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Roseola, Emergency Medicine

Basics

Description

- Complications - Febrile seizures in 5 " 35% - Aseptic meningitis/encephalopathy - Thrombocytopenic purpura

- CBC: - Initial increase in WBC, then normalization with lymphocytosis; WBC may decrease 3 " 5 days after onset of illness - Platelets may be decreased

- HHV-6 DNA: - Detected by polymerase chain reaction - Available at research level - IgM appears early and declines as IgG is produced - May be done on blood and CSF

  • Exanthem subitum
  • Incubation period of 5 " 15 days
  • Mode of acquisition unknown:Horizontal spread by oral shedding suggestedIt is spread person to person but is not very contagious.Human is the only host.
  • Pathophysiology:Complex immune response (cytokines, antibody responses, T-cell reactivity)

Etiology

  • Human herpesvirus 6 (HHV-6):Large, double-stranded DNAClosely related to human cytomegalovirus
  • Peak incidence at 6 " 12 mo; 90% occurrence within 1st 2 yr
  • Highest incidence in late spring and early summer

Diagnosis

Signs and Symptoms

  • Usually self-limited
  • Diarrhea
  • Irritability
  • Rarely causes severe or fatal disseminating diseases:Infectious mononucleosis syndrome of hepatitis
  • ComplicationsFebrile seizures in 5 " 35%Aseptic meningitis/encephalopathyThrombocytopenic purpura
  • Reactivation in immunocompromised individuals. Manifestations are fever, rash, hepatitis, bone marrow suppression, pneumonia, and encephalitis
  • Most newborns are seropositive for HHV-6 due to transplacental antibodies.
  • By age 1 " 2 yr, >90% of infants are seropositive.

History

  • Classic history is the onset of sudden, high fever 39.4 " 41.2 °C (103 " 106 °F) commonly followed by defervescence and the appearance of rash
  • Absence of physical findings:Child looks wellTemperature normalizes in 3 " 4 daysIrritability and anorexia may be presentBulging fontanelle may be noted

Physical Exam

  • Enlarged lymph nodes
  • Maculopapular eruption from trunk to arms and neck after temperature normalizes
  • Rash fades within 3 days.
  • Erythematous papules in pharynx (Nagayama spots)
  • Otitis media is common
  • Cervical and postoccipital lymphadenopathy

Essential Workup

Clinical diagnosis:

  • High fever in well-appearing child

Diagnosis Tests & Interpretation

Lab

  • CBC:Initial increase in WBC, then normalization with lymphocytosis; WBC may decrease 3 " 5 days after onset of illnessPlatelets may be decreased
  • HHV-6 DNA:Detected by polymerase chain reactionAvailable at research levelIgM appears early and declines as IgG is producedMay be done on blood and CSF
  • CSF if concern about meningitis

Differential Diagnosis

  • Fever of unknown origin
  • Scarlet fever: "Sandpaper " rash, Pastia lines, and strawberry tongue
  • Measles (rubeola):Koplik spots, cough, coryza, conjunctivitis, and fever
  • Rocky Mountain spotted fever:Rash begins at ankles and wrists.
  • Rubella:
  • "Fifth disease " (erythema infectiosum)
  • Dengue fever
  • Pneumococcal bacteremia
  • Meningitis, especially with bulging fontanelle

Treatment

Pre-Hospital

None

Initial Stabilization/Therapy

ABC management

Ed Treatment/Procedures

Medication

  • Acetaminophen: 500 mg (peds: 15 mg/kg/dose) PO q4h; do not exceed 5 doses/24 h or 4 g/24 h
  • Ibuprofen: 200 " 600 mg (peds: 5 " 10 mg/kg PO q6 " 8h); suspension 100 mg/5 mL; oral drops 40 mg/mL

Follow-Up

Disposition

Admission Criteria

Fever in child who is toxic and does not respond to initial supportive care

Discharge Criteria

Usually, all patients may be discharged. Usually may not return to daycare until rash has resolved

Followup Recommendations

Re-evaluate if persistent fever after 3 " 4 days

Pearls and Pitfalls

  • Child looks well
  • Antivirals are not recommended in the immunocompetent child.
  • Febrile seizures need appropriate evaluation.

Additional Reading

  • American Academy of Pediatrics. Report of the Committee on Infectious Diseases. 29th ed. Elk Grove, IL: American Academy of Pediatrics; 2012.
  • Laina I, Syriopoulou VP, Daikos GL, et al. Febrile seizures and primary human herpesvirus 6 infection. Pediatr Neurol. 2010;42:28 " 31.
  • Leach CT. Human herpesviruses 6 and 7. In: Hutto C, ed. Congenital and Perinatal Infections: A Concise Guide to Diagnosis. Totowa, NJ: Humana Press; 2006:101 " 109.
  • Leach CT. Roseola (human herpesviruses 6 and 7). In: Kliegman R, Behrman R, Jenson H, et al., eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, PA: WB Saunders; 2007:1380 " 1383.
  • Prober CG. Human herpesvirus 6. In: Hot Topics in Infection and Immunity in Children VII. Advances in Experimental Medicine and Biology. New York, NY: Springer; 2011:87 " 90.

See Also (Topic, Algorithm, Electronic Media Element)

  • Fever, Pediatric
  • Rash, Pediatric
  • Seizures, Febrile

Codes

ICD9

  • 058.10 Roseola infantum, unspecified
  • 058.11 Roseola infantum due to human herpesvirus 6

ICD10

  • B08.20 Exanthema subitum [sixth disease], unspecified
  • B08.21 Exanthema subitum [sixth disease] due to human herpesvirus 6

SNOMED

  • 54385001 Exanthema subitum
  • 402902002 Roseola infantum (HHV 6)