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Other Viral Infections

Definition

Measles (Rubeola): Infection with paramyxovirus, an RNA-virus related to canine distemper. Was previously common in childhood, but the numbers of cases dropped off significantly in the mid sixties after a nationwide immunization program.

Roseola (Exanthem subitum): Viral exanthem that is thought to be due to the human herpesvirus 6, one of the most common childhood diseases.

Erythema infectiosum (Fifth disease): Infectious exanthem caused by a parvovirus.

Rubella (German measles): A mild viral infection with mild illness and an exanthem of pink discrete and confluent macules.

Molluscum contagiosum: A poxvirus group DNA virus infection of the epithelium. MCV I and MCV II identified as the cause.

Warts (Verrucae): Epithelial cell infection from inoculation with human papillomavirus (HPV). Most common cutaneous infection. Occurs on any skin or mucosal surface. Classified by causative HPV strain and appearance and location. Classified as common warts (verrucae vulgaris), flat warts (verrucae plana), plantar warts (verrucae plantaris), and genital warts (condyloma acuminata). Common warts and genital warts are the most common varieties encountered.

History

Symptoms

Measles (Rubeola): Viral upper respiratory infection (high fever, respiratory congestion, sore throat, cough, and conjunctivitis) precedes a red papular rash, that spreads to cover entire body, by 2 to 4 days.

Roseola (Exanthem subitum): Three to 5 days of high fever, followed by body rash. Mild irritability or malaise possible with mild respiratory symptoms.

Erythema infectiosum (Fifth disease): Rare prodrome of low-grade fever, malaise, and headache. Rash on extremities and bright red cheeks. Five to 15 percent of children may have sore throat, coryza, and abdominal and joint pain. Arthritis is a common adult complaint.

Rubella (German measles): Prodrome consists of lymph node enlargement of the postauricular, posterior, cervical, and other nodes. The patient may complain of sore throat, malaise, fever, headache, cough, and eye pain which precedes a rash of the face which spreads downward.

Molluscum contagiosum: Painless, pearly papules on any area of skin. Sometimes reddened, scratched, and spreading.

Warts (Verrucae): Common warts: Hard rough papules on hands, elbows, finger, and knees. Painless except some palmar lesions with pressure are tender. Small and large with thickening.

Flat warts: Asymptomatic, slightly raised, flat-topped, flesh or pinkish brown colored, small lesions on face, hands, and occasionally on knee areas or lower legs.

Plantar warts: Small firm depressions or callused finn plaques or discrete, pressed papules on the sole of the foot. May be very tender with pressure, especially with bilateral squeeze.

Genital warts: Asymptomatic genital/perianal papules or cauliflower masses.

Age

Measles (Rubeola): Childhood, 30 percent under 5-years-old, but the majority at present occur in older children and college students.

Roseola (Exanthem subitum): Six months to 3 years. Over half seen less than 1-years-old.

Erythema infectiosum (Fifth disease): Usually children, but occasionally an adult.

Rubella (German measles): Was previously common in children, now most common in those over 15 years who have not been immunized.

Molluscum contagiosum: Children any age, adults.

Warts (Verrucae): Common warts: School children, decreasing incidence in young adults especially after 25-year-old. Periungual warts occur at any age. Flat warts: Young children, males in beard skin area, or lower legs in young women.

Plantar warts: Five to 25, but seen in any age.

Genital warts: Young adults, occasionally young children from parental inoculation or sexual abuse.

Onset

Measles (Rubeola): Acute, with prodrome after 1 week incubation. Next to appear are Koplik spots on buccal mucosa during the prodrome. An exanthem rash appears at 4 to 7 days, with some overlap to an average 7 to 10 days.

Roseola (Exanthem subitum): Acute with 3 to 5 days offever. May illicit exposure to infected individual about 1 week prior.

Erythema infectiosum (Fifth disease): Acute, with red cheek patches.

Rubella (German measles): Acute, with prodrome illness. Symptoms and rash develop quickly, beginning on the face. Fifteen-to 21-day incubation.

Molluscum contagiosum: Acute eruption of a few lesions.

Warts (Verrucae): Common warts: Sudden appearance of small papule(s). Flat warts: Sudden, with several lesions.

Plantar warts: Small papule acutely with growth and callus formation, in a progressive steady fashion.

Genital warts: Sudden appearance of one or more lesions.

Duration

Measles (Rubeola): Seven to 10 days.

Roseola (Exanthem subitum): High fever for 3 to 5 days, rash within 2 days which lasts for 1 to 3 days.

