PANCE Blueprint Dermatology (5%)

Exanthems

Erythema infectiosum (fifth disease) Parvovirus B19"slapped cheek" rash on face - lacy reticular rash on extremities, spares palms and soles

  • Resolves in 2-3 weeks

Treatment is supportive, anti-inflammatories

Erythema infectiosum (fifth disease): Symmetrical bright red cheeks, the rash does not extend over the bridge of the nose or around the mouth

Erythema infectiosum (fifth disease): Symmetrical bright red cheeks, the rash does not extend over the bridge of the nose or around the mouth

Hand-foot-and-mouth disease Children < 10 years old caused by coxsackievirus type A virus producing sores in the mouth and a rash on the hands, feet, mouth, and buttocks  (watch video)

  • The virus usually clears up on its own within 10 days

Treatment is supportive, anti-inflammatories

Coxsackievirus (hand, foot, and mouth disease): children< 10 years old with vesicles on pharynx, mouth, hands, feet

Coxsackievirus (hand, foot, and mouth disease): children< 10 years old with vesicles on pharynx, mouth, hands, feet

Measles (Rubeola) The 4 C's - cough, coryza, conjunctivitis and cephalocaudal spread

  • Morbilliform - maculopapular, brick red rash on face beginning at hairline then progressing to palms and soles last - rash lasts 7 days
  • Koplik spots (small red spots in buccal mucosa with blue-white pale center) precedes rash by 24-48 hours.

Treatment is supportive - anti-inflammatories, isolate for 1 week after onset of rash

Measles (Rubeola): 4 C's: cough, coryza, conjunctivitis and cephalocaudal spread of morbilliform (maculopapular, brick red rash on face beginning at hairline then progressing to palms and soles last - rash lasts 7 days)

Measles (Rubeola): 4 C's: cough, coryza, conjunctivitis and cephalocaudal spread of morbilliform (maculopapular, brick red rash on face beginning at hairline then progressing to palms and soles last - rash lasts 7 days)

Rubella (German measles)  "3-day rash"  pink light-red spotted maculopapular rash first appears on the face, spreads caudally to the trunk and extremities and becomes generalized within 24 hours (lasts 3 days)

  • Cephalocaudal spread of maculopapular rash, lymphadenopathy (posterior cervical, posterior auricular)
  • Although the distribution of the rubella rash is similar to that of rubeola, the spread is much more rapid, and the rash does not darken or coalesce
  • Teratogenic in 1'st trimester - congenital syndrome - deafness, cataracts, TTP, mental retardation

Rubella (German Measles)

Rubella (German Measles)

Roseola (sixth disease) Herpesvirus 6 or 7, only childhood exanthem that starts on the trunk and spreads to the face

  • High fever 3-5 days then rose pink maculopapular blanchable rash on trunk/back and face

Roseola

Roseola

_DM_Roseola_v1.5_ Roseola is a common exanthem in young children that presents with a high fever followed by a rash. It is usually caused by Human Herpesvirus 6 (HHV-6), which is an enveloped linear double-stranded DNA virus. Children will have 3-5 days of a high fever, which may exceed 40C or 104F, causing some children to develop febrile seizures. Following this, a diffuse macular rash starts on the trunk and spreads to the face and extremities.

View Roseola Picmonic

rubeola-virus_5732_1486069424 Rubeola virus is a single-stranded RNA paramyxovirus that causes measles. Measles is an exanthem that is distinguished by a fever, Koplik spots, cough, coryza (head cold), conjunctivitis and a characteristic rash. Koplik spots are pathognomonic for measles and present as small red spots with a blue-white center on the buccal mucosa. They usually appear during the prodrome phase or about 48 hours before a rash. The rash found in measles is an erythematous maculopapular rash that begins on the face and moves down to involve the entire body, much like the rash in rubella. However, in measles, the rash darkens over time and is confluent (the rash merges together). A rare but fatal complication of measles is subacute sclerosing panencephalitis, which can occur 7-10 years post-infection and is thought to be caused by persistent measles infection in the CNS. In immunocompromised patients, measles can cause pneumonia with Warthin-Finkeldey multinucleated giant cells. Children in the United States are typically vaccinated against measles; however, outbreaks are seen in under-vaccinated or unvaccinated children.

View Rubeola (Measles) Picmonic

coxsackie-virus_5728_1484692765 Coxsackievirus is a virus that belongs to the Picornaviridae Family. These viruses are divided into group A and group B. In general, group A coxsackieviruses infect the skin and mucous membranes, causing febrile pharyngitis, hand, foot, and mouth disease, herpangina, and conjunctivitis. This virus is also one of the most common causes of aseptic meningitis that usually occurs in the late summer months. Group B coxsackieviruses tend to infect the heart and the pleura, as well as the pancreas. Infection of the heart can lead to myocarditis, and dilated cardiomyopathy and can lead to pericardial effusions. Recently, the development of type 1 diabetes mellitus has been associated with previous coxsackievirus B infection.

