1

MINISTRY OF HEALTH OF UKRAINE

DANYLO HALYTSKYI LVIV NATIONAL MEDICAL UNIVERSITY

PEDIATRIC INFECTIOUS DISEASES DEPARTMENT

GUIDELINES
FOR PRACTICAL CLASSSES FOR 6th YEAR STUDENTS
SPECIALTY “GENERAL MEDICINE”
PROFILE COURSE OF YOUR CHOISE " INTERNAL MEDICINE "

"DIFFERENTIAL DIAGNOSTICS OF INFECTIOUS

DISEASES WITH EXANTHEMA IN CHILDREN"

LVIV-2022
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Guidelines are made according to the study program on Pediatric infectious diseases for students of the
second (Master Dergree) level of higher education in the field of knowledge 22 " Health Care " specialty
222 "General Medicine"
The Guidelines have been compiled by H. Lytvyn ( PhD), Associate Professor, the Head of Pediatric
Infectious Diseases Department, O. Hladchenko ( PhD), Assistant professor of Pediatric Infectious
Diseases Department, Danylo Halytskyi Lviv National Medical University

Reviewed by: D. Dobriansky, Doctor of Medical Sciences, professor, Department of Pediatrics №2

Danylo Halytskyi Lviv National Medical University
M. Shumylo Senior lecturer, of the Latin and Foreign Languages Department, Danylo
Halytskyi Lviv National Medical University

The editor-in-chief – E.Varyvoda, (MD, PhD) Associate Professor, the dean of the Faculty of Foreign
Students.
A. Nadraga Doctor of Medical Sciences, Professor, the dean of the medical faculty № 2, Danylo
Halytskyi Lviv National Medical University

Guidelines on the course of Pediatric Infectious Diseases

for students of the 5 t h year of General Medicine Faculty
“Approved” Protocol № 11 from 13.05.2022
Methodical Commission of Pediatric disciplines
Protocol № 3 from 13.06.2022
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Guidelines to lesson for students of the 6th year

(practical classes – 6 hours)

Differential diagnostics of infectious diseases with exanthema in children.

I.
Aim: to know diagnostic criteria of infectious diseases in children with exanthema; to
perform differential diagnostics of them.
Professional motivation: Exanthema – rashes on the skin, which occur in many infectious
diseases. Some rashes are typical only for one disease; other may be present in several
diseases. They differ by the rash morphology, localization, time of appearing, and dynamics
of development. That’s why it is very important to differentiate them and perform proper
diagnosis for adequate etiological and pathogenetic treatment.
Basic level
1. To know how to ask about complaints, history of the disease and life in children with
exanthema [propedeutic pediatrics, children infectious diseases].
2. To perform clinical examination of the child with exanthema [propedeutic pediatrics,
children infectious diseases].
3. To diagnose infectious exanthema after clinical, laboratory and instrumental examination
of the child [infectious diseases, propedeutic pediatrics, microbiology, and
pathophysiology].
4. To give etiological, pathogenetical and symptomatical treatment [pharmacology, children
infectious diseases].

II. Primary aims of the study

A student should know:
1. Etiology of Measles, Pseudotuberculosis, Scarlet fever, Varicella (Chicken-pox).
2. Epidemiology (source of infection, ways of transmission, age receptivity and
morbidity), Measles, Pseudotuberculosis, Scarlet fever, Varicella (Chicken-pox).
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3. Pathogenesis of disease, pathomorphologic changes in the skin and organs, Measles,

