direct contact with the lesion. Treat with oral antifungals such as terbinafine, fluconazole and topical ketoconazole. There are different types according to where on the body is affected:
• Ringworm (tinea corporis) affects the body
• Fungal nail infections (onchomycosis) affects the nails
• Athlete’s foot (tinea pedis) affects the feet
• Jock itch (tinea cruris) affects the groin
• Tinea capitis affects the scalp

Question 38

What management can be used for seborrhoaeic dermatitis?

Answer 38

Mild-moderate: baby shampoo and baby oils

Severe: mild topical steroids e.g. 1% hydrocortisone

Question 39

What is immune thrombocytopaenia purpura?

Answer 39

Diagnosis of exclusion; exclude sinister diagnoses using history/examination/blood film. Benign, self-limiting condition. 80% remit spontaneously within 6-8 weeks. Usually follows history of URTI or gastroenteritis.

Question 40

How should ITP be managed?

Answer 40

Reassure parents that severe bleeds are rare even with low platelets
No need for hospitalisation
Activity restrictions where risk of head trauma e.g. trampoline
Should not be given any IM injections
Avoid anti-platelet (aspirin and NSAIDs) and anti-coagulant medications
Seek immediate medical advice following falls/bumps to head
Have 24-hour access for treatment for life-threatening bleeds: steroids, IV Ig, platelet TF

Question 41

What is the management of Kawasaki’ infection?

Answer 41

• High-dose aspirin (Kawasaki disease is one of the few indications for the use of aspirin in children, due to the risk of Reye’s syndrome aspirin is normally contraindicated in children)
• Intravenous immunoglobulin
• Echocardiogram (rather than angiography) is used as the initial screening test for coronary artery aneurysms

Question 42

What causes meningococcal septicaemia?

Answer 42

Dissemination of Neisseria meningitidis into the blood stream. Presentation of meningitis with or without meningococcaemia or just meningococcaemia. 12 capsular groups most common in UK are B, C, W and Y. Incubation period of 2-7 days.

Question 43

How is meningococcal septicaemia transmitted and what ages does it typically affect?

Answer 43

Transmission is via droplet spread and requires prolonged contact. Peaks in winter with low levels in summers. Peak age is under 5 and second minor peak in 15-19-year olds.

Question 44

How does meningococcal septicaemia present?

Answer 44

High fever, poor feeding, diarrhoea, and vomiting followed by headaches, irritability, seizures, and drowsiness. Rash is initially erythematous, maculopapular, short lived following by petechia and purpura, it is non blanching.

Question 45

How should meningococcal septicaemia be managed?

Answer 45

Pre-Hospital – IM benzyl penicillin and transfer to emergency secondary care immediately.
Hospital – Senior lead management, rapid IO or IV access, fluid resuscitation, airway management, inotropes, and antibiotics.