Viral

Exanthems
Measles
 Measles
EPIDEMIOLOGY
•worldwide distribution
•remains a leading public health burden
• risk of mortality is highest in developing
countries, with most deaths due to complications
of the disease
•Before the development of a vaccine, measles
epidemics occurred every 2 to 5 years during in
children 5 to 9 years old.
 Measles
ETIOLOGY
•Measles virus
a member of the
Paramyxoviridae family
is a heat-labile virus with an
RNA core and
outer lipoprotein envelope
 Measles
PATHOGENESIS
•spread by direct or airborne contact with
infectious droplets
•incubation period is typically 8 to 12 days
•patients contagious
1 to 2 days before onset of symptoms to 4
days after appearance of the rash
 Measles
PATHOGENESIS
•both humoral and cell-mediated immunity are
needed to control measles virus infection
• immunoglobulin M (IgM) antibodies are
detected initially with onset of the rash, followed
by a rise in measles-specific IgG titers
• humoral response controls viral replication
and confers antibody protection
•cell-mediated response eliminates infected cells
 Measles
PATHOGENESIS
•transient immunosuppression occurs during
measles virus infection causing
depressed delayed-type hypersensitivity
depressed T-cell counts
increased risk of bacterial infections

• This process, as well as long-term immunity

against measles, is not well understood but may
be due to a weak T helper 1 response to the virus.
 Measles
CLINICAL FINDINGS
•HISTORY
■ Prodrome, which may last up
to 4 days, characterized by:
fever [up to 40oC to 40.5oC
malaise
coryza
cough (brassy or barking)
conjunctivitis (palpebral,
extending to lid margin)
 Measles
CLINICAL FINDINGS

pathognomonic enanthem of measles

begin as small, bright red macules that have a
1- to 2-mm blue-white speck within them
 Measles
CLINICAL FINDINGS

typically seen on the buccal

mucosa near the
second molars
appears 1 to 2 days before
and lasts 2 days after the
onset of the rash
 Measles
• Individuals with pre-existing partial
immunity (e.g., patients who received
exogenous immunolgobin) may have less
severe symptoms but a prolonged
incubation perion (14 to 20 days).
Conversely, immune-suppressed patients
may have more sever disease and ca
present without the typical rash.
 Measles
CLINICAL FINDINGS

■exanthem is characterized by erythematous,

non-pruritic, macules and papules that begin
on the forehead and behind the ears
 Measles
CLINICAL FINDINGS

■rashes quickly progresses to involve the neck,

trunk, and extremities
 Measles
CLINICAL FINDINGS
•CUTANEOUS LESIONS
■ hands and feet are involved
 Measles
CLINICAL FINDINGS

■lesions may coalesce, especially on the

face and neck
 Measles
CLINICAL FINDINGS
rash usually peaks
within 3 days and
begins to
•disappear in 4 to 5
days after the order
of its appearance
• desquamation
may occur as the
rash resolves
 Measles
RELATED PHYSICAL FINDINGS
•entire illness may last up to 10 days
•some individuals may also have:
► vomiting diarrhea abdominal

pain
► splenomegaly pharyngitis

► generalized
lymphadenopathy
 Measles
RELATED PHYSICAL FINDINGS

► at higher risk for pneumonitis, encepaltis,

and other fatal complications
► viral shedding may also be more
persistent in these individuals
 Measles
RELATED PHYSICAL FINDINGS

•rare
seen in individuals who received formalin-
inactivated measles vaccine (1963 to 1967)
and were subsequently exposed to wild-type
virus
 Measles
RELATED PHYSICAL FINDINGS

•symptoms are often more severe with

► high fever
► interstitial pneumonia

► pleural effusions

► extremity edema

► hepatitis

► hyperesthesias
 Measles
CLINICAL FINDINGS

•coryza, conjunctivitis, and Koplik spots are

usually not present
•rash
► maculo-papular, hemorrhagic, vesicular,

or urticarial
► spreads centripetally, making it difficult to

distinguish from Rocky Mountain

Spotted Fever
 Measles
LABORATORY TESTS
•Laboratory abnormalities may include:
► monocytosis

