Roseola

Ron Christian Neil T. Rodriguez, MD

First Year Pediatrics Resident
Roseola

 Also called exanthem subitum or sixth disease

 Acute, self-limited disease of infancy and early childhood
 Caused by Human Herpesvirus (HHV) 6 and 7, majority due to HHV 6B
 95% of children are affected by HHV-6 by the age of 2 years following loss of maternal
antibodies during the first few months of life; peak age of HHV-6B infection is at 6 to 9
months old
Pathogenesis of Roseola

 HHV-6B causes viremia demonstrated by co-culture of the patient’s peripheral blood

 Appearance of large refractile mononucleated or multinucleated cells with
intracytoplasmic and/or intranuclear inclusions
 Induces apoptosis of T-cells and can also infect the monocytes, NK cells, dendritic cells,
astrocytes, B-cells, megakaryotes, endothelial, and epithelial cells
 Primary infection with HHV 6 and HHV 7 is followed by lifelong latency or persistence of
virus at multiple sites
Clinical Manifestations

 Abrupt onset of high fever, which may be accompanied by fussiness

 Fever is the MOST CONSISTENT finding in roseola (mean average of 6 days)
 Faint pink to rose colored, non-pruritic 2-3 mm morbilliform rashes on the trunk; usually
lasts for 1-3 days, but has been described as evanescent, appearing only for few hours
before disappearing
 May appear during illness or after defervescence
 Rashes appear first on the trunk then spread to the face and extremities
 Nagayama spots – ulcers at the uvulopalatoglossal junction
Laboratory Findings

 Low numbers of WBC, lymphocyte, and neutrophils  most characteristic in children

with HHV-6B infection
 Others: Thrombocytopenia, elevated serum transaminases, atypical lymphocytes
 CSF: Normal or with minimal pleocytosis with mild elevation of protein
Diagnosis

 History and PE can diagnose roseola and can differentiate it from other, more serious,
disorders that causes rashes
 Three day history of high fever, blanching maculopapular rashes on the trunk
 Viral culture is the gold standard to document viral replication  EXPENSIVE
 Alternatives: PCR on acellular fluids or reverse transcriptase PCR on peripheral blood
mononuclear cells
Diagnosis

 Serologic methods such as indirect immunofluorescence assays, enzyme linked

immunosorbent assays, neutralization assays, and immunoblot can measure the amount of
antibodies to HHV-6 and HHV-7
 Absence of IgG in a 6 month old infant with a presence of a replicating virus is strong evidence of
HHV-6 or HHV -7 primary infection
 However, serologic methods cannot detect HHV reactivation
Differential Diagnosis

 Rubeola/Measles
 Cough, coryza, conjunctivitis, high grade fever are coincident with the appearance of rash
 Rubella
 Mild illness to low grade fever, sore throat, arthralgia, GI complaints
 Scarlet fever
 Rare in patients children younger than 2 years old, and gives a characteristic sandpaper like rash
concurrent with fever
 Enteroviral infection
 Drug hypersensitivity
Differential Diagnosis

 Enteroviral infection
 May be confused as roseola as these are common in the summer and fall months
 Drug hypersensitivity
 Can be mistaken as roseola especially if antibiotics have been started to children with fever before
the appearance of rash
Complications

 Convulsions is the MOST common complication of roseola, recognized in 1/3 of patients,

with peak age at 12 to 15 months
 Others: Encephalitis, acute disseminated demyelination, autoimmune encephalitis, acute
cerebellitis, hepatitis, myocarditis
 Reactivation of HHV has been reported in populations with immunocompromised patients
 May lead to a syndrome called posttransplant acute limbic encephalitis (PALE) to patients who
have undergone HSCT; characterized as short-term memory dysfunction, confusion, insomnia
with seizures
 PALE is associated with long-term neurocognitive sequelae and increased mortality
Treatment

 Supportive management
 Maintain hydration
 Antipyretics if febrile
 For routine cases, specific antiviral therapy is not recommended
 For complicated cases such as PALE or encephalitis, ganciclovir, foscarnet, and cidofovir have
been shown to have inhibitory activity to HHV-6 in vitro
 Ganciclovir or Foscarnet can serve as first-line drugs for patients with PALE, given with a
minimal duration of 3 weeks
Prognosis

 Self-limited disease associated with complete recovery

 Patients with primary infections often recover without any sequelae nor untoward events
 Risk of seizures nor recurrence of seizures appear is not higher as compared to other
etiologies which lead to simple febrile seizures
Prevention

 As of today, transmission is widespread with no current means to prevent it

THANK YOU!