Viral Rashes

Fourth Medical, 2007

Prof. Widad Al-Nakib, FRCPath.
 Viral Skin Rashes
Rash Virus
Maculopapular Measles
rash Rubella
Parvovirus B19
HHV-6
Echoviruses 9, 16, many others
Coxsackie A9, A16, B5, many others
Epstein-Barr virus, Cytomegalovirus
Dengue, chikungunya, Ross River, other arboviruses

Vesicular Varicella-zoster
Herpes simplex 1, 2
Coxsackie A9, A16; enterovirus 71; others
Pustular Monkeypox
Cowpox
Vaccinia
Nodular Papillomaviruses
Molluscum contagiosum
Milker’s nodes
Orf
Maculopapular Rashes
 Measles: The Disease

• Acute, highly contagious viral illness

• Commonly causes fever with rash
• Near universal infection of childhood in
pre-vaccination era
• Frequent and often fatal in developing
countries
 Measles: Pathogenesis

• Respiratory transmission of virus

• Replication in nasopharynx and
regional lymph nodes
• Primary viremia 2-3 days after exposure
• Secondary viremia days 5-7 after
exposure with spread to tissues
Pathogenesis
 Measles: Clinical Features

Prodrome
• Incubation period 10-12 days
• Stepwise increase in fever to 39.5°C
or higher
• Cough, coryza, conjunctivitis
• Koplik spots
Measles: Koplik’s Spots

“…small grains of white sand

on a red background…”
 Measles: Clinical Features

Rash
• 2-4 days after prodrome, 14 days after
exposure
• Maculopapular, becomes confluent
• Centrifugal: begins on face, head then
spreads to trunk, arms, legs
• Persists 5-6 days
• Fades in order of appearance
Measles Rash
Measles Rash in Adult
Measles: Macropapular Rash
 Measles: Complications

Condition Percent reported

• Any complication 29
• Hospitalization 18
• Diarrhea 8
• Otitis media 7
• Pneumonia 6
• Encephalitis 0.1
• Death 0.2
 Measles: Laboratory Diagnosis

• Isolation of measles virus from clinical

specimen, e.g., nasopharynx, urine
• Significant rise in measles IgG by an standard
serologic assay, e.g., EIA, haemagglutination
inhibition
• Demonstrating positive measles virus-
specific IgM in acute phase serum
Rubella Virus
Rubella Virions
 Rubella

• From Latin meaning “little red”

• Described in 18th century – thought to be
variant of measles
• Published clinical description in 1850’s
(Lancet The “German” measles)
• Congenital rubella syndrome described in
1941 (teratogenesis)
• Pandemic in Europe and US in 1962-65
 Rubella Pathogenesis

• Respiratory transmission
• Highly infectious
• Replication in nasopharynx and
regional lymph nodes
• Viraemia 5-7 days after exposure
• Placenta and fetus infected during
viraemia (transplancental barrier
crossed)
 Rubella Clinical Features

• Incubation period of 12-23 days

• Lymphadenopathy in second week
• Maculopapular rash 14-17 days after
exposure
• Rash on face and neck – may be more
prominent after hot shower
Rubella Pathogenesis
Rubella Rash in Adult
Rubella Rash in Child
 Rubella Complications

• Arthraligia or arthritis
– Children rare
– Adult female up to 70%
• Thrombocyopenic purpura 1:3000
• Encephalitis rare
• Neuritis rare
• Orchitis rare
 Congenital Rubella Syndrome
• Infection may affect all organs
• May lead to fetal death or premature
delivery
• Infection early in pregnancy most
dangerous (<12 weeks gestation)
• Organ specificity generally related to
stage of gestational infection
Congenital Rubella Syndrome
• Deafness
• Cataracts
• Heart defects
• Microcephaly
• Mental retardation
• Bone alterations
• Liver and spleen damage
Congenital Rubella Cataract
Hemorrhagic Rash in Congenital
Rubella
Rash in Congenital Rubella
 Rubella
Laboratory Diagnosis