Pseudotuberculosis, Scarlet fever, Varicella (Chicken-pox).
4. Classifications of clinical forms of Measles, Pseudotuberculosis, Scarlet fever,
Varicella (Chicken-pox).
5. Clinical signs of typical form of Measles, Pseudotuberculosis, Scarlet fever, Varicella
(Chicken-pox).
6. Clinical manifestations of Measles, Pseudotuberculosis, Scarlet fever, Varicella
(Chicken-pox).
7. Complications of Measles, Pseudotuberculosis, Scarlet fever, Varicella (Chicken-
pox).
8. Clinical signs of “acute abdomen” in patients with measles.
9. Clinical signs of atypical (rudimentary and aggravated) forms of Varicella (Chicken-
pox), secondary bacterial lesions in patients with Varicella (Chicken-pox).
10. Methods of laboratory research of Measles, Pseudotuberculosis, Scarlet fever,
Varicella (Chicken-pox).
11. Principles of therapy of Measles, Pseudotuberculosis, Scarlet fever, Varicella
(Chicken-pox) with the children doses.
12. Measures of prophylaxis of Measles, Pseudotuberculosis, Scarlet fever, Varicella
(Chicken-pox).
13. Definition and general concepts of Immunization.
14. Postexposure immunoprophylaxis.
A student should be able:
1. To follow the basic rules of work with a bed patient with measles, rubella, varicella,
Herpes zoster. Measles, Pseudotuberculosis, Scarlet fever, Varicella (Chicken-pox).
2. To take anamnesis with the estimation of epidemiology information (taking into
account seasonality, origin of febricities, polymorphism of clinical signs of illness).
3. To examine a patient and reveal the basic clinical signs of illness.
4. To represent information of anamnesis and objective inspection in a hospital chart
and formulate the preliminary diagnosis.
5. To write a plan of examination.
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6. To write a clinical diagnosis (form of disease, type, severity, complications, course

of disease).
7. To prescribe the treatment taking into account age, mass and severity of illness.
8. To write out a prescription.
9. To organize disease measures in the focus of infection (to find out the source of
infection, fill an urgent report in SES, to set the quarantine, to define the circle of contact
persons).
10. To write epicrisis with the estimation of illness development, results of inspection,
efficiency of treatment, prognosis, recommendations for a subsequent supervision or
treatment depending on the form of Measles, Pseudotuberculosis, Scarlet fever, Varicella
(Chicken-pox).

III. Educational aims of the study

- to form the deontological presentations, skills of conduct with the patients
- to develop deontological presentations, be able to carry out deontological approach to
the patient
- to develop the presentations of influence of ecological and socio-economic factors on
the health condition
- to develop sense of responsibility for the time of illness and loyalty of professional
actions
- to be able to set psychological contact with a patient and his family.

IV. Interdisciplinary integration

Table 1
Subjects To Know To Know How
Human Anatomy The main anatomic
characteristics of
respiratory system
Physiology Functions of the To explain a variety of clinical
respiratory, nervous and signs and laboratory
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immune systems abnormalities

Pathological Pathogenesis of disease To explain the main symptoms
Physiology and manifestations appearance,
causes of relapses, failure of
inadequate therapy
Pathological Pathology To explain the pathogenesis of
Anatomy complications and causes of
death
Microbiology Etiology (classification, To culture the organism
morphologic characteristic
of the pathogen, methods of
revealing and identification)
Pharmacology The main antiviral and To administer treatment of
antibacterial agents. specific infection including
Regimens of treatment. antiviral agents. To write the
Treatment of complicated scheme of treatment of severe
influenza. Supportive care influenza.
Histology Histological changes in Explanation of appearance of
different clinical forms of clinical signs
influenza
Propedeutics of History of disease. To gather information about
Internal Diseases Examination of a patient. patient’s history and chief
complaints, to distinguish the
ones, most important for
diagnosis of influenza. To
examine the patient, to reveal the
main symptoms and signs of
disease. To distinguish the set of
diagnostic features of influenza.
To argue the diagnosis.
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Surgery Chest pain, cough, Differential diagnostics of

respiratory failure surgical disorders, diagnostics of
complications
Internal Diseases Chest pain, cough, To differentiate with other
respiratory insufficiency disorders of respiratory system
Neurology Severe headache, vomiting, Differential diagnostics of
meningeal signs, delirium, encephalitis, meningitis, stroke
altered consciousness
Clinical immunology Immunologic changes as a To explain confirmative serologic
and allergology part of pathogenesis and tests
host defenses
Epidemiology The routes of transmission, Epidemiological history
main sources of infection
Themes integration
Encephalitis, To know peculiarities of To differentiate influenza and
meningitis, common manifestations, laboratory other infections of respiratory
cold, ARD, diagnostics, treatment tract from other infectious
parainfluenza, RS- diseases with similar symptoms
infection,
leptospirosis, sepsis

