MICROBIOLOGY AND PARASITOLOGY (SCI-111)

CHAPTER 23 VIRAL EXANTHEMS

Course Title: MICROBIOLOGY and PARASITOLOGY

Course Number: SCI 111
Name of Reporter: ELLEN JOY D. CASTAÑO
EDRALYN HILASQUE
Course Facilitator: DR. LOUIE S. DENOSTA

Learning Outcomes

At the end of this module the student will be able to:

A. recognize the common viral exanthems based on clinical manifestations;
B. compare and contrast the viral exanthems based on etiology, mode of transmission,
signs and symptoms, and prevention;
C. describe the characteristics of the causative organisms of each viral exanthem;
D. discuss the appropriate laboratory diagnosis and treatment of each infection; and
E. propose measures for the prevention and control of the common exanthems.

Introduction

A number of viruses and bacteria produce infections that have skin manifestations.
These skin manifestations may be a part of the disease and are referred to as exanthems. The
most common causes are viruses.
Skin lesions may take several forms. These may take the form of an alteration in
skin color that cannot be palpated (macule). Some are palpable solid lesions smaller than
0.5-1.0 cm called papules. Nodules are palpable lesions that are larger than a papule. In
some infections, the lesions may take the form of vesicles, which are raised, fluid-filled
lesions less than 0.5 cm in diameter. Larger forms of vesicles are called bullae. Pustules are
similar to vesicles but contain purulent material instead.

Indicative Content

A. INFECTIONS ASSOCIATED WITH MALUCOPAPULAR EXANTHEMS (RUBELLA)

B. INFECTIONS ASSOCIATED WITH VESICULAR EXANTHEMS

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INFECTIONS ASSOCIATED WITH MALUCOPAPULAR EXANTHEMS (

RUBEOLA)

Measles is a common and highly contagious childhood exanthem associated with

serious complications. The infection is seen worldwide. It is common among children
and youn somplications. The infe decreased dramatically since a vaccine has been
developed and used worldwide. The infection is limited to humans and there is no
animal reservoir or host.

Etiologic agent

The etiologic agent for measles is the Rubeola virus or the measles virus that belongs
to the family of Paramyxoviruses. There is only one stable serotype. The virus is a
single stranded RNA virus with envelope. On the envelope are two antigens-
hemagglutinin (H antigen) and fusion protein (F protein). Hemagglutinin is the viral
attachment protein and the target of neutralizing antibodies. The fusion of the viral
protein with the host membrane is mediated by the fusion protein resulting in the
formation of multinucleated giant cells known as syncytia formation.

Mode of transmission

Measles is transmitted through inhalation of respiratory droplets. The infection is

contagious even before the onset of symptoms but most contagious during the
prodromal period.

CLINICAL FINDINGS
During the initial stage of measles, the patient develops high grade fever with the 3
C's of f measles-cough, coryza (common cold or runny nose), and conjunctivitis with
photophobia. This stage is highly infectious. The pathognomonic enanthem, Koplik's
spots, develops after two days of prodrome. It is described as appearing like "grains of
salt over the inner cheek opposite the second molar that lasts for only 24 to 48 hours.
The Koplik's spots may also appear in other mucous membranes like the conjunctivae
and vagina. This is followed by the appearance of maculopapular rashes that undergo
branny desquamation. Fever persists as the temperature continues to increase as the
rashes appear, and the child is sickest at this point. The fever subsides once all the
rashes have appeared throughout the body.

COMPLICATIONS
Pneumonia is the most common and serious complication of measles, associated with
very high mortality of 60%, especially in immunocompromised individuals. There
can also be superimposed bacterial pneumonia on top of measles pneumonia. Otitis
media is the second most common complication. Post-infectious encephalitis is a rare
complication occurring in less than 1% of cases but associated with about 15%
mortality.

Subacute sclerosing panencephalitis (SSPE) is a very late and serious neurologic

sequela of measles. It occurs approximately 7 years after the initial measles infection
and common in children who had measles earlier than 2 years old. This occurs when

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wild-type measles virus persist in the brain and behave like a slow virus. This is
manifested by changes in behavior and personality, spasticity, myoclonic jerks, and
blindness.

LABORATORY DIAGNOSES

Diagnosis of measles is based primarily on the clinical manifestations.

