eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Roseola Infantum

Author: Lisa S Lewis, MD, Consulting Staff, Division of Emergency Medicine, Children's Hospital Medical Center of Cincinnati
Contributor Information and Disclosures

Updated: Jul 14, 2009

Introduction

Background

Roseola infantum is the sixth of the traditional exanthems of childhood. The condition is an acute benign disease of childhood characterized by a history of a prodromal febrile illness lasting approximately 3 days, followed by defervescence and the appearance of a faint pink maculopapular rash.

Since identification of the etiologic agent human herpesvirus type 6 (HHV-6), infection has been documented without the characteristic fever or rash. The virus may present as an acute febrile illness associated with respiratory or gastrointestinal symptomatology. In one prospective cohort, 93% of newly acquired infections were symptomatic, with fever, fussiness, diarrhea, and rash as the most distinguishing features.1

Newly recognized clinical manifestations of HHV-6 infection include hepatitis, encephalitis, myocarditis, hemophagocytic syndrome, and an adult mononucleosislike illness. The full spectrum of clinical manifestations of HHV-6 has not been elucidated.

Pathophysiology

Respiratory secretions of asymptomatic individuals probably transmit the virus. The child is most likely to spread the infection during the febrile and viremic phase of the illness.

Cell-associated viremia has been noted, usually on the third day of illness and immediately before rash appearance. By the eighth day of illness, antibody activity peaks and results in resolution of the viremia.

Children with the cell-free virus also have been noted. This likely represents a greater magnitude of viral dissemination because these children have more severe clinical manifestations.

Frequency

United States

Approximately 12-30% of children have clinical manifestations consistent with roseola. Eighty-six percent of children have acquired HHV-6 antibodies by age 1 year. By age 4 years, almost all children are seropositive. Roseola appears to peak in spring and fall.

International

A relationship seems to exist among prevalence, geographic location, and ethnicity. The prevalence of roseola is 92% in Ecuador, 60% in Japan, 20% in Morocco, and 49-76% in Malaysia. The disease is more prevalent among younger infants in Japan than in the United States or Europe.

Mortality/Morbidity

  • Roseola is usually a self-limited illness with no sequelae.
  • The major morbidity associated with roseola is seizures (6-15%) during the febrile phase of the illness.
  • Encephalitis, fulminant hepatitis, hemophagocytic syndrome, and disseminated infection with HHV-6 are extremely rare manifestations.

Sex

No predilection for roseola infantum exists.

Age

Most cases present within the first 2 years of life, with peak occurrence in infants aged 9-21 months.

Clinical

History

  • Roseola is typically characterized by a history of high fever followed by rapid defervescence and a characteristic rash.
  • Fever (often up to 40°C)
  • Rash (fades within a few hours to 2 d)
    • Maculopapular or erythematous
    • Typically beginning on the trunk and may spread to involve the neck and extremities
    • Nonpruritic
    • Blanches on pressure
  • Seizures (6-15%)
  • Diarrhea (68%)
  • Prodromal symptoms (14%)
    • Listlessness
    • Irritability
  • Cough (50%)

Physical

  • Alert, nontoxic appearance
  • Fever (98%)
  • Rash (98%)
    • Rose pink macules or maculopapules approximately 2-5 mm in diameter are present.
    • Lesions are characteristically discrete, rarely coalesce, and fade with blanching of the skin surface.
    • Typically, roseola infantum involves the trunk or back with minimal facial or proximal extremity involvement.
    • Some lesions may be surrounded by a halo of pale skin.
    • The rash typically evolves over 12 hours with a duration of 1-2 days.2
  • Bulging anterior fontanel (26%)
  • Nagayama spots (erythematous papules on the soft palate and uvula) (65%)
  • Periorbital edema, most common in the preexanthematous stage (30%); palpebral edema also common
  • Cervical, postauricular, and postoccipital lymphadenopathy (31%)
  • Splenomegaly
  • Encephalopathy
  • Conjunctival erythema

Causes

  • HHV-6 was identified as the etiologic agent in 1988.
    • This large, double-stranded deoxyribonucleic acid (DNA) virus is a member of the Herpesviridae family.
    • Two major strains, variants A and B, of this virus exist. HHV-6A appears to be more cytolytic and potentially more virulent. Strain B is responsible for most of the exanthem subitum infections in children.
    • The incubation period is approximately 9 days (range, 5-15 d).
  • HHV-6B is not believed to be the only causative agent of exanthem subitum. Primary infection with human herpesvirus type 7 (HHV-7) has also been implicated in exanthem subitum, but it is typically asymptomatic.
  • Transmission is likely horizontal via person-to-person oral secretions. Adult family members or older siblings appear to be the infective source. The virus has been found in the saliva of healthy adults.

More on Pediatrics, Roseola Infantum

Overview: Pediatrics, Roseola Infantum
Differential Diagnoses & Workup: Pediatrics, Roseola Infantum
Treatment & Medication: Pediatrics, Roseola Infantum
Follow-up: Pediatrics, Roseola Infantum
Multimedia: Pediatrics, Roseola Infantum
References
[ CLOSE WINDOW ]

References

  1. Zerr DM, Meier AS, Selke SS, Frenkel LM, Huang ML, Wald A. A population-based study of primary human herpesvirus 6 infection. N Engl J Med. Feb 24 2005;352(8):768-76. [Medline].

  2. Stoeckle M. The spectrum of human herpesvirus 6 infection: from roseola infantum to adult disease. Annu Rev Med. 2000;51:423-430. [Medline].

  3. Boutolleau D, Duros C, Bonnafous P, Caiola D, Karras A, Castro ND, et al. Identification of human herpesvirus 6 variants A and B by primer-specific real-time PCR may help to revisit their respective role in pathology. J Clin Virol. Mar 2006;35(3):257-63. [Medline].

  4. Yoshikawa T, Asano Y. Central nervous system complications in human herpesvirus-6 infection. Brain Dev. Aug 2000;22(5):307-14. [Medline].

  5. American Academy of Pediatrics. Human herpesvirus 6 (including roseola) and 7. In: Pickering, LK, ed. Red Book: Report of the Committee on Infectious Diseases. 2003:357-359.

  6. Asano Y, Yoshikawa T, Suga S, Kobayashi I, Nakashima T, Yazaki T. Clinical features of infants with primary human herpesvirus 6 infection (exanthem subitum, roseola infantum). Pediatrics. Jan 1994;93(1):104-8. [Medline].

  7. Braun DK, Dominguez G, Pellett PE. Human herpesvirus 6. Clin Microbiol Rev. Jul 1997;10(3):521-67. [Medline].

  8. Campadelli-Fiume G, Mirandola P, Menotti L. Human herpesvirus 6: An emerging pathogen. Emerg Infect Dis. May-Jun 1999;5(3):353-66. [Medline].

  9. Cherry JD. Contemporary infectious exanthems. Clin Infect Dis. Feb 1993;16(2):199-205. [Medline].

  10. De Araujo T, Berman B, Weinstein A. Human herpesviruses 6 and 7. Dermatol Clin. Apr 2002;20(2):301-6. [Medline].

  11. Dockrell DH. Human herpesvirus 6: molecular biology and clinical features. J Med Microbiol. Jan 2003;52(Pt 1):5-18. [Medline].

  12. Drago F, Rebora A. The new herpesviruses: emerging pathogens of dermatological interest. Arch Dermatol. Jan 1999;135(1):71-5. [Medline].

  13. Frieden IJ, Resnick SD. Childhood exanthems. Old and new. Pediatr Clin North Am. Aug 1991;38(4):859-87. [Medline].

  14. Grossman KL, Rasmussen JE. Recent advances in pediatric infectious diseases and their impact on dermatology. J Am Acad Dermatol. Mar 1991;24(3):379-89. [Medline].

