Gianotti-Crosti Syndrome 

Updated: Oct 09, 2020
Author: Sören A Craig-Müller, MD; Chief Editor: Dirk M Elston, MD 

Overview

Background

Gianotti-Crosti syndrome (GCS) is a distinct infectious exanthem with associated lymphadenopathy and acute anicteric hepatitis.[1, 2, 3] Gianotti and Crosti initially described GCS as associated with a hepatitis B virus exanthem, which they termed papular acrodermatitis of childhood. A similar constellation of characteristics was later found to be associated with several infectious agents and immunizations that were called papulovesicular acrolocated syndromes. Subsequent retrospective studies have shown that these 2 entities are indistinguishable from one another, and they are now consolidated under the unifying title of GCS.[4]

Also see Dermatologic Manifestations of Gianotti-Crosti Syndrome.

Pathophysiology

The most likely explanation for the exanthem is a local type IV hypersensitivity reaction to the offending viral or bacterial antigen within the dermis. This is based on the immunohistochemical characterization of the cutaneous inflammatory infiltrate. Findings on direct immunofluorescence examination of the skin are always negative. Electron microscopy has never revealed virus particles that suggested a reactive process other than an autoimmune phenomenon or direct infection of the skin. Inciting factors include various viral and bacterial infections, as well as recent immunizations. The rarity of Gianotti-Crosti syndrome (GCS) in adults suggests lifelong immunity to a common viral triggering agent. GCS is more common among children with atopic dermatitis, suggesting an immune mechanism. Increased human beta-defensin-4 (hBD-4) activity in the epidermis has been reported, indicating viral antigenemia rather than a type IV hypersensitivity reaction, as a possible cause of GCS in some viral cases.[5] However, more information is needed in order to define the precise mechanism involved. No genetic or familial predisposition is apparent.[6]  An association with oral polio vaccination has been reported.[7]

Etiology of Gianotti-Crosti Syndrome

Associated viral infections are as follows:

  • Hepatitis A, B, and C

  • Rotavirus

  • Epstein-Barr virus[7, 8]

  • Rubella virus

  • Cytomegalovirus

  • Coxsackieviruses A16, B4, and B5

  • Adenovirus

  • Enterovirus

  • Respiratory syncytial virus[9]

  • Parainfluenza virus type 1 and type 2[10]

  • Parvovirus B19

  • Paravaccinia (milker's nodules)

  • Human herpesvirus 6

  • Echovirus

  • Molluscum contagiosum virus

  • Human immunodeficiency virus (HIV)

Associated bacterial infections are as follows:

  • Group A b-hemolytic streptococci

  • Mycobacterium avium-intracellulare

  • Mycoplasma pneumoniae

  • Bartonella henselae

  • Borrelia burgdorferi

  • Meningococcemia

Associated immunizations are as follows:

  • Polio[7]

  • Diphtheria[11]

  • Influenza

  • Pertussis

  • Measles[11]

  • Smallpox

  • Hepatitis A

  • Hepatitis B

  • H1N1[12]

Epidemiology

Frequency

United States

Because of the benign self-limited nature of Gianotti-Crosti syndrome (GCS), most cases are not reported, and the overall incidence is unknown. Frequency probably parallels the incidence of a precipitating infection in a specific geographic region.

International

The underlying infection correlates with the endemic pathogens of a specific geographic region.

For example, in Japan and Mediterranean countries, GCS is more commonly associated with hepatitis B virus infection. With the advent of more universal hepatitis B immunization, Epstein-Barr virus is now the most common etiologic factor worldwide.[13, 14]

Race

No racial predilection has been noted; however, the underlying infection correlates with the endemic pathogens of a specific geographic region.

Sex

In the pediatric population, GCS affects males and females with equal frequency. However, affected adults have been almost exclusively female, with only 3 documented cases affecting men.[15] Thus, hormonal influences may play a role in GCS.[10]

Age

GCS primarily occurs in children aged 3 months to 15 years, with a peak in children aged 1-6 years. More than 90% of patients are younger than 4 years, with a mean age of diagnosis of 15 months to 2 years.[15]

Prognosis

Prognosis is excellent. Lesions clear within 4-12 weeks. No long-term complications are associated with Gianotti-Crosti syndrome (GCS). The mere presence of a rash does elicit some degree of social morbidity, depending on the age of the affected child. Although typically nonpruritic, some reports document pruritus in the later stages of the rash. The only significant morbidity involves the underlying infectious process, particularly the hepatitis B virus.

 

Presentation

History

The rash of Gianotti-Crosti syndrome (GCS) usually has sudden onset and may be associated with an acute infectious illness or immunization. Epstein-Barr virus (EBV) is the most common inciting cause of GCS. The rash is usually present for 2-4 weeks but can last as long as 4 months.[7] Although often asymptomatic, it may be mildly pruritic. Recurrent episodes have been rarely reported.[16]

Physical Examination

Children with Gianotti-Crosti syndrome (GCS) generally appear healthy; however, multiple papules may erupt on the face, buttocks, and extensor surface of the extremities; papules are symmetrically distributed, discrete, and flesh-toned–to–erythematous-to-brown and flat-topped. New lesions can continue to appear for 8-11 weeks.[6] See the images below.

Multiple erythematous flat-topped papules on the c Multiple erythematous flat-topped papules on the cheeks of an 18-month-old boy with Gianotti-Crosti syndrome.
Arm of a 3-year-old boy with Gianotti-Crosti syndr Arm of a 3-year-old boy with Gianotti-Crosti syndrome demonstrating well-defined erythematous lichenoid papules on the arm and forearm.
Thigh of the 3-year-old boy with Gianotti-Crosti s Thigh of the 3-year-old boy with Gianotti-Crosti syndrome.