TREATMENT AND PREVENTION

Treatment is symptomatic and supportive. Prevention is done through administration
of a live attenuated vaccine given in combination with Mumps and Rubella (MMR) at
2 years of age. Immune globulin may be given to exposed susceptible individuals like
those who are immunocompromised.

RUBELLA (GERMAN MEASLES)

Rubella is one of the common viral exanthems in childhood together with measles,
chickenpox, Fifth disease, and roseola. It is a benign infection in children, however,
infections in adults can be more severe especially when acquired during the first two
weeks of pregnancy, when organ development occurs.

ETIOLOGIC AGENT
The Rubella virus is a single-stranded RNA virus under the genus Rubivirus and is a
member of the Togavirus family. There is only hosts. only one stable serotype and
humans are the

MODE OF TRANSMISSION
The virus is mainly spread through inhaling respiratory droplets. However,
transplacental transmission can also occur when a seronegative mother becomes
infected during pregnancy

CLINICAL FINDINGS
The rubella virus causes German measles, also known as the "three-day measles" It
manifests with fever, followed by the appearance of maculopapular rashes that lasts
for three days. The rashes are pruritic and unlike measles due to Rubeola virus, do not
undergo desquamation. It is associated with conjunctivitis without photophobia, post-
auricular or occipital lymphadenopathy, and arthralgia. Pearly white dot-like lesions,
known as Forschemer spots can be present in the palate. Comparison between rubella
and rubeola is listed in Table 23.1. The fever usually disappears as the rashes appear.
Natural infection leads to lifetime immunity.

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Congenital rubella is the most serious outcome. The most common manifestations are
microcephaly, mental retardation, intrauterine growth retardation, cataracts and other
ocular defects, deafness, failure to thrive, and congenital heart disease. This is
associated with high mortality for the infected baby during pregnancy and during the
first year after birth.

LABORATORY DIAGNOSIS

Diagnosis of Rubella is based primarily on the clinical manifestations. Diagnosis is

confirmed by presence of anti-Rubella-specific IgM.

TREATMENT AND PREVENTION

Treatment is mainly symptomatic and supportive. Prevention involves administration
of vaccine (MMR vaccine) at 2 years of age as part of the immunization program for

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infants. The primary goal of vaccination is to reduce the number of seronegative

women hence, lowering the incidence of congenital infection. The vaccine is
contraindicated in pregnant women.
Roseola Infantum (Exanthem Subitum or Sixth Disease)

ETIOLOGIC AGENT
Sixth Disease is caused by Human Herpes Virus 6 (HHV6) that belongs to the family
of Herpesviridae. It primarily infects lymphocytes particularly CD4+ T cells. The
virus is latent in T cells and monocytes.

MODE OF TRANSMISSION
The mode of transmission is still unknown but respiratory transmission and oral
secretion are most likely because the virus replicates in the salivary gglands

CLINICAL FINDINGS
Roseola is manifested by sudden onset f high-grade fever followed by a generalized
rash that lasts for two days. However, it may also cause a spectrum of illness
including: fever withuth rash, rash without fever, encephalitis, hepatitis, and more
serious infections. Roseola is the most common cause of febrile seizures in children.

LABORATORY DIAGNOSIS
Diagnosis of roseola is based on clinical manifestations. Treatment and Prevention
Treatment for roseola is symptomatic. No vaccine is available for HHV6. Erythema
Infectiosum (Fifth Disease)

ETIOLOGIC AGENT
Fifth Disease is caused by Parvovirus B-19, a single-stranded DNA virus that belongs
to family Parvoviridae, the smallest among the DNA viruses. They are dependent on
rapidly replicating host cells or other viruses. The target of this virus is the erythroid
progenitor cells, causing lysis of these cells. The virus is associated with viremia and
can cross the placenta and infect the fetus.

MODE OF TRANSMISSION
Fifth disease is transmitted by respiratory droplets and oral secretions. It can also be
transmitted by blood transfusions and vertical transmission from an infected mother.

