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Roseola Infantum (Exanthema Subitum)
Abd El-Salam Dawood MD
Pediatric Cardiologist
FIBMS-Ped FIBMS-PedCard
Essentials of diagnosis & typical features:
High fever in a child aged 6–36 months.
Minimal toxicity.
Rose-pink maculopapular rash appears when
fever subsides.
General Considerations
Roseola infantum is a benign illness caused by
human herpesviruses 6 (HHV-6) or 7 (HHV-7). HHV-6
is a major cause of acute febrile illness in young
children. Its significance is its ability to mimic more
serious causes of high fever and its role in inciting
febrile seizures.
Clinical Findings:
The most prominent historical feature is the abrupt
onset of fever, often reaching 40.6 °C, which lasts up
to 8 days (mean, 4 days) in an otherwise mildly ill
child. The fever then ceases abruptly, and a
characteristic rash may appear. Roseola occurs
predominantly in children aged 6 months to 3 years,
with 90% of cases occurring before the second year.
It is the most common recognized cause of
exanthematous fever in this age group and is
responsible for 20% of emergency room visits by
children aged 6–12 months.
Symptoms and signs:
Mild lethargy and irritability may be present, but
generally there is a dissociation between systemic
symptoms and the febrile course. The pharynx,
tonsils, and tympanic membranes may be injected.
Conjunctivitis and pharyngeal exudate are notably
absent. Diarrhea and vomiting occur in one third of
patients. Adenopathy of the head and neck often
occurs. The anterior fontanelle is bulging in one
quarter of HHV-6-infected infants. If rash appears
(10–20% incidence), it begins on the trunk and
spreads to the face, neck, and extremities. Rose-pink
macules or maculopapules, 2–3 mm in diameter, are
nonpruritic, tend to coalesce, and disappear in 1–2
days without pigmentation or desquamation. Rash
may occur without fever.
Laboratory findings:
Leukopenia and lymphocytopenia are present early.
Laboratory evidence of hepatitis occurs in some
patients, especially adults.
Differential Diagnosis:
The initial high fever may require exclusion of serious
bacterial infection. The relative well-being of most
children and the typical course and rash soon clarify
the diagnosis. The erythrocyte sedimentation rate is
normal. If the child has a febrile seizure, it is important
to exclude bacterial meningitis. The CSF is normal in
children with roseola. In children who receive
antibiotics or other medication at the beginning of the
fever, the rash may be attributed incorrectly to drug
allergy.
Complications & Sequelae:
Febrile seizures occur in 10% of patients. There is
evidence that HHV-6 can directly infect the central
nervous system, causing meningoencephalitis or
aseptic meningitis. Multiorgan disease (pneumonia,
hepatitis, bone marrow suppression, encephalitis)
may occur in immunocompromised patients.
Treatment & Prognosis:
Fever is managed readily with acetaminophen and
sponge baths. Fever control should be a major
consideration in children with a history of febrile
seizures. Roseola infantum is otherwise entirely
benign.