Arch Dis Child: first published as 10.1136/adc.24.117.54 on 1 March 1949. Downloaded from

ROSEOLA INFANTUM AN OUTBREAK IN A MATERNITY HOSPITAL BY URSULA JAMES, M.B., M.R.C.P., and A. FREIER, M.B., B.S. (From the General Lying In Hospital, London) infantum was first described by Zahorsky onset, but generally there is remarkably little (1910), and since this time cases have been recorded constitutional disturbance. Conte et al. (1944) by many writers both in America and Europe but describe eighteen cases occurring in hospital over the disease has received little recognition in England. a ten-month period, and among these nine had It has been labelled subitum and sixth one to six convulsions at the onset. Most other disease but Zahorsky (1947) and others have put writers record fits much less often. forward a plea for the retention of the name roseola Glandular enlargement is described but does not infantum or the 'rose rash of infancy '. seem to be a constant finding, although Jennings The infectious nature of the disease was discussed (1940) stated that enlargement of the posterior by Barenberg and Greenspan (1939), who report cervical glands, without apparent cause in the scalp, it to be periodically epidemic in an institution for in an infant with a high temperature and with no children and describe an epidemic of twenty-seven other clinical findings should suggest the diagnosis cases occurring over a period of three months, the of roseola infantum, and in fact this sign led him to incidence of in the respective wards being diagnose 80 per cent. of his cases of this disease 35 per cent. and 45 per cent. The prior to the eruption. was five to fifteen days with an average of twelve Examination of the blood on the second or copyright. days. Cushing (1927) describes an epidemic in subsequent days may reveal leucopenia. In the Montreal with incubation periods between eight and cases described by Barenberg and Greenspan (1939) fourteen days. 50 per cent. showed leucopenia on the third day, Most cases occur during the first two years of life, 64 per cent. on the fourth day, and only 25 per cent. and the maximum incidence seems to be between on the seventh day. A relative lymphocytosis was six and eighteen months of age. Conte et al. (1944) present in 66 per cent. on the third day and in all two the cases on the fourth day. Zahorsky (1947) and found 95 per cent. of cases to be under years http://adc.bmj.com/ of age, and in the series described by Barenberg others stress that the lymphocytosis is only relative and Greenspan (1939) 93 per cent. were under this and that the important factor is the decrease in the age, the youngest being four months. Dickey (1945) polymorphonuclear cells. has seen one case at six weeks old, another at nine The mortality rate is nil, and the recovery is rapid weeks, and his oldest patient was a boy offour years. and complete. Zahorsky (1910) and Greenthal (1941) both cite The etiology has been discussed by Conte et al. cases aged eighteen years, and Cutts (1938) records (1944), who put forward three possibilities: a case aged thirty-one years which he regarded as (1) allergy, (2) grippe-like infection, (3) on September 28, 2021 by guest. Protected undoubtedly one of roseola infantum. infection. Most writers incriminate the virus Roseola infantum is characterized by an abrupt although Breese (1941) tried and failed to demon- onset with a rise oftemperature up to 103 or 104° F., strate a filterable virus in throat swabs from three which persists for two to five days and falls by of his cases. crisis. A rash appears usually as the temperature An Maternity Hospital falls but may be delayed for a few days. It is Epidemic in a from the The following description of an epidemic in a macular, rose pink in colour, and spreads maternity hospital of a disease conforming to trunk to the limbs and face, but is most profuse over descriptions of roseola infaptum is thought to be of the trunk; it reaches its maximum in twenty-four interest because such cases have not been recorded hours and fades during the next twenty-four hours, in England or in such young infants, and also usually without desquamation. because a proportion of the nurses, mothers, and The child may 1,5 fretful and irritable as the fathers were also affected. temperature rises, there may be convulsions at the The outbreak occurred between June 26 and 54 Arch Dis Child: first published as 10.1136/adc.24.117.54 on 1 March 1949. Downloaded from ROSEOLA INFANTUM 5.5

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Aug. 7, 1948. During this period there were 144 infectivity rate among the babies on the affected babies in the hospital, but the epidemic was confined floor was 29 *2 per cent. to one floor of the hospital only, on which there New cases occurred at intervals of one to thirteen were sixty-five babies. Nineteen were thought to days (average two to three days), and the age of

have roseola infantum, but in only sixteen was the onset was eight to twelve days (average eleven days). copyright. diagnosis definitely established by clinical findings In one doubtful case the pyrexia started on the fifth and by the typical temperature chart. In eight cases day of life, and another baby was eighteen days old (six infants and two mothers) the diagnosis was when the illness started. confirmed by the blood picture. The first two cases In addition five nurses working on the affected were at first labelled as 'pyrexia ofunknown origin', floor developed characteristic symptoms, and a and not until we had studied the disease more history of a similar illness was obtained from six closely did we include them in the series. The mothers and four fathers. Three mothers developed