CLINICAL FINDINGS
Fifth disease is common in early school age children and less common in adults. It is
biphasic infection consisting of the lytic stage and the immunologic stage. The initial
of lytic stage is manifested by mild signs and symptoms of upper respiratory tract
infections Although the manifestations are mild during this stage, it is also the most
contagious stage of the infection. This is followed by the immunologic stage
characterized by a generalized lace-like rash most prominent over the face ("slapped
cheek" appearance) and arthralgia B19 infection in adults leads to polyarthritis
involving the wrists, knees, and ankles. The most serious complication is aplastic
crisis in patients with chronic hemolytic anemia. In pregnant women, it is associated
with high risk of fetal death due to congestive heart failure (hydrops fetalis).

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LABORATORY DIAGNOSIS
Diagnosis of the fifth disease is based on the clinical presentation of the patient.
Definitive diagnosis can also be accomplished through ELISA and polymerase chain
reaction (PCR).

TREATMENT AND MEDICATION

There is currently no specific antiviral treatment or vaccine available for fifth disease.

INFECTIONS ASSOCIATED WITH VESICULAR EXANTHEMS

VARICELLA (CHICKENPOX)
Varicella is a benign, self-limiting, and highly communicable infection in children but
associated with severe infections in adults.

ETIOLOGIC AGENT
The causative agent is the Varicella-Zoster Virus (VZV), a double-stranded,
enveloped DNA virus that belongs to the Herpesvirus family of viruses. It infects
mucoepithelial cells and establishes latency in nerve ganglia. Because of the latency,
the virus persists in the infected host for an indefinite period and produces recurrent
infections (zoster or shingles) especially in elderly and immunocompromised persons.

MODE OF TRANSMISSION
The disease is most commonly transmitted by inhalation of respiratory droplets but
may also be transmitted by direct contact with the lesions.

CLINICAL FINDINGS
Varicella is characterized by fever and vesicular eruptions on the skin and mucous
membranes. The rashes are initially maculopapular which later becomes vesicular
with associated intense pruritus. The vesicles rupture and ulcerate and later leads to
scab formation (crusts). The lesions appear in crops of different stages and all the
stages of the lesions (macules, papules, vesicles, ulcers, crust) appear simultaneously.
The vesicles are described as "teardrop on a pink base" or "dew drop on a rose petal."
The lesions are superficial and do not leave permanent scars. Complications include
pneumonia (in adults) and encephalitis (in children).

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LABORATORY DIAGNOSIS
Diagnosis is based on clinical manifestations and a Tzanck smear of skin scrapings or
swab from the vesicle to demonstrate the Cowdry type A inclusions and
multinucleated giant cells.

TREATMENT AND PREVENTION

The treatment is mainly symptomatic. The drug acyclovir has been shown to be
effective in reducing the course of the disease but it does not prevent latency and
recurrent infections. Prevention is by administration of Varicella- Zoster Virus
vaccine, a live attenuated vaccine.

VARIOLA (SMALLPOX)
Variola or smallpox is a contagious infection responsible for very high fatality rate
worldwide before the 18th century. For centuries, smallpox was controlled through
the process known as variolation, which involved inoculation of high-risk individuals
with live virulent virus. The process was relatively dangerous but greatly helped
reduce the rate of outbreaks and epidemics. It was Edward Jenner who developed a
live vaccine from cowpox in the 17th century. The last reported case was reported in
Somalia in 1977. In 1980, smallpox was declared totally eradicated through
vaccination.

The success of vaccination is attributed to several factors, including: (1) there i one,
stable serotype, (2) there is no animal reservoir and humans are the only hosts, (3)
thes is no subclinical state, and (4) it is easily clinically recognizable. Smallpox is
listed amos the Category A bioterrorism-biowarfare agents by the Center for Disease
Control Prevention of the United States.

ETIOLOGIC AGENT
The etiologic agent is the Variola virus, a member of the human Poxviruses.
Poxviruses the largest among the DNA viruses. It shares antigenic determinants with
animal porvinνο and because of this, the Cowpox virus has been successfully used in
the development of vaccines for smallpox.

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MODE OF TRANSMISSION
The primary mode of transmission is through inhalation. It can also be transmittel by
direct contact with the lesions, dried virus, or contaminated materials like clothing.

