VIRAL
EXANTHEMS
Brenda Beckett, PA-C
NO PICTURES
Overview
Many of the “childhood” exanthems are
rare due to immunizations (rubella,
rubeola, etc)
 Some benign infections do not have
immunizations so there are still
outbreaks (coxsackievirus, etc)
 Some have been eradicated (smallpox)

General Considerations
Systemic viral infection leads to
cutaneous eruption (exanthem)
 Prodrome: fever, malaise, n/v,
headache, sore throat and other sx.
 PE: rash varies with virus, may have
other symptoms. Diagnosed on HX&PE
 Course: Incubations different, usually
resolves in <10 days

Rubella
(German Measles)

EPIDEMIOLOGY/ETIOLOGY:
– Rubella virus.
– Immunization has  incidence by 99%. Now seen
in young adults, developing countries.
– Trans. respiratory droplet. Mod. Communicable.

HISTORY:
– 14-21 d incubation.
– Usually no or mild prodrome, may have HA,
malaise, low grade fever, arthralgias.
Rubella

PE:
– Pink macules, papules.
– Start on forehead, move inferiorly to face, trunk,
extremities. Progress rapidly, gone by day 3.

LABS:
– Leukopenia
– Acute & convalescent antibody titers, cultures.

DIAGNOSIS:
– Clinical, can confirm with labs.
Rubella

PROGNOSIS:
– Usually mild disease. Rare: encephalitis
– In first trimester of pregnancy, can lead to
multiple congenital defects.
TREATMENT: Symptomatic.
 HEALTH MAINTENANCE:

– Immunize (2 doses MMR)
– Check titers in young women, immunize.
Rubeola
(Measles)

EPIDEMIOLOGY/ETIOLOGY :
– Measles virus.
– No longer endemic in US. Major worldwide cause
of pediatric morbidity and mortality.
– Trans. respiratory droplet. Highly contagious.

HISTORY:
– 10-15 d incubation.
– Prodrome – fever, malaise, URI, cough,
photophobia, conjunctivitis.
Rubeola

PE:
– Day 4 of fever: red macules & papules on
forehead, hairline.
– Spread to face, trunk, palms and soles last.
Can be confluent.
– Resolves 4-6 days.
– Koplik’s spots – pathognomonic.
– Lymphadenopathy, D/V, splenomegaly.
Rubeola

LABS:
– Leukopenia
– Serology, cultures (nasopharangeal washings)

DIAGNOSIS:
– Clinical, confirm with labs if questionable.

PROGNOSIS:
– Usually self limiting. Mortality can be up to 10%.
Can cause: otitis media, pneumonia, encephalitis,
diarrhea.
Rubeola

TREATMENT:
– Isolation until 1 wk after rash starts
– Symptomatic
– Treat secondary bacterial infections

HEALTH MAINTENANCE:
– Immunize (2 doses MMR)
Coxsackievirus
(Hand-foot-mouth disease)

EPIDEMIOLOGY/ETIOLOGY :
– Coxsackievirus A16 (and other types)
– Usually <10 years old.
– Epidemic outbreaks
– Highly contagious (oral-oral, fecal-oral).

HISTORY:
– 3-6 d incubation
– Prodrome: low fever, malaise, abd pain.
Coxsackievirus

PE:
– Painful oral lesions, refusal to eat.
– Cutaneous lesions +/- pain.
– Macules or papules  vesicles. +/Erosions, crusts.
– Palms, soles, buttocks, hard palate,
tongue, buccal mucosa.
Coxsackievirus

LABS:
– Serology, culture.

DIAGNOSIS:
– Usually clinical

PROGNOSIS:
– Self limiting.
– Rarely can cause meningitis, myocarditis
Coxsackievirus

TREATMENT:
– Symptomatic.
– Self-limiting.
– Topical lidocaine gel for oral discomfort.

HEALTH MAINTENANCE:
– OK for daycare.
Erythema Infectiosum
(Fifth Disease)

EPIDEMIOLOGY/ETIOLOGY :
– Human parvovirus B19.
– Common in young, can be any age.
– Transmission: respiratory droplet.

HISTORY:
– 4-14 d incubation.
– Prodrome: fever, malaise, HA, URI 2d prior. ST,
N/V coincides with rash.
– Adults: more severe with arthralgias.
Erythema Infectiosum

PE:
– Edematous, confluent plaques on malar
face, “slapped cheek”.
– Fade 1-4dconfluent macules, “lacy”, on
extensor surfaces, extremities, trunk.
– Adults: more constitutional symptoms
(fever, arthralgias, adenopathy).
Erythema Infectiosum

LABS:
– Serology

DIAGNOSIS:
– Clinical

PROGNOSIS:
– Slapped cheeks fade then reticulated rash lasts 59 d.
– Sunlight worsens, can last weeks to months
– Arthralgias, aplastic crisis (immunocomp, anemic)
Erythema Infectiosum

TREATMENT:
– Symptomatic

HEALTH MAINTENANCE:
– Prognosis excellent in immunocompetent
– Immunocompromised: persistent anemia
– Pregnant women: can cause hydrops
fetalis and fetal anemia.
Varicella
(Chicken Pox)

EPIDEMIOLOGY/ETIOLOGY :
– Varicella zoster virus (herpesvirus) primary
infection.
– 90% in <10 year olds.
– Airborne droplet, direct contact. Highly contagious.
– Contagious before vesicles until last vesicles
crust.
– Herpes zoster (secondary infection): shingles.
Varicella

HISTORY:
– About 14 d incubation.
– Prodrome absent or mild. Worse in adults
(fever, HA, malaise).

PE:
– Papulesvesicles. ‘Dewdrop on rose
petal’. umbilication pustules crusts in
8-12hr. PRURITIC
– Crops: face scalp trunk & extremities
Varicella

LABS:
– Leukopenia
– VZV antigen or culture (scrapings), serology

DIAGNOSIS:
– Usually clinical

PROGNOSIS:
– Healthy: usually self limiting.
– Bacterial superinfection, pneumonia, encephalitis,
maternal varicella syndrome.
Varicella

TREATMENT:
– Isolation until crusts gone
– Lotions and antihistamines for pruritis.
– Antivirals will  severity
– Bacterial infection: topical/oral antibiotics.

HEALTH MAINTENANCE:
– Immunization: 2 doses varivax
– Check titers in young women, immunize.