V. The contents of the theme

Scarlet fever differs from measles by the absence of catarrh of the respiratory tract,
spotty enanthem, and Belski – Filatov-Kolik’s spots. A constant symptom of scarlet fever is
tonsillitis; the disease is often heralded by vomiting, and the tongue presents typical changes.
The rash in scarlet fever does not break out in stages as in measles, but covers the whole
body almost at once and is minutely punctuate. The circumoral region remains free of rash.
There is no leukopenia or aneosinophilia typical of measles, but neutrophilia, eosinophilia
and leukocytosis are found.
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Rubella has to be differentiated from acute exanthems: measles, scarlet fever (see
corresponding sections).
Rubella rash has also to be differentiated from serum and various drug rashes, and
enteroviral exanthema. Epidemiological data are of value in differential diagnosis and should
be taken into consideration along with clinical manifestations of the disease. The indirect
immunofluorescence assay is successfully used.
An accurate retrospective diagnosis of rubella is ensured by revealing the increasing
antibody titre by the hemoagglutination-inhibition reaction, the neutralization and the
complement-fixation tests which are carried out twice at a ten-day interval.
The diagnosis of chickenpox is not difficult. The characteristic rash and a history of
recent exposure should lead to a prompt diagnosis. Other viral infections that can mimic
chickenpox include disseminated herpes simplex virus infection in patients with atopic
dermatitis and the disseminated vesiculopapular lesions sometimes associated with
Coxsackie virus infection, echovirus infection, or atypical measles. However, these rashes
are more commonly morbilliform with a hemorrhagic component rather than vesicular or
vesiculopustular.
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V. Logical scheme of practical classes

Exanthema followed by infectious diseases

Theme

Measles Rubella Chicken-pox Scarlet fever

Disease

Etiology RNA-virus RNA-virus DNA-virus β-hemolytic streptococcus

group A

Aerial- Aerial- Contact way

Ways of Aerial-droplet route Aerial-droplet route droplet route droplet route
transmission

Clinical signs Intoxication Exanthema Lymphadenopa Intoxic Exanth Acute Intoxic

thy ation ema tonsillit ation
is

Catarrhal signs in the upper respiratory tract

Methods of
laboratory Virusological, serological Bacteriolological,
research serological

Vaccination
Prevention
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VI. Planning of the lesson

Table 2
The main Time in %
stages of the The methods of Methodical from total
lesson, control equipment time of the
contents lesson
10-20 %
1 Organizational
stage
2 Purposes of Relevance of the 2-5 min
the lesson Theme. Tutorial
goals of a lesson
3 Control of Control questions The list of control 15-25 min
basic questions
knowledge
and skills
1.Etiology, Test-control (first Tests of the first
epidemiology, grade) level
classification
of disease
2. Methods of the second Questions
Manifestations grade: Individual
in connection questioning in oral and Clinical cases (tests
with written form. Standard of the second grade)
pathogenesis task solution. Second Theory tasks for
grade test-control writing answers.
Second grade tests
3. Treatment Methods of the third Third grade
grade: questions and tasks
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1. Solution of Third grade tests

complicated tasks.
2.Third grade test-
control
4. Prevention
70-80 %
1 Formation of Method of formation: Patients with studied 120-140
professional practical training disease and similar min
skills diseases, patients’
histories, medical
cases.
To master the Examination of the Laboratory data of
skills of: patients, distinguishing the patients,
a) Diagnosis of the set of important antibacterial drugs
b) Laboratory signs and symptoms. and drugs for
confirmation Composing of a plan of supportive care
c) Treatment laboratory
confirmation.
Administration of the
treatment depending on
the form and severity
of disease.
Independent Examination of the Patients, patient’s
work with patients with Measles, histories, medical
patients Scarlet fever and other cases.
infectious diseases
with similar
manifestations
(differential
diagnostics).
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Differential Practical training Drawing schemes of

diagnostics pathogenesis and
clinical course of
disease; making up a
differential
diagnostics table and
list of prescriptions
for intensive care.
10 %
1 Teacher’s 10-15 min
control,
recommendati
ons, the task
for the next
lesson

Students’ self-study program.

