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

2. 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

4. Enteroviruses Poliovirus 1, 2, 3 Echoviruses Coxsackievirus A
Coxsackievirus B
Enteroviruses

5. 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

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

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

10. Parvovirus B19 Erythema infectiousum, Fifth Disease Epidemiology
Incubation 4-14 days
Most contagious before onset of rash
Clinical Presentation
Fever, mild URI
Arthralgias/arthritis (especially young females)
Aplastic anemia (hemoglobinopathies)
Fetal hydrops (complication of infection during pregnancy)
Exanthem
“Slapped cheek,” circumoral pallor
Maculopapular, “lace-like,” reticular
Diagnosis /Treatment
Serology, PCR

12. 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

13. 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

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

15. Rubella

16. Varicella-Zoster Virus
Epidemiology
Incubation days; contagious 1-2 d before rash onset
Late winter, early spring
Clinical presentation
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)

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

18. Varicella

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

21. Herpes Viruses 1 and 2 Epidemiology Clinical presentation
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

22. Herpes Viruses 1 and 2 Exanthem / Enanthem Diagnosis Treatment
Vesicular lesions; coalesce with time
Enanthem: friable gingiva, lesions on tongue, gingiva
May be on lips, vermilion border
Diagnosis
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

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

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

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

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

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

28. What’s Your Diagnosis?

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

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

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

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

33. What’s Your Diagnosis?
Diagnostic evaluation?
Treatment?