• Isolation of rubella virus from clinical

specimen
• Significant rise in rubella IgG by any
standard serologic assay
• Positive serologic tests for rubella specific
IgM antibody
• Positive serologic test for rubella specific
IgM antibody in cord or neonatal blood to
diagnose congenital rubella
Measles Mumps Rubella (MMR) Vaccine

• Contains live, attenuated virus

• 12 months is recommended and
minimum age for MMR (younger in some
countries)
• If child younger than 9 months, maternal
antibody may interfere
• Revaccinate in 6 months to 5 years
(school entry age)
 MMR Adverse Reactions

• Fever 5-15%
• Rash 5%
• Joint symptoms 25%
• Thrombocytopenia 1:30,000 inj
• Parotitis rare
• Deafness rare
• Encephalopathy 1:1 million inj
 Immunization of Women of
Childbearing Age

• Determine if pregnant or likely to

become so in next 3 months
• Exclude those who say “Yes”
• For others:
– Explain theoretical risk of infection
– Administer vaccine
Parvovirus
Parvovirus B19 Rash
Parvovirus Fifth Disease
Exanthema Subitum or Roseola
Caused by HHV-6 & 7
Roseola
Roseola
Vesicular Rashes
Herpes Viruses
Herpes Virus Type 1 & 2
HSV Latency
Sites of HSV Infections
Active Site of Latency
HSV-1 Lesion Lower Lip
HSV-1 Cold Sore
Herpetic Cold Sore Upper Lip
Herpetic Gingivitis
Gingivostomatitis
Herpetic Whitlow
Herpetic Whitlow
Eczema Herpeticum
 HSV Encephalitis
• This is usually the result of an HSV-1
infection and is the most common
sporadic viral encephalitis. HSV
encephalitis is a febrile disease and
may result in damage to one of the
temporal lobes. As a result there is
blood in the spinal fluid and the patient
experiences neurological symptoms
such as seizures. The disease can be
fatal but in the US there are fewer than
1000 cases per year.
• HSV Meningitis
This is the result of an HSV-2
Genital Herpes Penis
Genital Herpes Vulva
 Laboratory Diagnosis of
Herpes Virus Infections

• Electron microscopy on vesicular fluids

• Immunofluoresence on scrapings or
cells from lesion
• Virus isolation in cell culture
• PCR on samples from lesion, CSF, BAL
depending on condition
 Treatment of HSV Infections

Acyclovir given :

c) Intravenously
d) Orally
e) As a cream
Varicella –Zoster Virus
(VZV)
 Varicella-Zoster Virus
( Human Herpes Virus-3)

Zoster means girdle from the

characteristic rash that forms a
belt around the thorax in many
patients
• The structure of Varicella-Zoster
Virus (VZV) is very similar to
Herpes Simplex Virus (HSV)
although the genome is somewhat
smaller
Varicella–Zoster Virus
 Diseases Caused by Varicella-
Zoster Virus
This virus causes two major diseases:

• Chicken-pox (Varicella), usually

in childhood, and shingles, later in
life
• Shingles (Zoster) is a
reactivation of an earlier varicella
infection via the cranial nerve
 Varicella (Chickenpox)
• This virus is highly infectious and even if
we do not remember getting it, more than
90% of the population of the US has
antibodies against varicella proteins
• In the household of an infected patient,
90% of contacts who have hitherto
not had the disease will get it (unless
vaccinated)
• It is spread by respiratory aerosols or
direct contact with skin lesions
• As with HSV, infection is via mucosa,
this time in the respiratory tract.
Varicella (Chickenpox)
 Chickenpox Pathogenesis
• During the 10-12 day prodromal stage,
the virus in the respiratory mucosa infects
macrophages and pneumocytes. At this
stage, there are no symptoms.
• The virus spreads from the lungs to
lymphocytes and monocytes and to the
reticulo-endothelial system.
• At about 5 days, a second viremia occurs
and the virus travels to the skin, mouth,
conjunctiva, respiratory tract and,
indeed, to epithelial sites throughout the
body.
Close-up Varicella Rash
 Chickenpox
• Spreading of the disease can be from virus in the
respiratory tract (by a cough) or from contact with
ruptured papulae on the skin containing infectious virus.
• Thus the contagious period starts at about 12-14 days
after the initial infection.
• For some reason, the rash is most pronounced on the
face, scalp and trunk and less on the limbs.
• The disease is more severe in older children and adults.
• This is particularly the case in immunocompromised
patients (AIDS, transplantation etc) where the disease may
linger for several weeks and the fever may be more
pronounced.
• The spread of the virus may lead to problems in the
lungs, liver and to meningitis. In this case mortality
may be up to 20%.
 Complications
• Pneumonia can be associated with a
varicella infection (about 15% of adult
patients) and may be fatal