1. Objectives for students' self-studies.
You should prepare for the practical class using the available textbook and lectures. Special
attention should be paid to the following:

Differential diagnostics of viral infectious rashes (exanthemas)

Table 3
Signs Measles Rubella Chicken-pox
Initial symptoms catarrhal signs from Increase of occipital Acutely, observing
upper airways, dry lymph nodes, minor catarrh, intoxication, rash
cough, conjunctivitis catarrhal signs and
during 2-4 days, intoxication
intoxication
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Time of the rashe on the 4-5 days of the 1 day, seldom 2 On 1-2 days rashe
appearance disease, with stages appear, next 3-5 days –
crusts
Morphology maculopapulous small-papulous Polymorphic (spots,
papules, vesicles, crusts)
Sizes of elements middle, large small, middle Middle
Localization gradual appearing of on whole body, Throughout the whole
the rash: 1 day - on mainly on body, on hair part of the
the face 2 - on the unbending surfaces head, seldom - on palms
face, trunk; 3 - on the of the limbs and soles
face, trunk, limbs
Brightness and bright red pale-rose Papules are pink, vesicles
color of elements – on hyperemic base
Further rashes' pigmentation, slight disappear on the 3-4 After desquamation of
development desquamation days the crusts - a slight
pigmentation
Catarrhal expressed in first 5-6 small, short for 1-2 Moderate,
phenomena days days
Oral mucous hyperemia, friability, clear, sometimes On pink background -
membranes enanthem, Koplick's single elements of polymorphic elements
spots enanthem
Intoxication significant, lasts 5-7 small or absent Small or moderate
days
Other symptoms complications increased and Seldom: generalized
(respiratory, digestive, painful posterior visceral forms,
nervous, urinary neck and occipital meningoencephalitis
systems, eye, ears, lymph nodes (ataxia)
skin)
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Laboratory leucopenia, leukopenia, Leukopenia,

criteria lymphocytosis, lymphocytosis, lymphocytosis,
aneosinophylia, increase of the serological: binding
serological reaction plasmatic cells' complement reaction
with measles antigen number, serological with Chickenpox antigen
(+) reactions with (+)
rubella antigen (+)

Differential diagnostics of bacterial infectious rashes (exanthemas)

Table 4
Signs Pseudotuberculosis Meningococcemia Scarlet fever
Initial symptoms acutely with many intoxication, Acutely - intoxication,
symptoms develops very angina, regional
(intoxication, acutely, initial lymphadenitis
intestinal changes, measles-like rash
seldom - catarrhal
signs
Time of the On the 2-8 day first hours of the 1 day (in 20% - 2)
appearance of disease
rashes
Morphology puncture-like, small hemorrhagic "star- small point-like
spots, erythema like" with necrosis
in the centre
Sizes of elements Small, middle, large from small to small
significant
Localization "hood", "mitten", buttocks, lower mainly on bending
"socks" signs, in skin limbs, less - on surfaces of limbs, down
folds, bends, around trunk, hands, face the abdomen, lumbar
joints region, face, lateral
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surfaces of the trunk,

pale nose-labial triangle
Brightness and bright hemorrhagic, bright, bright
color of elements sometimes cyanotic
Further rashes gradually disappear Small, disappear gradually turn pale for 4-
development for 2-5 days, small, gradually, 5 days, small, lamellar
lamellar shelling significant, leave desquamation
"dry" necrosis
Catarrhal Not typical are absent, in 30- Not typical
phenomena 40% on previous 2-3
days –
nasopharyngitis
Oral mucous Possible hyperemia of hyperemia and marked off, bright
membranes the pharynx, tonsils swelling of back hyperemia, enanthem on
pharyngeal wall, palate, tonsillitis
hypertrophy of (catarrhal, follicular,
follicles necrotic forms)
Intoxication expressed, long- acutely expressed proportional to local
lasting (2-3 weeks) signs, short for 1-3 days
Other symptoms arthritis, myocarditis, meningitis, angina, changes on the
diarrhea, hepatitis, encephalitis, tongue (from 4-5 days
abdominal syndrome, arthritis, "strawberry"),
lymphoproliferative iridocyclitis, complications on the 2-3
symptom, kidneys, endocarditis, aortitis, weeks
nervous system pneumonia, pleurisy
damage, pneumonia
Laboratory leucocytosis, shift to leucocytosis, shift to leucocytosis, shift to the
criteria the left, high ESR, the left, left, neutrophilosis,
Indirect neutrophilosis, high increased ESR, in
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hemoagglutination ESR in pharyngeal, nasal swabs -

