This video/podcast presents an approach to the diagnosis and management of viral rashes in children. Listeners will learn the classic presentations of common viral exanthems and enanthems in infants and children and specific features of some viral rashes to help differentiate between them. The podcast was developed by Carly Rumley in collaboration with Dr. Mel Lewis. Carly is a medical student the University of Alberta and Dr. Lewis is a general pediatrician and Associate Professor at the University of Alberta and Stollery Children’s Hospital in Edmonton, Alberta.
Welcome to pediatric videos for pedes cases comm hello my name is karli rumley and i’m a medical student at the university of alberta this podcast was developed with dr. melanie lewis a pediatrician at the university of alberta in this pedes cases podcast we will discuss viral rashes that can present in a child under the age of two or in school-aged children the
Learning objectives of this podcast are number 1 describe the classic presentations of common viral examples and an anthem zin infants and children number 2 list specific features of some viral rashes to help differentiate between them we will start by defining some terms that are important to use when describing rashes an example is a rash involving the skin
Whereas an anatomy is a rash involving mucous membranes some viruses will cause a macular rash whereas others will cause a vesicular rash a macul is a circumscribed flat lesion that has a different color than the surrounding skin you cannot feel it when you run your finger over it a papule is a small solid elevated lesion that is usually less than one centimeter
In size a vesicle is an elevated circumscribed lesion that contains fluid usually less than one centimeter in size it’s important to know which viruses can cause which type of rash some viruses that cause red macular rashes are measles rubella parvovirus b19 and herpes virus six and seven viruses that can cause vesicular rashes include herpes simplex one and two
Varicella-zoster virus smallpox and monkey pox and coxsackievirus let’s think of our approach to a 1 year old baby girl presenting with a rash in a family doctor’s office some initial questions to ask on history should be is there a fever are there systemic symptoms are her immunizations up-to-date has she had any animal contacts or stings where has she traveled to
Recently is she on any medications has she tried new foods where did the rash start what did it look like and what is the timeframe of development on physical exam you’d want to get vital signs and examine the scalp ears neck and mucous membranes skin folds digits palms and soles depending on where the rash originated you would of course start there and then make
Sure to examine the rest of the body as location of rashes can guide the differential for this 1 year old patient or any child under 2 the most common viral rashes are roseola herpes simplex one virus and hand foot and mouth disease herpes simplex virus 1 is a common cause of oral lesions or gingival stomatitis vs. herpes simplex virus 2 which is which more commonly
Causes genital lesions hsv one is spread by respiratory droplet and direct contact the incubation period is 2 to 14 days after exposure these oral vesicles are extremely painful and will eventually crust over hsv 1 can be detected via pcr from the fluid of a nun roofed vesicle also this virus can show trigeminal nerve latency meaning the viral dna can stay in the
Nerve latent for years where it can be reactivated and affected the same dermatome as before the treatment of a viral cause of these oral lesions is symptomatic so lidocaine can be used the next virus to consider is human human herpes virus 6 which causes roseola in phantom also called exam thumb subatomic disease it is a common febrile childhood illness that is
Characterized by an abrupt high fever for 3 to 5 days then deaf for essence then the rash appears and it lasts for 1 to 2 days specifically the rash is described as an erythema dhis macula popular eruption that is discrete pale pink lesions that are two to five millimeters in diameter on the neck trunk buttocks and maybe face and proximal extremities the lesions
Blanch with pressure this illness can also present with a mild cough coryza anorexia abdominal discomfort in lymph adenopathy the fever can be treated with acetaminophen the last common viral rash that will be discussed for an infant is hand foot and mouth disease the most common viruses that can cause this are coxsackievirus a or enterovirus 71 the incubation
Period is four to six days then the patient will present with fever anorexia malaise sore throat and a rash coxsackie is transmitted via direct contact and causes a maculopapular rash that starts on the face and neck extends to the trunk and feet and is sometimes on the palms and soles buccal mucosa and tongue coxsackie a causing fever sore throat and gray or white
