Emergency Medicine Forum

A three y/o presents with a bright red rash.  She was well until last week when mom noted she had a fever.  Tylenol would reduce the fever (which went as high as 101F), and when the fever went down, she was acting more normal.  When the fever was high, she just wanted to lie down and rest….very atypical for this active toddler!  She had a decreased appetite, but no vomiting.  She preferred to only drink water or juice (did not want to eat solid food). No diarrhea, no cough, no runny nose, no pulling at ears.  No one around her has been sick, and she is not in day care. Mom called the doctor’s office when the fever started, and the nurse thought it was probably a virus and told mom to treat with her with Tylenol.

She had seemed to recover and was doing well, until today when she woke up with a bright red rash on both cheeks. It scared mom, so she brought her baby in to be checked.

PMH: Full term baby, no hospitalizations.  Went home with mom after delivery.   Shots up to date.
SH: No daycare, no smokers in the home.
FH: Neg, no other siblings at home. 
VS: BP 95/60, HR=105, RR=25, Temp=98 F, Sat 96%
Playful toddler appearing non-toxic, interactive with mom as you enter the room.
PE: Essentially unremarkable except for bright red rash to cheeks. No other abnormalities are appreciated.  Rash localized to cheeks only, does blanch, and is not itchy.

1.  What is the diagnosis?   Is it contagious?  What causes it?

Sudden bright red rash to the cheeks after a febrile illness in a non-toxic child screams 5th disease or erythema infectiousum. It is contagious in the acute phase (febrile phase), but once the rash appears, is no longer contagious. It is caused by the human parvovirus B-19. It can be itchy! See the following link:
“http://www.emedicine.com/derm/topic136.htm“.

2.  What are the other diseases in this numerical sequence?

It’s interesting to note the historical nature of the numbering system.  Erythema Infectiousum was the 5th pediatric illness with rash and fever identified.  The numbering system is no longer used (except for 5th disease).

1st disease; Measles = Fever x 3 days and Cough, Coryza and Conjunctivitis (three C’s).  Will see Kopliks spots in mouth.  See the following link for pictures and a quick review:
“http://en.wikipedia.org/wiki/Measles” Thanks to immunizations, we rarely see this. 

2nd disease:  Scarlet Fever. It is caused by Group A strep. Very classic rash (scarlitiniform) is seen, with perioral sparing.  See the following link for pictures and quick review: “http://en.wikipedia.org/wiki/Scarlet_fever“.  Treatment for strep is required.  Make sure you warn parents that skin may peel as this heals (especially around the fingers).

3rd disease:  Rubella or ‘German Measles’.   This is nicknamed German Measles because the disease was first described by a German physician (in the 1800’s!!).  Even back then it was identified that pregnant women infected in the first 20 weeks of pregnancy might deliver babies with congenital rubella syndrome (heart, eye, and hearing deformities).  See the following link for more information on the congenital infection: “http://en.wikipedia.org/wiki/Congenital_rubella_syndrome“.

For a link to pictures and more information on rubella, see:  “http://en.wikipedia.org/wiki/Rubella“.

4th disease:  Dukes disease –which turned out to be fever/rash illness from several different viruses.  It was never identified as a specific organism related illness.  See the following link for more information: “http://en.wikipedia.org/wiki/Duke’s_disease”

5th disease:  Erythema infectiousum. Discussed above.  More information and pictures available at: “http://en.wikipedia.org/wiki/Fifth_disease”

6th disease:  Roseola. Other nicknames include Exanthem Subitum (which means sudden rash), baby measles, or three day fever.   This rash occurs after infection with herpes virus #6.  It presents after a high fever, usually in kids under 2, and when the fever resolves, the rash evolves.  The rash goes away quickly (usually in one day).  For more information see the following link: “http://en.wikipedia.org/wiki/Roseola“ 

3. Is it serious?  Any other concerns to tell the mom?

No it is not serious, and usually resolves without treatment.  You will need to tell mom a few things:

1.  The rash may develop all over, and this is expected so don’t be alarmed.
2.  Exposure to sunlight may make the rash worse.
3.  Your child is not contagious now.
4.  Some children (more common in adults) may get joint swelling/pain (arthritis).  This is also self limiting.