reaction with special nasopharyngeal streptococci
diagnosticum (+), swab, thick drop of
separation of Y. blood –
pseudotuberculosis meningococci
from excrements

In some occasions, in patients with measles, lesions of the mesenteric lymph nodes
may be realized in clinics of “acute abdomen”. At the beginning of the disease there is pain,
most often it is acute, localized on the right in the lower abdomen, mimics an attack of acute
appendicitis. Some children with measles may develop cortical appendicitis, a very serious
condition.
Atypical forms of chickenpox are divided into rudimentary and aggravated. The
rudimentary form is characterized by a mild course, single rashes, normal or subfebrile body
temperature (usually typical for patients who received immunoglobulin). The aggravated
form is characterized by a very intense clinical picture of the disease. It includes visceral,
gangrenous and hemorrhagic forms, which are treated in hospital.
At a hemorrhagic form of a disease at the patient high temperature, strong intoxication,
defeat of internals is noted, blood appears in bubbles, they bleed. There is hematuria,
hemorrhage into the skin and tissue, mucous membranes and internal organs.
Visceral form of chickenpox is mainly found in premature infants, newborns and
children with immunodeficiency. It is characterized by prolonged intoxication, abundant
rashes, severe fever, lesions of the nervous system and internal organs (kidneys, lungs, liver,
heart).
The gangrenous form is diagnosed very rarely, mainly in patients with
immunodeficiency. There is a pronounced intoxication. The bubbles in this form are large,
quickly covered with a crust with a zone of tissue necrosis. When the crust falls off, deep
ulcers appear on the skin, which heal very slowly.
In patients with chicken pox, in the case of secondary infection of the vesicles, with
their improper care or damage, there are abscesses, phlegmons, erysipelas, bullous
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streptodermia, stomatitis, lymphadenitis caused by S.aureus and S.pyogenes. Sometimes

