Patient Presentation
A 4-year-old male came to clinic with a new rash and a low grade fever that had begun the night before. The mother said that the child had a recent sore throat but had been doing well until the last night when she noticed some papules on his upper legs. In the morning the rash had spread to his thighs and knees, buttocks and upper arms including the elbows. He had none on his face or trunk. The spots were becoming more extensive and were now red whereas the night before they were more flesh-colored or slightly pink. She denied new soaps, lotions, detergents or other similar products. He had not and was not taking any medication. There were several children in his daycare with colds. The past medical history was non-contributory.
The pertinent physical exam showed a well-appearing male with normal vital signs including being afebrile and growth parameters in the 5-10%. He had a mildly erythematous throat, and some shotty cervical and inguinal adenopathy. His skin exam showed multiple pink to red papules that were clustered around the knees and elbows but also were scattered on his upper thighs, upper arms and buttocks. He had none on his face or trunk. There were no excoriations and the papules did not seem to have a central indentation. The physician wasn’t sure what the diagnosis was, so he got a rapid strep test and then found one of his partners. She believed that the diagnosis was Gianotti-Crosti. “Gianotti-Crosti has elements of many things so I always tuck it into the back of my brain when the rash looks different. The keys for me are nothing on the trunk, its usually not pruritic but it can be sometimes, and that the patient looks well. It looks like one of those rashes that you’re pretty sure is benign, but it still bothers you. It’s a viral exantham so you can just watch it.” The patient was discharged with instructions to monitor the patient and in followup the patient had resolution of the rash.
Discussion
Infectious exanthams are usually considered when rashes are bilateral, symmetric and relatively widespread. They usually involve the trunk too and have associated systemic symptoms. Gianotti-Crosti syndrome (GCS) or acropapular dermatitis of childhood is often misdiagnosed because it doesn’t follow these rules. A discussion of common viral exanthams can be reviewed here and a differential diagnosis of rashes by pattern and distributions can be reviewed here.
Dr. Ferdinando Gianotti came from a poor family, underwent several personal tragedies, but entered medicine and created the first department of pediatric dermatology in Italy (possibly in Europe). He became interested in a child with papular eruption that he could not classify and after seeing several other cases over the next few months he published his first case series in 1955. Dr. Agostino Crosti was the head of the Department of Dermatology and together they published another article in 1956.
Learning Point
Gianotti-Crosti Syndrome (GCS) usually occurs in children 6 months – 12 years of age. Clusters of cases occur because of various viral and bacterial etiologies.
It is an acute papular eruption that usually begins on the buttocks and thighs, then the outer arms and later the face. The trunk is notably spared (a key sign). The rash is also asymmetric. The papules are 5-10 mm in size and may occur singly or in clusters and be quite extensive. The papules can be flesh-colored, light to deep red or purpulish in color also. The papules can blister. Generally they are non-pruritic and resolve over several weeks (2-8) and there can be some scaling during this time.
The rash can mimic other causes such as molluscum contagiosum (especially in single or few lesions that are flesh-colored), a drug rash or even purpura.
There have been numerous etiologies linked with GCS especially Hepatitis B in Europe and Epstein-Barr virus in the US. Other viruses include Adenovirus, Coxsackie, Cytomegalovirus, Echovirus, Hepatitis A and C, Human Herpes Virus 6, HIV, Influenza A, Influenza H1N1, Mumps, Parvovirus B19, Respiratory Syncytial Virus and Rotavirus. Post vaccination eruption has also been documented with Hepatitis B, Influenza, Japanese B Encephalitis, MMR and Polio vaccines.
No specific treatment is necessary. Antihistamines can be used for pruritis. If there is jaundice or hepatomegaly, testing for Hepatitis B can be considered, but increased liver function tests are usually more common with Epstein-Barr virus.
Questions for Further Discussion
1. GCS is considered an atypical viral exantham. What other viral exanthams are considered atypical and why?
2. What are indications for consultation with a dermatologist?
Related Cases
- Disease: Gianotti-Crosti Syndrome | Skin Diseases | Rashes
- Symptom/Presentation: Fever and Fever of Unknown Origin | Erythematous Maculopapular Lesions | Sore Throat
- Specialty: Dermatology | General Pediatrics | Medical History
- Age: Preschooler
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.
Information prescriptions for patients can be found at MedlinePlus for these topics: Skin Conditions and Rashes.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
May J, Pollack R. Giannoti-Crosti syndrome associated with type A influenza. Pediatr Dermatol. 2011 Nov-Dec;28(6):733-5.
Kroeskop A, Lewis AB, Barril FA, Baribault KE. Gianotti-Crosti syndrome after H1N1-influenza vaccine. Pediatr Dermatol. 2011 Sep-Oct;28(5):595-6.
Biesbroeck L, Sidbury R. Viral exanthems: an update. Dermatol Ther. 2013 Nov-Dec;26(6):433-8.
Gianotti F, Pesapane F, Gianotti R. Ferdinando Gianotti and the papular acrodermatitis of childhood: a scientist against all the odds. JAMA Dermatol. 2014 May 1;150(5):485.
DermNet NZ. Available from the Internet at http://dermnetnz.org/viral/gianotti-crosti.html (rev. 12/29/2013, cited 6/24/14).
ACGME Competencies Highlighted by Case
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.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
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.
19. The health professional works effectively with others as a member or leader of a health care team or other professional group.
26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 