Pediatric Exanthems

Sarah Stein, MD
Sections of Dermatology and Pediatrics
University of Chicago

Definitions
Exanthem: A skin eruption occurring as a
symptom of a general disease.
Enanthem: Eruptive lesions on the mucous
membranes.

Classic Childhood Exanthems

I.
II.
III.
IV.
V.
VI.

Measles (Rubeola)
Scarlet Fever
Rubella (German measles)
Filatow-Dukes Disease
Erythema Infectiosum
Roseola Infantum

1st Disease=Measles
Paramyxovirus
At risk: preschool-age children who escaped
vaccination; school-age children/adolescents in
whom vaccination failed
Season: late winter/spring
Incubation period: 8-12days
Infectious period: 1-2d before prodrome to 4d
after onset of rash

Measles: clinical features

Prodrome: day 7-11 after exposure
Fever, cough, coryza, conjunctivitis

Enanthem: Kopliks spots appear 2 days

before the rash, last 2 days into the rash

Measles:
morbilliform
exanthem
Presents day 14

after exposure

Measles: complications

Otitis media
Bronchopneumonia
Encephalitis
Myocarditis
Pericarditis
Subacute sclerosing panencephalitislate
sequellae due to persistent infx of the CNS

2nd Disease=Scarlet Fever

Due to erythrogenic exotoxin-producing
group A beta-hemolytic streptococci
At risk: <10yo, peak 4-8yo
Season: late fall, winter, spring
Likely due to close contact indoors in school

Incubation period: 2-4 days

Infectious period: during acute infection,
gradually diminishes over weeks

Scarlet Fever: clinical features

Abrupt onset fever, headache, vomiting,
malaise, sore throat
Enanthem
Bright red oral mucosa
Palatal petechiae
Tongue changes

Strawberry tongues

Scarlet Fever: exanthem

(12-48hrs after fever onset)

Scarlet Fever: complications

Purulent
complications
Otitis media
Sinusitis
Peritonsillar/retropharyngeal abscesses
Cervical adenitis

Nonsuppurative
sequalae
Rheumatic fever
Acute
glomerulonephritis

Scarlet Fever and a negative strep

culture?
Scarlet fever-like syndrome in a young
adult
Arcanobacterium haemolyticum (aka
corynibacterium haemolyticum)
Gram positive rod
Grows on 5% human blood agar
More sensitive to erythromycin

3rd Disease=Rubella

Togavirus
At risk: unvaccinated adolescents
Season: late winter/early spring
Incubation period: 14-21 days
Infectious period: 5-7d before rash to 3-5d
after rash

Rubella: clinical features

Asymptomatic infection in up to 50%
Prodrome
Children: absent to mild
Adol and Adult: Fever, malaise, sore throat,
nausea, anorexia, painful occipital LAD

Enanthem
Forschheimers spots = petechiae on the hard
palate

Rubella: exanthem

Rubella: complications
Arthralgias/arthritis in older patients
Peripheral neuritis, encephalitis,
thrombocytopenic purpurarare
Congenital rubella syndrome
Infection during first trimester
IUGR, eye findings, deafness, cardiac defects,
anemia, thrombocytopenia, skin nodules

4th Disease=Filatow-Dukes
Disease
Obsolete
Probably now better defined as another
clinical entity

5th Disease=Erythema
Infectiosum

Human Parvovirus B19

At risk: school-age children
Season: sporadic
Incubation period: 4-14 days
Infectious period: up until onset of the rash

EI: clinical features

Over 50% of infections are asymptomatic
Prodrome
Mild fever (15-30%), sore throat, malaise

Adultsflu-like symptoms, arthralgias/arthritis

(potentially chronic), rash in up to 40%
Hematological changesproerythrocyte tropic
virus
Drop in RBC count

Erythema
Infectiosum:
slapped cheek
appearance

EI: complications
Immunocompromisedchronic infection
with severe, persistent, relapsing and
remitting anemia, prolonged viral shedding
Patients with decreased RBC survival time
(hemoglobinopathies, hemolytic dis)
aplastic crises, prolonged viral shedding
Fetal infectionhydrops fetalis (overall
risk of fetal death 1-9%)

Papular purpuric glove and sock

syndrome
2nd syndrome ascribed to Parvovirus B19,
other viruses may be possible causes
Spring/summer; young adults
Rash, LAD, fever, anorexia, arthralgias
Self-limited over 7-14 days
Viremia clears after rash

Papular purpuric glove and sock

syndrome

th
6

Disease=Roseola infantum
(aka Exanthem subitum)

