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Continuity Clinic
Objectives
• Be familiar with the terminology to describe rashes accurately to other providers
• Be able to identify the rashes of Measles, Rubella, Scarlet Fever, Erythema Infectiousum, and Roseola Infantum
• Know the general clinical features of each of the above rashes
Continuity Clinic
The Basics of Rashes
• Distribution– Localized vs. Systemic– Sun exposed areas?
• Configuration– Round– Serpiginous– Coalesce
• Description– Macular, Papular, Petechial
• Evolution– Where it began and where it ended
• Associated Findings
Continuity Clinic
Description of Rashes
• Macule – circumscribed color change in the skin that is flat
• Papule – solid, elevated area < 1 cm in diameter• Plaque – solid, circumscribed area >1 cm in diameter• Vesicle – circumscribed, elevated < 1 cm with serous
fluid• Bulla – circumscribed, elevated > 1 cm with serous
fluid• Pustule – vesicle with purulent material• Nodule – mass with indistinct borders, elevates over
epidermis• Wheal – circumscribed, flat topped, firm elevation of
skin resulting from tense edema of papillary dermis
Continuity Clinic
Definitions
• Exanthem – a skin eruption occurring as a symptom of a general disease
• Enanthem – eruptive lesions on the mucous membranes
Continuity Clinic
Classic Childhood Exanthems
1. Measles (Rubeola)
2. Scarlet Fever
3. Rubella (German Measles)
4. Filatow-Dukes Disease
5. Erythem Infectiousum
6. Roseola Infantum
Continuity Clinic
“1st Disease” - Measles
• Paramyxovirus
• At risk:– Preschool age children unvaccinated– School age children in whom vaccine failed
• Season: late winter/spring
• Incubation: 8-12 days
• Infectious: 1-2 days before prodrome to 4 days after onset of rash
Continuity Clinic
Measles – clinical features
• Prodrome– Day 7-11 after exposure– Fever, cough, coryza, conjunctivitis
• Enanthem– Koplik’s spots appear 2 days before rash and
lasts 2 days into rash
Continuity Clinic
Complications of Measles
• Otitis Media
• Bronchopneumonia
• Encephalitis
• Pericarditis
• Subacute sclerosing panencephalitis – late sequellae due to persistent infection of the CNS
Continuity Clinic
“2nd Disease” - Scarlet Fever
• Due to erythrogenic exotoxin-producing group A beta-hemolytic streptococci
• At risk:– <10 years old– Peak 4-8 years old
• Season: – late fall, winter, spring– Likely due to close contact indoors in school
• Incubation period: 2-4 days• Infectious period: during acute infection,
gradually diminishes over weeks
Continuity Clinic
Scarlet Fever – Clinical Features
• Abrupt onset fever, headache, vomiting, malaise, sore throat
• Enanthem– Bright red oral mucosa– Palatal petechiae– Tongue changes
Continuity Clinic
Scarlet Fever - Complications
• Purulent – Otitis media– Sinusitis– Peritonsillar/retropharyngeal abscesses– Cervical adenitis
• Nonsuppurative sequalae– Rheumatic Fever– Acute glomerulonephritis
Continuity Clinic
“3rd Disease” - Rubella
• Togavirus
• At risk: Unvaccinated adolescents
• Season: late winter/early spring
• Incubation: 14-21 days
• Infectious period: 5-7 days before rash to 3 to 5 days after rash
Continuity Clinic
Rubella – Clinical Features
• Asymptomatic infection in up to 50%
• Prodrome– Children: absent to mild– Adolescent & adult: fever, malaise, sore
throat, nausea, anorexia, painful occipital LAD
• Enanthem– Forschheimer’s spots petechiae on the
hard palate
Continuity Clinic
Rubella - Complications
• Arthralgias/arthritis in older patients
• Peripheral neuritis, encephalitis, thrombocytopenic purpura (rare)
• Congenital rubella syndrome– Infection during first trimester– IUGR, eye findings, deafness, cardiac
defects, anemia, thrombcytopenia, skin nodules
Continuity Clinic
“4th Disease” – Filatow Dukes Disease
• Obsolete
• Probably now better defined as another clinical entity
Continuity Clinic
“5th Disease” – Erythema Infectiosum
• Human Parvovirus B19
• At risk: school age children
• Season: sporadic
• Incubation period: 4-14 days
• Infectious period: up until onset of the rash
Continuity Clinic
Erythema Infectiosum Clinical Features
• Over 50% of infections are asymptomatic• Prodrome:
– Mild fever (15-30%)– Sore throat– Malaise
• Adults: flu like symptoms, arthralgias/arthritis, rash in up to 40%
• Hematological changes: proerythrocyte tropic virus – drop in RBC count
Continuity Clinic
EI: Complications• Immunocompromised:
– Chronic infection with severe, persistent, relapsing and remitting anemia, prolonged viral shedding
• Patients with decreased RBC survival time– Hemoglobinopathies, hemolytic disease– Aplastic crises– Prolonged viral shedding
• Fetal infection – hydrops fetalis (1-9% risk of death)
Continuity Clinic
“6th Disease” – Roseola Infantum
• Human Herpes Virus 6 (and 7)
• At risk: 6-36 months (peak 6-7 months)
• Season: sporadic
• Incubation: 9 days
• Infectious period:– Virus is intermittently shed into saliva
throughout life; asymptomatic persistent infection
Continuity Clinic
Roseola – Clinical Features
• High fever for 3-4 days
• Abrupt defervescence with appearance of rash
• Associated seizures likely due to infection of the meninges by the virus