Erythema infectiosum (Fifth disease): Extremity and possible body rash within 4 days of cheek eruption. Lasts days to weeks and may reappear after apparent resolution. Triggered by temperature, sunlight, emotional, or exertional and other factors.

Rubella (German measles): The rash fades in about 3 to 4 days.

Molluscum contagiosum: Up to 2 years without treatment. Single lesions come and go over several months.

Warts (Verrucae): Common warts: Weeks, months, years. Flat warts: Weeks, month. Plantar warts: Months to years. Genital warts: Months, with recurrences possible for years.

Intensity

Measles (Rubeola): From several morbilliform areas about the head and centrally to involvement of most skin areas.

Roseola (Exanthem subitum): Fever 103° to 104° possible that resolves and rash appears on neck and trunk.

Erythema infectiosum (Fifth disease): Bright red cheeks and papules on extremities. Evolve into reticulate lacy patterns and may spread to the trunk. May wax and wane for days to weeks.

Rubella (German measles): No prominent rash to confluent morbilliform or scarlatiniformlike rash. Involves face, trunk, and extremities.

Molluscum contagiosum: Children: 5 to 100 papules.

Adults: 5 to 30 papules.

Immunocompromised: Hundreds or thousands.

Warts (Verrucae): Common warts: Single lesion to discrete, scattered lesions that may number several to many.

Flat warts: Always multiple discrete lesions, close set groups to several groups, wide set. Plantar warts: One, few, or numerous.

Genital warts: Single, isolated lesion to several confluent masses to near total coverage of genitals or anus.

Aggravating Factors

Measles (Rubeola): Malnourishment.

Roseola (Exanthem subitum): Pharyngitis and adenopathy may also be present with upper respiratory infection like symptoms.

Erythema infectiosum (Fifth disease): None.

Rubella (German measles): None.

Molluscum contagiosum: Depressed cell mediated immunity.

Warts (Verrucae): Common warts: Trauma, pressure, and skin breakage injury sites. Autoinoculation.

Flat warts: Skin trauma, leg shaving, face shaving, autoinoculation.

Plantar warts: Pressure trauma.

Genital warts: Highly contagious.

Alleviating Factors

Measles (Rubeola): None or symptomatic treatment. Roseola (Exanthem subitum): Only acetaminophen for fevers.

Erythema infectiosum (Fifth disease): Temperature extremes, especially heat.

Rubella (German measles): Symptomatic prodrome treatment.

Molluscum contagiosum: Enhanced cellular immune mechanism treatments.

Warts (Verrucae): Common warts: Occasionally resolve spontaneously with time. Hypnosis or "charming" away possibly effective in susceptible patients.

Flat warts: Tincture of time may resolve many.

Plantar warts: Tincture of time. Genital warts: Sometimes spontaneous resolution or no recurrence.

Associated Factors

Measles (Rubeola): Pneumonia is present in half of patients and otitis media is common. Less common are encephalitis, myocarditis, and croup like condition. Conjunctivitis can be significant, especially light sensitive patients.

Roseola (Exanthem subitum): Enanthem of pink discrete papules on uvula and soft palate possible. Rare complications include febrile seizures, encephalitis, and thrombocytopenic purpura.

Erythema infectiosum (Fifth disease): Sunlight exposure, heat, emotions, exercise.

Rubella (German measles): Severe infection of fetus transplacentally causes developmental abnormalities in the first trimester. Most common in the spring. Arthritis occasionally occurs, mostly in adults and females.

Molluscum contagiosum: Sexual activity with infected individual. Autoinoculation common. Immunological factors. Incubation 4 to 8 weeks on average, but is variable.

Warts (Verrucae): Common warts: Kuebner's phenomena positive.Immunosuppression or compromise.

Flat warts: Kuebner's phenomena. Immunocompromise.

Plantar warts:Autoinoculation.

Genital warts: Immunocompromise. One percent or more are common warts.

Physical Examination

General

Measles (Rubeola): Pharyngitis, conjunctivitis, splenomegaly, adenopathy, fever, occasional otitis media, and pneumonia are present in 50 percent of cases.

Roseola (Exanthem subitum): Fever, with mild respiratory infection signs, pharyngitis, mild adenopathy, or no findings.

Erythema infectiosum (Fifth disease): Most patients are otherwise well. Adults may have arthritis.

Rubella (German measles): Mild fever, arthritis, and arthralgia most common in women. Patients may have findings of an upper respiratory infection.

