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The Six Common Childhood Reactive Rashes (exanthems) Akua Asare Kinza Khan Lecture Timings 18:00-18:45 (Part One) Paediatric Dermatology: Six Common Childhood Reactive Rashes (exanthems) 18:45-19:15 (Part Two) UKMLA Lecture Conditions: Atrial Fibrillation, Pneumonia and MeningitisLearning Objectives By the end of the lesson students should be able to 1. Synthesise information from case studies to make differentials for common paediatric skin conditions. 2. Apply cultural and racial awareness in the diagnosis of childhood reactive rashes using photography depicting a wide range of skin tones. 3. recall the underlying pathophysiology of the six classic childhood exanthems.Menti meter Voting code: 46720795 https://www.menti.com/alqkh3c5ujsrCase 1 A mother presents to A&E with her 7 year old son who returned to school 2 weeks ago. Her son has had a persistent cough for the past week, runny nose and conjunctivitis. You note a widespread erythematous maculopapular rash on his neck and arms which his mother said started from his head. His mother tells you that this appeared around 3 days ago. Upon examination you note small white spots inside the child’s mouth. Temp: 38.5; O2 saturations: 99%; BP: 101/82; HR: 122 Given the above, what is the most likely diagnosis? A) Measles B) Mumps C) Rubella D) Chicken pox E) Kawasaki’s diseaseRef: Lightning Learning - Measles (v1.0).png Ref: RCEM Learning- MeaslesReference: Mind the gap. Available from: https://www.blackandbrownskin.co.uk/mindthegap (Date accessed: 01/02/23)Measles (First disease) salient points part 1 ● Caused by paramyxovirus ● occurs in epidemics in winter and spring ● infection spread by droplets, or, less commonly, by aerosol spread ● primary site of infection is the nasopharynx ● incubation period - typically 7-21 daysMeasles (First disease) salient points part 2 ● Infectivity period c. 4 days either side of rash appearance ● erythematous maculopapular rash beginning on the head, with a cephalocaudal progression ● clinical case definition of this disease has been defined as a fever >38.3°C or ‘felt hot’ if not measured, a generalised maculopapular rash lasting in excess of 3 days and at least one of: cough, conjunctivitis or coryza.● Ix: 1st: measles specific IgM and IgG serology (ELISA) is most sensitive 3-14 days after onset of the rash; 2nd: measles RNA detection by PCR best for swabs taken 1-3 days after rash onset ● Mx: Children kept off school until 5 days after the appearance of rash; Supportive care which will normally include an antipyrexial; Vitamin A in all children under 2Case 2 A couple present to A&E with their 10 year old child with a history of asthma. The child was ill the day before with a fever and sore throat. This morning his mother noticed a red, pinpoint rash on his trunk which feels like sandpaper. Upon examination you note that the child’s tongue looks very red and somewhat swollen. His parents say that his tongue had a white coating over it which progressively became more red. What is the patient’s most likely diagnosis? A. Bacterial meningitis B. Scarlet fever C. Allergic reaction to asthma inhaler D. Rubella E. MeaslesScarlet Fever (salient points)Investigations - Non specific symptoms —> fever (>38.3), sore throat, headache, fatigue, nausea & vomiting. - Specific symptoms —> blanching red rash, develops on trunk, within 12-48hrs after initial symptoms. - Rash characteristics —> pinpoint (punctate), rough, sand-paper like texture. Pastia’s lines (accentuated in flexures) - Examination —> strawberry tongue, cervical lymphadenopathy, flushed face w/ circumoral pallor, pharyngitis, & petechiae (small red spots) on hard & soft palates - Throat swab —> Group A streptococcus (prior to starting treatment).Management - Severe cases: Urgent hospital admission - 10 day course of Antibiotics (phenoxymethylpenicillin)Case 3 A 6 year old girl comes into the gp with her father as he has recently noticed some new red rashes on her skin. The father reports that his child has been suffering from headaches and a very bad fever. He also says that there are some small lumps felt around her neck. He said the rash started on her face then passed down over her body to her feet. As the GP you note pin-point red macules and petechiae on her soft palate and uvula. Her joints hurt and she has trouble breathing. There is associated tenderness around her eyes and posterior auricular lymphadenopathy. What is the most likely diagnosis? - A) Rubella - B) Measles - C) Chickenpox - D) Mumps - E) Roseola Reference: https://emedicine.medscape.com/a rticle/968523-overview Reference RCEM learning- rubella Rubella salient points 1 ● Rubella is a self-limiting benign illness occurring in adults and children worldwide. It is caused by the rubella virus and spread by airborne transmission or droplet. ● The incubation period for rubella is around 2 weeks after which a prodrome of headaches, fever and lymphadenopathy occur. The infectivity period is typically from 7 days before to around 7 days after the onset of the characteristic rash. Rubella salient points 2 ● Rubella is most commonly associated with a characteristic macular rash starting on the face then passing down over the body to the feet. In addition, it is also associated with: ● Fever ● Tender occipital and posterior auricular lymphadenopathy ● Arthralgia ● Respiratory involvement ● Another characteristic is the appearance of Forschheimer spots. These are pin-point red macules and petechiae, which may be seen on the soft palate and uvula during the rash phase.Investigations The clinical signs of rubella can be difficult to distinguish from other viral illnesses such as parvovirus B19, measles, dengue and human herpesvirus 6. Clinical diagnosis of rubella is therefore unreliable and laboratory confirmation of the disease is required, particularly during pregnancy due to the potential consequences to the foetus. Immunoglobulin G and Immunoglobulin M assays should be used.Management ● Rubella is a notifiable disease and notification is required based on clinical suspicion. Children diagnosed with rubella should remain off school for at least 5 days following the onset of the rash. ● Women should avoid pregnancy until 3 months after immunisation.Complications Complications of rubella are rare, although conditions which can arise are listed in Table 1. The risks of congenital defects (congenital rubella syndrome) are highest (90%) if infection occurs within the first 12 weeks of pregnancy. Under these circumstances, follow-up should be arranged.Case 4 A mother brings a child to the GP complaining that her child has had a rash which began on the chest and has since spread to the back and face. The rash is itchy and consists of fluid filled blisters- some of which have turned into scabs. The child is febrile and is not up to date with vaccinations. What is the most likely diagnosis? A. Measles B. Scabies C. Chicken pox (varicella) D. Sepsis E. Roseola InfantumChicken Pox - salient points - Varicella zoster virus (VZV) - average incubation period is 14-16 days - Mild prodrome (fever, malaise 1-2 days prior) - Prodrome less common in children (rash usually first sign) - Rash: itchy, blistering rash with turns into scabs (pancorporeal varicella lesions) - Note: Possibility of reactivation of latent infxn — herpes zoster (shingles)Chickenpox (varicella) https://i0.wp.com/images-prod.healthline.com/hlcmsresource/images/642 x361_Chickenpox.jpg?w=1155&h=758Investigations - Generally diagnosed based on examination and Hx . - lab testing: PCR testing, DFA testingManagement - Usually no medical tx required - Antihistamine for itching - paracetamol (pain and fever) - Calamine lotion - Cool bath with baking soda, aluminium acetate, oatmeal More severe/presenting within 24hrs of rash onset: - acivlovirCase 5 A 2 year old boy presents with fever and nonspecific symptoms. On examination his cheeks look they they have been ‘slapped’. This is more accurately described by the GP as a confluent, erythematous, oedematous rash with patches or plaques on his cheeks, with sparing of the nasal bridge and periorbital areas. On trunk and limb inspection there is a maculopapular rash with some lacy areas. The mother tells the GP that her child often winces in pain when moving his joints. What is the most likely diagnosis? A) Erythema multiforme B) Chicken pox C) Stevens-johnson syndrome D) Erythema infectiosum E) Erythema ab igne Erythema infectiosum Ref: https://www.rcemlearning.co.uk/reference/common-childhood-exanthems/#1622630293051-7d9 527c2-b469Erythema infectiosum (fifth disease) salient points part 1 ● caused by parvovirus B19 ● spread in respiratory droplets or pass from mother to fetus and in blood transfusions ● incubation period 4-14; max 21 days ● infectivity period commences at exposure - lasts until symptoms appearErythema infectiosum (fifth disease) salient points part 2 ● Face appearance - ‘slapped cheek’ ● Rest of body appearance - maculopapular rash; lacy when rash fades ● Clinical associations: Arthropathy, Henoch-Schönlein purpura, Autoimmune disorders, Myocarditis, Hepatitis, Papular purpuric glove and socks syndrome, Meningitis and encephalitis, Fibromyalgia and chronic fatigue syndrome, Chronic infection (in patients with immunodeficiency)● Ix: most don’t need any - only pregnant, immunocompromised, haemoglobinopathy ptx should; IgM antibodies c. 10 days lasting max 3 months or IgG antibodies appear c. 14 days post infection & remain for life. ● Mx: mild self-limiting illness for most children; analgesics for joint pain; transfusion for aplastic crisis; IVIG containing pooled neutralising anti-B19 antibody has been used to treat immunocompromised patients; pregnancy- Referral to an obstetrician for regular monitoring and follow-up.Case 6 A parent bring their 8 month old child to ED after they developed a rash. upon examination the rash is widespread on the chest and neck as well as the child’s shoulders, thigh and buttocks . Her temperature is 39. Upon examination the rash is a mixture of pink macules and papules surrounded by a fine white halo. You note some swelling of the cervical lymph nodes. Given this what is the patient’s most likely diagnosis? A. Acne rosacea B. Shingles C. Measles D. Rubella E. Roseola InfantumRoseola Infantum - salient points - Herpes virus 6 (sometimes herpes virus 7) - most commonly affects infants (6 months - 18 months) - Incubation period: 5-15 days - Key features: temperature (falls rapidly on 4th day), pharyngitis, lymphadenopathy Rash: rose-pink macular, surrounded by fine white halos - often disappears within 2 days.Roseola Infantum (sixth disease)Investigations - Clinical diagnosis based on examination and inspection of rash. - In conjunction with HxManagement Tx is generally supportive. - antivirals for some immunosupressed individuals. - Beware of contact with pregnant women and children under 4 weeks of age.Learning Objectives By the end of the lesson students should be able to 1. Synthesise information from case studies to make differentials for common paediatric skin conditions. 2. Apply cultural and racial awareness in the diagnosis of childhood reactive rashes using photography depicting a wide range of skin tones. 3. recall the underlying pathophysiology of the six classic childhood exanthems.Any Questions? Please fill in the doctor as teacher feedback forms and email to kinza.khan@kcl.ac.uk and Akua.asare@kcl.ac.ukReferences https://www.rcemlearning.co.uk/reference/common-childhood-exanthems https://www.blackandbrownskin.co.uk/mindthegap https://www.rcemlearning.co.uk/reference/common-childhood-exanthems/ https://em3.org.uk/foamed/15/7/2019/lightning-learning-measles https://em3.org.uk/foamed/29/7/2019/lightning-learning-rubellaFurther Reading - https://www.rcemlearning.co.uk/reference/common-childhood-exanthems/ Common Childhood Exanthems - https://www.atsu.edu/faculty/chamberlain/exanthems.htm Skin Rashes: Diseases 1-6 - https://youtu.be/UE4a8uBB7WM Childhood Exanthems YT videos