the disease while in hospital. http://adc.bmj.com/ AGE N DAYS All pineteen bab5ies with roseola infantum were 2 3 4 5 6 7 8 9 10 11 12 13 14 15 lb breast fed. A past history of having had T. OZ. was obtained from three of their mothers, one of 13 whom developed symptoms and exanthem of 106 12 TEMPERATURE CONVULSION roseola infantum herself while in hospital. Of the 11I @- WEIGHT 1 RASHI remaining mothers, only three were able, to say 105 with certainty that they had not had rubella, and thirteen gave a history of and one of 104 glandular . on September 28, 2021 by guest. Protected 103 Clinical manifestations. The condition was characterized by high fever, rash, and glandular 102 enlargement, and in the majority of cases by an astonishing absence of any constitutional upset. 101 In the adults the clinical picture was rather different and -will be dealt with later. 100 TEMPERATURE. The temperature was an out- standing feature and indicated the onset of the 99 disease. There was a sharp rise to 1030 F. or higher (figs. 1, 2, 3); it remained up for twenty-four to 98 seventy-two hours, showing an occasional drop of 0 5 to 20, but rose again before the characteristic 97 fall by crisis. The temperature then remained FIG. 3.-Case 17, temperature and weight. normal except in ten cases, where there was a Arch Dis Child: first published as 10.1136/adc.24.117.54 on 1 March 1949. Downloaded from 56 7ARCHIYES OF DISEASE IN CHILDHOOD I -t @0 0 *I -0- SnO m 0 , ii _i I 2I5,I io -a3 ' I la 4aSr0,0 .9 es VM .1t S,a .E "I e0 I. ~o *g 0. 0) a 12 a A%. I 'c 1.1 ,o, g~~~~~-us,. 0 1.- ~.9 a l0 a I 0 a *Y g 0 § .2 0 09 i2 !S ao> .1 iis I0 0 *gal .2 I I 2 10C 0

