Infectious exanthema in children презентация

Infectious exanthema in children Natalya Viktorovna Rymarenko M.D., Ph.D Department of pediatrics, course of infectious diseases in children Medical Academy named after S.I.Georgievsky Vernadsky CFU

What is a rash? Rash — pathological elements on the skin (exanthema) and mucosal (enanthema), different from normal skin or mucous membrane color, texture and appearance.  Mechanism of the appearance Rash: Caused by infection – direct invasion into the skin of viruses/bacteria/fungi (herpes simplex, Lyme disease), immune response to the pathogen (measles, nodular erythema); Rash is not associated with infection - allergic diseases, vascular diseases, etc..

Characteristic of the rash Need to distinguish between: Morphology – spot, papule, vesicle, bulla, etc.; Form of the elements - round, oval, irregular, star shape, with clear or fuzzy edges; Size of individual elements – mm or sm; The number of elements - single, multiple; Color - from pale pink to bluish-purple; Localization - head, trunk, flexor or extensor surface of the extremities, large folds of skin, etc .; Symmetric / asymmetric.

Characteristic of the rash Time of eruption: rash appears completely in the first day - scarlet fever, rubella; step by step - rash spread top down a few days – measles; with effect false polymorphism – chickenpox - all stages of the rash (red bumps, blisters, and scabs) located on the body at the same time; ephemeral rash - disappears and reappears in the same place in a short time, change the initial location, characterized by variability in size - allergic urticaria. Haw is rash disappears? without a trace - rubella, with the transition to pigmentation - measles, development crusts – chickenpox, With desquamation - scarlet fever, pseudotuberculosis, Kawasaki sindrome.

Scarlet fever МКБ-10 (А38) Etiology Β-hemolytic streptococcus group A (BGSA ) -streptococcus pyogenic - produced erythrogenic exotoxin. Source - patients with scarlet fever, str.tonsillitis and carriers. Way - airborne, more often children 3-10 years. Pathogenesis Septic, toxic and allergic mechanism. Clinical manifestations The onset of the disease is sudden: fever, headache, sore throat, 1-2 time vomiting. Rash: appears at the end of the first or in the beginning of the second day, rash - punctual, background - on hyperemic skin, accompanied by mild itching, rash disappears after 3 to 4 days. on 2 week of disease appears desquamation on the palms and soles.

Scarlet fever. Rash

Scarlet fever Other symptoms Tonsillitis - catarrhal, follicular, lacunar, necrotic. Bright delimited hyperemia throat – “flaming throat“. In 1-2 days - coated tongue, after 3 days - "raspberry" tongue. The regional cervical lymphadenitis. Clinical forms: typical - mild, moderate, severe; atypical - ekstrabukkal (wounds, burn) - tonsils and pharynx generally are not involved. Without antibiotical threatment development complications Early (purulent) – lymphadenitis, paratonsillitis, paratonsillar abscess, otitis media, sinusitis, pneumonia. Later (infectious-allergic) - glomerulonephritis, myocarditis, synovitis, arthritis.

Scarlet fever Diagnosis CBC – leukocytosis, shift to the left, increase ESR. Rapid antigen detection tests – “Streptotest” - positive. Pathogen isolation - a positive result for a throat culture. Serological test – antistreptolysin O (ASLO) titers - increase to greater than 166 Todd units.

PSEUDOTUBERCULOSIS МКБ-10 (A04.8, A28.2) Pseudotuberculosis - is characterized by polymorphism of clinical symptoms rashes like in scarlet fever, the damage of gastro-intestinal tract and liver, often has relapsed motion. Ethiology/Epidemiology Yersinia pseudotuberculosis – gram-negative bacillus, Source of infection - wild and home animals (mouse, rats, dogs, foxes, cats and other); Way of transmitting – alimentary. Clinical criteria: Acute onset - high temperature, headache, arthralgias, muscle pain, sore throat, nausea, abdominal pain, dyspepsia, Lymphadenopathy – inlarged cervical, axillary, abdominal lymph nodes.

PSEUDOTUBERCULOSIS Rash: At the 3-4 days after starts disease appeares maculopapulous (like in scarlet fever) rash. Rash are present on face, intensified periorbitally, on the neck - “hood” symptom; Rash on the body - in skin folds, round the joints, more intensive on hands/feet - “gloves” and ”socks” symptom; Exanthema usually disappears after 4 to 5 days and then begins desquamation, first on the face, other parts of the body and last on the palms and soles . Nodular erythema development in case of relapsed course.

Other simptoms Catarrhal syndrome - pharyngeal and tonsil erythema (without tonsillitis), conjunctivitis, scleritis. “Strawberry” tongue - simulates the scarlet fever. Gastrointestinal syndrome – painfully palpation of abdomen, nausea, vomiting, liquid stool. Hepatomegaly, rare – splenomegaly. Arthritis of knees, elbows, foot and hand small joints or arthralgia. Hepatitis with or without the jaundice. Toxic myocarditis. Toxic nephritis, pyelonephritis. Bronchitis or pneumonia may also develop.

