VIRAL EXANTHEM

February 26, 2022

Cebu Doctors’ University Clinical Clerks Group 9B
Cabacaba | Dela Torre | Do | Lee | Perales
 Cutaneous manifestations of Systemic Infections
(“Rashes”)

● Rashes: caused by many dierent types of viruses, bacteria, fungi, protozoan and metazona

agents

● Exanthem: often oers important clues to the etiology of a patient’s illness

● By skin examination alone, it is diicult to dierentiate a “rash” from a systemic infection vs

primary cutaneous (local) diseases

Important Aspects in the Diagnosis of Exanthematous
Illness
● Exposure
● Season
● Incubation period
● Age
● Previous exanthems
● Relationship of rash to fever
● Adenopathy
● Type of rash
● Distribution of rash
● Progression of rash
● Enanthem
● Other associated signs and symptoms
● Laboratory tests
Erythematous Macular Exanthems
Vesicular Exanthems
Petechial and Purpuric Exanthems
 Measles (Rubeola)
Etiology and Incubation Period

● Measles Virus
● SS-RNA, lipid enveloped
● F. Paromyxoviridae ; G. Morbillivirus
● Inductors of Immunity:
○ H protein: antibodies neutralize
○ F protein: limit proliferation
Manifestations:

● High grade fever with cough

● Conjunctivitis and colds (3-5 days)
● Photophobia
● Enanthem: Koplik spots (grayish white dots with
red border opposite lower molars) appear before
the rash
● Craniocaudal dissemination
● Branny desquamation, disappears 7-10 days
● If uncomplicated’ symptoms subside rapidly and
fever abates as rashes appears on the legs & feet
MEASLES

Koplik Spots
MEASLES
 Transmission & Period of Communicability
● Airborne
● Viable virus may be found:
○ Air- 1 hour
○ Contact surface- 2 hours
● Communicability: 4 days before to 4 days after onset of rash
 Diagnosis & Management
● Reduced total WBC count
● Decreased lymphocytes > neutrophils
● ESR and CRP normal in the absence of bacterial infection
● Neutropenia
● IgM (1-2 days after rash onset)--> detectable for 1 month

Management:
● Supportive
● Vitamin A oral OD for 2 days
 Complications

● Most common: Otitis media

● Most common cause of mortality: pneumonia
● Subacute sclerosing panencephalitis
● Final common pathway to a fatal outcome: Bronchiolitis obliterans
 German Measles (Rubella or 3-day Measles)
Etiology:
● Togavirus

Manifestation:
● Incubation period: 14-21 days
● Prodrome of:
- Low-grade fever
- Sore throat
- Red eyes
- Headache
- Malaise
- Anorexia
- LAD (suboccipital, postauricular
and anterior cervical)
German Measles (Rubella or 3-day Measles)

Rash Forschheimer spots

- 1st manifestation in children - Tiny, rose colored lesions or
- Cephalocaudal spread petechial hemorrhages on the
- 3 days duration soft palate
 German Measles (Rubella or 3-day Measles)
Transmission:
● Droplet or transplacental
● Communicability: 5 days before to 6 days after onset of rash

Diagnosis:
● IgM and igG antibody - fourfold increase
 German Measles (Rubella or 3-day Measles)
Management:
● Supportive care

Complications:
● Thrombocytopenia - occurs 2 weeks after onset of rash
● Arthritis - occurs within 1 wk of rash, involves small joints of the hands
● Encephalitis
- PostInfectious syndrome
- Progressive rubella panencephalitis (PRP)
 Erythema Infectiosum (Fifth Disease)
Etiology:
● Parvovirus B19
● Incubation period: 4-14 days

Manifestation:
● 5-15 years old
● Mild fever and systemic symptoms -> facial rash
● Hallmark: “slapped-cheek” -> trunk and Proximal extremities (diuse macular
erythema)
● Atypical skin eruption : PPGGS -> fever, pruritus, painful edema and erythema
(distal extremities) -> acral petechiae and oral lesions
● Resolves within few weeks without desquamation
● Wax and wane over 1-3 weeks
 Erythema Infectiosum (Fifth Disease)
Transmission:
● Large droplet spread (nasopharyngeal shedding)
● blood/blood-borne products
● Communicability: before onset of rash until after onset of rash

Diagnosis:
● Serum IgM antibodies
● PCR
 Erythema Infectiosum (Fifth Disease)
Management:
● Supportive

