April Week 1: Roseola


Pediatrics – Clinical Features of Infants With Primary Human Herpesvirus 6 Infection (Exanthem Subitum, Roseola Infantum) – 1994


A mother brings her ten month old baby girl to clinic for a sick visit with CC “fever.” There is a phone note from the night before documenting mom’s concern about three days of fever with a temperature to 102 at 10 pm last night. You quickly glance at the child’s chart from today and notice she now has a normal temperature of 37 (98.6 Farenheit). She is up to date on her vaccines.

After you walk into the room mom starts saying the following about her baby: “I barely slept last night. I have never seen such a high fever! And she was hot for three days! She didn’t have a fever when the nurse took her temperature here…but she was miserable last night. And now she has this rash. It just popped up this morning out of nowhere so I decided to bring her in.”

You patiently listen to mom and find out the following: the rash doesn’t seem to be itchy or painful, the child has not received any Tylenol this morning, and the infant attends daycare. On ROS, she has been irritable but seems to be happier this morning. Mom denies any eye changes and denies coughing, rhinorrhea, diarrhea, and/or vomiting. Exam is as follows: 
GEN: interactive, babbling; she cries when you approach her but eventually calms
HEENT: b/l erythematous TM; no rhinorrhea; no mouth ulcers; 
RESP: good air entry over lung fields; no crackles or wheezing
CV: RRR, no murmur; cap refill 1 sec
AB: pt crying during abdominal exam; no HSM appreciated 
DERM: blanching macular rash on the neck and trunk

Mom asks you “What is this? Is this measles? There are some kids in the daycare she goes to that aren’t vaccinated. I have no idea what shows up in that daycare.”

• What is your differential diagnosis? What about the history and presentation seems to fit or not fit with these diagnoses? 
• What are some alternative names for this illness? 
• What viruses can cause this?
• What age of children typically develops this illness?
• How is this illness spread? 
• What is the typical clinical course of this illness?

You reassure mom that this usually goes away on its own. Mom asks, “But can’t the fever harm her?” You let her know that fevers due to this illness can be associated with seizures (as can all fevers in children of a certain age), but usually there are no complications.

Mom says “So there is nothing I can give her to help this go away? What can I do to prevent this from happening again?”

• What advice would you give the mom at this point? 
Later that night mom decides to take her child to the ED given she is concerned about the fever and the rash. A CBC is drawn.
• What are potential lab findings associated with this illness? 
In the ED mom asks them to test for this specific virus that you mentioned in clinic. 
• As the ED doctor would you test for it?

You find out about the ED visit two weeks later when mom brings in the infant for another visit. Mom says “Well. In the ED they did some blood. It was fine from what they told me. And the rash went away the next day. It just showed up and then went away. She seemed back to normal the following day.” 

Case/Questions written by Dr. Lisa Odaibo, PGY2