Vesicles on the posterior palate and tonsils is termed herpangina these vesicles can form bolle and ulcerate enterovirus a 19 can cause hand foot and mouth disease which also presents with fever anorexia malaise sore throat and oral lesions one to two days later these oral lesions are vesicles on an erythema de space which ulcerate and are very painful the cutaneous
Lesions caused by enterovirus a 19 are red populus that change to grey vesicles three to seven millimeters in size and can affect the palms and soles most causes of hand foot and mouth disease are self-limiting within one week the treatment is symptomatic therapy with hydrations pain control and antipyretics overall we have discussed that exposure history location
Of rash duration of symptoms and presence or absence of a fever are important clinical signs that can guide the diagnosis and treatment plan now we will change demographics slightly to consider a school-age male or female presenting with a rash some common viral rashes to consider our chicken pox measles rubella parvovirus b19 and mumps consider this situation
While working at a family medicine clinic one of your patients is an 8 year old girl and her parents say she has a fever and sore throat she presents with a red rash on her neck and upon further physical examination has a maculopapular rash over her trunk and arms you take a throat culture which is negative it is possible to obtain a blood sample to perform viral
Serology which could indicate measles rubella or b 19 if positive but realistically this would only be done if the child was quite unwell let’s go through five common viral causes of a rash in this age group and consider some of the defining characteristics measles is caused by a paramyxovirus with airborne transmission hence is one of the most contagious of all
Infectious diseases there is a 10-day incubation period followed by a three-day prodrome which can include upper respiratory symptoms malaise fever conjunctivitis photophobia and cough the rash first forms behind the ears and forehead hairline it then spreads in a centrifugal pattern which is central to peripheral and from head to feet the rash initially is red
Blanche’s on pressure and lasts about seven days the patient can also have colic spots which is pathognomonic and anthem for measles this rash is white or bluish one millimeter discrete spots with a red base on the buccal mucosa the measles rash is a self-limiting infection unless the patient is immunocompromised complications of measles can include otitis media
Diarrhea secondary bacterial infections or acute post infectious encephalitis treatment is isolation because measles is airborne spread after that treatment is symptomatic as there is no effective antiviral for measles there’s also the complication of subacute sclerosing pan and sefa lightest or sspe this complication is but can develop two to ten years after a
Measles infection sspe is a progressive neurologic disease characterized by personality change intellectual deterioration development of myoclonic jerks and motor dysfunctions and possibly blindness children can eventually become bedridden and stuporous progressive super infection and metabolic imbalances eventually lead to death the pathology of sspe is due to
Measles virus infection in the cns and retina the incidence of this is about one in 100,000 measles cases and there is no effective therapy at present importantly vaccination is key for prevention of measles there is a combined mmrv vaccine which covers measles mumps rubella and varicella children can receive the first dose at age 12 to 15 months and then a second
Dose at age 4 to 6 years secondly the rubella virus which is sometimes called german measles or third disease is from the touge of writted a family of viruses transmission is droplet or vertical from mum to baby and there is an incubation period of 12 to 25 days after exposure there is a one to five day prodrome which can include fever malaise headache nausea runny
Nose and a sore throat when the exam time appears afterward it starts as a regular pink macules and papules on the face which spreads to the neck arms and trunks the rash usually lasts three days pinpoint petechiae involving the soft palate can also occur called for shimer spots lymph adenopathy involving the sub occipital and posterior auricular nodes can also
Occur with a rebel infection as well the treatment is also symptomatic pregnant women will be screened for rubella at their first prenatal visit if they are not vaccinated or the results are in determinant the mom will need postpartum vaccination since rubella is a live virus vaccination cannot be given during pregnancy there is a risk of congenital rubella syndrome
In the newborn which can present with all or any of microcephaly cataracts heart disease osteitis hepatosplenomegaly anemia deafness and or developmental delay third on the list is chickenpox from the varicella zoster virus which is human herpes virus 3 transmission is airborne chickenpox presents as a paretic vesicular example with mild systemic manifestations