Molluscum contagiosum/Warts: Patients generally appear normal.

Skin

Measles (Rubeola): Red, discrete papules that become confluent and form the typical morbillifom rash beginning on the head and/or neck and spreading over the body. Koplik spots on buccal mucosa; tiny white or gray dots on inflarnmed base.

Roseola (Exanthem subitum): After fever, a pink maculopapular 2 to 5 mm lesion rash develops. It is diffuse on the neck and trunk. Fades within 3 days.

Erythema infectiosum (Fifth disease): Bilateral, fiery red cheek patches or plaques. Within 4 days, a papular rash becomes evident on the arms and possibly the legs. Evolves into a reticulate, lacy pattern and may spread to the trunk. Occasional exanthem of rose colored pinpoint macules (Forscheimer spots) and/or petechiae of the soft palate.

Rubella (German measles): Pink, discrete macules of the face that spread rapidly to involve the trunk and extremities. Lesions can be absent in up to 40 percent of infected patients or appear morbilliform or scarlatiniform.

Molluscum contagiosum: Pearly, flesh colored, white, or reddened papules, sometimes translucent with a white bead molluscum body visible in papule. Asymptomatic and smooth surfaced. Round, oval, or hemispherical from a few to several millimeters in diameter. A central umbilication is pathognomonic. Occasionally will exhibit significant inflammation. May become larger in size or furuncle-like. In children, 5 to 100 papules occur on the extremities, face, and upper trunk. In healthy adults 5 to 30 papules may be on inner thighs, pubis, and genitalia. Sometimes occur on the mucosal epithelieum in children and adults.

Warts (Verrucae): Common warts: Hyperkeratotic papules ranging from 1 mm to a few centimeters in diameter. Occur on the extremities (especially hands and knees). Lesions appear as round and skin colored with pathognomonic, central black dots (thrombosed dermal capillaries). Common on nail borders or under nail edges. Occasionally exhibit filiform I mm bases, are several millimeters long, isolated, or arising from hyperkeratotic papule on face, neck, or genitalia. Flat warts: Flesh colored or pinkish brown flat topped papules, a few millimeters in diameter. Smooth surface compared to vegetative surface of other warts. Round, oval, polygonal, and linear in shape due to induction by physical trauma. Found on face, hand, dorsums, and shins. Plantar warts: Occur at points of pressure (e.g., under toes, under metatarsal heads, or heel, or where footwear presses chronically). Appear as flesh-colored punctate depressions, shiny papules, or crowded confluent plaques (mosaic warts), or deep thick plaques (myrmecla warts). Most develop a thick hyperkeratotic covering early. Tenderness, sometimes marked, with pressure. Genital warts: Skin colored, pink or red pin head papules or cauliflower like excrescences. Soft and filiform or sessile. Occur as single or clustered lesions on frenulum, corona, punis glans, prepuce, meatus, shaft, scrotum, and perianally in males; labia, clitoris, perineum, vagina, and perianal areas in females.

Pathophysiology

Measles (Rubeola): The paramyxovirus enters the respiratory system and incubates for approximately 1 week then manifests itself as an acute infection in the respiratory prodrome. Koplik exanthem and skin exanthem pathologically demonstrate syncytial giant cells, dyskeratosis, spongiosis, and parakeratosis.

Roseola (Exanthem subitum): Simple viral pathology.

Erythema infectiosum (Fifth disease): Respiratory tract is invaded by single-stranded DNA parvovirus after contact with infected person.

Rubella (German measles): Papillomorbiliform body eruption involving the trunk initially, caused by infection with rubella virus. White blood cell (lymphocytes) infiltrates (inflammation) in the skin layers.

Molluscum contagiosum: DNA-poxvirus invades the epidermal cells, interacts and transforms into papular enclosed cores or molluscum bodies, which are globules of viral protein and transformed epithelial cells.

Warts (Verrucae): Mucosa or cutaneous epithelium becomes infected with HPV, a double stranded DNA papovavirus. Acquired by direct contact with infected human or possibly from sloughed, infected epidermal cells. As name implies, humans are the only reservoir of HPV. Inoculation is through open skin and spreads, in part, by autoinoculation. Infection is somewhat dependent on cell mediated immunity and susceptibility of host. Incubation or latency periods are unknown but, with condyloma, studies suggest a 3-month average. Approximately 60 HPV types have been identified.

Diagnostic Studies

Laboratory

Measles (Rubeola): Clinical presentation is generally sufficient for diagnosis. Koplik spots are pathognomonic.