Complication:
● severe anemia
● infection in pregnant patients may cause miscarriage, intrauterine death, hydrops
fetalis
 Hand-Foot-Mouth Disease
Etiology:
● Coxsackie A 16
● Enterovirus 71
● Incubation period: 4-6 days

Manifestation:
● <10 years of age
● 1-2 days fever -> enanthem (vesicles & ulcerations in the oral cavity) -> exanthem
● Vesicles resolve by absorption of fluid in ~1 week
 Hand-Foot-Mouth Disease
Transmission:
● Fecal-oral
● respiratory routes
● Communicability: Viral shedding ( 1-3 weeks) & fecal shedding (7-11 weeks
post-infection)

Diagnosis:
● Viral culture (gold standard)
● Serotype identification for outbreak investigation
 Hand-Foot-Mouth Disease
Management:
● Supportive

Complication:
● More severe disease with enterovirus 71:
- neurologic disease,
- Encephalomyelitis,
- pulmonary edema,
- hemorrhage
 ROSEOLA
Etiology/Epidemiology

● Roseola Infantum/Exanthem subitum/6th disease

● Human Herpesvirus 6A, 6B (responsible for majority of cases) and 7
● Incubation period - 9-10 days

HHV-6
● Most often by 2 y/o
● Peak - 6-9 months age
● MOT - saliva or respiratory droplets, congenital infection (1%) via transplacental infection or
chromosomal integration (86%)

HHV-7
● Occurs later in childhood at a slower rate
● Most often by 3 y/o
● Seroprevalence reaches 75% at 3-6 y/o
● Mean age of 26 months
● MOT - saliva
 ROSEOLA
Pathology/Pathogenesis

● Primary infection is followed by lifelong latency or persistence of the virus at multiple

sites
● HHV-6 - exists in true state of viral latency in monocytes and macrophages
● HHV-6 and 7 - may be persistent in salivary glands
● DNA HHV - routinely detected in the saliva of both adults and children
 ROSEOLA
Clinical Manifestations

● Acute, self-limited disease

● Abrupt onset of high fever (mean of 39.7 degrees
Celcius) - 3-5 days
● Rash (20%)- appears within 12-24 hrs of fever
resolution: faint pink/rose-colored, nonpruritic,
2-3mm morbilliform rash on trunk to face and
extremities (centripetal paern), fades in 1-3 days;
but often described as evanescent and may be
visible for only a few hours
● Other associated signs - mild injection of pharynx,
palpebral conjunctivae, or tympanic membranes,
and enlarged suboccipital nodes; rhinorrhea and
congestion, GI complaints, encephalopathy
● Nagayama spots - ulcers in uvulopalatoglossal
junction (Asian countries)
● Mean duration of illness - 6 days
 ROSEOLA
Diagnosis

● Specific dx if not necessary except when manifestations are severe or unusual

● Gold standard - viral culture
● PCR/RT-PCR, serologic methods for measurement of antibodies
● Most characteristic lab finding in primary HHV-6B - lower mean numbers of WBC, lymphocytes
and neutrophils
● Other lab findings - thrombocytopenia, elevated serum transaminase, atypical lymphocytes

Complications

● Convulsions - most common complication; ⅓ of patients

● Seizures - most common complication w/ primary HHV-6B infection; 15% with peak age of
12-15 mos
● Posransplant acute limbic encephalitic (PALE) - in patients following stem cell transplant;
characterized by short-term memory dysfunctions, confusion and insomnia with seizures;
HHV-6B DNA has been identified in the CSF in the majority of these patients
 ROSEOLA
Treatment

● Supportive care
● Maintain hydration, use of antipyretics
● Severe manifestations such as encephalitis/PALE - may benefit from viral treatment
● Ganciclovir, foscarnet, cidofovir - has inhibitory activity against HHV-6 in vitro ;
however clinical data are sparse and contradictory
● Ganciclovir or foscarnet - first-line agents recommended for minimum of 3 weeks in
patients w/ PALE

Prognosis
● Self-limited associated with complete recovery
● Most recover without sequelae
● Risk of recurrent seizures - not appear to be higher than that associated with other
causes of simple febrile seizures
 Varicella-Zoster Virus
- Causes primary, latent, and recurrent infections

Etiology
- Neurotropic human herpesvirus with similarities to herpes simplex virus
- Contain double stranded DANA genomes that encode more than 70 proteins, including
proteins that are targets of cellular and humoral immunity