View Coxsackie Virus Picmonic

rubella_5730_1489021355 Rubella is a viral exanthem that occurs in both children and adults. It is caused by the rubella virus, which is an enveloped, single-stranded icosahedral RNA virus, and is a member of the togavirus family. It is also known as the German measles, or the three-day measles. Rubella can present with fever and tender postauricular lymphadenopathy. Following this is a diffuse, light pink maculopapular rash that first appears on the face and then spreads to the trunk and extremities within 24 hours. The rash usually lasts about three days, hence the name three-day measles. Adults can also have arthritis. In pregnancy, rubella is a TORCH infection and can cause serious complications, including hearing loss, ocular and cardiovascular defects and mental retardation.

View Rubella (German Measles) Virus Picmonic

IM_NUR_EythemaIfectiosumFifthsDisease_v1.2_ Erythema infectiosum or Fifth's Disease is a mild viral infection that is characterized by the slapped face appearance. It typically occurs in school-age children; however, adults can contract the disease. Pain and swelling in the joints (polyarthropathy syndrome) is a common finding in adult women with the disease. It is transmitted by respiratory secretions, blood, and blood products. The period of communicability is uncertain and the incubation period is 4 to 14 days and may be as long as 21 days. Isolation is not necessary.

View Fifth's Disease Picmonic

Question 1
A 13-month old boy is brought to your office by his mother on account of body rash on his chest and back which she noticed this morning. She gives a history of high fever which started 3 days ago but came down today. On examination, you notice rose-pink maculopapular rash on his chest and back. The most likely diagnosis is
A
Rubella
Hint:
Usually presents with fever, lymphadenopathy and fine maculopapular rash.
B
Roseola
C
Rubeola
Hint:
Typically presents with maculopapular rash with fever, conjunctivitis, cough, coryza.
D
Varicella
Hint:
Presents with pruritic rash that starts as erythematous maculopapular rash that become vesicles.
Question 1 Explanation: 
Roseola (sixth disease) typically presents as rose-pink maculopapular rash which starts after a 3 to 4-day episode of high fever. Fever comes down when rash starts. Fever may be associated with seizures.
Question 2
A 6-year old boy presents with fever, tender posterior auricular and suboccipital adenitis, and pink maculopapular rash which started on the face and has now moved to the trunk and extremities within 24 hours. Which of the following is the most likely diagnosis?
A
Rubella (German measles)
B
Varicella
Hint:
Presents with pruritic rash that starts as erythematous macules that become vesicles and later pustules.
C
Infectious mononucleosis
Hint:
Presents as fever, pharyngitis, and lymphadenopathy.
D
Rubeola (measles)
Hint:
Presents as maculopapular rash with fever, conjunctivitis, cough, coryza.
Question 2 Explanation: 
Children with Rubella (German measles) typically present as described above.
Question 3
A 2-year-old presents with an erythematous rash on the face (slapped-cheek appearance) that has spread to involve the trunk; the extremities are spared. She also has a low-grade fever and malaise. Which of the following is the most likely diagnosis?
A
Measles
B
Congenital syphilis
C
Erythema infectiosum
D
Meningococcemia
E
Rubeola
Question 3 Explanation: 
Erythema infectiosum is referred to as fifth disease because it represents the fifth major viral childhood illness (which also includes measles, mumps, rubella, and rubeola). The disease is caused by parvovirus B19 and is characterized by mild constitutional symptoms, such as low-grade fever, malaise, and joint pain (particularly in adult women). Also, there is a classic indurated, erythematous maculopapular facial rash that may progress to the trunk and extremities (but spares the palms and soles). The rash is often pronounced on extensor surfaces. The rash is often referred to as a “slapped-cheek” appearance and can be exacerbated with exposure to sunlight, heat, emotional stress, or fever. The illness usually lasts 5 to 10 days, and only symptomatic treatment is necessary. Occasionally, complications include arthropathies, myocarditis, and a transient aplastic crisis. Fifth disease may occasionally cause fetal death secondary to fetal hydrops; therefore, pregnant women should avoid contact with affected patients. Children are not infectious once the rash develops because the rash and arthropathy (when present) are immune-mediated, postinfectious reactions. Therefore, isolation from school and/ or day care is not necessary.
Question 4
Erythema infectiosum (fifth disease) is caused by
A
Parvovirus
B
Adenovirus
C
Rhinovirus
D
Paramyxovirus
E
Herpes virus
Question 4 Explanation: 
Parvovirus B19 is the causative agent responsible for erythema infectiosum, or fifth disease. The incubation period is 6 to 14 days. Outbreaks frequently occur at day schools, elementary schools, or junior high schools, and they frequently occur in the spring. Symptoms include a distinctive facial rash that has a “slapped-cheek” appearance, fever, arthralgias, and fatigue. Within 2 days, the facial rash gives rise to a generalized lacelike macular rash that involves the trunk. It has become increasingly clear over the past several years that parvovirus B19 causes arthritis and arthralgias in adults and children. Although parvovirus infections in adults are most commonly asymptomatic, an estimated 50% to 60% of women with symptomatic disease manifest arthropathy. Men appear to be affected much less frequently. Blood cell counts during the illness show leukopenia, lymphopenia, and