Sick Child With A Rash - Macular/ Maculopapular Flashcards
What is a macule?
A flat area of altered colour
What is a papule?
A small raised lesion < 0.5cm diameter
What causes roseola infantum?
Human herpes virus type 6B
What is roseola infantum characterised by?
High fever, mild coryzal symptoms, irritability and tiredness lasting 3-5 days
As fever subsides, macular or maculopapular rash occurs
- rash blanches
- non itchy, painless, do not blister
In roseola infantum, where does the rash start?
Starts on chest, back, abdomen and spreads to face, arms and legs
Roseola infantum typically occurs in what age group?
6 months to 3 years
How is roseola infantum spread?
Person to person via saliva of asymptomatic family members
How long does the rash associated with roseola infantum last?
May fade within a few hours or persist for 2 days
How is roseola infantum treated?
No specific treatment
Usually mild and self limiting
Rest, maintain fluid and paracetamol for fever
What complication can occur with roseola infantum (although rare)?
Febrile seizure due to high temperature
What is another term for erythema infectiosum?
Slapped cheek syndrome
Fifth disease
What causes slapped cheek syndrome?
Parvovirus B19 or erythrovirus EVB19
Single stranded DNA virus that targets red cells in the bone marrow
How does slapped cheek syndrome spread and what is the incubation period?
Spread via respiratory droplets, vertical transmission, transfusion of infected blood products
Incubation: 7 to 10 days
What occurs initially with slapped cheek syndrome?
Non specific mild prodrome - mild fever, headache
What are the 3 distinct phases of slapped cheek syndrome (after mild prodrome)?
1) bright red erythema over cheeks - 2 to 4 days, cheeks feel hot and firm
2) erythematous macular to morbilliform rash on extensor surfaces 1-4 days
3) rash fades leaving reticulated lacy pattern for days to weeks
Is erythema infectiosum a serious condition?
Generally not
Arthritis and arthralgia in adults
Some complications can occur in adults e.g pregnant women small risk of spontaneous abortion or hydrops fetalis due severe anaemia
In those with haemolytic blood disorders it could cause potentially dangerous low blood count (those with sickle cell disease or thalassaemia) -> aplastic crisis
Children that are immunocompromised may not be able to clear infection
How is erythema infectiosum managed?
No specific treatment
Affected children may stay at school as the infectious stage occurs before rash evident
Cold flannel to cheeks
When are erythema infectiosum outbreaks most common?
Spring
What is rubella also called?
German measles
3 day measles
What type of disease is rubella?
Viral disease
Rubella is generally a mild disease unless..
You are pregnant - results in miscarriage, stillbirth or birth of infant with major abnormalities
What time of year does rubella typically occur?
Winter and spring
How does rubella spread?
Respiratory route frequently from a known contact
Describe the prodrome symptoms associated with rubella
Eye pain on eye movement Conjunctivitis Sore throat Headache Body aches Low grade fever
Generally lasts 1-5 days before rash
Prodrome phase does not always occur - more common in adults
Describe the rash associated with rubella
Maculopapular rash Pink/light red spots Lasts up to 5 days May or may not be itchy Usually not as widespread as measles Begins on face and spreads to trunk and extremities
What almost always accompanies rubella?
Tender lymphadenopathy- especially posterior auricular and sub occipital
What is the Forchheimer sign seen in the prodromal phase of rubella?
Pinpoint or large petechiae on soft palate and uvula
How is rubella treated?
No specific treatment
Usually mild and self limiting
Rest, fluids, paracetamol for fever
Are complications of rubella rare in childhood?
Yes but they include: Arthritis Arthralgia Encephalitis Thrombocytopenia Myocarditis
In childhood rubella, what should be done if risk of exposure to non immune pregnant woman?
Confirm diagnosis with serology
How can Rubella and congenital rubella syndrome be prevented?
Vaccination - part of routine immunisation programme in UK (MMR vaccine) - 2 dose strategy
What type of infection is measles?
Highly contagious viral infection
SS RNA
Describe the early symptoms (prodrome) of measles
Conjunctivitis
Cough
Coryza - swelling of mucus membranes of nose
Koplik spots - small white spots in the mouth (pathognomonic)
Fever
Malaise
Appetite loss
Prodrome typically lasts 3 days
When does a rash appear in measles?
3rd day of illness
Describe the rash in measles
Initial red, discrete maculopapular rash
On the face initially, behind ears then spreads to trunk and becomes more generalised and confluent
May desquamate in second week
Non itchy
Why has there been a recent increase in the number of measles?
Recent trend of some parents to not immunise their children
How is measles spread?