• Although most children recover rapidly

from the disease, there are some
complications. These include fulminant
encephalitis and cerebellar ataxia. It
is possible that some of these
complications may be Reyes
syndrome. It has been suggested that
the latter may be cause by aspirin used
in chicken pox infections
• Other rare complications of chicken
Chickenpox in the Newborn
Disseminated Chickenpox
Disseminated Chickenpox
 Zoster or Shingles
• After the infectious period, the virus
may migrate to the ganglia
associated with areas in which the
virus is actively replicated
• The virus may then be reactivated
under stress or with immune
suppression
• This usually occurs later in life
• The recurrence of varicella
replication is accompanied by
severe radicular pain in discrete
 Zoster
• A few days later chicken pox-like
lesions occur in restricted areas
(dermatome) that are innervated by
a single ganglion
• New lesions may appear in
adjacent dermatomes and even
further afield
• Reactivation can affect the eye via
the trigeminal nerve (uveitis,
keratitis, conjunctivitis,
ophthalmoplegia, iritis) and the
Rash in Zoster
Zoster on Left Side of Trunk
Recurrent Zoster on Right Side of
Face
 Atypical Zoster in an
Immunocompromised Patient
Disseminated Lesions Affecting
Multiple Dermatomes
Facial Shingles
 Laboratory Diagnosis of
Varicella-Zoster Virus
Diagnosis often is on clinical grounds.
However, the laboratory diagnosis may involve:
• Immunofluorescence on cells from the
bottom of lesions and scrapings
• PCR on vesicular fluids material from the
lesions, BAL (pneumonia) or CSF (meningitis
or encephalitis)
• Electron microscopy on fresh vesicular
fluids
• Virus isolations of material from vesicular
fluids and material
• Virus-specific IgM in the serum
 Treatment

• As with HSV, acyclovir (or other

nucleoside analogs) can be useful,
particular in preventing
dissemination in
immunosuppressed patients
• Varicella immunoglobulin can
also be used
• Normally, however, only supportive
care is used in children who quickly
recover if they mount an adequate
 Immunization

• There is a live attenuated vaccine

virus and this is used in the United
States. It leads to antibody
production and cell-mediated
immunity.
• It can be used in pre- or post-
exposure.
• Recommended to be given to
medical personnel and
immunocompromised patients at
Enteroviruses and Rashes
Enteroviruses
Hand, Foot and Mouth Disease
Hand, Foot and Mouth Disease
Hand, Foot and Mouth Disease
Hand, Foot and Mouth Disease
 Herpangina

• Coxsackie virus A can cause a

fever with painful ulcers on the
palate and tongue leading to
problems swallowing and
vomiting
• Treatment of the symptoms is all
that is required as the disease
subsides in a few days
• Despite its name, the disease has
nothing to do with herpes or the
chest pain known as angina
Pustular Rashes
Monkeypox
Monkey pox
Smallpox Virus
Smallpox Virus
Smallpox Rash
Pustular Rash in Smallpox
Smallpox
Molluscum Contagiosum on Face
Molluscum Contagiosum on Chest
Human Papillomaviruses
Papilloma Virus
Planter Warts
Warts on the Tongue
Warts Vulgaris
Warts Vulgaris
 Febrile Viral Illnesses/ Rashes

Blood, vesicular fluids, CSF / Ag, PCR, IgM

• EBV, HSV-1and 2 ( EM, Ag or PCR), VZV (EM,

Ag or PCR), HHV-6, CMV (PCR), parvovirus
B19 (IgM), measles (IgM), and rubella (IgM).
Smallpox (EM, Ag or PCR).

HSV, VZV and CMV are treatable.