Viral Exanthems and Enanthems Amina Ahmed MD Pediatric

Viral Exanthems and Enanthems Amina Ahmed, MD Pediatric Infectious Disease Levine Children’s Hospital

Adenovirus n n Epidemiology n Year-round; peak in winter/spring/early summer n Incubation 2 -14 d respiratory disease, 3 -10 enteric disease Clinical Presentation n Respiratory n Conjunctivitis, pharyngitis (pharyngoconjunctival fever) n Exanthem- Usually mp lesions, erythematous, blanching n Enteric n Diarrhea n Cystitis Diagnosis n DFA, culture (culture more sensitive) n PCR (blood, urine, secretions)- usually for immunocompromised population Treatment

Enteroviruses n Poliovirus 1, 2, 3 n Echoviruses n Coxsackievirus A n Coxsackievirus B n Enteroviruses

Enteroviruses n n Epidemiology n Peak in summer (May-October) n Incubation 3 -6 days Clinical Presentation n Fever (“fever without a source” in infants) n Respiratory- pharyngitis, URI, “summer cold, ” conjunctivitis n Meningitis, meningoencephalitis Diagnosis n Clinical n Culture, PCR (CSF typically) Treatment

EV : Hand-Foot-Mouth Disease n Exanthem n n Enanthem n n Vesiculopustular lesions on palms, soles Vesicular lesions in mouth n Typically buccal mucosa, anterior mucosa Diagnosis n n Culture of oral secretions PCR

EV: Herpangina n Exanthem n n Enanthem n n None Vesiculopustular lesions in mouth n Typically soft/hard palate n Not on lips (vermilion border) Diagnosis n n Culture of oral secretions PCR

Parvovirus B 19 n Erythema infectiousum, Fifth Disease n Epidemiology n n Clinical Presentation n n Fever, mild URI Arthralgias/arthritis (especially young females) Aplastic anemia (hemoglobinopathies) Fetal hydrops (complication of infection during pregnancy) Exanthem n n n Incubation 4 -14 days n Most contagious before onset of rash “Slapped cheek, ” circumoral pallor Maculopapular, “lace-like, ” reticular Diagnosis /Treatment n Serology, PCR

Human Herpes Virus 6 (Roseola infantum) n n Epidemiology n Infants 6 -24 months of age n No seasonal pattern n Incubation 9 -10 days Clinical Presentation n High fever for 3 -4 days followed by rash n Pharyngitis, occipital nodes n Seizures Exanthem n Discrete rose-red mp lesions on chest and trunk n Spread to face and extremities n Lasts hours-days Diagnosis/ Treatment n Clinical n Serology, PCR

Morbillivirus (Measles) n n n Epidemiology n Incubation 8 -12 days n Highly contagious (droplets, airborne); 3 -5 d before-4 d after rash n Late winter, early spring Clinical Presentation n Fever, cough, coryza, conjunctivitis (prodrome) Exanthem / Enanthem n Starts on head, spreads cephalocaudally n Coppery-red; may coalesce; desquamation n Enanthem- Koplik’s spots (before exanthem) Diagnosis n Serology, PCR n Culture (urine) Treatment n Prevention of superinfection with antibacterials n Vitamin A n ? Ribavirin

Rubivirus (Rubella) n Epidemiology n n n Clinical Presentation n n Typically asymptomatic in 25 -50% of cases Fever, adenopathy Congenital rubella- cataracts, bony lesions, heart defects Exanthem n n Incubation 14 -21 days Contagious few days before to 5 -7 days after onset of rash Pinkish, maculopapular Diagnosis / Treatment n Culture (especially congenital rubella), serology

Rubella

Varicella-Zoster Virus n Epidemiology n n n Clinical presentation n n Incubation 10 -21 days; contagious 1 -2 d before rash onset Late winter, early spring Fever, URI (prodrome) Exanthem /Enanthem n n n Lesions evolve: mp to vesicular to excoriated; pruritic n Hallmark- lesions in different stages (“crops”) “Dew drop on a rose petal” Similar lesions may involve mouth Presentation altered by vaccination Reactivation: zoster (dermatomal distribution)

Varicella-Zoster Virus n Diagnosis n n Treatment n n VZV DFA from lesions (rapid) n Tzanck not specific PCR from lesion Serology Acyclovir n Immunocompromised or nonimmune neonate n Encephalitis n Adults, adolescents, pregnant females Prevention n VZV vaccine

Varicella

Epstein-Barr Virus n Epidemiology n n n Clinical presentation n n Fever, pharyngitis (exudative), lymphadenopathy Splenomegaly Hepatitis, thrombocytopenia Exanthem n n n Incubation 30 -50 d “Kissing disease” Erythematous, mp lesions; may coalesce May follow ampicillin use Diagnosis / Treatment n n Clinical, serology PCR (immunocompromised host)

Herpes Viruses 1 and 2 n Epidemiology n n n Incubation 2 d- 2 weeks Herpes is forever Clinical presentation n n Neonatal disease n Skin, eye, mucous membranes n Meningoencephalitis n Disseminated Primary gingivostomatitis; herpes labialis Genital disease Encephalitis

Herpes Viruses 1 and 2 n Exanthem / Enanthem n n n Diagnosis n n Vesicular lesions; coalesce with time Enanthem: friable gingiva, lesions on tongue, gingiva n May be on lips, vermilion border DFA of base of lesions (rapid) Culture of secretions, vesicular fluid PCR (lesions, blood, CSF) n Gold standard for meningoencephalitis Treatment n Acyclovir, valacyclovir n Neonates, encephalitis, immunocompromised host

What’s Your Diagnosis? Lesions in mouth and crossing the vermilion border. Tongue and gingiva involved

What’s Your Diagnosis? n n 32 year old school teacher with low grade fever, sore throat, painful swallowing Diagnostic evaluation?

What’s Your Diagnosis? n n 2 year old with fever and refusal to eat Lesions present for 2 days

What’s Your Diagnosis? n 7 year old with lesions on hands; no fever n Differential diagnosis? n Diagnostic evaluation?

What’s Your Diagnosis? n n 4 year old with fever for 2 weeks and rash for 1 week Differential diagnosis?

What’s Your Diagnosis?

What’s Your Diagnosis? n 6 year old Swiss girl with fever for 7 days n Mild sore throat n Diagnostic evaluation? n Prevention of transmission?

What’s Your Diagnosis? n n 4 year old Swiss girl with fever, cough, and rash Diagnostic evaluation?

What’s Your Diagnosis? n 9 year old with headache for 1 week n Diagnostic evaluation? n Treatment?

What’s Your Diagnosis? n 15 year old with fever and sore throat n Differential diagnosis? n Diagnostic evaluation? n Treatment?

What’s Your Diagnosis? n Diagnostic evaluation? n Treatment?