Acute and convalescent serum: Hemagglutination antibodies rise fourfold.

Complete blood count: Leukopenia and lymphopenia common.

Roseola (Exanthem subitum): None specific.

Erythema infectiosum (Fifth disease): The red cheek pattern with lacy arm leg rash is an easy diagnosis. IgM or IgG measurement to parvovirus: Is available at selected laboratories, but rarely required.

Rubella (German measles): Hemagglutination-inhibition: Four fold rise in IgG to rubella is diagnostic. Acute infection evident if rubella specific IgM is positive.

Molluscum contagiosum: Not applicable. Warts (Verrucae): Usually easy to diagnose by clinical presentation.

Southern blot hybridization analysis: Definitive test for DNA virus and HPV typing. Rarely required.

Radiology

Measles: Chest X-ray: May reveal pneumonia.

Other

Molluscum contagiosum: Microscopy: Excision of a molluscum body pearl is performed and contents viewed. It will show viral protein and epithelial cells.

Shave biopsy: Diagnostic and curative.

Warts (Verrucae): Microscopy: Pare the hyperkeratotic surface and View.

Biopsy: Identifies verrucae, but not HPV.

Differential Diagnosis

Traumatic

Roseola (Exanthem subitum): Heat rash: No fever prodrome, and wider areas of distribution.

Erythema infectiosum (Fifth disease): Child abuse (slapping): Will not have extremity-body lacy rash.

Warts (Verrucae): Not applicable, except it leads to Kuebner's warts.

Measles (Rubeola)/Rubella (German measles)/Molluscum contagiosum: Not applicable.

Infectious

Measles (Rubeola): Other exanthem's: Are without Koplik spots and morbilliform rash.

Roseola (Exanthem subitum): Other exanthem's: Not as typical following 3 to 5 days of fevers and limited rash areas.

Roseola: Milder than most others and patient appears well.

Erythema infectiosum (Fifth disease): Not applicable.

Rubella (German measles): Other exanthem's: Rashes vary enough as does pattern of spread. IgG-and IgM-specific antibodies confirm suspicions.

Molluscum contagiosum: Obliquities: No umbilications or viral molluscum core. More often tender.

Warts (Verrucae): Condyloma lata: Tend to be fiat and not papillomatous but vegetative appearing. Also are dark field and RPR positive as it is secondary syphilis. Patients with condyloma acuminata may need RPR.

Metabolic: Not applicable.

Neoplastic

Molluscum contagiosum: Basal cell carcinoma: Hard on palpation with telangiectasias and rolled borders, but not typical unbilication. Keratoacanthoma: Has a firm keratin central plug, and are larger than most molluscum. No molluscum bodies.

Warts (Verrucae): Bowenoid papulosa: Red or hyperpigmented small papules, sometimes tiny with fiat tops. Isolated to many on genitalia. Biopsies as squamous cell carcinoma in situ though behaves as a benign lesion. Caused by HPV 16. Probably a cause of cervical neoplasia in infected and sexual contacts.

Measles (Rubeola)/Roseola (Exanthem subitum)/Erythema infectiosum (Fifth disease)/Rubella (German measles): Not applicable.

Vascular: Not applicable.

Congenital

Warts (Verrucae): Epidermodysplasia verruciformis: Is a rare, autosomal recessive condition, in which individuals are predisposed to many HPV-type infections. These begin in childhood with patches of lesions on the trunk and arms. Thirty percent will develop squamous cell carcinoma, usually in sun-induced areas, with tumors arising in third decade of life.

Measles (Rubeola)/Roseola (Exanthem subitum)/Erythema infectiosum (Fifth disease)/Rubella (German measles)/Molluscum contagiosum: Not applicable.

Acquired

Roseola (Exanthem subitum): Reactive allergic rash: Generally some Pruritis and more prominent rash.

Erythema infectiosum (Fifth disease): Lupus: Rare in children and will not have extremity rash. Will not spontaneously resolve in days to weeks.

Warts (Verrucae): Calluses: No black dot capillaries after Parring. No underlying discrete lesion. Skin lines not usually disrupted throughout thickness.

Measles (Rubeolal/Rubella (German measles)/Molluscum contogiosum: Not applicable.

Treatment

Measles (Rubeola): None specific. Treat secondary infection as outlined in bacterial infection. Protect exposed patients 1-year-old and under with immune serum globulin. Susceptible individuals should receive live measles vaccine.

Roseola (Exanthem subitum): None, symptomatic for fever Reassurance.

