ACUTE EXANTHEMA

Sri Rezeki S Hadinegoro Dept of Child Health Faculty of Medicine, University of Indonesia/ Dr Ciptomangunkusumo hospital Jakarta Lecture

Objective

Definition acute exanthema Relationship between fever and skin exanthema in some diseases Difficulty in diagnosis of acute exanthema Most common acute exanthema diseases

Acute exanthema is disease characteristic with fever and exanthema (rash)

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Introduction

Under certain circumstances a physician who examines a patient with a rash is charged with a grave responsibility An error in diagnosis may have a profound effect on the patient, the contacts and the community

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Exanthemas

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Effect on the patient

Meningococcemia mistakenly diagnosed as measles

Specific therapy not given early Potentially fatal cases

Miliaria was said to have measles

Parent refused to have measles vaccination to their child

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Effect on contacts

Exanthem subitum erroneously label as rubella

If the mother of the child was two months pregnant, it will create an unnecessary period of anxiety to her who had visions of the future birth

A child with mild measles was said to have rubella

A young sibling contact develop severe measles complicated by pneumonia, that could be prevented by a correct diagnosis
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Effect on the community

HFMD (hand-food-and mouth disease) that was labeled to a 6 yrs old boy could lead to a temporarily closing of the school which maybe a wrong decision Occasionally a child with stomatitis only maybe erroneously diagnosed as having the hand-food-and mouth disease.

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Clinical manifestations

Prodromal period (1)

Measles

Rash preceded by 3-4 days of fever, conjunctivitis, coryza and cough Usually no prodromal period in children Adolescents may have 1-2 days malaise and low fever Fever 12 hrs, sore throat and vomiting Fever, vomiting, irritability, chills, headache in 24 hrs

Rubella

Scarlet fever

Meningococcemia

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Prodromal period (2)

Roseola infantum

High fever for 3-4 days and irritability Non specific fever and sore throat for 2-5 days

Kawasaki disease

Varicella
Usually absent, in adolescent maybe 1-2 days fever, headache, malaise and anorexia

HFMD hand, foot and mouth disease

Flu like syndrome for 1-3 days

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Natural history of Measles

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Natural history of diseases

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Rash characteristics (1)

Measles

Reddish brown, appears first on the face and neck, progress

downward to involve the trunk and extremities Generalized by the 3rd day, and tend to be confluent Fades by the 5th or 6th day, followed by desquamation

Rubella

Pink in color, distributed in the same way as measles, but generalized within 24 48 hrs and fades by the 3rd day Usually discrete and does not desquamate

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Rash characteristics (2)

Meningococcemia

Transient maculopapular eruption precede the petechial , purpuric rash No regular, predictable distribution

Roseola infantum / exathem subitum

Discrete rose-red papules frequently appear on the chest and trunk followed by the face and extremities Fades within several hrs and disappear within 2 days

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Rash characteristics (3)

HFMD

Papulovesicular eruptions in the hand and foot (palmar area), perineal and enanthemas in the mouth

Kawasaki disease

Generalized maculopapular rash, palm and soles are swollen and reddened

Varicella

Rapid evolution of macules to vesicles and crusts Central distributions of lesions, crops Presence of all stages of lesions in one area Presence of scalp and mucous membrane lesions
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Rash distribution

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Pathognomonic /diagnostic sign/ lab test

Measles

Kopliks spot Post auricular and occipital lymphadenopathy

Rubella

Serological test
Morbili Rubella Toxoplasmosis Enterovirus etc

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Differential diagnosis (1)

The rashes of various exanthematous diseases are so similar in appearance clinically indistinguishable Each disease has its own characteristic that is distinctive (pathognomonic) Many of exanthematous diseases attack is followed by permanent immunity, so past history will rule-out the disease.

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Differential diagnosis (2)

The past history of infectious diseases and immunization Type of prodromal period Features of the rash Presence of pathognomonic or other diagnostic signs Laboratory diagnostic tests

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Differential diagnosis (3)

Acute exanthematous diseases maybe separated into : Maculopapular eruption Papulovesicular eruption base on the type of the rash

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Differential diagnosis (3)

Maculopapular eruptions

Measles Rubella Scarlet fever Meningococcemia Toxoplasmosis Cytomegalovirus infecton Roseola infantum Enteroviral infection Drug eruptions Miliaria Kawasaki disease others

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Differential diagnosis (4)

Papulovesicular eruptions

Varicella-zoster infection Smallpox Excema herpeticum Coxsackie virus infection Rickettsial pox Impetigo Insect bites Drug eruptions Molluscum contagiosum Papular urticaria others

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Differential diagnosis

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Measles

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Varicella Zoster Infection

Presence of all stages of lesions in one area

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HFMD

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Kawasaki disease

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Meningococcemia

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Erythema infectiosum (Parvovirus)

Erythema multiforme

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Rocky Mountain spotted fever

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Cytomegalovirus infection

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Conclusions

Exanthema acute is an acute disease with fever and rash (skin/mucosal eruption) Devided by maculapapular & vesicobullosa rash Viral infections are the most common cause of acute exanthemas Diagnosis established mainly by clinical features Differential diagnosis is important to distinguished severety of the disease

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