The trunk is strikingly spared, although a transient eruption can occur. The mucous membrane is not involved.[5]  Individual papules are monomorphous and range in size from 1-5 mm. They may be hemorrhagic or edematous to the point of forming vesicles. They may coalesce into larger plaques. The face may be the only area of involvement. One report that highlighted this clinical presentation showed that all children with an exclusively facial eruption had Epstein-Barr virus.[17]

Hepatosplenomegaly and axillary or inguinal adenopathy are inconsistent findings.

 

DDx

Diagnostic Considerations

Guidelines for the diagnosis help to differentiate it from other disorders with similar cutaneous manifestations.[18]

Differential Diagnoses

 

Workup

Laboratory Studies

In general, no laboratory studies are needed in patients with Gianotti-Crosti syndrome (GCS). Jaundice or hepatomegaly should prompt a search for the hepatitis B virus and elevated levels of liver enzymes. However, elevated levels of liver enzymes are most likely related to Epstein-Barr virus infection.

Procedures

A skin biopsy may be performed to rule out other diseases in the differential diagnosis.

Histologic Findings

Skin biopsy findings are nonspecific and are more helpful in ruling out other diseases. The epidermis shows focal spongiosis, parakeratosis, mild acanthosis, and psoriasiform epidermal hyperplasia.[5]  The upper dermis has a moderately intense perivascular infiltrate of lymphocytes and histiocytes with occasional scattered eosinophils.[19] Extravasated erythrocytes can be found in the papillary dermis.[15]

 

Treatment

Medical Care

Gianotti-Crosti syndrome (GCS) is a benign self-limited condition that requires no treatment. Topical steroids are generally not effective, although anecdotal responses have been reported. Systemic treatment with antihistamines has been moderately helpful in relieving pruritus.

Also see Dermatologic Manifestations of Gianotti-Crosti Syndrome.

Consultations

Consultation with a dermatologist or a pediatric dermatologist should be sought in confusing cases.

Consultation with a pediatric gastroenterologist should be sought for the rare cases associated with the hepatitis B virus.

Activity

Activity is limited only by symptoms. The infectious period ends when the exanthem appears; therefore, the patient may participate in daycare or school at this time.

Long-Term Monitoring

No specific follow-up is necessary for uncomplicated cases of Gianotti-Crosti syndrome (GCS); however, transaminase elevations, if present, should be monitored until normalization.

GCS associated with hepatitis B infection has an increased incidence of a carrier state compared with hepatitis B infection alone. In this instance, some suggest monitoring the surface antigen as an indicator of potential infectivity.

 

Medication

Medication Summary

No medical therapy is necessary. Topical corticosteroids and oral antihistamines might provide some symptomatic relief of pruritus.

Corticosteroids, topical cream

Class Summary

These agents may provide relief when pruritus is present.

Triamcinolone topical (Aristocort)

The antipruritic effect of this cream is fairly marginal but may be somewhat effective. It treats inflammatory dermatoses that are responsive to steroids. Triamcinolone topical decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability.

Antihistamines

Class Summary

These agents may provide some relief when pruritus is present. They are used to treat minor allergic reactions and anaphylaxis and may be used to pretreat patients with prior documentation of minor allergic reactions. These agents may control itching by blocking effects of endogenously released histamine.

Hydroxyzine (Atarax, Vistaril)

Hydroxyzine offers a mild degree of relief from pruritus. It antagonizes H1 receptors in the periphery. Hydroxyzine may suppress histamine activity in the subcortical region of the CNS.

 

Questions & Answers

Overview

What is Gianotti-Crosti syndrome (GCS)?

What causes the exanthem associated with Gianotti-Crosti syndrome (GCS)?

Which viral infections are associated with Gianotti-Crosti syndrome (GCS)?

Which bacterial infections are associated with Gianotti-Crosti syndrome (GCS)?

Which immunizations are associated with Gianotti-Crosti syndrome (GCS)?

How common is Gianotti-Crosti syndrome (GCS) in the US?

What is the international prevalence of Gianotti-Crosti syndrome (GCS)?

Does Gianotti-Crosti syndrome (GCS) have a racial predilection?

Is Gianotti-Crosti syndrome (GCS) more common in males or females?

What age is most frequently affected by Gianotti-Crosti syndrome (GCS)?

What is the prognosis of Gianotti-Crosti syndrome (GCS)?

Presentation

How is the rash of Gianotti-Crosti syndrome (GCS) characterized?

How does Gianotti-Crosti syndrome (GCS) present in children?

DDX

How is Gianotti-Crosti syndrome (GCS) differentiated from other disorders with similar cutaneous manifestations?

What are the differential diagnoses for Gianotti-Crosti Syndrome?

Workup

Which lab studies are indicated in the workup of Gianotti-Crosti syndrome (GCS)?

Which procedures are indicated in the workup of Gianotti-Crosti syndrome (GCS)?

What are the histologic findings in Gianotti-Crosti syndrome (GCS)?

Treatment

How is Gianotti-Crosti syndrome (GCS) treated?

When is a dermatology consultation indicated in the treatment of Gianotti-Crosti syndrome (GCS)?

When is a gastroenterology consultation indicated in the treatment of Gianotti-Crosti syndrome (GCS)?

Are activity restrictions indicated in the treatment of Gianotti-Crosti syndrome (GCS)?

What follow-up is indicated in the treatment of Gianotti-Crosti syndrome (GCS)?

Medications

What medical therapy is indicated in the treatment of Gianotti-Crosti syndrome (GCS)?

Which medications in the drug class Antihistamines are used in the treatment of Gianotti-Crosti Syndrome?

Which medications in the drug class Corticosteroids, topical cream are used in the treatment of Gianotti-Crosti Syndrome?