► leucopenia

► thrombocytopenia

•during the prodrome stage, virus can be found in

► nasopharyngeal secretions

► blood

► urine
 Measles
LABORATORY TESTS
•The pharyngeal virus shedding ends by the
second day of the rash.
•Virus may be seen in the urine until 4 days after
rash onset.
•Viral culture has a low sensitivity for finding the
virus.
 Measles
LABORATORY TESTS
•measles virus can be detected in clinical
specimens such as nasopharyngeal
secretions, blood, and urine
► Indirect enzyme-linked immunoassay
(ELISA)
► polymerase chain reaction (PCR)
► real-time (RT)-PCR assays
 Measles
LABORATORY TESTS
•Serologic studies demonstrate measles virus
infection with a documented increase in IgM
and/or IgG anti body titer
• IgM increases with the onset of the rash
and lasts approximately 1 month
• IgG appears 2 weeks after rash onset
and peaks 4 to 6 weeks later
 Measles
LABORATORY TESTS
•Many laboratories may have access to viral
immunofluorescence test that quickly detect
measles in throat or nasopharyngeal specimens.
• In the United States, measles should be
reported to the local health department.
 Measles
COMPLICATIONS
•Age-specific rates of complications are highest
among children less than 5 years old and adults
over 20 years.
•most common complications of measles:
► otitis media

► pnueumonia

► diarrhea

► laryngotracheobronchitis
 Measles
COMPLICATIONS
•Less common complications of measles:
► hepatitis

► thrombocytopenia

► encephalitis

•Thrombocytopenia-associated purpura
may be severe
 Measles
COMPLICATIONS

• most common fatal complication of measles in

children

•most common complication overall in adults

• disease severity is worse in immune-
compromised and malnourished individuals
 Measles
CLINICAL COURSE AND PROGNOSIS
•Clinical diagnosis of measles is typically made
with onset of the characteristic rash as the
prodromal symptoms can mimic influenza-like
illness.
•Uncomplicated measles is self-limited lasting 10
to 12 days.
 Measles
TREATMENT
• Treatment for measles in the majority of cases is
supportive.
• Patients with secondary bacterial infections need
to be treated with appropriate antibiotics.
• Ribavirin may be considered, as it has been
shown to inhibit measles virus in tissue culture
and reduce the severity and duration of measles
in some cases.
 Measles
TREATMENT

►recommended for all children with measles

who live in communities where vitamin A
deficiency is known or where measles fatality
rate is 1 percent.
 Measles
TREATMENT

Measles virus infection decreases serum levels

of vitamin A and can lead to higher risk of
mortality from disease.
Malnutrition and vitamin A deficiency can
depress cell-mediated immunity in children,
increasing the risk and severity of childhood
infections.
 Measles
TREATMENT

All individuals at risk (children less than 1 year of

age, pregnant women, unimmunized,
immunocompromised, exposed to measles virus)
should receive immunoglobulin prophylaxis within 6
days of exposure.
 Measles
TREATMENT

if given within 72 hours of exposure, the

individual will not be infected with the virus
healthy individuals should receive 0.25 mL/kg of
intramuscular immunoglobulin
immunocompromised patients require
0.5 mL/kg.
 Measles
TREATMENT

Exposed patients (excluding pregnant women

and those with impaired immune system) should
also be given the measles vaccine 5 months
later to confer lasting protection
 Measles
PREVENTION

Common potential side effects of measles

vaccine include fever and transient morbilliform
rash that resolve without treatment.
• Less common adverse reactions include
thrombocytopenia and transient neurologic
reaction.
 Measles
PREVENTION

