Viral Rashes: New and Old Peggy Vernon, RN, MA, CPNP, DCNP, FAANP C5 Disclosures •There are no financial relationships with commercial interests to disclose Viral Rashes: New and Old •Any unlabeled/unapproved uses of drugs or products referenced will be disclosed Peggy Vernon, RN, MA, CPNP, DCNP, FAANP ©Pvernon2021 ©Pvernon2021 Restrictions Objectives • Permission granted to the 2021 National Nurse • Identify a potential sequelae from hand, foot and Practitioner Symposium and its attendees mouth disease • Describe the pattern of distribution and lesion • All rights reserved. No part of this presentation may description of varicella be reproduced, stored, or transmitted in any form or • Identify a precursor of Henoch Schonlein Purpura by any means without written permission of the author •Contact Peggy Vernon at [email protected] ©Pvernon2021 ©Pvernon2021 Viral Exanthems Morbilliform Exanthems •Morbilliform • Measles (rubeola) •Papular-nodular • Rubella •Vesiculobullous • Roseola •Petechial • Erythema Infectiosum •Purpuric • Pityriasis Rosea • Infectious Mono ©Pvernon2021 ©Pvernon2021 1 Viral Rashes: New and Old Peggy Vernon, RN, MA, CPNP, DCNP, FAANP C5 Measles (Rubeola) MEASLES (RUBEOLA) • Prodrome: fever, malaise, cough, DIFFERENTIAL DIAGNOSIS conjunctivitis. Patient appears quite ill •Other morbilliform eruptions: Rubella, • Koplik’s spots: bluish-white erythema infectiosum, pityriasis rosea, elevations on buccal mucosa infectious mono • Exanthem: erythematous •DRUG maculopapular eruption, from scalp to forehead, posterior ears, face, •Papulosquamous disorders: psoriasis, guttate neck, to trunk and extremities. psoriasis Fades in same progression • Incubation: 10-12 days • Contagious 4 days before and 4 days after rash appears ©Pvernon2021 Photo Courtesy Visual DX ©Pvernon2021 Measles Diagnosis • Throat or nasal swab Measles: Treatment and Prevention • Labs to detect antibodies • Symptomatic and • Report to Health Department • Who should get the vaccine? supportive • Those who received vaccine between 1963 and 1967 • Appropriate but don’t know which version received treatment of • International travelers who don’t have evidence of immunity secondary bacterial • Who is exempt from vaccine? infections: otitis • Those born before 1957 media, • Those who received live vaccine between 1963 and bronchopneumonia 1967 • Those who received 2 live measles vaccines • IMMUNIZE! ©Pvernon2021 ©Pvernon2021 Measles Cases and Outbreaks CDC • Measles cases in 2021 Rubella • As of June 4, 2021, there have been 2 cases of measles confirmed in 1 jurisdiction.* • Measles cases in 2020 • Mild illness • From January 1 to December 31, 2020, 13 individual cases of measles were confirmed in 8 jurisdictions.* • Suboccipital and posterior • * Jurisdictions refer to any of the 50 states, New York City, and the District of Columbia. auricular adenopathy • Measles cases in 2019 • From January 1 to December 31, 2019, 1,282* individual cases precedes cutaneous of measles were confirmed in 31 states. • This is the greatest number of cases reported in the U.S. since eruption by several days 1992. The majority of cases were among people who were not vaccinated against measles. Measles is more likely to spread and • Pink macular eruption first cause outbreaks in U.S. communities where groups of people are unvaccinated. on face to trunk and • For more information please see the following reports: • Increase in Measles Cases – United States, January 1-April 26, 2019 MMWR. May 3, 2019 proximal extremities Photo Courtesy Visual DX • National Update on Measles Cases and Outbreaks – United States, January 1-October 1, 2019. MMWR. October 11, 2019 ©Pvernon2021 ©Pvernon2021 2 Viral Rashes: New and Old Peggy Vernon, RN, MA, CPNP, DCNP, FAANP C5 Rubella STAR Complex • Prodrome: headache, •Sore malaise, anorexia, •Throat conjunctivitis, sore throat, cough, low-grade fever in •Arthritis adolescents and adults. Mild •Rash disease in children •Most common in adolescent girls. • Forchheimer’s sign: petechiae Arthritis may persist for several months Photo Courtesy Visual DX on soft palate • Incubation: 16-18 days ©Pvernon2021 ©Pvernon2021 RUBELLA CONGENITAL RUBELLA DIFFERENTIAL DIAGNOSIS • First trimester may result in embryopathy: neonatal purpura and petechiae secondary to •Other morbilliform eruptions thrombocytopenia. •Scarlet fever • Jaundice due to rubella hepatitis • May include deafness, congenital heart •DRUG! defects, cataracts, glaucoma, growth retardation, and psychomotor retardation ©Pvernon2021 ©Pvernon2021 ERYTHEMA INFECTIOSUM Rubella: Treatment and Prevention (FIFTH DISEASE) •Symptomatic • Parvovirus B19 • Stage 1: day 1: intense macular •Avoid exposure to pregnant women blush, “slapped cheek appearance” • • Stage 2: day 2: erythematous