Roseola infantum

definition of Roseola Infantum , cause ,clinical features,differential diagnosis ,

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Roseola infantum Prof. Saad S Al Ani
Prof.Saad S Al Ani
Senior Pedaitric Consultant
Head of pedaitric Department
Khorfakkan Hospital
Sharjah ,UAE
Roseola infantum

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Roseola infantum Prof. Saad S Al Ani
Roseola is a mild febrile, exanthematous illness
occurring almost exclusively during infancy
Roseola Infantum
(exanthem subitum, or sixth disease )
More than 95% of roseola cases occur in children
younger than 3 yr, with a peak at 6-15 mo of age
Roseola infantum Prof. Saad S Al Ani

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Roseola infantum Prof. Saad S Al Ani
Roseola Infantum (cont.)
(exanthem subitum, or sixth disease )
Transplacental antibodies likely protect most infants until
6 mo of age.
Infants with classic roseola exhibit a unique constellation
of findings displayed over a short period of time
Roseola infantum Prof. Saad S Al Ani

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Roseola infantum Prof. Saad S Al Ani
Etiology
Human herpesvirus 6 (HHV-6) is the etiologic agent for
most cases of and human herpesvirus 7 (HHV-7) is in
some cases of roseola
HHV-6 and HHV-7 belong to the β-herpesvirus
subfamily of herpesviruses

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Roseola infantum Prof. Saad S Al Ani
Etiology (cont.)
The principal target cells for HHV-6 and HHV-7
infection in vivo are CD4 T cells
HHV-6 can also infect other cells, including : CD8
(suppressor) T cells, natural killer T cells, δγ T cells,
glial cells, epithelial cells, monocytes,
megakaryocytes, and endothelial cells

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Roseola infantum Prof. Saad S Al AniRoseola infantum Prof. Saad S Al Ani
Epidemiology
Primary HHV-6 infection occurs early in life.

More than 90% of newborn infants are HHV-6
seropositive, reflecting transplacental transfer of maternal
antibodies.

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Roseola infantum Prof. Saad S Al Ani
Epidemiology (cont.)
By 4-6 mo of age, the prevalence drops
significantly (0-60%).
By 12 mo of age, 60-90% of children
possess antibodies to HHV-6,

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Roseola infantum Prof. Saad S Al AniRoseola infantum Prof. Saad S Al Ani
Epidemiology (cont.)
By 3-5 yr, 80-100% of children are
seropositive.

Peak acquisition of primary HHV-6
infection, from 6-15 mo of age,
corresponds with peak acquisition of
roseola.

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Roseola infantum Prof. Saad S Al AniRoseola infantum Prof. Saad S Al Ani
Epidemiology (cont.)
Less than half of HHV-6 infections in U.S.
infants are clinically recognizable as roseola,
Primary infection with HHV-7 occurs slightly
later than HHV-6 infection, with 45-75% of
children infected by 2 yr of age and 90% by 7-10
yr of age
whereas 80% of Japanese infants with primary
HHV-6 infection develop roseola.

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Roseola infantum Prof. Saad S Al Ani
Epidemiology (cont.)
Roseola can develop in children year-round
A higher incidence during spring and fall months

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Roseola infantum Prof. Saad S Al Ani
Epidemiology (cont.)
Children with roseola rarely report contact with other
affected children
Outbreaks are uncommon .

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Roseola infantum Prof. Saad S Al Ani
The incubation period averages 10 days (range
of 5-15 days).
Epidemiology (cont.)
Sex, race, and geography ,do not play an important
role in acquisition of roseola.

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Roseola infantum Prof. Saad S Al Ani
Pathogenesis
Virus is probably acquired from the saliva of healthy persons
and enters the host through the oral, nasal, or conjunctival mucosa.
Cellular receptors for both viruses have been identified:
* HHV-6 uses the CD46 receptor
* HHV-7 uses the CD4 receptor
Both viruses may evade the immune system through
downregulation of the major histocompatibility
complex (MHC) type I response

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Roseola infantum Prof. Saad S Al Ani
Clinical Manifestations
Infants with classic roseola exhibit a unique constellation
of findings displayed over a short period of time.
The prodromal period is usually asymptomatic but
may include mild upper respiratory tract signs, among
them:
* minimal rhinorrhea*slight pharyngeal inflammation*
mild conjunctival redness.

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Roseola infantum Prof. Saad S Al Ani
Clinical Manifestations (Cont.)
Mild cervical or, less frequently, occipital
lymphadenopathy may be noted
Some children may have mild palpebral edema

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Roseola infantum Prof. Saad S Al Ani
Clinical Manifestations (Cont.)
Physical findings during the prodromal stage may
simply reflect an accompanying respiratory viral
infection.
Clinical illness is generally heralded by high
temperature usually ranging from 37.9 to 40°C
(101-106°F), with an average of 39°C (103°F).

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Roseola infantum Prof. Saad S Al Ani
Clinical Manifestations (Cont.)
Some children may become irritable and anorexic
during the febrile stage, but most behave normally
despite high temperatures.
Seizures may occur in 5-10% of children with roseola
during this febrile period. Infrequent complaints
include:
* rhinorrhea*sore throat* abdominal pain, vomiting,
and diarrhea .