Common potential side effects of measles vaccine

include fever and transient morbilliform rash that
resolve without treatment.
 Measles
PREVENTION

Less common adverse reactions include

thrombocytopenia and transient neurologic
reaction.
 Measles
PREVENTION

Contraindications:
moderate to severe illness allergic to eggs or
neomycin
pregnant women impaired immune systems
[cancer, non-human immunodeficiency virus
(HIV) immune deficiency disease,
immunosuppressive therapy].
 Measles
PREVENTION

Patients off chemotherapy or immune

suppressive medications for 3 months can
receive the measles vaccine
 Measles
PREVENTION
Immunization
There have been many unconfirmed,
unsubstantiated but widely publicized reports
suggesting a potential link between measles and
the development of autism and possibly
inflammatory bowel disease.
Current scientific evidence does not support a
causal link between MMR vaccine and autism or
inflammatory bowel disease.
Rubella

Roberto M Manlapig, M.D., FPDS, FAAD

Our Lady of Fatima University
College of Medicine
 Rubella
EPIDEMIOLOGY
•worldwide distribution
•outbreaks occurring most frequently in late winter
and early spring months
• school-aged children, adolescents, and young
adults most often develop the disease
• epidemics occasionally occur in developing
countries, especially where vaccine are
unavailable
 Rubella
EPIDEMIOLOGY
•Since introduction of the rubella vaccine in the
United States in 1969, the incidences of rubella
and congenital rubella syndrome have drastically
declined with no widespread epidemics occurring
in the United States.
• Occasional outbreaks have largely been
attributed to failure to vaccinate susceptible
individuals.
 Rubella
ETIOLOGY
•Rubella virus
► is an enveloped RNA virus in
the Togaviridae family
 Rubella
ETIOLOGY
•Rubella virus
► spread through direct or droplet contact

from nasopharyngeal secretions

► infected individuals shed virus for 5 to 7 days

before and 14 days after onset of disease

► viremia unlikely after the rash occurs
► infection leads to lifelong immunity in most
individuals
 Rubella
ETIOLOGY
Rubella virus
•congenital rubella occurs when a nonimmunized,
susceptible, pregnant woman is exposed to the
virus
• transplacental infection of the fetus occurs
during
the viremic stage
• risk is greatest to a fetus exposed to the virus
in the first trimester
 Rubella
ETIOLOGY
Rubella virus
•Congenitally infected infants may shed the virus
through urine, blood, and nasopharyngeal
secretions for up to 12 months after birth, thus
being a potential source of viral exposure to other
susceptible individuals.
 Rubella
CLINICAL FINDINGS
History
• Primary rubella infection is typically a mild,
sub- clinical disease, particularly in adults.
• prodrome is characterized by low-grade
fever, rhinitis, cough, sore throat, and
lymphadenopathy
• symptoms that may last up to 4 days and
often resolve with appearance of rash.
 Rubella
CLINICAL FINDINGS
• up to 50 percent of children with primary
rubella infection may gave a sub-clinical infection or
present only with lmphadenopathy or rash
(no prodrome)
• older adults may have more severe and
persistent prodromal symptoms that may make
distinction from rubeola difficult in some situations
► presence of Koplik spots in the mouth favors

