Pediatrics [INFECTIOUS RASHES]

Introduction
Children are prone to viruses. Many can be prevented by vaccines but all
it takes is one suspicious parent to say no to a vaccine. Quick vocab
lesson: exanthem is a rash on the skin; enanthem is a rash on the mucous
membranes. See Derm - Rashes for more rash diseases. To nail these on
the test, learn the Pattern, Development, and Timeline of the fever &
rash.

Erythema Infectiosum
Caused by parvovirus B19, there’s usually a nonspecific prodrome that
gives rise to an erythematous rash. It’s isolated to the face bilaterally
(slapped-cheek). You may see some spread to the trunk/limbs, which will
be lacy or reticular in appearance. This disease is benign on its own in a
normal healthy baby and resolves spontaneously. If there’s increased cell
turnover with increased baseline reticulocyte production (sickle cell) or
decreased production (anemia, heavy metals) this infection may
precipitate an aplastic crisis. If baby gets sick and is near mom while
she’s pregnant it can cause hydrops fetalis in the new baby. Separate any
gravid mom. Can see arthritis in adults.

Measles
Caused by a paramyxovirus, there’s an obvious prodrome of low grade
fever and the “four hard Cs” – cough, coryza (runny nose),
conjunctivitis, and Coplik Spots (Koplik Spots, an enanthem, are small
irregular spots with white centers on bright red buccal mucosa). The rash
starts on the face, after the prodrome. As it spreads to the body, fever
starts with the rash. The rash spreads and clears from head to toe. Later
in life a potentially lethal complication (subacute sclerosing
panencephalitis) can occur.

Rubella (aka “German Measles”)

Caused by the togavirus named Rubella, the rash itself looks just like
measles. It starts on the face, spreads down to the toes, and is likewise
macular. However, during the rash these patients don’t look as sick as
measles. The rash tends to be fainter and spreads quicker. The prodrome
of tender generalized (periorbital, postauricular) lymphadenopathy
precedes the rash. Forchheimer spots on the palate (red enanthem) can
be seen. Since measles and rubella look the same they’re in the same
vaccine.

Roseola
Caused by HHV-6, there’s a prodrome of a high-fever (>40 C) that
breaks as the rash starts. The rash is a macular rash that begins on
trunk and spreads to the face. Febrile seizures may result from extreme
fever during the prodrome.

Varicella (aka “Chickenpox”)

This is caused by varicella zoster virus. A vague, nonspecific viral
prodrome indicates contagion. What follows is a rash that starts on the
trunk and head followed by outward spread to extremities. The vesicles
are on an erythematous base and are in different stages (eruption,
ulceration, crusting). Contagion ends with a final crust. Scarring and
secondary infections (Staph and GAS) are two complications. Shingles
(reactivation) can be prevented with immunization.

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 Pediatrics [INFECTIOUS RASHES]

Varicella Zoster (aka “Shingles”)
A sequelae of Varicella seen in immunocompromised adults who had
chicken pox. Reactivation causes an extremely painful prodrome that
precedes a rash in the same dermatomal distribution of the pain and
never crosses midline. It generally isn’t treated, though acyclovir may
decrease duration and pain. If pain persists beyond resolution of the rash
(postherpetic neuralgia) treat the pain with TCA or gabapentin.

Mumps
Caused by the mumps virus, mumps is a little inappropriate for this
section as it doesn’t cause a rash. Instead, it causes bilateral parotid
swelling and orchitis in pubertal males. Sterility is rare. Its prodrome is
nonspecific.

Hand-Foot-Mouth Disease (aka “HFMD”)

Caused by coxsackie A virus, it also has a vague, nonspecific prodrome
but may present with oral pain. Like varicella, it has a vesicle on an
erythematous base, but will primarily involve only the hands, feet, and
mouth (thus the name). It can also involve the buttocks. Herpangina
involves vesicular lesions on the soft palate, tonsils, and uvula.

Disease Bug Prodrome Rash Other

Erythema Parvovirus B19 Vague, Nonspecific Slapped Cheek appearance Aplastic Crisis
Infectiosum Hydrops Fetalis
Measles Paramyxovirus Cough, Coryza, Conjunctivitis Erythematous Macular Rash SSPE
with “Coplik” Spots Starts 2-4 days after fever Vaccine
Starts Head à Toes
Clears Head à Toes
Rubella Togavirus Tender, generalized Erythematous Macular Rash TORCH
lymphadenopathy Starts Head à Toes Vaccine
Fainter, quicker spread
Roseola HHV-6 High Fever Truncal Rash Spreads to Face. Febrile Seizures
Starts when the fever breaks
Varicella Varicella Zoster Vague and Nonspecific Vesicles on an erythematous Shingles
(Chickenpox) base in different stages Vaccine
(eruption, ulceration, crusting)
Trunk/head then outward spread
Varicella Zoster Varicella Zoster Pain in a dermatome Vesicles on an erythematous Vaccine
(Shingles) Reactivation base in a single dermatome and
respects midline
Mumps Paramyxovirus Vague and Nonspecific Parotid Swelling + Orchitis Vaccine
(if pubertal male), ↑ Amylase.
Hand Foot and Coxsackie A Vague and Nonspecific Vesicles on an erythematous
Mouth Disease May have oral pain base located on the hands, feet,
and mouth (possibly buttocks)

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