  15. Hukin J, Farrell K, MacWilliam LM, Colbourne M, Waida E, Tan R. Case-control study of primary human herpesvirus 6 infection in children with febrile seizures. Pediatrics. Feb 1998;101(2):E3. [Medline].

  16. Hurwitz S. Clinical Pediatric Dermatology. 2nd ed. WB Saunders Co; 1993:35.

  17. Jones CA, Isaacs D. Human herpesvirus-6 infections. Arch Dis Child. Feb 1996;74(2):98-100. [Medline].

  18. Leach CT. Human herpesvirus-6 and -7 infections in children: agents of roseola and other syndromes. Curr Opin Pediatr. Jun 2000;12(3):269-74. [Medline].

  19. Millichap JG, Millichap JJ. Role of viral infections in the etiology of febrile seizures. Pediatr Neurol. Sep 2006;35(3):165-72. [Medline].

  20. Okada K, Ueda K, Kusuhara K, Miyazaki C, Tokugawa K, Hirose M. Exanthema subitum and human herpesvirus 6 infection: clinical observations in fifty-seven cases. Pediatr Infect Dis J. Mar 1993;12(3):204-8. [Medline].

  21. Prober C. Sixth disease and the ubiquity of human herpesviruses. N Engl J Med. Feb 24 2005;352(8):753-5. [Medline].

  22. Ranger S, Patillaud S, Denis F, Himmich A, Sangare A, M'Boup S. Seroepidemiology of human herpesvirus-6 in pregnant women from different parts of the world. J Med Virol. Jul 1991;34(3):194-8. [Medline].

  23. Scott LA, Stone MS. Viral exanthems. Dermatol Online J. Aug 2003;9(3):4. [Medline].

  24. Suga S, Yoshikawa T, Asano Y, Yazaki T, Hirata S. Human herpesvirus-6 infection (exanthem subitum) without rash. Pediatrics. Jun 1989;83(6):1003-6. [Medline].

  25. Ward KN. The natural history and laboratory diagnosis of human herpesviruses-6 and -7 infections in the immunocompetent. J Clin Virol. Mar 2005;32(3):183-93. [Medline].

  26. Ward KN, Andrews NJ, Verity CM, Miller E, Ross EM. Human herpesviruses-6 and -7 each cause significant neurological morbidity in Britain and Ireland. Arch Dis Child. Jun 2005;90(6):619-23. [Medline].

  27. Yamanishi K, Okuno T, Shiraki K, Takahashi M, Kondo T, Asano Y. Identification of human herpesvirus-6 as a causal agent for exanthem subitum. Lancet. May 14 1988;1(8594):1065-7. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

roseola infantum, childhood exanthem, roseola, prodromal febrile illness, maculopapular rash, pink maculopapular rash, human herpesvirus type 6, HHV-6, hepatitis, encephalitis, hemophagocytic syndrome, mononucleosis-like illness, fulminant hepatitis, adult mononucleosislike illness, cell-associated viremia

febrile seizure, erythematous rash, bulging anterior fontanel, Nagayama spots, HHV-A, HHV6-B, palpebral edema, Herpesviridae, human herpesvirus type 7, HHV7, exanthem subitum, immunoglobulin M serology, IgM serology, HHV-6-specific immunoglobulin G, HHV-6-specific IgG

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Lisa S Lewis, MD, Consulting Staff, Division of Emergency Medicine, Children's Hospital Medical Center of Cincinnati
Lisa S Lewis, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Medical Editor

Garry Wilkes, MBBS, FACEM, Director of Emergency Medicine, Bunbury Hospital, Western Australia; Medical Director, St John Ambulance, WA Ambulance Service; Adjunct Associate Professor, Edith Cowan University; Clinical Associate Professor, Rural Clinical School, University of Western Australia, Australia.
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Grace M Young, MD, Associate Professor, Department of Pediatrics, University of Maryland Medical Center
Grace M Young, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Emergency Physicians
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD, Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston
Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.