rubeola
 Rubella
CLINICAL FINDINGS
Froschheimer spots
• enanthem consisting of tiny red macules on
the soft palate and uvula
 Rubella
CLINICAL FINDINGS
Forschheimer spots
•seen to develop in some patients as
the prodrome resolves and the rash
begins to appear
•enanthem is not diagnostic for rubella
 Rubella
CLINICAL FINDINGS
CUTANEAOUS LESIONS
exanthem occurring 14 to 17 days after exposure,
is characterized by pruritic pink to red macules
and papules
 Rubella
CLINICAL FINDINGS
CUTANEAOUS LESIONS
pink to red macules and papules begin to erupt on
the face, quickly rogressing to involve neck, trunk,
and extremities
 Rubella
CLINICAL FINDINGS
•Lesions on the trunk may coalesce, whereas
those on the extremities often remain more
discrete.
 Rubella
CLINICAL FINDINGS
• rash usually begins to disappear in 2 to 3
days, unlike rubeola, which can be more
persistent and clears the head and neck first
•desquamation may follow resolution of the rash
 Rubella
CLINICAL FINDINGS
•RELATED PHYSICAL FINDINGS
Lymphadenopathy is usually most sever in the
posterior cervical, suboccipital, and post-auricular
lymph nodes and is noted up to 7 days before the
rash appears. Enlargement of the nodes may
persist for several weeks
 Rubella
CLINICAL FINDINGS
RELATED PHYSICAL FINDINGS
•Adults, particularly women (up to 70 percent),
may develop arthritis with rubella infection
• Both small and large joints may be
affected. Joint symptoms often first appear as
the rash fades and can last several weeks. In
some individuals, the symptoms may become
persistent or recurrent. Joint swelling may
progress to form joint effusion.
 Rubella
RELATED
PHYSICAL
FINDINGS
• may develop in adults, particularly women (up to
70 percent), with rubella infection
• both small and large joints may be affected
• joint symptoms often first appear as the rash
fades and can last several weeks
• symptoms may become persistent or recurrent
in some individuals
• joint swelling may progress to form joint effusion
 Rubella
LABORATORY TESTS
•Laboratory tests
•Serum complete blood cell count usually shows
leukopenia with relative neutropenia. Increased
numbers of atypical lymphocytes or abundant
plasma cells may be noted as well. Patients with
meningeal involvement have lymphocytes in the
cerebrospinal fluid (CSF).
 Rubella
LABORATORY TESTS
•Viral culture (nose, throat, blood, urine, CSF,
synovial fluid) is sensitive but often difficult due to
the unstable nature of the virus.
• Diagnosis is typically made using serology to
detect rubella-specific IgM antibody (up to 8
weeks after infection) or to document a fourfold
rise in antibody titer in acute and convalescent-
phase serum.
 Rubella
LABORATORY TESTS
•Hemagglutination-inhibition, complement fixation,
immunofluorescence assay, and ELISA are some
of the methods used to detect antibodies.
• As with measles, rubella cases should be
reported to local health departments.
 Rubella

Congenital Rubella Syndrome

•Women who are infected with rubella during
pregnancy may only exhibit minor clinical
symptoms.
• The effects however, of rubella infection on
the fetus can be profound, with the greatest risk
of fetal malformation in the early stages of
pregnancy.
 Rubella
Congenital Rubella Syndrome
•Up to 5 percent of fetuses exposed to rubella
within the first 4 weeks develop serious sequelae
such as:
► microcephaly with mental retardation

► congenital heart diseas (VSD, PDA)

► sensorineural deafness

► cataracts

► low birth weight

► fetal death
 Rubella

Diagnosis of congenital rubella infection

•Virus is obtained by isolating rubella virus in the
throat, urine, or CSF of the affected neonate
• Serologic testing is not as sensitive but is
easily available for confirmatory testing.
 Rubella
COMLICATIONS
•Encephalitis
► rare

► 1 in 6000 cases

► mortality reates varying from

0 percent to 50 percent
 Rubella
COMLICATIONS
•Other rare complication include:
► peripheral neuritis

► optic neuritis

► myocarditis

► pericarditis

► hepatitis

► orchitis

► hemolytic anemia
 RUBELLA
PROGNOSIS AND CLINICAL COURSE
•typically a self-limited disease
• Infants who have congenital rubella are
infectious until viral shedding form the
nasopharynx and urinary tract ends
• majority of infants (85 percent) infected in
utero excrete virus in the first month of life
• 1 percent to 3 percent continue to excrete
virus in the second year of life
 Rubella
PROGNOSIS AND CLINICAL COURSE
• Pregnant women caring for these infants
are at risk for developing rubella.
• Clinical course depends on how severely
affected the fetus is from intrauterine infection.
 Rubella
TREATMENT
•uncomplicated rubella
► supportive