Droplet spread - can survive for up to 2 hours in air or on surfaces
An infected person is contagious from 2 days before any symptoms show to at least 5 days after onset of rash
Incubation period = 10-14 days
What does a the rash in measles usually coincide with?
High fever
How is measles diagnosed?
History and exam
But because it is rare in developed countries - any suspected case requires laboratory confirmation
- viral nasopharyngeal swab and throat swab for PCR
- blood and urine samples can also be used
What complications can occur with measles?
GI: diarrhoea, mouth ulcers, appendicitis, hepatitis, mesenteric adenitis
Ears: otitis media (most common complication) - may lead to deafness
Respiratory: pneumonia (most common cause of death)
CVS: myocarditis, pericarditis
Neurological: febrile seizures, encephalitis, subacute sclerosing panencephalitis (very rare, may occur 5-10 years after illness)
Eyes: corneal ulceration
Renal: acute glomerulonephritis
Haematological: thrombocytopenia
Measles can suppress the immune system for up to 6 weeks - bacterial superinfection e.g OM and pneumonia
Do children or adults tend to have more severe form of measles?
Adults
How is measles treated?
Supportive
In immunocompromised- antiviral drug ribavirin can be used
Vitamin A (modulates immune response) should be given in low income countries - often malnutrition and vit A deficiency causing protracted course of measles with severe complications
If a child not immunised comes into contact with measles, the MMR should be offered as vaccine induced measles antibodies develop more rapidly than following natural infection)
What type of infection is scarlet fever?
Bacterial infection
- streptococcal pyrogenic endotoxin strain of streptococcus pyogenes (group A beta haemolytic streptococcus)
Who does scarlet fever affect?
Those who have recently had a sore throat (strep pharyngitis) or impetigo caused by certain strains of streptococcus pyogenes
What age group does scarlet fever typically affect?
Children aged 4 to 8
By 10 years up to 80% of children have developed lifelong protective antibodies against streptococcal toxins
What are the initial symptoms of scarlet fever?
Sore throat High fever > 38.5 Headache Flushed cheeks Bright red swollen tongue ‘strawberry red’ Lymphadenopathy (cervical) Nausea and vomiting Loss of appetite Abdominal pain Malaise
When does the characteristic rash appear in scarlet fever?
1-2 days after start of fever
Describe the rash seen in scarlet fever
Scarlet spots or blotches ‘boiled lobster’ appearance
As it progresses, looks like sunburn with goose pimples
Skin may have rough sand paper feel
In folds, capillaries can rupture - red streaks called Pastia lines
Where does the rash generally appear in scarlet fever?
Usually starts on chest, abdomen and spreads to other areas e.g ears and neck
How long does the rash last in scarlet fever?
Approximately 1 week
Fades and peels
How is scarlet fever diagnosed?
Characteristic history and examination
Supported by:
Throat swab culture or rapid streptococcal antigen test from posterior pharynx/tonsils
How is scarlet fever managed?
Antibiotics - usually oral penicillin V for 10 days (important to take full course)
Paracetamol for fever, headache, throat pain
Soft foods, plenty of liquids
Oral antihistamines to relive rash
What complications can occur with scarlet fever?
Rheumatic fever - typically 20 days after infection Otitis media (most common complication) Pneumonia Sepsis Meningitis Necrotising fasciitis Glomerulonephritis Osteomyelitis
What is Kawasaki disease?
An acute febrile illness with inflammation of small and medium sized blood vessels throughout body, in particular the coronary arteries
Kawasaki disease typically affects what age group?
Children 6 months to 4 years
What ethnicity is Kawasaki disease more common in?
Japanese and black-Caribbean ethnicity
What features are associated with Kawasaki disease?
High fever that is difficult to control
Strikingly irritable
Rash - measles like or maculopapular or red skin, peeling occurs later
Oral signs - strawberry tongue, redness in mouth and throat, cracked lips
Eyes - conjunctivitis
Peripheral limbs - swelling of hands and feet, redness of palms and soles
Lymphadenopathy (cervical)
Is there a diagnostic test for Kawasaki disease?
No
Diagnosis: fever for at least 5 days, 4/5 of cardinal signs and absence of other illness to account for signs
Bloods: raised CRP, ESR, WCC, raised platelets
How is Kawasaki disease treated?
IV immunoglobulin - lowers the risk of coronary artery aneurysm if given within 10 days
Aspirin to reduce thrombosis risk
What complications can occur with Kawasaki disease?
Dilatation / narrowing of coronary artery
Can lead to angina, MI or sudden death
What is performed as follow up on all children with Kawasaki disease?
ECHO to check the heart at 6-8 weeks
Is scarlet fever a notifiable disease?
Yes
Is measles a notifiable disease?
Yes
