VIRAL EXANTHEMS Brenda Beckett, PA-C NO PICTURES Overview Many of the “childhood” exanthems are rare due to immunizations (rubella, rubeola, etc) Some benign infections do not have immunizations so there are still outbreaks (coxsackievirus, etc) Some have been eradicated (smallpox) General Considerations Systemic viral infection leads to cutaneous eruption (exanthem) Prodrome: fever, malaise, n/v, headache, sore throat and other sx. PE: rash varies with virus, may have other symptoms. Diagnosed on HX&PE Course: Incubations different, usually resolves in <10 days Rubella (German Measles) EPIDEMIOLOGY/ETIOLOGY: – Rubella virus. – Immunization has incidence by 99%. Now seen in young adults, developing countries. – Trans. respiratory droplet. Mod. Communicable. HISTORY: – 14-21 d incubation. – Usually no or mild prodrome, may have HA, malaise, low grade fever, arthralgias. Rubella PE: – Pink macules, papules. – Start on forehead, move inferiorly to face, trunk, extremities. Progress rapidly, gone by day 3. LABS: – Leukopenia – Acute & convalescent antibody titers, cultures. DIAGNOSIS: – Clinical, can confirm with labs. Rubella PROGNOSIS: – Usually mild disease. Rare: encephalitis – In first trimester of pregnancy, can lead to multiple congenital defects. TREATMENT: Symptomatic. HEALTH MAINTENANCE: – Immunize (2 doses MMR) – Check titers in young women, immunize. Rubeola (Measles) EPIDEMIOLOGY/ETIOLOGY : – Measles virus. – No longer endemic in US. Major worldwide cause of pediatric morbidity and mortality. – Trans. respiratory droplet. Highly contagious. HISTORY: – 10-15 d incubation. – Prodrome – fever, malaise, URI, cough, photophobia, conjunctivitis. Rubeola PE: – Day 4 of fever: red macules & papules on forehead, hairline. – Spread to face, trunk, palms and soles last. Can be confluent. – Resolves 4-6 days. – Koplik’s spots – pathognomonic. – Lymphadenopathy, D/V, splenomegaly. Rubeola LABS: – Leukopenia – Serology, cultures (nasopharangeal washings) DIAGNOSIS: – Clinical, confirm with labs if questionable. PROGNOSIS: – Usually self limiting. Mortality can be up to 10%. Can cause: otitis media, pneumonia, encephalitis, diarrhea. Rubeola TREATMENT: – Isolation until 1 wk after rash starts – Symptomatic – Treat secondary bacterial infections HEALTH MAINTENANCE: – Immunize (2 doses MMR) Coxsackievirus (Hand-foot-mouth disease) EPIDEMIOLOGY/ETIOLOGY : – Coxsackievirus A16 (and other types) – Usually <10 years old. – Epidemic outbreaks – Highly contagious (oral-oral, fecal-oral). HISTORY: – 3-6 d incubation – Prodrome: low fever, malaise, abd pain. Coxsackievirus PE: – Painful oral lesions, refusal to eat. – Cutaneous lesions +/- pain. – Macules or papules vesicles. +/Erosions, crusts. – Palms, soles, buttocks, hard palate, tongue, buccal mucosa. Coxsackievirus LABS: – Serology, culture. DIAGNOSIS: – Usually clinical PROGNOSIS: – Self limiting. – Rarely can cause meningitis, myocarditis Coxsackievirus TREATMENT: – Symptomatic. – Self-limiting. – Topical lidocaine gel for oral discomfort. HEALTH MAINTENANCE: – OK for daycare. Erythema Infectiosum (Fifth Disease) EPIDEMIOLOGY/ETIOLOGY : – Human parvovirus B19. – Common in young, can be any age. – Transmission: respiratory droplet. HISTORY: – 4-14 d incubation. – Prodrome: fever, malaise, HA, URI 2d prior. ST, N/V coincides with rash. – Adults: more severe with arthralgias. Erythema Infectiosum PE: – Edematous, confluent plaques on malar face, “slapped cheek”. – Fade 1-4dconfluent macules, “lacy”, on extensor surfaces, extremities, trunk. – Adults: more constitutional symptoms (fever, arthralgias, adenopathy). Erythema Infectiosum LABS: – Serology DIAGNOSIS: – Clinical PROGNOSIS: – Slapped cheeks fade then reticulated rash lasts 59 d. – Sunlight worsens, can last weeks to months – Arthralgias, aplastic crisis (immunocomp, anemic) Erythema Infectiosum TREATMENT: – Symptomatic HEALTH MAINTENANCE: – Prognosis excellent in immunocompetent – Immunocompromised: persistent anemia – Pregnant women: can cause hydrops fetalis and fetal anemia. Varicella (Chicken Pox) EPIDEMIOLOGY/ETIOLOGY : – Varicella zoster virus (herpesvirus) primary infection. – 90% in <10 year olds. – Airborne droplet, direct contact. Highly contagious. – Contagious before vesicles until last vesicles crust. – Herpes zoster (secondary infection): shingles. Varicella HISTORY: – About 14 d incubation. – Prodrome absent or mild. Worse in adults (fever, HA, malaise). PE: – Papulesvesicles. ‘Dewdrop on rose petal’. umbilication pustules crusts in 8-12hr. PRURITIC – Crops: face scalp trunk & extremities Varicella LABS: – Leukopenia – VZV antigen or culture (scrapings), serology DIAGNOSIS: – Usually clinical PROGNOSIS: – Healthy: usually self limiting. – Bacterial superinfection, pneumonia, encephalitis, maternal varicella syndrome. Varicella TREATMENT: – Isolation until crusts gone – Lotions and antihistamines for pruritis. – Antivirals will severity – Bacterial infection: topical/oral antibiotics. HEALTH MAINTENANCE: – Immunization: 2 doses varivax – Check titers in young women, immunize.