•nonpregnant individual
► rubella vaccine administration within
3 days of exposure may theoretically
prevent illness, though this is yet to be
proven
 Rubella
TREATMENT
•Immune globulinis
► not routinely recommended as post-exposure

prophylaxis of rubella-susceptible pregnant

women
► limited data indicate that intramuscular

immune globulin (0.55mL/kg) may decrease

clinically apparent infection from 87 percent to
18 percent if given to an exposed, susceptible
pregnant woman.
 Rubella
TREATMENT
•However, absence of clinical sign after
administration of immune globulin does not
assure that congenital infection din not occur.
 Rubella
TREATMENT
•Neonates with congenital rubella syndrome
require supportive care as well as appropriate
attention to significant health issues.
• These infants are contagious and should be
isolated to prevent transmission to susceptible
individuals.
•Contact isolation is recommended for these
infants until they are at least 12 months old or if
repeated cultures are negative after 3 months of
age.
 Rubella
PREVENTION
Rubella vaccine
• typically administered as part of a three-
fold vaccine (MMR)

•at 12 to 15 months of age

•again at 4 to 6 years of age
•serocoversion after a single dose of MMR
vaccine occurs in 95 percent individuals
 Rubella
PREVENTION
• individuals at risk for rubella
infection should immunized
► health care workers
► military recruits
► college students
► recent immigrants
 Rubella
PREVENTION
•Potential adverse reactions to rubella vaccine
occurs in some individuals and include
► fever

► morbilliform rash
► lymphadenopathy

► artharlgia
 Rubella
PREVENTION
Precautions:
•Pregnant woman should not be immunized with
rubella to minimize risk to the fetus
• Any woman receiving the rubella vaccine
should not become pregnant for 28 days
•Infants of vaccinate breast-feeding mother may
become infected with rubella via breast milk
 Rubella
PREVENTION
• Typically they develop a mild erythematous
exanthema of macules and papules with no
serious effects.
• As rubella infection confers lifelong immunity, a
woman who is re-exposed during pregnancy has
a low risk of having her fetus contact congenital
rubella.
• Concern about possible infection can be
addressed by looking for IgM antibodies in fetal
serum (cordocentesis).
VARICELLA
 VARICELLA

■ commonly known as chickenpox

■ primary infection with the
Varicella zoster virus (VZV)
 VARICELLA

■ temperate regions
 90% of cases occur in children
younger than 10 years of age

■ tropical countries
tends to be a disease of teenagers
 VARICELLA
■ INCUBATION PERIOD
10 t o 21 days
usually 14 to 15 days
■ TRANSMISSION
 direct contact with the lesions
respiratory route, with initial
viral replication in the
nasopharynx and conjunctiva
 VARICELLA
■ initial viremia
between days 4 and 6
seeding the liver, spleen, lungs, and perhaps
other organs
■ secondary viremia
• occurs at days 11 to 20
• results to infection of the epidermis and
the appearance of the characteristic skin
lesions
 VARICELLA
■ CLINICAL MANIFESTATIONS
• patients are infectious for at least 4

days before and 5 days after the

appearance of the exanthem
• usually present but slight:
 Low-grade fever
 malaise
 headache
 VARICELLA
■ CLINICAL MANIFESTATIONS
• disease severity
age dependent
adults have more severe disease and
a greater risk of
visceral disease
 VARICELLA
■ CUTANEOUS FINDINGS
• eruption starts with faint
macules that develop rapidly
into vesicles
within 24 hours
 VARICELLA
■ CUTANEOUS FINDINGS
• successive fresh crops of vesicles