hematogenous spread of pathogens leads to the development of sepsis, pneumonia, arthritis
and osteomyelitis.
Evidences to obligatory hospitalization of patients with infectious exanthema
1. severe form of the disease, when there is need in intensive therapy; patients with
moderate forms at the age under 3 years
2. ill children from families with bad social-home conditions, especially in the event of
impossibility of their isolation to prevent transmission of infections
3. obligatory isolation of children with different manifestations of meningococcal
infection
4. absence of conditions for examination and treatment at home
5. ill children from closed children establishments
Advantages of home treatment
1. possibility of additional infection with hospital bacteria is completely excluded
2. realization of individual care principle for ill child is more complete
3. avoiding stressful reactions, which could appear in case of hospital treatment
Treatment in home conditions is possible
1. in conditions of isolated apartment
2. in case of satisfactory financial condition of the parents
3. in case parents desire to organize individual care and treatment at home
Treatment of measles 1. Adequate hydration, bed rest; 2. Antipyretics as needed for fever;
3. Vitaminized nutrition; 4. Nasal decongestants; 5. Mucosolvents and cough suppressants;
6. Antihistamine medicine; 7. Oral cavity hygiene. In case of bacterial complication –
antibacterial therapy should be used. In case of severe episodes –corticosteroids (1-2 mg/kg
for 2-3 days). In case of croup: mist tent with 25-30 % oxygen inhalation, anti-anxiety
medicines, steroids and mechanical ventilation in severe cases. In case of meningitis:
steroids, dehydrates, parenteral detoxication (albumin, plasma), anticonvulsants.
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Treatment of scarlet fever 1. Recommended treatment for scarlet fever is penicillin either
orally (penicillin V) or intramuscularly (penicillin G) for 10 days 50000-100000 EU/kg/day
divided in 3-4 doses. Erythromycin is alternative antibiotic (30 –50mg/kg/day).
2. Vitamins, calcium medicine, antihistamines.
3. Local treatment with antiseptic fluids.
Patient may be discharged from infection department not earlier the 10th day of the illness,
in 10 days blood analysis, urinalyses, ECG must be done.
Treatment of Chicken-pox in most cases is only symptomatic – antiseptic fluids for skin
lesions; antihistamines for pruritus; acetaminophen for fever control. Acyclovir – for
immunocompromised children. Also for them – varicella-Zoster immunoglobulin, given as
prophylaxis within 72 hours of exposure. Acyclovir (1500 mg/sq/m/day for 7 days in patient
under 12 years of age; 30 mg /kg/day in adults). In case of encephalitis – acyclovir, parenteral
detoxication, dexamethasone, dehydration, symptomatical treatment.
Prevention of measles
1. Specifically active immunization by MMR vaccine (measles, mumps, rubella) at age
12 months. Revaccination at the age 4 to 6 years or 10 to 11 years.
2. Specifically passive prophylaxis with immune serum globulin in the dose of 0.25
ml/kg as a postexposure prophylaxis.
3. Nonspecifically: – isolation of ill person until 5th day of the exanthema period,
isolation of contact person from the 8th to 21st days after exposure.
Prevention of scarlet fever: isolation of the patient for 10 days, but he mustn’t visit school
until 22nd day of the disease. Contact persons (children under 8 years) must be isolated for 7
days (period of incubation).
Prevention of Chicken pox:
1.To isolate ill person until the 5th day after the last vesicles appeared.
2. To isolate contact persons from the 9th till 21st days after exposure.
3. VZ immunoglobulin in immunocompromised children.
Self study
Diseases
Measles Rubella Chicken pox Scarlet fever
Signs
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Intoxication
Conjunctivitis
Dry cough
Koplick's spots
Enanthem on the soft
palate
Gradual appearing of
the rash
Localization of the
rash:
mainly on bending
surfaces of limbs
on unbending
surfaces of the
limbs
on the whole body
scalp
Sore throat
“Strawberry” tongue
Rash:
maculopapular rash
small papular rash
polymorphic (spots,
papular, vesicles,
crusts)
small point-like
Pigmentation
Pastia’s lines
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Desquamation large
(major)
Desquamation small
(minor)

Tasks and assignments for self-assessment

Task 1
1. The Physician is called to the boy, 5 years old. Patient is ill during 4 days: the temperature
increased to 38.2º С, rash appeared on skin since the first day of the disease. On examination
polymorphic rash (the papules, vesicles, crusts) is observed on the whole body, there are
several vesicles with purulent contents and hyperemia around them. What complication is
possible?
A.Phlegmona
B.Furunculosis
C.Pustulosis
D.Paronychia
E.Eczema
2. The child, 7 years old, is ill for 5 days. He complains of rashes that appear on the nose
back. He became acutely ill , when the body temperature increased to 38 ºС, the liquid
discharge from nose appeared. On the third day of the disease temperature fell to 37 ºС.
Objectively: the general condition is moderate; the temperature is 38 ºС. Hyperemia of the
child is weak, sleepy. The face is puffy, conjunctival hyperemia and edema are observed.
The back pharyngeal wall. On soft palate - single small rose spots. On cheeks - white spots
with red corolla. The skin of the face and neck is covered with large amount of small rose
spots, places overflow, irregular form, on unchanged basis. What diagnosis is the most
probable?
A. Measles, catarrhal period.
B. Measles, rash period.
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C. Infectious mononucleosis.
D. Scarlet fever.
E. Meningococcemia.
3. The child, 5 years old, was admitted to the infectious department. The complaints are:
increasing of the body temperature to 39º С, headache, sore throat, vomiting. Objectively: in
skin folds, lateral surface of the trunk and neck - small macula rash. Circumoral pallor is
noted on the background of bright colored cheeks. Anterior cervical lymphatic nodes are
enlarged. The tongue is covered with white stratification, hyperemia of the. What is the
diagnosis?
А. Rubella.
В. Chickenpox.
С. Pseudotuberculosis.
D. Scarlet fever.
E.Haemorrhagic purpura.
4. In a girl, 10 years old, pediatrician diagnosed "Pseudotuberculosis". It is known that 1.5
months ago she had maculous rash on lateral surface of the trunk, lower part of the abdominal
wall, pain in the throat, increased body temperature to 38,5 ºC. The girl was treated at home.
At the moment the patient complains of the rash around knees and feet, with expressed pain,
with breach of the joint function. Name the severity of the disease:
А. Mild.
В. Moderate.
С. Severe.
D. Acute.
E. Prolonged.
5. The Child, age 2 years, with meningococcal infection, is examined by the group of
students together with physician. Typical rash is present on skin of the whole body,
especially on the buttocks and lower limbs. Name which sign is not present at meningococcal
rash:
А. Hemorrhagic nature.
В. The elements are mildly increased on the skin level of the skin.
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С. The necrosis in the centre.