IMMUNIZE! maculopapular eruption on extensor surfaces of extremities • Stage 3: Day 6: rash on proximal extremities with reticulated or lacy pattern: most characteristic; reappears several times with exposure to heat or friction, lasting weeks to months Photo Courtesy Visual DX ©Pvernon2021 ©Pvernon2021 3 Viral Rashes: New and Old Peggy Vernon, RN, MA, CPNP, DCNP, FAANP C5 ERYTHEMA INFECTIOSUM ERYTHEMA INFECTIOSUM RISKS DIFFERENTIAL DIAGNOSIS • • Aplastic crisis in those Other morbilliform exanthems with sickle cell disease •Phototoxic reaction • Chronic anemia in •Systemic lupus immunodeficient patients •DRUG!! • STAR complex and arthritis • Hydrops fetalis and fetal Photo Courtesy Visual DX death in first trimester Photo Courtesy Visual DX ©Pvernon2021 ©Pvernon2021 Pityriasis Rosea • Prodrome: Usually no prodrome. Occasional Pityriasis Rosea pharyngitis, lymphadenopathy, headache, malaise. • DIFFERENTIAL DIAGNOSIS • Annular, scaly, • Tinea corporis erythematous lesion • Drug (herald Patch) precedes rash by 1-30 days • Nummular eczema • • Multiple erythematous Morbilliform eruptions macules follow lines of • Guttate psoriasis skin markings in • DURATION: “Christmas Tree” • Lesions may last 4-8 weeks configuration ©Pvernon2021 ©Pvernon2021 ROSEOLA PITYRIASIS ROSEA • Most common • TREATMENT: exanthem in children younger than 3 years • Antipruritics • Fever in otherwise well child for 3-5 days • UVL • Discrete rose-pink maculopapular exanthem, usually on the trunk, as the fever subsides • Incubation 5-15 days Photo Courtesy Visual DX ©Pvernon2021 ©Pvernon2021 4 Viral Rashes: New and Old Peggy Vernon, RN, MA, CPNP, DCNP, FAANP C5 Infectious Mononucleosis ROSEOLA DIFFERENTIAL DIAGNOSIS AND TREATMENT • Clinical triad: fever, pharyngitis, cervical adenopathy •Other morbilliform eruptions • Headache, malaise, fever, lymphadenopathy, sore throat •DRUG!!! with exudative tonsillitis, hepatosplenomegaly, periorbital •Treat symptomatically edema, photophobia • Macular, maculopapular, morbilliform eruption trunk, upper arms, occasionally on the face, forearms, thighs, legs Photo Courtesy Visual DX • Discrete bright red petechiae on the palate, fade to brownish hue in 2 days ©Pvernon2021 ©Pvernon2021 INFECTIOUS MONONUCLEOSIS Vesiculobullous Lesions • Epstein-Barr virus (EBV) •Hand-Foot-Mouth • DDX: Streptococcal infections, other morbilliform eruptions •Herpes Simplex • Treatment: Symptomatic, rest. •Varicella Prednisone 2-3 mg/kg for adolescents •Herpes Zoster • AVOID ANTIBIOTICS without confirmation of bacterial infection • Education: Avoid contact sports until hepatosplenomegaly resolves ©Pvernon2021 Photo Courtesy Visual DX ©Pvernon2021 Hand-Foot-Mouth Disease Hand-Foot-Mouth Disease • Prodrome: occasional low- grade fever, anorexia, sore •Enterovirus infection mouth, malaise, abdominal that causes a vesicular pain eruption that is clinically • Scattered papules & vesicles characteristic in on palms, fingertips, soles of appearance and feet. Discreet oral lesions on distribution soft palate, hard palate, buccal •Seasonal Peak summer mucosa, gingivae, tongue. and fall Photo Courtesy Visual DX • Fever, malaise, diarrhea, occasionally joint pain •Incubation 3-6 days • Cervical or submandibular adenopathy Photo Courtesy Visual DX ©Pvernon2021 ©Pvernon2021 5 Viral Rashes: New and Old Peggy Vernon, RN, MA, CPNP, DCNP, FAANP C5 HAND-FOOT-MOUTH DISEASE DIFFERENTIAL DIAGNOSIS HFM Treatment • Other morbilliform eruptions • Varicella • Herpes simplex virus •Symptomatic: • Herpangina Analgesics • 1-2 mm papules/vesicles, red halo, to shallow grey ulcer on soft Anti-pyretics, palate, tonsillar pillars, pharynx, Fluids Buccal mucosa • Fever, sore throat • Aphthous ulcers • Shallow erosions gums, tongue, palate, lips, buccal mucosa, gray- yellow base, burning, tenderness, heal in 7-10 days ©Pvernon2021 ©Pvernon2021 Photo Courtesy Visual DX Sequelae •Onychomadesis • Painless spontaneous separation of proximal nail plate ©Pvernon2021 ©Pvernon2021 Herpes Simplex • Grouped vesicles on Herpes Gladiatorum erythematous base • Tense vesicles •Skin-to-skin exposure • May be recurrent and through contact reactivated by fever, UVB, sports trauma (dental procedures) •>1/3 of wrestlers • Regional adenopathy infected after single • Prodrome tingling, itching, match with infected individual burning 12-24 hours before Photo Courtesy Visual DX lesions appear Photo Courtesy Visual DX ©Pvernon2021 ©Pvernon2021 6 Viral Rashes: New and Old Peggy Vernon, RN, MA, CPNP, DCNP, FAANP C5 Herpetic Whitlow Eczema Herpeticum • Lesions on fingers •Herpetic lesions in and periungual area sites of recent or • Common in health- active atopic care workers, dental dermatitis workers •Painful, edematous, • Children crusted vesicles autoinnoculate by sucking thumbs and biting