When Does the Rash of Roseola Occur?

Patient Presentation
A 12-month-old male came to clinic for a rash. Six days prior he had his health supervision visit where he had received MMR-V, Prevnar and Influenza vaccines. Three days prior he developed a fever to 102° F and was fussy. One day prior he became quite fussy and had decreased oral intake, but his fever stopped. The morning of the clinic visit he woke up with a rash that began on his head and progressed down to his body. He had no history of vaccine reactions, food allergies, or atopia. There were normal bowel movements, with slight decrease in urination, no cough, upper respiratory tract symptoms or localized pharyngitis. He had no difficulty walking. The past medical history was positive for upper respiratory infections and one ear infection. The family history was non-contributory. The social history showed he attended daycare and roseola was circulating in the community.

The pertinent physical exam showed a tired appearing male who was afebrile with normal vital signs and growth parameters in the 75-90%. HEENT revealed moist mucous membranes. There was no conjunctival or pharyngeal injection. Nose and ears were normal. He had shoddy anterior cervical lymph nodes and groin nodes with all < 1.0 cm. Skin showed anerythematous macular-papular rough rash on the body, groin and axilla. It was blanching and non-pruritic. He had no mucositis or joint swelling or pain. The rest of his examination was normal. At this time, the pediatrician's working differential diagnosis included Group A beta-hemolytic streptococcal infection, viral exantham especially roseola, vaccine reaction, Kawasaki Disease (unlikely) and unrecognized food allergy/sensitivity (unlikely). The work-up included a normal rapid strep test and later throat culture for streptococcus. A complete blood count showed a white blood cell count of 5.0 x 1000/mm2 with slight neutropenia. The diagnosis of a viral exantham most likely roseola was made. The patient’s clinical course showed that he had resolution of the rash and other symptoms over the next 1.5 days. Long-term he had no similar reactions with subsequent vaccines.

Rashes, particularly ones caused by viruses, are common presenting problems. In his first edition of Pediatrics, Dr. Rotch spent 72 pages describing infectious exanthemata. The cause of the exanthemata was unknown at the time, and thankfully many of those that he wrote of have been eradicated (smallpox), have effective vaccines to prevent (measles, rubella, varicella) or effective antibiotics for treatment (streptococcus).

Dr. Rotch ends his extensive treatise with a table describing “the chief points of differential diagnosis in the exanthemata.” This is what was state-of-the-art in 1896 with his spellings:

  • Variola (Smallpox)
    • Incubation: 12 days
    • Prodromata: 3 days
    • Efflorescence: macules, papules, vesicles, pustules
    • Desquamation: large crusts
    • Complication and sequelae: larynx, lungs
  • Varicella
    • Incubation: 17 days
    • Prodromata: a few hours
    • Efflorescence: vesicles
    • Desquamation: small crusts
    • Complication and sequelae: …..
  • Scarlet Fever
    • Incubation: 4 days
    • Prodromata: 2 days
    • Efflorescence: erythema
    • Desquamation: lamellar
    • Complication and sequelae: kidney, ear heart
  • Measles
    • Incubation: 10 days
    • Prodromata: 3 days
    • Efflorescence: papules
    • Desquamation: furfuraceous
    • Complication and sequelae: eye, lung, tuberculosis
  • Rubella
    • Incubation: 21 days
    • Prodromata: a few hours
    • Efflorescence: papules
    • Desquamation: …..
    • Complication and sequelae: …..

    Learning Point
    Not long after Dr. Rotch’s description, around the turn of the last century, several viral exanthamas were given numbers and therefore some still carry these distinctions (i.e. Fifth’s disease). Below is a comparison of these exanthamas with two additional other common viral exanthamas described today for comparison.

    Common viral exanthamas:

    • 1. Measles (First disease)
      • Etiology: Measles virus (paramyxoviridae family)
      • Description: Erythematous macules and papules that first appears on the lateral and posterior neck, that progresses to involve the face, trunk and extremities (spreading distally). The rash fades in the same direction. Cough, coryza, Koplik spots and fever also occur.
      • Time course: Incubation is 8-12 days. Patients are contagious from 1-2 days before the rash until 4 days after the rash.
    • 2. Scarlet Fever (Second disease)
      • Etiology: Group A, beta-hemolytic streptococcus
      • Description: Erythematous papules that are fine giving a rough, sandpaper feel to the face, trunk and extremities. Begins often in flexural areas and linear petechiae may be seen in the fold. Fever, sore throat, and emesis may also occur.
      • Time course: Incubation 1/2-10 days depending on presentation, but pharyngitis is 1-2 days. Patients are contagious until at least 24 hours after antibiotics are begun.
    • 3. Rubella (Third disease)
      • Etiology: Rubella virus (togaviradae family)
      • Description: Erythematous macules that occur first on the face and then spread to extremities and trunk (spreading distally). The rash fades in the same direction. Fever, posterior cervical lymphadenopathy or arthritis may also occur.
      • Time Course: Post-natally acquired infection incubation is 14-23 days, patients are contagious from 7 days before the rash until 14 days after the rash. Rash generally last 3 days.
    • 4. Duke’s disease (4th disease)
      • No longer a recognized entity
    • 5. Erythema infectiosum (Fifth’s disease)
      • Etiology: Parvovirus B19
      • Description: Lacy, reticulated pink colored rash of trunk or extremities, fades in 3-5 days but can recur with sun exposure, overheating or exercise
      • Time Course: Incubation is 4-21 days, patients are contagious before the onset of the rash.
    • 6. Roseola (Exanthem Subitum, 6th disease)
      • Etiology: Human herpesvirus 6 or echovirus 16
      • Description: Erythematous pink macules on trunk and extremities. The patient has a high fever for 2-3 days, then the fever resolves and the rash begins. Rash fades in 1-2 days.
      • Time Course: Incubation is 9-10 days.
    • Hand Foot and Mouth
      • Etiology: Coxsackievirus A16, other coxsackievirus, echovirus or enterovirus
      • Description: Erythematous papules or intact vesicles on the palms, soles and also buttocks. Small ulcers on the palate, uvula, tonsils and tongue are also seen. Rash resolves in 1 week.
      • Time Course: Incubation is 3-6 days, patients can be contagious for weeks because of fecal shedding.
    • Varicella
      • Etiology: Varicella-zoster virus (herpes virus)
      • Description: Erythematous macular-papular, pruritic lesions that develop a vesicle (“dew drop on a rose petal”). The vesicles rupture and form crust. Lesions occur on the trunk, extremities and head. The lesions appear in new crops over 3-4 days
      • Time Course: Incubation is 10-21 days, patients are contagious until all lesions are crusted over.

    Questions for Further Discussion
    1. What other viral exanthamas can you list?
    2. When can patients return to group settings like school or childcare for the viral exanthamas listed above?
    3. What are the indications for consultation with infectious disease or dermatology for a viral exantham?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Rotch TC. Pediatrics. Lippincott and Company, Philadelphia, PA. 1896:517-89.

    Woodhead JC. Pediatric Clerkship Guide. Mosby. St. Louis MO, 2003:425-26.

    American Academy of Pediatrics. Measles, Rubella, Parvovirus B19, Human Herpes Virus 6 and &, Enterovirus (nonpoliovirus) Infections, Group A Streptococcal Infections, In Pickering LD, Baker CJ, Long SS, McMillan JA, eds. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2009;287, 378, 445, 491-92, 579-80, 618-19.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital