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8 Viral Exanthems of Childhood

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8 Viral Exanthems of Childhood Carlos A. Arango, MD; Ross Jones, MD 8 viral exanthems of childhood Department of Community Health and Family Medicine, University of Florida, Some share features, making them difficult to Jacksonville distinguish. Others may not be on your radar. Here we [email protected]. edu review 8 you’re likely to see or need to exclude. The authors reported no potential conflict of interest relevant to this article. amily physicians encounter skin rashes on a daily basis. PRACTICE First steps in making the diagnosis include identifying RECOMMENDATIONS the characteristics of the rash and determining whether ❯ Administer the varicella- F the eruption is accompanied by fever or any other symptoms. zoster vaccine to all adults In the article that follows, we review 8 viral exanthems of child- ≥60 years of age to prevent or attenuate herpes zoster hood that range from the common (chickenpox) to the not-so- infection. A common (Gianotti-Crosti syndrome). ❯ Avoid congenital rubella syndrome by vaccinating all at-risk pregnant women. A Varicella-zoster virus Varicella-zoster virus (VZV) is a human neurotropic alphaher- ❯ Administer 2 doses of the pesvirus that causes a primary infection commonly known as measles vaccine (one at chickenpox (varicella).1 This disease is usually mild and re- 12-15 months of age and solves spontaneously. one at 4-6 years of age) to all children to avoid a This highly contagious virus is transmitted by directly resurgence. A touching the blisters, saliva, or mucus of an infected person. It is also transmitted through the air by coughing and sneezing. Strength of recommendation (SOR) VZV initiates primary infection by inoculating the respiratory A Good-quality patient-oriented evidence mucosa. It then establishes a lifelong presence in the sensory B Inconsistent or limited-quality ganglionic neurons and, thus, can reactivate later in life caus- patient-oriented evidence ing herpes zoster (shingles), which can affect cranial, thoracic, C Consensus, usual practice, opinion, disease-oriented and lumbosacral dermatomes. Acute or chronic neurologic evidence, case series disorders, including cranial nerve palsies, zoster paresis, vas- culopathy, meningoencephalitis, and multiple ocular disor- ders, have been reported after VZV reactivation resulting in herpes-zoster.1 ❚ Presentation. With varicella, an extremely pruritic rash follows a brief prodromal stage consisting of a low-grade fe- ver, upper respiratory tract symptoms, tiredness, and fatigue. This exanthem develops rapidly, often beginning on the chest, trunk, or scalp and then spreading to the arms and legs (cen- trifugally) (FIGURE 1). Varicella also affects mucosal areas of the body, such as the conjunctiva, mouth, rectum, and vagina. The lesions are papules that rapidly become vesicular with clear fluid inside. Subsequently, the lesions begin to crust. Scabbing occurs within 10 to 14 days. A sure sign of chicken- pox is the presence of papules, vesicles, and crusting lesions in close proximity. 598 THE JOURNAL OF FAMILY PRACTICE | OCTOBER 2017 | VOL 66, NO 10 ❚ Complications. The most common FIGURE 1 complications of chickenpox—especially Varicella infection (chickenpox) in children—are invasive streptococcal and staphylococcal infections.2 The most serious complication occurs when the virus invades the spinal cord, causing myelitis or affecting the cerebral arteries, leading to vasculopa- thy. Diagnosis of VZV in the central nervous system is based on isolation of the virus in cerebral spinal fluid by polymerase chain re- PHOTO COURTESY OF: JOHN HICKNER, MD, MSC PHOTO COURTESY action (PCR). Early diagnosis is important to minimize morbidity and mortality. Reactivation is sometimes associated with post-herpetic neuralgia (PHN), a severe neuropathic pain syndrome isolated to the dermatomes affected by VZV. PHN can cause pain and suffering for years after shingles re- solves, and sometimes is refractory to treat- ment. PHN may reflect a chronic varicella virus ganglionitis. This pruritic rash, which often develops first on the trunk, consists of papules that rapidly become vesicular with clear fluid inside. Subsequently, these lesions A number of treatment choices exist for begin to crust. shingles, but not so much for varicella Oral treatment. Oral medications such as acyclovir and its prodrug valacyclovir are ❚ Non-FDA approved treatments in- the current gold standards for the treatment clude tricyclic antidepressants (TCA), such of VZV.3 as amitriptyline, nortriptyline, and desipra- Famciclovir, the prodrug of penciclovir, mine, which are sometimes used as first-line is more effective than valacyclovir at resolv- therapy for shingles. TCAs may not work well ing acute herpes zoster rash and