thrombocytopenia with decreased reticulocytes. Because parvovirus B19 infects erythroid progenitor cells in the bone marrow and causes temporary cessation of RBC production, patients who have underlying hematologic abnormalities (and thus depend on a high rate of erythropoiesis) are prone to cessation of RBC production if they become infected. This can result in a transient aplastic crisis, which may occur in persons with chronic hemolytic anemia and conditions of bone marrow stress. Thus, patients with sickle cell anemia, thalassemia, acute hemorrhage, and iron-deficiency anemia are at risk. The diagnosis of erythema infectiosum is made clinically, and laboratory studies are not needed under normal circumstances. Serologic tests are usually relied on for the diagnosis of parvovirus B19 infection in patients with transient aplastic crisis or arthropathy; a positive parvovirus B19– specific IgM antibody or a significant rise in parvovirus B19– specific IgG titer is indicative of an acute or recent infection. Exposure during pregnancy can lead to fetal hydrops, spontaneous abortion, and fetal death. Supportive care during an attack of fifth disease is usually adequate, and the illness is self-limited. The risk of respiratory transmission is decreased significantly when the rash starts to fade. Children with erythema infectiosum are not infectious and can attend school and day care.
Question 5
Which of the following conditions is associated with congenital cataracts?
A
Maternal rubella infection
B
Maternal varicella infection
C
Congenital hypothyroidism
D
Acromegaly
E
Fetal hydrops
Question 5 Explanation: 
A cataract is a proteinaceous opacity of the lens. Causes of congenital cataracts include ocular trauma, maternal rubella, diabetes mellitus, galactosemia, Marfan’s syndrome, and Down’s syndrome. Monocular cataracts should be corrected as soon as possible (within the first 3 months of birth) so that vision can develop properly. Delayed intervention can lead to development of abnormal vision. Treatment of the amblyopia may be the most demanding and difficult step in the visual rehabilitation of infants and children with cataracts.
Question 6
Which of the following statements about measles immunizations is true?
A
Allergies to eggs or neomycin are not contraindications to the measles vaccine
B
Those who received killed virus immunization between 1963 and 1967 should receive a live attenuated booster vaccination
C
Infants receiving vaccination before 15 months of age do not need booster vaccinations
D
The present immunization is a genetically derived recombinant vaccine
E
Those born before 1956 should receive a measles booster vaccination
Question 6 Explanation: 
Measles immunization is accomplished with a live attenuated virus given at 12 to 15 months of age in the MMR vaccine and then as a booster with the preschool physical at 4 to 6 years of age. Those vaccinated with the killed virus (available in the United States from 1963 to 1967) should be given the live attenuated vaccine, because ineffectiveness is associated with the killed virus given during that period. Those born before 1956 are, in most cases, immune as a result of natural infection and therefore require no additional vaccination. Also, infants vaccinated before 12 months of age should receive two additional boosters. Prior anaphylactic reactions to eggs or neomycin are relative contraindications to the administration of the measles vaccine. A pediatric allergist or immunologist should be consulted before administration.
Question 7
A 4-year-old boy is brought to your office by his mother. The child has evidence of a stomatitis and a vesicular rash that affects his hands and feet. The most likely cause is
A
Coxsackievirus
B
Adenovirus
C
Syphilis
D
Varicella
E
Measles
Question 7 Explanation: 
The coxsackievirus is responsible for several infections that usually affect the pediatric population. There are two types of the virus:
  • Coxsackievirus A
    •  A16 is responsible for hand, foot, and mouth disease, which is characterized by stomatitis and a vesicular rash that affects the hands and feet. It is usually mild, affects young children, and may occur in epidemics.
    • A2, A4, A5, A6, A7, and A10 are responsible for herpangina, which is a more severe febrile illness that sometimes leads to febrile seizures. Other symptoms include a severe sore throat; vesiculoulcerative lesions that affect the tonsils, soft palate, and posterior pharynx; headaches; myalgias; and vomiting.
  • Coxsackievirus B
    • B1, B2, B3, B4, and B5 are responsible for pleurodynia with pain associated with the area of diaphragmatic attachment. Other symptoms include fever, headache, sore throat, malaise, and vomiting. Orchitis and pleurisy may also occur.
Coxsackievirus B infection is rare in persons older than 60 years and is more common in children and young adults. The infection is transmitted by hand-to-mouth contact and may become widespread in certain populations. This virus has been called “the great pretender” because of the variety of clinical syndromes it can produce. Many infections that are caused by the virus are subclinical. More serious conditions caused by coxsackievirus B include myocarditis, orchitis, myalgia, and pleurodynia. Pleurodynia may be severe and can occur in epidemics referred to as Bornholm disease, named after the original description of an early epidemic on the Danish island of Bornholm. Patients with pleurodynia are usually children or young adults who present with severe pleuritic pain, tachypnea, and systemic upset. The condition is usually self-limiting, but there can be serious, though rare, long-term
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