D. Disappears at pressure.
E. In scraper it is possible to find meningococci.
6. What does not apply to atypical forms of chickenpox?
A. hemorrhagic;
B. ulcerative-necrotic
C. nodal;
D. jaundice.
E. gangrenous
Case 1
A girl 13 years old, who had received steroid hormones for a long time before, was
hospitalized because of disseminated spots, respiratory distress for 5 days. Two weeks
ago, she was exposed to her young brother with varicella. On admission: P 120, RR 40,
temperature 390C, crop of vesicular lesions present at various stages of maturation,
including the soft palate; bibasilar bubbling rale. Chest film showed diffuse, bilateral
lower lobe interstitial infiltrates.

What is the diagnosis, including clinical form? What is the most appropriate antiviral
drug? Why the infection disseminates?

Case 2

A boy 6 years old acutely developed headache, throat pain when swallowing,
submandibular lymphatic nodes markedly enlarged, body temperature 39,0°C, vomited
twice. On the 1st day of the disease rash occurred: small red macules on hyperemic skin,
more intensive on flexion surface, Pastia’s signs.

Your is your presumed diagnosis? How to confirm the diagnosis? Which pathognomonic
signs can be found in mouth cavity on 5th day after the onset of disease?

Case 3

A 4-year-old child has been in contact with a patient experienced vesicular lesions on
the chest unilaterally with severe local pain, increased body temperature to 37,4°C. On the
13th day of the contact the child's body temperature raised to 38,4°C. On the second day of
 23

the disease macular, papular and vesicular lesions were found on the trunk, face, limbs and
scalp.

Your assumptive diagnosis? What is in common between Shingles and presumptive

disease? What is possible source of infection? What can be found in vesicles?

Case 4
A child of 1 year suffered from chickenpox. On the medical examination: along with
the elements of vesicular rash, black areas of necrotized skin and underlying tissues of 0.5
to 2 cm in diameter were detected.

What clinical form of chickenpox is the child ill with? Enumerate other atypical clinical
forms of chickenpox. What is the causative agent of this disease?

Case 5

A child was borne on term to a young mother, he presented bilateral cataract,

microcephaly, Patent Duct Anterious. During pregnancy the mother had viral hepatitis A
and rubella. The following medications were taken in tablets: trimethoprim
sulfamethoxazole, mefenamic acid.

What is the most probable reason of the inborn defects? Which kind of defects they are
according to gestational period: embryopathy or fetopathy? How this inborn defects
could be prevented?

Case 6
In the period of crusta drying a 10 year old boy with varicella developed headache,
lethargy, loss of balance probes, Kernig and Brudzinsky signs were negative. Lab tests:
WBC 4,600 x 109 with 6% Bands, 27% PMN, 64% LC, 3 M, ESR 8 mm/hr.

Which complication developed? Which kind of brain lesion this neurological

syndrome is characteristic for? What antiviral drug should be used for treatment?