shortening in patients with burning pain, and can have the duration of PHN.4 Gabapentinoids (eg, significant adverse effects, including possible pregabalin) are the only oral medications ap- cardiotoxicity.9 proved by the US Food and Drug Administra- Opioids, including oxycodone, mor- tion (FDA) to treat PHN.5 phine, methadone, and tramadol, are some- ❚ Topical medications can also be used. times used in pain management, but concern Lidocaine 5% is favored as first-line therapy exists for abuse. Because patients may de- for the amelioration of pain due to shingles, velop physical dependence, use opioids with as it provides modest pain relief with a better considerable caution.10 safety and tolerability profile than capsaicin ❚ Prevention. The United States became 8% patch, which is a second-line choice. The the first country to institute a routine vari- latter must be applied multiple times daily, cella immunization program after a varicella has minimal analgesic efficacy, and frequently vaccine (Varivax) was licensed in 1995.11 The causes initial pain upon application. vaccine has reduced the number of varicella Gabapentinoids and topical analge- infection cases dramatically.11 Vaccine effec- sics can be used in combination due to the tiveness is high, and protective herd immu- low propensity for drug interactions.6,7 The nity is obtained after 2 doses.11-13 The vaccine treatment of choice for focal vasculopathy is administered to children after one year of is intravenous acyclovir, usually for 14 days, age with a booster dose administered after although immunocompromised patients the fourth birthday. should be treated for a longer period of time. A live, attenuated VZV vaccine (Zostavax) Also consider 5 days of steroid therapy for pa- is given to individuals ≥60 years of age to pre- 8 tients with VZV vasculopathy. vent or attenuate herpes zoster infection. CONTINUED JFPONLINE.COM VOL 66, NO 10 | OCTOBER 2017 | THE JOURNAL OF FAMILY PRACTICE 599 FIGURE 2 tion period, it remains latent in lymphocytes Roseola infantum and monocytes, thus persisting in cells and tissues. It may reactivate late in life, particu- larly in immunosuppressed individuals. Re- activated infection in immunocompromised patients may be associated with serious ill- ness such as encephalitis/encephalopathy. In patients who have received a bone mar- row transplant, it can induce graft vs host disease.17 ❚ Presentation. The virus causes a 5- to 6-day illness characterized by high fever (temperature as high as 105°-106° F), miringi- tis (inflammation of tympanic membranes), and irritability. Once defervescence occurs, an erythematous morbilliform exanthem ap- pears. The rash, which has a discrete macu- lar/papular soft-pink appearance, starts on the trunk and spreads centrifugally to the ex- tremities, neck, and face (FIGURE 2). It usually resolves within one to 2 days. ❚ Complications. The most common complication of roseola is febrile seizures.17 Less common ones include encephalitis, encephalopathy, fatal hemophagocytic syn- drome,18 or fulminant hepatitis.19 PHOTO COURTESY OF: CARLOS A. ARANGO, MD PHOTO COURTESY ❚ Treatment and prevention. Treatment The rash of roseola infantum has a discrete macular/papular soft- pink coloration and starts on the trunk, spreading centrifugally to depends on symptoms and may include anti- the extremities, neck, and face. pyretics for fever management and liquids to maintain hydration. Recovery is usually com- plete with no significant sequelae. If a child This vaccine is used to boost VZV-specific develops a seizure, no antiepileptic drugs are cell-mediated immunity in adults, thereby recommended. No vaccine exists. decreasing the burden of herpes zoster and the pain associated with PHN.14 Fifth disease Human parvovirus B19, a minute ssDNA vi- Roseola rus, was first associated with human disease Roseola infantum, also known as exan- in 1981, when it was linked to an aplastic thema subitum and sixth disease, is a com- crisis in a patient with sickle cell disease.20 mon mild acute febrile illness of childhood Since then researchers have determined that caused by infection with human herpesvirus it is also the cause of erythema infectiosum (HHV) 6 (the primary agent causing roseo- or fifth disease of childhood. The B19 virus la) or 7 (a secondary causal agent for ro- can also cause anemia in the fetus as well as seola).15 HHV-6 has 2 variants (HHV-6a and hydrops fetalis. It has been linked to arthral- HHV-6b). Roseola infantum is mostly asso- gia and arthritis (especially in adults). There ciated with the HHV-6b variant, which pre- is an association with autoimmune diseases dominantly affects children 6 to 36 months with characteristics similar to rheumatoid of age.16 arthritis.20 The virus replicates in the salivary glands The B19 virus is transmitted via aerosol-
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