PANCE Blueprint Dermatology (5%)

Exanthems (PEARLS)

Erythema infectiosum (fifth disease)
ReelDx Virtual Rounds (Erythema infectiosum)
Patient will present as → a 4-year-old who is brought to the office by his mother. The child has had a low-grade fever, headache, and sore throat for the past week. Four days ago, he suddenly developed a bright red rash on his cheeks, which during the past two days has spread to the trunk, arms, and legs. On physical examination, the child has erythema of the cheeks and a maculopapular rash with central clearing on the trunk spreading to the extremities. There are no other significant findings.

Erythema infectiosum (also known as Fifth's disease) is a common viral exanthem observed in pediatric patients caused by parvovirus B19

  • Slapped cheek rash on the face with circumoral pallor 2-4 days of lacy reticular rash (blanching) on extremities
  • Often preceded by prodrome sequence with a low-grade fever
  • Sickle cell patients are at high risk of developing aplastic crises with this disease

DX: is based primarily on clinical observations, history, and physical exam

  • Serology: associated with enlarged nuclei with peripherally displaced chromatin
  • PARVO B19-specific IgM antibodies and PCR

TX: Treatment is symptomatic

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
ReelDx Virtual Rounds (Hand Foot and Mouth Disease)

Patient will present as → a 2-year-old who is brought to the office by his mother. The child has had a low-grade fever, rash, and loss of appetite for the past two days. On physical exam, there are multiple 2-3-mm grey vesicular lesions on the bilateral palms and soles and several vesicles and ulcers on the oral mucosa. The physician assistant informs her parents that this disease typically resolves spontaneously and to keep the patient hydrated.

A common children's infection caused by coxsackievirus type A virus - producing sores in the mouth and a rash on the handsfeetmouth, and buttocks 

  • Children < 10 years old with small, tender, erythematous papules or vesicles on the pharynx, mouth, hands, and feet
  • Symptoms include fever, sore throat, feeling unwell, irritability, and loss of appetite
  • Coxsackievirus is quite contagious, especially in the first week of illness. Spread by direct contact with saliva or mucus

DX: based primarily on clinical observations, history, and physical exam

TX: supportive, anti-inflammatories

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

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)
Patient will present as → a 6-year-old child who is brought to the emergency room for a complaint of high fevers and a rash. His mother reports that she thought he had “just a cold” approximately one week ago—he had a mild fever, runny nose, conjunctivitis, and cough. Then he developed a rash that started on his face and gradually spread downward. The child has no significant past medical history, however, he was adopted from Russia at age 5, and his medical history prior to adoption is unknown. On examination, the child appears lethargic and has a temperature of 104.3. There is a mild injection of his conjunctiva and a generalized macular rash. White macules are noted on his buccal mucosa.

The 4 C'sc ough, c oryza, c onjunctivitis, and c ephalocaudal spread

Measles (Rubeola) is caused by a paramyxovirus and is transmitted by respiratory droplets, it has a 10-12 day incubation period. It progresses in three phases characterized by a prodrome, enanthem, and exanthem

  • Prodrome: 1-3 days of "the 3 C's" - cough, coryza, conjunctivitis, as well as fever
  • Enanthem (48 hours prior to exanthem) Koplik spots - are pathognomonic for measles and present as small red spots with a blue-white center on the buccal mucosa
  • Exanthem (2-4 days after onset of fever): consists of a morbilliform, brick red erythematous, maculopapular, blanching rash, which classically begins on the face/hairline and spreads cephalocaudally progressing to palms and soles last - rash lasts 7 days

DX: Clinical diagnosis of measles requires a history of fever of at least three days, with at least one of the three C's (cough, coryza, conjunctivitis)

  • Observation of Koplik's spots is also diagnostic of measles.
  • Laboratory diagnosis with confirmation of positive measles IgM antibodies or isolation of measles virus RNA from respiratory specimens

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

  • Immunoglobulin administration is indicated for use in exposed high-risk individuals (pregnant women and infants) to alter clinical disease
  • prevention with vaccines - MMR (live attenuated) at 12-15 months then again at 4-6 years of age

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)
Patient will present as → a mother who brings her 14-month-old daughter for evaluation of a rash. The mother describes the rash as beginning on the face and subsequently spreading to the rest of her body over 1 day. She also reports that her daughter has a mild fever and redness in her eyes. She has not been vaccinated per her parents’ preferences. Temperature is 100°F (37.8°C). There is mild bilateral nonexudative conjunctivitispostauricular lymphadenopathy, and petechiae on the soft palate and uvulaPink maculopapules are found in the face, neck, trunk, and extremities. The rash disappears in three days.

Distinguish from measles (rubeola) by → confluent maculopapular rash, coryza (stuffy nose), and Koplik spots (in 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

DX: detection of rubella-specific immunoglobulin M or G

TX: supportive care ⇒ no specific therapy for rubella infection is available

  • Prevention with vaccines - MMR (live attenuated) at 12-15 months then again at 4-6 years of age

Rubella (German Measles)

Rubella (German Measles)

Roseola (sixth disease)
Patient will present as → a mother who brings her 8-month-old infant into the clinic with a complaint of high fevers for three days. She denies any other symptoms. On examination, the child appears very well and is playful with you despite having a temperature of 103.9 F. A complete physical examination and urinalysis are done and no source of the fever is found. You send her home with fever control measures and a follow-up appointment for the next day. The next day, the child is afebrile but has a generalized pink maculopapular rash

Also known as exanthema subitum, caused by Herpesvirus 6 or 7 - only childhood exanthem that starts on the trunk spreads to the face

  • High fever 3-5 days in small children then as fever subsides a rose pink maculopapular blanchable rash appears on the trunk/back then spreads to the face
  • 6 months - 3 years old, transmission airborne

DX: The diagnosis is clinical

TX: Treatment is supportive and in most cases, roseola is a benign and self-limited disease

  • Fever can be controlled with antipyretics (eg, acetaminophen) if it is associated with discomfort
  • The rash resolves without treatment

Roseola

Roseola

Picmonic
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.

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Rubeola (Measles)

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.

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Coxsackievirus

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.

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View Rubella (German Measles)

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.

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Fifth’s Disease

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.

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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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