Epidemiology
- Most children were infected by 15 years of age
- 4 million of cases of varicella, 11,000-15,000 hospitalizations and 100-150 deaths every
year
- Contagious 24-48 hours before the rash is evident and until vesicles are crusted,
usually 3-7 days after onset of rash
 Varicella Zoster Virus
Pathogenesis
- Transmied by contact with oropharyngeal secretions and the fluid of skin lesions of infected
individuals, either by airborne spread or through direct contact
- During the early part of the 10-21 day incubation period, virus replicates in the local lymphoid
tissue, and viremia spreads to the RES
- Widespread cutaneous lesions occur during a 2nd viremic phase that lasts 3-7 days
- VZV is transported back to the mucosa of the upper respiratory tract and oropharynx during the
late incubation period

Clinical Manifestations
- Fever, malaise, anorexia, headache, and occasionally mild abdominal pain, may occur 24-48 hours
before the rash appears
- Temperature elevation (37.8-38.9C)
- Varicella lesions often appear first on the scalp, face, or trunk
- The initial exanthem consists of intensely pruritic erythematous macules that do evolve through
the papular stage to form clear, fluid vesicles
Varicella Zoster Virus
 Varicella Zoster Virus
Neonatal Varicella
- Infants whose mothers demonstrate varicella in the period from 5 days prior to delivery to 2 days
afterward are at high risk for severe varicella
- These infants acquire the infection transplacentally as a result of maternal viremia, which may
occur up to 48 hours prior to onset of maternal rash
- Nevborns whose mothers develop varicella during the period of 5 days before to 2 days after
delivery should receive VZIG

Congenital Varicella Syndrome

- Occurs in approximately 0.4% of infants born to women who have varicella during pregnancy
before 13 weeks of gestation and in approximately 2% of infants born to women with varicella
between 13 and 20 week of gestation
- Characterized by cicatricial skin scarring in a zoster-like distribution, limb hypoplasia , and
abnormalities in the neurologic system
Varicella Zoster Virus
 Varicella Zoster Virus
Complications
- Mild thrombocytopenia occurs in 1-2% of children with varicella and may be associated with
transient petechia
- Purpura, hemorrhagic vesicles, hematuria, and gastrointestinal bleeding
- Acute cerebellar ataxia, encephalitis, pneumonia, nephritis

Herpes Zoster
- In children, infrequently associated with localized pain, hyperesthesia, pruritus, low grade fever or
complications
- Rash is mild, with new lesions appearing for a few days
- Symptoms o acute neuritis are minimal
 Varicella Zoster Virus
Diagnosis
- Leukopenia during the first 72 hr after onset of rash, it is followed by a relative and absolute
lymphocytosis
- Liver function tests are mildly elevated
- Direct fluorescence assay of cells from cutaneous lesions
- PCR ammplification testing
- Serology

Treatment
Varicella
- Oral therapy with acyclovir (20mg/kg/dose; max: 800mg/dose) given as 4 doses/day for 5 days to
treat uncomplicated varicella in individuals at increased risk for moderate to severe varicella
- Valacyclovir (20mg/kg/dose; max: 1000mg/dose, administered 3 times daily for 5 days) for
children 2 to <18 yr of age
- Intravenous therapy for severe disease and immunocompromised patients IV acyclovir therapy
(500mg/m2 every 8hr) for 7-10 days or until no new lesions have appeared fo r48 hr
 Varicella Zoster Virus

Prevention
- Infection control practices, including caring for patients with varicella in isolation rooms with
filtered air systems
- All healthwokers should have evidence of varicella immunity
- Unvaccinated healthcare workers without evidence of immunity who have had a close exposure
should be furloughed for days 8-21 after exposure

Vaccine
- 2 dose regimen to healthy children at 12-15mo and 4-6yr
- Catch up vaccination with the 2nd dose is recommended for children and adolescents who
received only 1 dose
- The minimum interval between the 2 doses is 3 mo for persons 12 yr of age or younger and 4 wk
for older children, adolescents, and adults
 Varicella Zoster Virus
Post exposure prophylaxis
- Vaccine given to healthy children within 3 or 5 days after exposure is eective in preventing or
modifying varicella
- High-titer anti VZV immune globulin as PEP is recommended for immunocompromised children,
pregnant women and newborns exposed to varicella
- The recommended dose is 1 vial(125 units) for each 10 kg increment of body weight (max: 625
units), except for infants weighing <= 2kg who should receive 0,5 vial
References
Kliegman R. et al. Nelson Textbook of Pediatrics (21st
ed). Philadelphia 2020

hp://www.pidsphil.org/home/wp-content/uploads/20
17/02/10Lec-FEVER-AND-RASH-More-Than-MEETS-the-
Eye.pdf
Thank you!!!