Case 7

The child is 5 years old, suffers from chickenpox. On the fifth day from the onset of
the disease, the child had a fever to 38.5, in the area of the anterior surface of the neck,
around the chickenpox element, a reddening area is visualized, the skin is swollen to the
 24

touch. Lab tests: WBC 18,600 x 109 with 15% Bands, 67% PMN, 15% LC, 3 M, ESR 28
mm/hr.
Which complication developed? What other secondary bacterial complications may
occur? What strategy of managment of the diseases should be chosen by the doctor?

Case 8
A 4-year-old child, ill for the second day, complains of severe abdominal pain
localized on the right in the lower abdomen, fever up to 38.5. On examination, the
abdomen is sharply painful on palpation in the iliac region on the right. Examination of the
oral cavity revealed enanthema on the soft palate, small-spotted spots near the canines
(Koplik's spots). Lab tests: WBC 3,900 x 109 with 6% Bands, 27% PMN, 64% LC, 3 M,
ESR 8 mm/hr.
What is the preliminary diagnose? How do you explain the acute abdominal pain?
What are the tactics of treatment? What possible complications should be expected
from the patient?

Diseases
Measles Rubella Chicken pox Scarlet fever
Signs
Intoxication + + +
Conjunctivitis + ±
Dry cough +
Koplick's spots +
Enanthem on soft
+ + +
palate
Gradual appearing of
+
the rash
Localization of the
rash:
mainly on bending
+
surfaces of limbs
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on unbending
surfaces of the +
limbs
on the whole body + + + +
scalp +
Sore throat +
“Strawberry” tongue +
Rash:
maculopapular rash +
small papular rash +
polymorphic (spots,
papular, vesicles, +
crusts)
small point-like +
Pigmentation +
Pastia’s lines +
Desquamation large
+
(major)
Desquamation small
+ +
(minor)

Student’s practical activities:

I. Treatment of patients with infectious exanthema at children infectious department.
1. Ask complaints, anamnesis and life history.
2. Examine the patients; find clinical features of infectious exanthema.
3. Prescribe laboratory investigations to prove the diagnose.
II. To perform the diagnosis:
1. Make previous diagnosis due to complaints, disease history, epidemiological
anamnesis, clinical objective features.
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2. Make complete diagnosis based on previous diagnosis, laboratory dates, differential

diagnosis.
III. Provide the treatment (diet, medicine) depending on patient’s age, severity of the disease.
IV. Prescribe measures in the focus of infection, specific prevention of the disease.
V. Clinical analyzing of the case.
Students must know:
1. Diagnostic features of infectious exanthema in children.
2. Differential diagnosis of infectious exanthema in children.
3. Indications to hospitalization of children with infectious exanthema.
4. How to organize home treatment in case of Measles, Rubella, Scarlet fever, Varicella.
5. Common treatment of infectious exanthema in children.
6. Prevention of infectious exanthema in children.
Student should be able to
1. Find diagnostic clinical criteria of infectious exanthema during examination of patients.
2. To perform differential diagnosis among diseases having the same clinical features.
3. To organize home treatment in case of Measles, Rubella, Scarlet fever, Varicella.
4. To prescribe measures in the focus of infection, specific prevention of the disease.
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References:
1. Kramarev B. B. Pediatric infectious diseases / B. B. Kramarev, O. B. Nadraga. – Kyiv, 2015.
– 238 с.
2. Long S. S. Principles and Practice of Pediatric Infectious Diseases / S. S. Long, K. L.
Pickering, G. C. Prober. – Churhill Livingstone, 2017. – 1618 с. – (Fifth edition).
3. Textbook of Pediatric Infectious Diseases / [J. Cherry, G. G. Demmler-Harrison, S. L.
Kaplan та ін.]., 2018. – 1618 с. – (Eight edition).
4. Nelson Textbook Of Pediatrics - Volume 1 & 2 (International Edition) Edition:
eighteenth by Robert M Kliegman Richard E Behrman Hal B Jenson Bonita F Stanton. –
21th Edition. – 2018. – 3250 р.

1.