Human Herpes Virus 6 (and 7)

At risk: 6-36 mo (peak age 6-7mo)
Season: sporadic
Incubation period: 9 days
Infectious period: virus is intermittantly
shed into saliva throughout life; asymp
persistent infection

Roseola: clinical features

High fever for 3-4 days
Abrupt defervescence with appearance of
rash
Associated seizures likely due to infection
of the meninges by the virus

Roseola: exanthem

The rest of the herpes family

Herpes simplex virus 1 and 2

Varicella-zoster virus
Cytomegalovirus
Epstein-Barr virus
Human Herpes virus 6 and 7
Human Herpes virus 8

Chicken Pox=Varicella
Varicella zoster virus, family herpesviridae
At risk: young children, nonimmune inds
Second attack rate within households is 80-95%

Season: sporadic
Incubation period: 10-21 days
Infectious period: via resp drop and vesicle
fluid, 2d before to 5d after onset of rash

Chicken Pox: clinical features

Prodrome
Ranges from asymp to fever, malaise, cough,
coryza, sore throat

Pruritus
Variable from mild to severe

Chicken Pox: exanthem

Chicken Pox: complications

Secondary bacterial infection5-10%
Otitis media5%
Higher risk for adults, neonates, immunocomp.

Pneumonitis
Encephalitis
Cerebellar ataxia
Hepatitis

Other rare compsReye syn, Guillain-Barre,

nephritis, carditis, arthritis, orchitis, uveitis

Smallpox
(variola):
exanthem

Herpes Zoster: clinical features

Reactivation of latent VZV in sensory
ganglia
At risk: elderly, immunocomp., children
who had chicken pox in utero or in 1st year
Prodrome
Unusual in children
In adults, dull ache for up to a week before rash

Varicella Zoster:
exanthem

Cephalic herpes zoster: RamseyHunt Syndrome

Varicella Zoster: complications

Post-herpetic neuralgiauncommon in kids
Disseminated disimmunocompromised
Widespread cutaneous lesions
Visceral disease

Ulcerations
Secondary infection

Infectious Mononucleosis

Infectious Mononucleosis: and

ampicillin/amoxicillin

Enterovirus rashes
Hand-foot-mouth disease
Herpangina
Nonspecific eruptions

Hand-foot-mouth disease
Typically due to Coxsackie A16
At risk: preschool-school aged children
Highly contagious

Incubation period: 4-6 days

Prodrome: 1-2 days before rash
Low-grade fever, anorexia, malaise, sore mouth

HFMD: enanthem

HFMD: exanthem

Nail matrix arrest and HFMD

Herpangina
Coxsackie A viruses
At risk: young children
Prodrome
Fever, sore throat

Herpangina: enanthem

Nonspecific enteroviral
exanthems
Multitude of presentations

Morbilliform or rubelliform
Vesicular
Petechial (typical of echovirus 9)
Urticarial

Involvement of other systems-rare, but not

to be ignored
CNS, pulmonary, GI, muscular, cardiac

Enterovirus:
nonspecific
exanthem

Named exanthems
Gianotti-Crosti Syndrome, aka papular
acrodermatitis of childhood
Unilateral Laterothoracic Exanthem, aka
asymmetric periflexural exanthem of
childhood (APEC)
Pityriais Rosea

Gianotti-Crosti syndrome:
clinical features
Most often due to EBV, also Hep B and all
other viruses
At risk: 6mo-14yrs, mean 2yrs
Season: spring and early summer
Constitutional symptoms: mild
Low grade fever, malaise, LAD, rare pruritus,
mild hepatitis (except in Hep B-associated case)

Gianotti-Crosti Syndrome

Gianotti-Crosti Syndrome

Gianotti-Crosti Syndrome

Unilateral Laterothoracic
Exanthem
aka Asymmetric Periflexural Exanthem
?viral: suggested by age, clustering, resp
symptoms
At risk: 1-5yos, mean 2yo
Prodrome: 60-75%
Rhinitis, pharyngitis, bronchitis, conjunctivitis,
gastroenteritis
Fever in 40-65%

Unilateral
Laterothoracic
Exanthem

Pityriasis Rosea
?viral: suggested by seasonality, mild
prodromal symptoms, assoc URI, clustering
of cases
Season: spring, autumn, winter
At risk: 10-35yos, can be seen in younger
Prodrome: very mild, if any
Malaise, nausea, anorexia, headache, low fever

Pityriasis Rosea

Pityriasis Rosea

Pityriasis Rosea