appear for a few days, mainly on the

trunk, face, and oral mucosa
 VARICELLA
■ CUTANEOUS FINDINGS
• Initially, the exanthem may be limited

to sun-exposed areas, the diaper area

of infants, or sites of inflammation
 VARICELLA
■ CUTANEOUS FINDINGS
• vesicles quickly become
pustular, umbilicated, then
crusted.
 VARICELLA
■ CUTANEOUS FINDINGS
• lesions tend not to scar
• larger lesions and those that become

secondarily infected may heal with a

characteristic round, depressed scar
 VARICELLA
■ COMPLICATIONS
• Secondary bacterial infection is the

most common complication

Staphylococcus aureurs
Streptococcal organism
-Pneumonia
-Encephalitis
-Reye's syndroma
 VARICELLA
■ DIAGNOSIS
• The diagnosis of varicella is easily

made clinically.

• Tzanck smear from a vesicle

 multinucleate giant cells
 VARICELLA
■ DIAGNOSIS
• DFA test
direct immunofluorescence test
done if needed
the most useful chemical test
rapid
will confirm both the infection and
type the virus


•
 VARICELLA
■ DIAGNOSIS
• viral culture
 rarely indicated
VZV grows poorly and slowly in
the laboratory
 VARICELLA
■ TREATMENT
• routine treatment is not recommended
complications of varicella are
infrequent in children
• therapeutic decisions are made on a
case-by-case basis
 VARICELLA
■ TREATMENT
• Acyclovir
benefits both immnnocompetent
children and adults with varicella if
started early (within 24 hours of the
appearance of the eruption)
therapy does not appear to alter the
development of adequate immunity to
reinfection

•
 VARICELLA
■ TREATMENT
• Acyclovir
dose is 20 mg/kg (maximum 800mg
per dose) four times a day for 5 days
 VARICELLA
■ TREATMENT
• Acyclovir
should be given to children with :
▪ atopic dermatitis
▪ Darier's diseas
▪ diabetes
▪ cystic fibrosis


•
 VARICELLA
■ TREATMENT
• Acyclovir
should be given to children with :
▪ conditions requiring chronic

salicylate or steroid therapy

▪ inborn errors of metabolism
▪ exacerbations of their
underlying illness with varicella
 VARICELLA
■ TREATMENT
• Acyclovir
treatment is recommended in adolescents
and adults (13 and older)
varicella is more severe
complications are more
dose IS 800 mg four or five times a day
for 5 days
 VARICELLA
■ TREATMENT
• Aspirin and other salicylates
 should not be used as
antipyretics in varicella
 use increases the risk of
Reye syndrome
 VARICELLA
■ TREATMENT
• Relief of symptoms
topical antipuritic lotions
oatmeal baths
dressing the patient in light, cool,
clothing
keeping the environment cool
 VARICELLA

• Varicela Vaccine Live attenuated viral

vaccine forvaricella
• is a currently recommended childhood
immunizationA
• single dose is recommended for children aged
1 to 12, and
• persons aged 13 and older should receive two
vaccinations 4 to 8 weeks apart.
 VARICELLA
• ■Tlre vaccine is less protective if given before
• 15 months of age. Complications are uncommon.
• occurring locally at the injection slte within 2 days
or generalized 1 to 3 weeks after immunizahon,
occur in 6% of children

•
 VARICELLA

• ■In healthy children, the vaccine is very

efficacious,
• with 97% efficacy during the first year and
84% efficacy for the next 8 years.
• Household exposures resulted in a 12%
rate of breakthrough varicella, well below the
expected 90%. 
•
 VARICELLA
• ■Many of the breakthrough cases were mild and
many of the skin lesions were not vesicular
• Prevention of severe varicella is
• virtually low, even when the vaccine IS given
within 36 h of exposure.

•
 VARICELLA
• ■Secondary complications of varicella
Including scarring are
• virtually eliminated by vaccination.
Antibodies appear to persist for at
least between 15 to 20 years.