Definitions
Exanthem (exanthema)
A rash that appears abruptly and affects
several areas of the skin simultaneously
Greek origin exanthema which means a
breaking out
Enanthem (enanthema)
An eruption upon a mucous membrane
3
Viral Exanthems
Commonly described as morbilliform which
means composed of erythematous macules
and papules that resemble a measles rash.
Viral exanthems can be difficult to distinguish
from a drug eruption. However, viral exanthems
are more common in children, and drug
eruptions tend to be more common in adults. A
thorough history will aid in the diagnosis.
4
Morbilliform Rash
Viral Exanthem
Drug Rash
NAME
ETIOLOGY
First Disease
Measles (Rubeola)
Measles virus
Second Disease
Scarlet Fever
Streptococcus pyogenes
Third Disease
Rubella
Rubella virus
Fourth Disease
Dukes Disease
No longer accepted as a
distinct disorder
Fifth Disease
Sixth Disease
Roseola Infantum
Case One
Ana Haydon
History Continued
Upon further questioning you discover that Ana
has never received vaccinations due to her
mothers fear regarding autism.
The augmentin was started 24 hours before the
onset of her rash.
You also discover that a close family member
recently visited from the Netherlands, who also
developed a similar rash.
9
Exam Continued
Inspection of Anas mouth reveals, bluish-white
dots on the mucosal surface. These are called
Koplik spots.
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12
Drug Eruption
Erythema Infectiosum
Measles
Roseola
Rubella
13
Measles (Rubeola)
Measles is a viral disease
Spread by respiratory droplets
Incubation period tends to be 8-12 days from
exposure to onset of symptoms
Patients are contagious from 1-2 days before onset
of symptoms (3-5 days before the rash) to 4 days
after appearance of the rash
Immunocompromised patients can be contagious
for the duration of the illness
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Measles (Rubeola)
Most common in children 3-5 years old
Diagnosis
Measles is a distinct clinical syndrome with the presence of
high fever, Koplik spots, characteristic conjunctivitis, upper
respiratory symptoms, and typical exanthem.
All cases of suspected measles should be serologically
confirmed and reported immediately to the local or state
health department without waiting for results of diagnostic
tests.
Testing includes:
Serology: Anti-measles IgM and IgG, isolation of measles virus or
identification of measles RNA
Histologic evaluation of skin lesions or respiratory secretions may
show syncytial keratinocytic giant cells
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Management
Uncomplicated measles is self-limiting, lasting 10 to
12 days.
Treatment in the majority of cases is supportive
(antipyretics, fluids).
Malnutrition, immunosuppression, poor health, and
inadequate supportive care can worsen the prognosis
in any patient. In developing nations, measles is a
major cause of infant mortality.
Vitamin A supplementation has shown to be of benefit
in the treatment of measles.
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Complications
Groups at increased risk for complications of measles
include immunocompromised hosts, pregnant
women, malnourished individuals, and persons at
extremes of age
Most common complications include otitis media,
pneumonia, laryngotracheobronchitis (croup), and
diarrhea. Hepatitis, thrombocytopenia, and
encephalitis occur less commonly.
Pneumonia is the most common fatal complication of
measles in children and the most common
complication overall in adults.
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Case Two
Ms. Kylie Hinkle
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25
History Continued
Upon further questioning you discover that
Ms. Hinkle has never received the MMR
(Measles, Mumps, Rubella) vaccine.
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Drug Eruption
Erythema Infectiosum
Measles
Roseola
Rubella
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Rubella
Rubella is a viral disease
Synonym: German measles, 3-day measles
Spread through direct or droplet contact from
nasopharyngeal secretions
Infected individuals shed virus up to one week
before and two weeks after onset of disease
Appearance of the rash typically occurs 14-17
days after exposure
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Epidemiology
Outbreaks occur most frequently in late
winter and early spring
School-age children, adolescents, and
young adults most often develop the
disease
The incidence of rubella has dramatically
decreased with routine vaccination
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Clinical Course
Adults tend to have more prodromal symptoms and
complications (although rare) compared to children
Arthritis sometimes accompanies exanthem (more
common in teenagers and adult women)
Rash begins to disappear in 2-3 days and clears the
head and neck first
Encephalitis and thrombocytopenia are potential
complications
Other rare complications include: peripheral neuritis,
optic neuritis, myocarditis, pericarditis, hepatitis, orchitis,
and hemolytic anemia
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Sensorineural deafness
Mental retardation
Eye abnormalities
Congenital heart disease
Cloudy Cornea
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Case Three
Keith Walters
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Drug Eruption
Erythema Infectiosum
Measles
Roseola
Rubella
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Parvovirus B19
There are many clinical presentations
associated with B19 infection (ranging from
benign to life-threatening).
Most infections are asymptomatic and
unrecognized
We will focus on Erythema Infectiosum, the
most common clinical presentation.
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Epidemiology
Most common in children 4-10 yrs old, but can affect all
ages
Tends to occur in epidemics, especially associated with
school outbreaks in the late winter and early spring
Secondary spread among susceptible household members
is common, with infection occurring in ~ 50% of susceptible
contacts
Serologic studies show increasing prevalence of antibodies
with age
In most communities, ~ 50% of young adults and often more than
90% of elderly people are seropositive
45
Diagnosis
Detection of serum parvovirus B19specific IgM antibody is the preferred
diagnostic test
Positive IgM test result indicates that
infection probably occurred within the
previous 2 to 4 months
47
Immunodeficiency
Can cause chronic erythroid hypoplasia with severe anemia
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Treatment
There is no specific treatment for
uncomplicated parvovirus B19 infection
Supportive therapy for relief of fatigue, malaise,
pruritus, and arthralgia may be needed
Generally resolves after 5-10 days, but can
reoccur for months upon exposure to sunlight,
hot temperature, exercise, bathing, and stress
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Case Four
Caleb
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Drug Eruption
Erythema Infectiosum
Measles
Roseola
Rubella
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Drug Eruption
Erythema Infectiosum
Measles
Roseola
Rubella
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Roseola Infantum
Synonyms: Exanthema subitum, Sixth disease
Caused by Human Herpesvirus 6 (HHV-6) and
less commonly Human Herpesvirus 7 (HHV-7)
Mode of transmission unknown (possibly from
nasopharyngeal secretions)
Children 6 months 4 years
Most common exanthem before age 2
No vaccine; infection results in immunity
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HHV-6
HHV-6 infection in children results in:
Subclinical infection
Acute febrile illness without rash
Exanthema subitum
Measles (Rubeola)
Rubella
(German measles)
Erythema Infectiosum
Begins with bright red cheeks and as the facial rash fades
over 1-4 days, a symmetric, erythematous, reticular
eruption appears on the trunk and extremities.
Roseola Infantum
(Exanthem subitum)
Acknowledgements
This module was developed by the American Academy
of Dermatology Medical Student Core Curriculum
Workgroup from 2008-2012.
Primary authors: Laura S. Huff, MD; Cory A. Dunnick,
MD, FAAD
Contributor: Sarah D. Cipriano, MD, MPH
Peer reviewers: Anna L. Bruckner, MD, FAAD; Brandon
D. Newell, MD; Timothy G. Berger, MD, FAAD
Revisions and editing: Sarah D. Cipriano, MD, MPH,
Jillian W. Wong. Last revised March 2011.
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References
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Barinaga J, Skolnik P. Epidemiology and transmission of measles.
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2010.
Bialecki C, Feder HM, Grant-Kels JM. The six classic childhood
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891-903.
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References
Belazarian Leah, Lorenzo Mayra E, Pace Nicole C, Sweeney Susan
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