CLINICAL FINDINGS
There are two variants of smallpox-smallpox minor (1% mortality) and smallpox
major (up to 40% mortality). The disease initially presents with fever and malaise,
followed by the appearance of rashes that are macular that then become papular, later
becoming vesicular, and eventually pustular. Unlike chickenpox, the lesions of
smallpox appear one stage at a time. In addition, the lesions are deep-seated, leaving
permanent scars. In severe cases, the rashes may become hemorrhagic. The
comparison of varicella and variola is shown in Table 23.2

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LABORATORY DIAGNOSIS
The disease is easy to recognize based on the symptoms. Virus isolation can be done
by growing of the virus in chorioallantoic membrane of embryonated eggs where the
characteristic pocks develop. Antibody assays can confirm the diagnosis.

TREATMENT AND PREVENTION

Methisazone is effective as prophylaxis but not for therapeutic purposes. The vaccine
is a live, attenuated vaccine. Smallpox has been totally eradicated since 1980 because
of the success of vaccination

CHAPTER SUMMARY

The five most common childhood exanthems are measles, chickenpox, German
measles, roseola, and fifth disease. All five exanthems are caused by viruses,
worldwide in distribution, and highly contagious. Measles, Rubella, and chickenpox
are preventable by vaccination.
Rubeola or measles is characterized by fever, a prodrome consisting of the 3 C's
(coryza, cough, conjunctivitis with photophobia), Kopliks spots, and maculopapular
rash with desquamation. Rubella is a common cause of congenital viral infection. It is
manifested by fever, lymphadenopathy, joint pains, and maculopapular rash. Roseola
is the most common cause of febrile seizures in children.

Chickenpox is a benign self-limiting infection in children but severe in adults and

characterized by vesicular lesions. Herpes zoster or shingles present with severe pain
over the path of sensory nerve distribution followed by appearance of vesicular
lesions. The thoracic dermatome is most commonly affected. Fifth disease
generalized erythematous rash but it is most prominent over the face and is described
as "slapped cheek" appearance. Smallpox is a highly contagious viral infection. It was
totally eradicated in 1980 by vaccination.

Drills/exercise
s
I. Fill in the blank

1. A _______ is a widespread rash.

2. Measles is caused by a _______.
3. The measles rash is typically _______ in color.
4. Chickenpox is also known as _______.
5. A characteristic symptom of chickenpox is _______.
6. The characteristic "slapped cheek" appearance is seen in _______ disease.
7. Roseola infantum is often preceded by a high _______.
8. Rubella is also known as _______ measles.
9. Serological tests can detect _______ to diagnose viral exanthems.
10. Complications of measles can include _______ and _______.
11. The Koplik's spots are pathognomonic for _______.

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II. TRUE OR FALSE

Here are five true or false statements based on the provided search results, along with
explanations:

1. Viral exanthems are usually self-limited.

2. Prednisone is usually the first choice of treatment for suspected viral rashes.
3. Measles is contagious even before the onset of symptoms. period, meaning
individuals can spread the virus before they even develop symptoms.
4. Pityriasis rosea is a common reported manifestation of COVID-19 in children.
5.Hard nodules are a morphology that can be seen in viral exanthems.

ANSWER KEY:

1. True.
2. False.
3.True.
4. False.
5. False.

1. exanthem
2. virus
3. red or reddish
4. varicella
5. itchy blisters or vesicles
6. Fifth
7. fever
8. German
9. Antibodies
10.pneumonia, encephalitis - accept other reasonable complications
11.measles

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Evaluation

1.It is common and highly contagious childhood exanthem associated with serious
complications.

A. Measles
B. Variola (smallpox)
C. Congenital rubella
D. Varicella

2. It is benign, self- limiting, and highly communicable application In children but

associated in several indault.

A. Measles
B. Variola (smallpox)
C. Congenital rubella
D. Varicella

3. It is contagious infection responsible for very high fatality rate worldwide before
the 18th century.

A. Measles
B. Variola (smallpox)
C. Congenital rubella
D. Varicella

4. It is the most serious outcomes. The most common manifestation, mental

retardation, intrauterine, growth retardation, cataracts and other ocular defects,
deafness, failure to thrive, and congenital disease.

A. Measles
B. Variola (smallpox)
C. Congenital rubella
D. Varicella

5. It is one of the common exanthems in childhood together with measles,

chickenpox, fifth disease and roseola.

A. Measles
B. Rubella
C. Congenital rubella
D. Varicella

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Answer key

1.A measles
2.D varicella
3.B variola (small pox)
4.C congenital rubella
5.B rubella

Reference

Bartolome, F. A., MD, FPASMApiz1.

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