Such as low-grade fever malaise or headache the exempt amount red macules on the trunk or scalp and then 24 hours later we’ll show the typical vesicular varicella appearance which is described as teardrop vesicles on an erythema test base spreading centrifugal ii and sparing the palms and soles most infected children can have 250 to 500 vesicular skin lesions and
An important factor to note is that the skin vesicles will present in different stages of lesion formation diagnosis can be made by clinical presentation pcr but serology is not very useful in an acute infection serology can be used to assess immunity after vaccination each hb 3 is usually a self-limited infection the treatment for chicken pox is acetaminophen
For fever not aspirin because it can predispose the patient to rise syndrome which is a rapidly progressing encephalopathy if the patient is immunocompromised then the antiviral therapy acyclovir can be used it is not recommended for uncomplicated varicella infections in immunocompetent children complications of a varicella infection can be encephalitis meningitis
Myelitis pneumonia hepatitis or a secondary bacterial super infection of ruptured vesicles with staph or strep since chickenpox is caused by a herpes virus remember the virus can remain latent in dorsal root ganglia or the trigeminal nerve and can reoccur later in life as shingles or herpes zoster fourth in our list is human parvovirus b19 also called v disease
Erythema infection or slapped cheek syndrome transmission is vertical or via respiratory routes a b19 infection presents with a unique example that is a red rash on the cheeks that gives a slapped cheek appearance lasting four to five days one to two days after this facial rash the child can have an on critic maculopapular rash on the trunk and limbs this rash
Has a lacier reticulated appearance with the palms and soles usually spared children infected with parvovirus b19 can also present with fever headaches sore throat cough vomiting diarrhea and myalgia b19 has a biphasic incubation period where the child presents with a fever for days 5 to 7 and then a rash at day 15 to 17 for the second phase however an asymptomatic
Infection is possible with b 19 the virus has a tropism for your acidic precursor cells which can cause a lack of release of rbc’s from the bone marrow thus causing anemia and puts the patient at risk of transient aplastic crisis however a b 19 infection is self-limiting so the treatment is symptomatic there is no antiviral or vaccine for a b 19 infection the last
Viral infection we will discuss is the mumps virus mums is characterized by an acute onset unilateral or bilateral tender swelling of the parotid or other salivary glands that lasts at least two days before that the incubation period after exposure is 7 to 23 days there is a prodrome that can be characterized by low-grade fever myalgia headache and anorexia the
Mumps virus is transmitted via the respiratory route in the form of droplets saliva or full mites the virus can replicate commonly in the salivary glands testes pancreas ovaries mammary glands and cns in 15 to 30 percent of mumps in post pre-brew to pubertal males epididymal orchitis can occur this can develop up to six weeks after parotitis five percent of women
With mumps infection can develop over itis which can present as lower abdominal pain and vomiting other complications of mumps infections include pancreatitis thyroiditis or abnormal renal function it is important to remember a differential for parotitis which includes the viruses of hiv coxsackievirus parainfluenza virus type 3 in enza a virus epstein-barr virus
Adenovirus parvovirus b19 and hhv-6 some non viral causes of parotitis are gram positive bacteria atypical mycobacteria and bartonella species parotitis can also occur in the setting of sjogren’s syndrome uremia diabetes mellitus malnutrition cirrhosis tumors or some medications generally mumps is self-limiting let’s return to consider the eight-year-old girl who
Presented with a fever and red rash upon further inspection she has blue whitish spots on a red base inside her mouth in this case you decide to do viral serologies because measles is a reportable disease it’s important to remember that the viral serology tests must have two weeks between the two blood samples there must be i gm present or a four-fold increase
In igg levels from sample 1 to 2 for a positive test overall when considering the etiology for an infectious rash in an infant or child consider number 1 the morphology of the rash 2 the distribution and progression of the rash remember to check oral mucosa and 3 presence of systemic features such as arthritis fever lymph adenopathy or parotid swelling we have
Discussed the clinical diagnosis commonly made for viral rashes and have reviewed that viral rash treatment is symptomatic in the majority of cases this concludes our pedes cases podcast on viral rashes
Transcribed from video
Viral Rashes in Children By pedscases