Childhood Exanthems
Dr Turlough Bolger
Paediatric Emergency Medicine
Tallaght Hospital
WHY ARE WE ALL HERE?
Woman dying of meningitis texted
pictures of rash, inquest hears
Joanne Dowling died after 'breakdown in communication' between
doctors led to her being denied antibiotics, says coroner
OUTLINE
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Definitions
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Classic Exanthems
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Other viral rashes
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Secondary phenomena
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Meningococcal Disease
DEFINITIONS
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Exanthem
skin rash associated with a systemic disease
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Enathem
mucosal rash associated with systemic disease
Classic Childhood Exanthems
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First Disease
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Second Disease
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Third Disease
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Fourth Disease
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Fifths Disease
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Sixth Disease
Classic Childhood Exanthems
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Measles (rubeola, morbilli)
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Second Disease
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Third Disease
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Fourth Disease
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Fifths Disease
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Sixth Disease
MEASLES
Paramyxovirus
At risk: unvaccinated and failed vaccinations
Season: late winter/spring
Incubation: 7-14 days
Infectious: 1-2d before to 5d after rash
MEASLES
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Fever
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Cough
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Conjunctivitis
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Miserable
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Rash
MEASLES
MEASLES
Approximately 30% of reported measles cases have one or more
complications. The most common complications that occur are:
• Diarrhoea
• Otitis media
• Pneumonia - most common cause of death.
• bronchitis, croup, conjunctivitis and/or corneal ulceration leading
to blindness (especially if vitamin A deficient), mouth ulceration,
acute glomerulonephritis (inflammation of kidneys) and acute
renal failure
• Measles infection during pregnancy increases the risk of
premature labour and delivery, and foetal loss
Classic Childhood Exanthems
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Measles (rubeola, morbilli)
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Second Disease
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Third Disease
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Fourth Disease
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Fifths Disease
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Sixth Disease
Classic Childhood Exanthems
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Measles (rubeola, morbilli)
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Scarlet Fever
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Third Disease
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Fourth Disease
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Fifths Disease
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Sixth Disease
SCARLET FEVER
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erythrogenic exotoxin-producing group A beta-hemolytic streptococci
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At risk: <10yo, peak 4-8yo, immunity to toxin in 80% by 10 years
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Season: late autumn, winter, spring
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Incubation period: 2-4 days
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Infectious period: during acute infection
SCARLET FEVER
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Scarlet fever usually starts with a sudden fever associated with sore throat,
swollen neck glands, headache, nausea, vomiting, loss of appetite, swollen
and red strawberry tongue, abdominal pain, body aches, and malaise
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The rash usually starts on day 2 below the ears, neck, chest, armpits and
groin before spreading to the rest of the body over 24 hours.
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Scarlet spots or blotches, giving a boiled lobster appearance, are often the
first sign of rash.
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Then skin may have a rough sandpaper-like feel.
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In body folds, especially the armpits and elbows, fragile blood vessels
(capillaries) can rupture and cause classic red streaks called Pastia lines
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Day six rash starts to fade and peeling, similar to that of sunburned skin,
occurs. Peeling of the skin is most prominent in the armpits, groin, and tips
of the fingers and/or toes and may continue up to 6 weeks.
SCARLET FEVER
SCARLET FEVER
SCARLET FEVER
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Rheumatic fever
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Otitis media
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Pneumonia
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Septicaemia
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Glomerulonephritis
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Osteomyelitis
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Death
Classic Childhood Exanthems
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Measles (rubeola, morbilli)
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Scarlet Fever
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Third Disease
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Fourth Disease
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Fifths Disease
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Sixth Disease
Classic Childhood Exanthems
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Measles (rubeola, morbilli)
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Scarlet Fever
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Rubella
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Fourth Disease
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Fifths Disease
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Sixth Disease
RUBELLA
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Togavirus
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At risk: unvaccinated adolescents
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Season: late winter/early spring
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Incubation: 14-21 days
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Infectious: 5-7d before rash to 3-5d after rash
RUBELLA
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In 25-50% of rubella cases the disease is usually so mild there may be
few or no signs or symptoms
Slight fever, sore throat, runny nose and malaise (may occur prior to
appearance of rash, more so in adults than in children).
Rash begins on the face that spreads to the neck, trunk and extremities.
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Appear as pink or light red spots about 2-3mm in size.
Lasts up to 5 days (average is 3 days).
May or may not be itchy.
As rash passes, affected skin may shed in flakes.
Usually not as widespread as in measles.
