Viral Exanthems and Enanthems
Amina Ahmed, MD
Pediatric Infectious Disease
Levine Children’s Hospital
Adenovirus




Epidemiology
 Year-round; peak in winter/spring/early summer
 Incubation 2-14 d respiratory disease, 3-10 enteric disease
Clinical Presentation
 Respiratory
 Conjunctivitis, pharyngitis (pharyngoconjunctival fever)
 Exanthem- Usually mp lesions, erythematous, blanching
 Enteric
 Diarrhea
 Cystitis
Diagnosis
 DFA, culture (culture more sensitive)
 PCR (blood, urine, secretions)- usually for
immunocompromised population
Treatment
Enteroviruses

Poliovirus 1, 2, 3

Echoviruses

Coxsackievirus A

Coxsackievirus B

Enteroviruses
Enteroviruses




Epidemiology
 Peak in summer (May-October)
 Incubation 3-6 days
Clinical Presentation
 Fever (“fever without a source” in infants)
 Respiratory- pharyngitis, URI, “summer cold,” conjunctivitis
 Meningitis, meningoencephalitis
Diagnosis
 Clinical
 Culture, PCR (CSF typically)
Treatment
EV : Hand-Foot-Mouth Disease

Exanthem


Enanthem


Vesiculopustular lesions on palms, soles
Vesicular lesions in mouth
 Typically buccal mucosa, anterior mucosa
Diagnosis


Culture of oral secretions
PCR
EV: Herpangina

Exanthem


Enanthem


None
Vesiculopustular lesions in mouth
 Typically soft/hard palate
 Not on lips (vermilion border)
Diagnosis


Culture of oral secretions
PCR
Parvovirus B19

Erythema infectiousum, Fifth Disease

Epidemiology


Clinical Presentation





Fever, mild URI
Arthralgias/arthritis (especially young females)
Aplastic anemia (hemoglobinopathies)
Fetal hydrops (complication of infection during pregnancy)
Exanthem



Incubation 4-14 days
 Most contagious before onset of rash
“Slapped cheek,” circumoral pallor
Maculopapular, “lace-like,” reticular
Diagnosis /Treatment

Serology, PCR
Human Herpes Virus 6 (Roseola infantum)




Epidemiology
 Infants 6-24 months of age
 No seasonal pattern
 Incubation 9-10 days
Clinical Presentation
 High fever for 3-4 days followed by rash
 Pharyngitis, occipital nodes
 Seizures
Exanthem
 Discrete rose-red mp lesions on chest and trunk
 Spread to face and extremities
 Lasts hours-days
Diagnosis/ Treatment
 Clinical
 Serology, PCR
Morbillivirus (Measles)





Epidemiology

Incubation 8-12 days

Highly contagious (droplets, airborne); 3-5 d before-4 d after rash

Late winter, early spring
Clinical Presentation

Fever, cough, coryza, conjunctivitis (prodrome)
Exanthem / Enanthem

Starts on head, spreads cephalocaudally

Coppery-red; may coalesce; desquamation

Enanthem- Koplik’s spots (before exanthem)
Diagnosis

Serology, PCR

Culture (urine)
Treatment

Prevention of superinfection with antibacterials

Vitamin A

?Ribavirin
Rubivirus (Rubella)

Epidemiology



Clinical Presentation




Typically asymptomatic in 25-50% of cases
Fever, adenopathy
Congenital rubella- cataracts, bony lesions, heart defects
Exanthem


Incubation 14-21 days
Contagious few days before to 5-7 days after onset of rash
Pinkish, maculopapular
Diagnosis / Treatment

Culture (especially congenital rubella), serology
Rubella
Varicella-Zoster Virus

Epidemiology



Clinical presentation


Incubation 10-21 days; contagious 1-2 d before rash onset
Late winter, early spring
Fever, URI (prodrome)
Exanthem /Enanthem





Lesions evolve: mp to vesicular to excoriated; pruritic
 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

Diagnosis




Treatment


VZV DFA from lesions (rapid)
 Tzanck not specific
PCR from lesion
Serology
Acyclovir
 Immunocompromised or nonimmune neonate
 Encephalitis
 Adults, adolescents, pregnant females
Prevention

VZV vaccine
Varicella
Epstein-Barr Virus

Epidemiology



Clinical presentation




Fever, pharyngitis (exudative), lymphadenopathy
Splenomegaly
Hepatitis, thrombocytopenia
Exanthem



Incubation 30-50 d
“Kissing disease”
Erythematous, mp lesions; may coalesce
May follow ampicillin use
Diagnosis / Treatment


Clinical, serology
PCR (immunocompromised host)
Herpes Viruses 1 and 2

Epidemiology



Incubation 2 d- 2 weeks
Herpes is forever
Clinical presentation




Neonatal disease
 Skin, eye, mucous membranes
 Meningoencephalitis
 Disseminated
Primary gingivostomatitis; herpes labialis
Genital disease
Encephalitis
Herpes Viruses 1 and 2

Exanthem / Enanthem



Diagnosis




Vesicular lesions; coalesce with time
Enanthem: friable gingiva, lesions on tongue, gingiva
 May be on lips, vermilion border
DFA of base of lesions (rapid)
Culture of secretions, vesicular fluid
PCR (lesions, blood, CSF)
 Gold standard for meningoencephalitis
Treatment

Acyclovir, valacyclovir
 Neonates, encephalitis, immunocompromised host
What’s Your Diagnosis?
Lesions in mouth and crossing
the vermilion border.
Tongue and gingiva involved
What’s Your Diagnosis?


32 year old school teacher
with low grade fever, sore
throat, painful swallowing
Diagnostic evaluation?
What’s Your Diagnosis?


2 year old with fever and
refusal to eat
Lesions present for 2 days
What’s Your Diagnosis?

7 year old with lesions on
hands; no fever

Differential diagnosis?

Diagnostic evaluation?
What’s Your Diagnosis?


4 year old with fever for 2
weeks and rash for 1 week
Differential diagnosis?
What’s Your Diagnosis?
What’s Your Diagnosis?

6 year old Swiss girl with
fever for 7 days

Mild sore throat

Diagnostic evaluation?

Prevention of transmission?
What’s Your Diagnosis?


4 year old Swiss girl with
fever, cough, and rash
Diagnostic evaluation?
What’s Your Diagnosis?

9 year old with headache for
1 week

Diagnostic evaluation?

Treatment?
What’s Your Diagnosis?

15 year old with fever and
sore throat

Differential diagnosis?

Diagnostic evaluation?

Treatment?
What’s Your Diagnosis?

Diagnostic evaluation?

Treatment?