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I -_! a I r- 1°c IO V co10 T" :2 -I Arch Dis Child: first published as 10.1136/adc.24.117.54 on 1 March 1949. Downloaded from ROSEOLA INFANTUM 57 second peak up to 100° F. about forty-eight hours Pathological investigations later which was only sustained for a few hours. URiNE. In the early days of the outbreak every In one case the temperature rose to only 99.80 F., case had an examination of the urine performed. but the presence of a typical rash, glandular enlarge- Altogether ten specimens were examined and the ment, and neutropenia made us include this case. results are put forward in the accompanying table. RASH. The rash was seen in fifteen cases. The other four were early cases and it is possible that BLOOD. In a number of cases white-cell and the rash was overlooked. As can be seen in the differential counts were done on the second or third accompanying table, the rash usually appeared as day of the illness, and in two cases they were the temperature fell or shortly after. In two cases repeated several days later. In addition blood the rash appeared with the pyrexia, and in one it counts were done on two mothers who developed occurred before the pyrexia, but in this case the the disease while in hospital, and in one of these a etiology of the rash is in doubt since it also persisted Paul Bunnell test was also taken and found to be for eight days. negative. The rash began on the chest and very soon spread Leucopenia and neutropenia were usually found, to the limbs, abdomen, and back. In only a few although in one infant the cell count totalled cases was the face involved, and in no cases were 20,000 per c.mm. of blood with 62 per cent. of the palms and soles affected. The exanthem con- polymorphonuclear cells. This count, however, was sisted ofmacules, 2 to 4 mm. in diameter, which were taken shortly after a convulsion (see table). usually surrounded by an area of erythema. On Treatment. No treatment was required in most the back and the limbs the macules tended to be cases. Those infants with abnormal physical signs more confluent and in some areas had a scarlatini- in the chest or excessive pus cells in the urine were form or a morbilliform appearance. All these given penicillin and/or sulphonamides, but no features were present in different areas in one case difference was noted in the course of the disease, at the same time. A macular rash, however, was nor was there any alteration in the temperature most usual, and there were never any vesicles or curves. pustules. The rash varied in intensity in the same infant, and usually faded, without desquamation Manifestations of roseola infantum in adults. Five or staining ofthe skin, in about twelve to twenty-four nurses, all of them contacts with the affected babies, hours. developed the disease. ENLARGEMENT OF THE LYMPH GLANDS. This was The first nurse developed pyrexia, severe retro- copyright. another prominent feature and was usually noticed orbital , photophobia, and general malaise. soon after the onset of pyrexia. The occipital There was definite neck rigidity and a doubtful glands were enlarged in fourteen cases, the axillary positive Kemig's sign was elicited. She was trans- glands in fourteen, those of the posterior triangle ferred to an isolation hospital where a lumbar of the neck in seven, and the inguinal glands in five. puncture was performed and normal cerebrospinal In the first two cases of the series enlarged glands fluid was obtained. Several days later her tempera- were not looked for, whilst in two others the glands ture fell and she developed a rash. She was were not enlarged, but in these cases other character- discharged without a definite diagnosis having been http://adc.bmj.com/ istic features were present and therefore they were made. included in the series. Four other nurses developed similar symptoms The glands were enlarged to the size of a pea, with pyrexia followed by a macular rash, and three were discrete, and never suppurated. of them- were transferred to fever hospitals. They In no case was the spleen found to be enlarged. were discharged with the tentative diagnosis of OTHER FEATURES. Certain other features were atypical rubella. found in some cases. At the onset of the illness in Three mothers developed a similar condition while five cases there was some dullness on percussion of in hospital, and we heard from six others who the chest, and in two of these moist sounds were developed severe malaise followed by a rash on the on September 28, 2021 by guest. Protected audible on auscultation suggesting a broncho- face and limbs after they reached home. The onset . These signs, however, disappeared in was within fourteen days of the onset of roseola twelve to twenty-four hours. In some cases there infantum in their babies. A similar condition, with was slight of the palate and , and very severe retro-orbital headache, has been reported in some the tympanic membranes were injected, but in four fathers. These cases were seen by their this was attributed to the pyrexia. private doctors who were unable to make a certain There was no vomiting or diarrhoea, and no diagnosis but suggested rubella as a possible cause. jaundice. Most of the babies had normal vigour The mothers themselves felt certain that it was the and fed well. Only four babies lost weight, the same disease which they had seen in the babies in maximum loss being 4 oz.; four babies failed to the hospital. gain weight during the period of pyrexia, and the The striking coincidence and similarity of remainder gaithed weight steadily throughout. symptoms and signs in the nurses and parents led One infant had a major convulsion at the onset us to conclude that there was a common etiology of the infection. and that the disease was indeed roseola infantum. Arch Dis Child: first published as 10.1136/adc.24.117.54 on 1 March 1949. Downloaded from 58 ARCHIVES OF DISEASE IN CHILDHOOD The blood pictures obtained in two mothers was curves and the time of onset of the rash was similar characteristic. in all cases. Walifield (1934) describes a girl of -. Measles can be excluded twelve years who was admitted with the clinical by the absence of typical prodromal coryza, the picture of , but was eventually proved time relationship of the rash to the tempperature, to have roseola infantum. She had a two-day and by the differential white cell count. Dickey history of high fever, vomiting, headache, vertigo, (1945) gives excellent charts comparing the pro- and stiffness of the neck. The temperature fell by dromal periods, the degree and duration oftempera- crisis on the third day and a typical rash developed. ture, the fall by crisis or lysis, and the relation of Her cerebrospinal fluid was normal but her blood fever to rash in roseola infantum, rubella, measles, count showed the typical changes. There were no and . He also gives charts showing the sequelae. This description closely resembles that varieties of temperature curves and the times of found in our adult cases. appearance of the rash in roseola infantum. The The epidemic described in this paper was, there- age incidence in our epidemic was also strong fore, considered to be one of roseola infantum, but evidence against measles. was unusual in that it affected the newborn, and Rubella was considered a likely diagnosis early also a relatively high proportion of adults. on in the epidemic mainly -because the first nurse to be affected was provisionally labelled as a case Summary of rubella, but later this was thought not to be so, and she was discharged from an isolation hospital 1. A review of the literature concerning roseola with no definite diagnosis. infantum is given, together with a description of the The babies developed the disease from the sixth disQase drawn from these records. to the eighteenth (average eleventh day of life) and 2. An epidemic of roseola infantum occurring usually the rash appeared after the temperature had in a maternity hospital is described. fallen by crisis. These two factors together with the 3. The differential diagnosis is discussed. blood findings do not suggest rubella. Hynes (1946) performed serial blood counts on sixty-one adults with rubella and concluded that there was a leuco- We wish to thank Dr. Van de Merwe for the penia at the onset with an absolute lymphopenia, haematological investigations. but that an absolute lymphocytosis occurred after the fifth day, the total count rising to normal by the REFERENCES copyright. tenth day. He found Turck cells present in every Barenberg, L. H., and Greenspan, L. (1939). Amer. J. case and plasma cells appeared in from half to Dis. Child., 58, 983. two-thirds of the cases. Rosenblum (1945) gives Breese, B. B. (1941). N.Y. St. med. J., 41, 1854. figures for the blood changes in roseola infantum, Conte, A. N. (1944). Arch. Pediat., 61, 559. and shows clearly that there is leucopenia with Cushing, H. B. (1927). Canad. med. Ass. J., 17, 905.. marked neutropenia by the third day and that the Cutts, M. (1938). Ann. int. Med., 11, 1752. lymphocytosis so often described is only relative. Dickey, L. B. (1945). Stanford med. Bull., 3, 37.

A high percentage of our cases had generalized Greenthal, R. M. (1941). Wisconsin med. J., 40, 25. http://adc.bmj.com/ Hynes, M. (1940). Lancet, 2, 679. glandular enlargement, but glandular fever was, Jennings, R. E. (1940). J. med. Soc. New Jersey, 37, 577. excluded by the blood counts, and by a Paul Bunnell Rosenblum, J. (1945). Amer. J. Dis. Child., 69, 234. reaction in one case. Wallfield, M. J. (1934). J. Pediat., 5, 800. The clinical picture in the adults differed some- Zahorsky, J. (1910). Pediatrics, 22, 60. what from that in the infants but the temperature (1947). Arch. Pediat., 64, 579. on September 28, 2021 by guest. Protected