Tender or swollen glands almost always accompany rubella
Arthralgia in older children
Congenital rubella syndrome
• Cloudy corneas or white appearance to pupil
• Deafness
• Dev delay
• Irritability
• IUGR
• Seizures
• Microcephaly
• Skin rash
Classic Childhood Exanthems
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Measles (rubeola, morbilli)
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Scarlet Fever
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Rubella
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Fourth Disease
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Fifths Disease
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Sixth Disease
Classic Childhood Exanthems
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Measles (rubeola, morbilli)
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Scarlet Fever
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Rubella
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Filatow Dukes Disease (Staphylococcal)
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Fifths Disease
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Sixth Disease
Filatow Dukes Disease
(Staphylococcal)
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Original classification does not fit any single diagnosis
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Not accepted as an entity
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May include Staphylococcal disease
Classic Childhood Exanthems
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Measles (rubeola, morbilli)
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Scarlet Fever
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Rubella
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Filatow-Dukes Disease
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Fifths Disease
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Sixth Disease
Classic Childhood Exanthems
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Measles (rubeola, morbilli)
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Scarlet Fever
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Rubella
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Filatow-Dukes Disease
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Erythema Infectiosum
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Sixth Disease
Erythema Infectiosum
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Human Parvovirus B19
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At risk: school-age children
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Season: sporadic
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Incubation period: 4-14 days
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Infectious period: up until onset of the rash
Erythema Infectiosum
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Over 50% of infections are asymptomatic
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Mild fever (15-30%), sore throat, malaise
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flu-like symptoms
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arthralgias/arthritis (potentially chronic)
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rash in up to 40%
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Aplastic anaemias (esp hereditary spherocytosis)
COMPLICATIONS
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Immunocompromised—chronic infection with severe, persistent, relapsing and
remitting anaemia, prolonged viral shedding
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Aplastic anaemia
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Foetal infection—hydrops foetalis1-9% mortality
Classic Childhood Exanthems
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Measles (rubeola, morbilli)
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Scarlet Fever
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Rubella
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Filatow-Dukes Disease
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Erythema Infectiosum
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Sixth Disease
Classic Childhood Exanthems
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Measles (rubeola, morbilli)
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Scarlet Fever
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Rubella
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Filatow-Dukes Disease
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Erythema Infectiosum
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Roseola (exanthem subitum)
Roseola (exanthem subitum)
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Human Herpes Virus 6(and 7)
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At risk: 6-36 mo (peak age 6-7mo)
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Season: sporadic
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Incubation period: 9 days
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Infectious period: lifelong (intermittent
Roseola (exanthem subitum)
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High fever for 3-4 days
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Abrupt defervescence with appearance of rash
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Associated seizures likely due to infection of the meninges by the virus
Roseola (exanthem subitum)
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symmetric red papular
truncal rash
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red papular morbilliform
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lasted less than 24 hours.
Classic Childhood Exanthems
I.
Measles (Rubeola)
II. Scarlet Fever
III. Rubella (German measles)
IV. Filatow-Dukes Disease
V. Erythema Infectiosum
VI. Roseola Infantum
Varicella zoster virus
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At risk: young children, non immune people
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Second attack rate within households is 80-95%
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Season: sporadic/Spring
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Incubation period: 10-21 days
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Infectious period: 2d before to 5d after rash
Varicella zoster virus
Varicella Complications
• Secondary bacterial infection—5-10%
• Otitismedia—5%
• Higher risk for adults, neonates, immunocomp.
Pneumonitis
Encephalitis
Cerebellarataxia
Hepatitis
• Other rare comps—Reye syn, Guillain-Barre, nephritis,
carditis, arthritis, orchitis, uveitis
EBV and amoxycillin
Enterovirus - HFMD
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Typically due to Coxsackie A16
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At risk: preschool-school aged children
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Highly contagious
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Incubation period: 4-6 days
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Prodrome: 1-2 days before rash
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Low-grade fever, anorexia, malaise, sore mouth
Enterovirus - HFMD
Gianotti-Crosti syndrome
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Most often due to EBV, also Hep B
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At risk: 6mo-14yrs, mean 2yrs
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Season: spring and early summer
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Constitutional symptoms: mild
Low grade fever, malaise, pruritus
mild hepatitis (except in HepB-associated case)
Gianotti Crosti Syndrome
Pityriasis Rosea
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?viral: suggested by seasonality, mild prodromal symptoms, assoc URTI, clustering
of cases
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Season: spring, autumn, winter
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At risk: 10-35yos, can be seen in younger
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Prodrome: very mild, if any
Malaise, nausea, anorexia, headache,
low fever
Pityriasis Rosea
Meningococcal Disease
HISTORY IS CRUCIAL
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Fever
the classic picture is of a disease of rapid onset.
symptoms may be initially trivial and suddenly become more serious
A history of a fever in a child presenting afebrile is important.
A fever that subsides after antipyretics cannot be dismissed as viral in origin.
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Rigors
Aches
Limb pain
Isolated severe limb pain in the absence of any other physical signs in that limb is a well-established
phenomenon
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Gastrointestinal symptoms
Vomiting, nausea and poor appetite (poor feeding in babies) are common in septicaemia
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Weakness
Rash
Urine output
Cold hands and feet, mottled skin
EXAMINATION
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Vital signs
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Behaviour
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CRT
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Skin
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General physical exam
More subtle rashes of
meningococcal disease
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Any questions?