Erythema infectiosum (Fifth disease): None.

Rubella (German measles): None, but vaccination provides effective protection. Upper respiratory infection like prodrome is treated symptomatically.

Molluscum contagiosum: Cure is dependent on removal or mechanical destruction, or chemical drying out of the infected epithelial cells in the lesion and molluscum body.

Adults: May be treated with currettment removal, cryotherapy (with liquid nitrogen), trichloracetic acid (50 to 80 percent applied), cantharidin, and tape or application of salicylic acid preparations (e.g., Duo film or Occlusal). Children: Cryosurgical liquid nitrogen (painful), salicylic acid preparations (e.g., Duo film, Transversal or Transplantar patches, or Occlusal), cantharidin (with caution as major blistering can occur), excision, electrocautery, or laser surgery (likely to scar and are more costly so best. avoided for this viral infection).

Warts (Verrucae): No reliable cure. Treatment is generally aimed at destruction, but with modalities designed to minimize morbidity and scarring as many recur or new ones erupt. Try not to cause nail deformity in periungual wart treatment and avoid plantar scars that can be painful to walk on for a lifetime. This is especially true in that many warts will resolve in up to 2 years.

Liquid nitrogen cryosurgery: Is the most widely used for single or few lesions, but is painful.

Topical salicylic acid: In acrylic vehicle (Occlusal) or in plasters (Medi-plast) or gel patch (Transversal-Trans plantar) may be effective alone or in combination with lactic acid (as in Duo film) and are painless.

Formalin: May help eradicate plantar and flat warts, can be used on facial lesions and is mostly painless.

Bleomycin and alpha interferon: Intralesionally are effective. Painful necrosis may develop with bleomycin.

Tretinoin: Applied daily, can help flat warts.

Systemic retinoids: May help immunosuppressed patients with infection and those with epidermodysplasia verruciformus.

Immunotherapy: After sensitization to dinitrochlorobenzene, can be successful in creating an allergic reaction in the wart area and may lead it to resolve. Some concern of mutagenicity however.

Podophylline: 20 to 25 percent weekly or 50 percent or greater trichloroacetic acid. Effective in genital warts.

Electrosurgery, excision, laser destruction: Used as a last resort for warts and for large widespread condyloma.

Cantharidin: (Presently unavailable) is quite effective applied at the office every I to 2 weeks. May cause a major, painful blister reaction. Hypnosis and charming: Has shown positive effect on warts.

Blenderm tape: Applied to each lesion overnight to soften. Abraded the next day with a pad like substance or Buff Puf.

Pediatric Considerations

Never use aspirin as an antipyrexic.

Erythema infectiosum (Fifth disease): Once the patient has broken out in a rash, they are probably no longer contagious, and can attend school.

Viral exanthem's: In the pediatric age group, numerous viral infections exist that are associated with dermatologic manifestations. A variety of different patterns are seen in these viral exanthem's including a generalized maculopapular eruption that mimics measles (morbilliform), petechial eruptions, vesiculobullous eruptions, scarlet fever like eruptions (scarlatiniform), and oral eruptions. These include measles, rubella, erythema infectiosum, roseolainfantum, varicella, and many others.

Molluscum contagiosum: A common cutaneous viral infection acquired by direct contact with an infected person or contaminated fomites. Removal of the papule with a dermal curet is curative but painful and frightening to infants and children. Careful application of cantharidin to the central umbilication is less traumatic and usually successful.Recurrences are common.

Verrucae (Warts): Children and adolescents have the highest incidence of all types of warts. Condylomata acuminata can be transmitted with or without sexual contact. However, in prepubertal children, be suspicious of sexual abuse.

Obstetrical Considerations

Measles (Rubeola): Isolate infected patients from pregnant or other hospitalized patients.

Erythema infectiosum (Fifth disease): Can cause hydrops fetal is if pregnant woman is infected.

Rubella (German Measles): Congenital rubella infection is a devastating disease that occurs in 20 to 80 percent of infants born to mothers infected in the first trimester of pregnancy. The infection causes congenital malformations of the ophthalmologic, cardiac, and neurological systems as well as tissue inflammation and damage, intrauterine growth retardation, and increased possibility of spontaneous abortion. Often, therapeutic abortions are recommended in the early stages of pregnancy if there has been maternal rubella infection in the first trimester. It is unclear if passive immunization of the woman at the time of infection helps to modify the congenital sequelae. Rubella vaccination with live attenuated virus is contraindicated in pregnant women.

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