PSEUDOTUBERCULOSIS

PSEUDOTUBERCULOSIS Laboratory data CBC: leucocytosis, neutrophilia with left shift, eosynophilia, ERS is enlarged. Bacteriological method: Yersinia Pseudotuberculosis may be found in feces, urine, blood. ELISA test: specific antibodies IgM are positive in an acute phase of the disease. Treatment 1. Antibiotic therapy: chloramphenicol , severe form - cephalosporins III and IV generations, aminoglycosides i/v. 2. Alternative drugs - doxycycline (over 8 years), fluoroquinolones (over 13 years). 3. Deintoxication (infusion glucose-solts solution). 4. Symptomatic.

Rubella МБК -10 (В06) Rubella - a viral infection, with the air-droplet mechanism of transmission, mild clinical signs and benign completion. Innate Rubella - transplacental mechanism of transmission and development of severe fetal defects. The source of infection - patient or carrier; Diagnostic criteria of the acquired Rubella: Incubation period – 11-21 days. Prodromal period – 1-2 days: mild intoxication syndrome and catarrhal syndrome - rhinitis, pharyngitis; pathognomonic sign - increase of posterior cervical and occipital lymph nodes.

Rubella Period of exanthema – 3-4 days: Rash – small macula and papule, pinky, appear at the 1st day after disease manifestation, it spreads during one day; Situated on face, trunk, extensor surfaces of extremities, on the unchanged background; After 3-4 days disappears without a trace. Complications – encephalitis, arthritis of small joints. Diagnostic criteria of the innate Rubella, Classical Triad: Cataract. Congenital heart disease - open aortic channel, aortic valves defect, aortic stenosis, coarctation of the aorta, large arteries transposition, etc. Deafness.

Rubella Confirmation of the diagnosis: 1. CBC - leucopenia, lymphocytosis, plasmatic cells, normal ESR. 2. PCR – selection of virus from the nasopharyngeal smears, excrements, urine, blood, saliva and CSF. 3. ELISA test - specific antibodies IgM in the acute phase (and in the innate rubella) and IgG after the recovery (in the blood or, if necessary, in CSF). Treatment Symptomatic, no specific therapy; In cases arthritis - NSAIDs (non-steroidal anti-inflammatory drug) - 3-5 days. Prophylaxis: Isolation of patients on 4 days from the disease beginning, new-born with innate Rubella – up to 1 year. An active immunization (vaccination) - MMR vaccine (together with vaccination against measles, and mumps).

  MEASLES МКБ-10 (В05) Measles is a viral infection, transmitted by an air-droplet way, characterized by syndromes of intoxication, catarrhal inflammation of respiratory tract, conjunctiva, and rashes on the skin. Source of infection – infected person during last 2 days of incubation period, catarrhal period, and 4 days period of rash. Susceptible organism – no immunized people, older than 6 month, which never had measles. Incubation period - 9-17 days. Clinical presentation 1. Prodromal period – catarrhal period - 3 to 5 day. Temperature + classic three “C”: cough, corryza, conjunctivitis - make their appearance. 2. Pathognomonic sign - Koplick’s spots - small, bluish-gray papules on a red base, localized on oral mucosa. It appears at the 2 day catarrhal period and disappear by the 2 day of the exanthema period.      

MEASLES

MEASLES 3. Exanthema period: Initial element of rash - behind the ears, then on the face and neck. During 3-4 days rash spread up to down – step by step - involve the trunk and extremities. Rash - large maculopapular element (till 1 сm). 4. Pigmentation period – change color of the rash – brown – spreaded same the rash appeared - up to down. Complications: Viral – laryngotracheitis (croup), encephalitis, viral pneumonia, serous meningitis, encephalomyelitis, keratitis; Secondary bacterial – otitis media, pneumonia, gingivostomatitis, pyelonephritis. Laboratory investigation CBC – leucopenia, lymphocytosis, eosynophylia, and thrombocytopenia (may be). ELISA – presence of IgM antibodies in acute period. PCR – till 4-5 days rash period.

MEASLES

MEASLES Treatment Noncomplicated mild, moderate measles and atypical forms do not need specific medicine: 1. Adequate rehydration with oral fluids (lemon tea, warm drinks). 2. Control of fever - paracetamol 10-15 mg/kg not often than every 6 hours or ibuprophen 5 mg/kg per dose, not often than every 8 hours. 3. In case of dry cough – mucolytics - ambroxol, acetylcystein etc.. 4. Vitamin A orally. In case of bacterial complication – antibacterial therapy should be used. In case of meningitis - pathogenetic therapy : glucocrticoids 3-5 mg/kg (by prednisolon), IVIG. Prevention 1. Specific active immunization by MMR vaccine (measles, mumps, rubella). 2. Specific passive prophylaxis with immune serum globulin in a dose of 0.25 ml/kg. 3. Nonspecific – isolation of ill person until 5th day of the exanthema period (if complicated by pneumonia, encephalitis – up to 10th day). 4. Isolation of contact person from 8 to 17 days (in case of the specific immunoglobulin prevention – up to 21 day).