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Roseola infantum Prof. Saad S Al Ani
Clinical Manifestations (Cont.)
In Asian countries, ulcers at the uvulopalatoglossal
junction (Nagayama spots) are common in infants
with roseola.
Fever persists for 3-5 days, and then typically
resolves rather abruptly ("crisis").
A rash appears within 12-24 hr of fever resolution

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Roseola infantum Prof. Saad S Al Ani
Clinical signs associated with primary HHV-6 infection and the
proportion of children with primary HHV-6 infection manifesting each
sign as documented by both viremia and seroconversion in 335
children studied in Rochester, NY.

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Roseola infantum Prof. Saad S Al Ani
In patients with primary HHV-6 infection, the mean total white blood cell
(WBC) and lymphocyte counts are shown by day of illness in relation to
the average course of fever
Pruksananonda P, Hall C, Insel R, et al. Primary human herpesvirus 6
infection in young children. N Engl J Med 1992;326:1445–1450.)

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Roseola infantum Prof. Saad S Al Ani
Exanthems associated with roseola

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Roseola infantum Prof. Saad S Al Ani
The rash
In many cases, the rash develops during
defervescence or within a few hours of fever
resolution.
The rash of roseola is rose colored and is fairly
distinctive

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Roseola infantum Prof. Saad S Al Ani
The rash (cont.)
it may be confused with exanthems resulting
from rubella, measles, or erythema
infectiosum
The roseola rash begins as discrete, small (2-5
mm), slightly raised pink lesions on the trunk
and usually spreads to the neck, face, and
proximal extremities

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Roseola infantum Prof. Saad S Al Ani
The rash (cont.)
The rash is not usually pruritic, and no vesicles
or pustules develop
Lesions typically remain discrete but occasionally
may become almost confluent
After 1-3 days, the rash fades

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Roseola infantum Prof. Saad S Al Ani
Subtle differences in clinical
presentation
In roseola associated with HHV-7 Subtle
differences in clinical presentation compared with
HHV-6 cases include :
1. Slightly older age
2. Lower mean temperature
3. Shorter duration of fever
These differences are insufficient to clinically
distinguish HHV-6- from HHV-7-associated roseola

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Roseola infantum Prof. Saad S Al Ani
LABORATORY FINDINGS
By the time the exanthem appears, the WBC
count falls to 4,000-6,000 WBCs/μL with a
relative lymphocytosis (70-90% )
White blood cell (WBC) counts of 8,000-9,000 WBCs/μL
may be found during the first few days of fever in children
with roseola

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Roseola infantum Prof. Saad S Al Ani
LABORATORY FINDINGS (cont.)
The cerebrospinal fluid from rare cases of HHV-6-
associated meningoencephalitis and encephalitis is
characterized by:
* mild pleocytosis with predominance of
mononuclear cells
* normal glucose
* normal to slightly elevated protein.
The cerebrospinal fluid in children with HHV-6-
associated febrile seizures typically is normal

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Roseola infantum Prof. Saad S Al Ani
DIFFERENTIAL DIAGNOSIS

1.Rubella
2.Measles
3.roseola-like illnesses i.e. Enteroviruses
4.Scarlet fever
5.Drug hypersensitivity

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Roseola infantum Prof. Saad S Al Ani
Treatment
The generally benign nature of roseola precludes
consideration of antiviral therapy
Children with neurologic complications of roseola
or immunocompromised children with severe HHV-6
or HHV-7 infection may address the need for specific
antiviral therapy
Children in the febrile, pre-eruptive phase of roseola
usually are quite comfortable and require little
supportive therapy

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Roseola infantum Prof. Saad S Al Ani
Treatment (Cont.)
Adequate fluid balance should be maintained in
all affected children
Those children who are uncomfortable and
irritable, or in whom histories of febrile
convulsions exists, may benefit from treatment
with acetaminophen or ibuprofen.

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Roseola infantum Prof. Saad S Al Ani
Prognosis
The prognosis for the great majority of children with
roseola is excellent, with no obvious sequelae
Damage resulting from direct viral invasion of the brain,
liver, and other organs has been demonstrated for HHV-6
Deaths directly attributable to HHV-6 have been reported
in normal as well as immunocompromised patients in
whom encephalitis, hepatitis, pneumonitis, disseminated
disease, or hemophagocytosis syndrome developed.

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Roseola infantum Prof. Saad S Al Ani
References
•Caserta MT, Mock DJ, Dewhurst S: Human herpesvirus 6. Clin Infect Dis
2001;33:829-33. Medline Similar articles
• Chua KB, Lam SK, AbuBakar S, et al: The predictive value of uvulo-
palatoglossal junctional ulcers as an early clinical sign of exanthem subitum
due to human herpesvirus 6. J Clin Virol 2000;17:83-90. Medline
Similar articles
• Desachy A, Ranger-Rogez S, Francois B, et al: Reactivation of human
herpesvirus type 6 in multiple organ failure syndrome. Clin Infect Dis
2001;32:197-203. Medline Similar articles
• Leach CT: Human herpesvirus-6 and -7 infections in children: Agents of
roseola and other syndromes. Curr Opin Pediatr 2000;12:269-74. Medline
Similar articles
• Leach CT, Pollock BH, McClain KL, et al: Human herpesvirus 6 (HHV-6)
and cytomegalovirus (CMV) infections in children with acquired
immunodeficiency syndrome (AIDS) and cancer. Pediatr Infect Dis J
2002;21:125-32. Medline Similar articles
• Mendez JC, Dockrell DH, Espy MJ, et al: Human ß-herpesvirus
interactions in solid organ transplant recipients. J Infect Dis
2001;183:179-84. Medline Similar articles