HHV-6 В - roseola infantum or sixth disease МКБ-10 (В08.2) More often in children till 2 years old; In 10% of cases the disease is established communication with HSV-7; Way - airborne, season - spring and early summer; The incubation period of 5-15 days.

HHV-6 В - roseola infantum or sixth disease Clinical manifestations: Acute onset, a temperature rise to febrile, absence of other symptoms; Catarrhal symptoms (cough, runny nose) - no or minor, The fever stay 3-4 days, than decreased critically to normal; After temperature decreased - appear maculopapular rash (same rubella) - on the face, chest and abdomen, and a few hours spreaded to the body; Disappeared gradually, without pigmentation or desquamation; Diagnosis – ELISA - identification of IgM, IgG to HHV type 6 (HHV -6), PCR. Treatment - symptomatic

VARICELLA (Chickenpox) Etio/Epidemiology Varicella-zoster virus (VZV) is DNA containing human herpesvirus. Primary infection with VZV causes chickenpox. The virus establishes latent infection in dorsal root ganglia - its reactivation causes herpes zoster (shingles). Source of infection – ill person with chicken pox, rare – herpes zoster. Chickenpox is transmitted from person to person by airbone or by the direct contact. Clinical presentation The incubation period - from 11 to 21 days. The contagious period - from 1 to 2 days before the rashes erupt until 5 days after the last rashes have appeared. The prodromal period consists of 1 to 2 days of fever, headache, malaise, and anorexia.

Chickenpox Rash Begin as a maculae and progresses rapidly to papule, vesicle, pustule and crusted. Often pruritic. Firstly appear on the trunk, obvious on the scalp. In severe cases may be present on palms and soles. Different stages of rash (macule, papule, vesicile) may be found on one area - false polymorphism. The vesicle is 2 to 3 mm - with clear fluid - surrounded by an erythematous base. Then fluid clouds and crust forms appear within 1 day. Lesions occurring on the mucous membranes do not crust but form a shallow ulcer. Posterior cervical lymph nodes usually are enlarged.

Chickenpox

The congenital varicella syndrome The congenital varicella syndrome In case of infection in the 1st trimester of pregnancy – embryopathies. Maternal varicella 5-10 days before delivery - mild chickenpox in newborn from the first days of his life. Maternal varicella 4 days or less before delivery - result in severe disseminated or total chickenpox in the newborn.

Chickenpox Clinical classification Typical forms: mild, moderate, severe. Atypical forms: Rudimentary - in children with passive immunity received transplacentally or due to immune globulin or plasma injection in the latent period - several papules with single vesicles appear, body temperature is normal. Hemorrhagic - in immune compromised children, vesicles with hemorrhagic content. Other signs of hemorrhagic syndrome are present - petechia, ecchymosis, nasal bleeding etc. Gangrenous - necrosis of deep layers of epidermis. Generalized (visceral) - is typically for the newborns and in case of the immune deficit.

Bullous form - together with typical rashes appear large vesicles up to 2-3 cm with cloudy content, after them erosion and pigmentation develop.

Chickenpox Complications: Secondary bacterial infection: Staphylococcus – pustulosis, b-hemolytic group A streptococcus - erysipelas, phlegmonae, otitis, pneumonia, lymphadenitis, stomatitis, purulent conjunctivitis and keratitis, sepsis, osteomyelitis. Viral: Primary varicella pneumonia - immunodefitient patients, newborn and up to 35 % of normal adults; Encephalitis - involvement of the cerebellum. Meningoencephalitis, encephalomyelitis, Guillain-Barre syndrome, transverse myelitis, optic neuritis, and facial nerve palsy. Other: thrombocytopenic purpura, nephritis, myocarditis, arthritis, acute adrenal insufficiency because of adrenal hemorrhages. Diagnosis CBC: leucopenia, relative lymphocytosis, normal ESR. 2. PCR, ELISA test  

Chickenpox Treatment Symptomatic up to disappear of clinical signs; Antiseptic fluids for skin lesions to prevent secondary infection - 1 % brilliant green; Gurgling with oral antiseptic fluids; Antihistamines - for itching; Paracetamol - for fever control. Etiological therapy by Acyclovir (IV 10 mg/kg 3 t/d for 7 – 14 days): Patients with oncohematologic diseases, bone marrow or inner organs transplantation; Who achieve corticosteroids, with the primary immune deficit, with HIV-infection; Newborn chicken pox; Chicken pox complicated by the damage of CNS, hepatitis, thrombocytopenia, pneumonia; Severe forms of Chicken pox - Acyclovir orally. For severe cases in neonates – Varicella-Zoster immune globulin (0.2 ml/kg). Prevention: 1. To isolate ill person until the 5 day after the last vesicles has appeared. 2. To isolate contacts from 11 till 21 day after contact. 3. VZ immune globulin in immunodeficiency children (not later than 72 hours after contact).

Diagnosis? Simptom?

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