Table II: Occupational health Management Strategy for Infectious Diseases in HCWs

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Viruses Causing Maculopapular Rash
By Dr. Mona Badr
Assistant Professor Consultant Virologist
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Viruses Causing Maculopapular Rash

• Definition of Maculopapular Rash
• A small cicumscribed, solid, discoloured spot,
  slightly elevated lesion on the skin
• Some important viruses causing maculopapular rash
  mainly in children
• Measles virus Paramyxvirus family
• Rubella virus Togavirus family
• Parvovirus B19 Parvoviridae family
• Herpes virus type-6 Herpesvirus family

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Viruses Causing Maculopapular Rash (Continued)

• Measles
• Measles is a highly contagious, serious disease
  affecting young children mainly and occasionally
  adults.
• A- Virology Aspects
• Family paramyxoviridae
• Enveloped virus
• ss-RNA, negative polarity
• Virion contain enzyme transcriptase
• Paramyxovirus are able to induce cell-cell
  fusion multinucleated giant cell (syncytia)
• Measles virus -One serotype only
• - Infect human only

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Viruses Causing Maculopapular Rash (Continued)

• B- Pathogenesis and Immunity
• Measles virus transmitted from respiratory
  secretion by direct contact OR droplet and air
  borne transmission mainly in winter and spring.
• Virus infects first epithelial cells of
  respiratory tract, then virus spreads in
  lymphatic system blood then measles viruses
  wildly disseminated to the skin and other
  internal organs.
• Cell-mediated immunity is essential for the
  control of measles infection will be fatal in
  immunocompromised.
• Long-life immunity to measles virus develop after
  recovery from rash.

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Viruses Causing Maculopapular Rash (Continued)

• C- Clinical Symptoms
• Incubation period 7-13 days
• Prodromal symptoms Fever, cough, runny nose,
  conjunctivitis, (1-2 days).
• Kopliks spot Small, white papules appear mostly
  in buccal mucosa, of 70-80 of patients for 2
  days
• Rash typical maculopapular rash first on the
  face, trunk and extremities.
• The patient become very sick and temperature
  become very high (39-40oC) when this rash appear.
  
• Recovery can be complete, but complication also
  can occur.
• Diagnosed by detection of Measles IgMAb in the
  serum.

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Viruses Causing Maculopapular Rash (Continued)

• D- Complication
• Common complication
• bronchitis, otitis media and 2nd bacterial
  pneumonia
• Rare Complication
• Encephalitis occur in 1 per 1000 of infected
  children.
• Occur 7-10 days after the onset of measles,its
  serious its fatal.
• Giant cell pneumonia (Intestinal pneumonia)
• Occur in immunocompromised children, due to
  direct invasion of the virus to lung.

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Kopliks Spot
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Measles
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Measles
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Viruses Causing Maculopapular Rash (Continued)

• D- Complication
• Very rare Complication
• Subacut-slerosing-pan-encephalitis (SSPE)
• Is very rare complication (5/million)
• Develops several month or years after recovery
  average after 7 years.
• It occur when measles virus persist in brain
  tissue and act as slow virus and replicate in
  brain cells.
• Patients develops change in personality,
  behavior, memory blindness and convulsion will
  lead to coma then death.
• SSPE is confirmed by characteristic EEG patterns
  and demonstration of measles Ab in CSF with
  increased CSF measles Ab ratio to serum measles
  Ab.
• No effective treatment .

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Viruses Causing Maculopapular Rash (Continued)

• E- Treatment and Prevention
• No specific treatment
• Prevention
• Active
• Live attenuated vaccine (MMR)
• Contain live attenuated measles, mumps and
  rubella viruses
• Given by I.M. or subcutaneously in one dose.
• Excellent immunity
• Should not be given to pregnant or
  immunocompromised patient.
• Passive
• Exposed people who are immunocompromised should
  be given passive immunization with immune serum
  globulin must be given within 6 days of exposure.

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Viruses Causing Maculopapular Rash (Continued)

• Rubella
• Rubella is a mild exanthematous moderately
  contagious disease. When the disease is acquired
  by the mother during first 4 months of pregnancy.
  The virus may infect the fetus and cause
  malformation.
• Virology Aspects
• Family Togavirus
• Enveloped, nucleocapsid virus
• Single stranded RNA, positive polarity
• Agglutinate avian erythrocytes

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Viruses Causing Maculopapular Rash (Continued)

• Epidemiology
• Humans are the only host for rubella
• Virus is spread in respiratory secretion and is
  generally acquired during childhood.
• The incidence of infection peaks in the spring
• Before the development and use of the rubella
  vaccine, cases of rubella in school children
  would be reported evey spring.

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Viruses Causing Maculopapular Rash (Continued)

• 3- Clinical Syndromes
• Rubella is a mild disease of children
• But if contracted in early pregnancy (first 4
  months) the virus can cause severe congenital
  abnormalities in the fetus (Teratogenic)
• So we have 2 different
• Clinical Syndrome

Post natal Rubella Infection
Congenital Rubella Infection
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Viruses Causing Maculopapular Rash (Continued)

• A- Post natal Rubella
• It is mild self limiting disease occur in
  childhood.
• Incubation period 14-21 days
• Prodromal symptoms as fever, cough,
  conjunctivitis and enlarged of post cervical
  lymph node.
• Macupapular rash first appear in face then trunk
  and limbs (usually mild), with complete recovery.
• Fever is low grade or absent during the rash.
  The general condition is good.
• If infection occur in adult (especially female)
  arthritis reported.
• Diagnosed by detection Rubella IgM Ab in the
  serum
• Complication
• Post infectious encephalitis
• Thrombocytopenic purpura

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Viruses Causing Maculopapular Rash (Continued)

• A- Congenital Rubella
• Congenital defect occur mainly if the mother has
  rubella in the first 16 weeks of pregnancy (first
  trimester), after that rubella does not damage
  the fetus.
• Virus can replicate in the placenta and then
  spread to fetal blood supply and so, Rubella
  virus can replicate in most tissue of the fetus,
  this can lead to improper development of the
  fetus and teratogenic effect associate with
  Congenital Rubella infections.
• In about 15 of cases infection of the fetus
  leads to spontaneous abortion.

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Congenital Rubella
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Viruses Causing Maculopapular Rash (Continued)

• The main defects are
• Eye defect cataract, glucoma, chorioretenitis
• Nerve deafness
• Cardiac abnormalities
• e.g. Fallots tetralogy
• Ventricular septal defect.
• Mental retardation
• Hepatosplenomegally
• Low birth weight
• Notes Infected infants shed the virus into
  throat and urine for 2 years and can infect
  susceptible individual.

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Viruses Causing Maculopapular Rash (Continued)
5- Laboratory Diagnosis
Post natal Rubella
Congenital Rubella
1- Clinical diagnosis 2- Serological detection
of IgM Ab 3- Detection of IgG Ab indicate
past infection OR immunization.

• 1- History of Infection of mother
• 2- Virus isolated by immuno-
• flourescent assay from
• Urine
• CSF
• Blood
• 3- Serological diagnosis by
• detection of IgM Ab from Cord blood
• 4- Detection of IgG Ab Not diagnostic

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Viruses Causing Maculopapular Rash (Continued)

• Treatment and Prevention
• No specific treatment available.
• Prevention
• Active Immunization
• Immunization of all children at age of 15 months
  with MMR-vaccine (live attenuated vaccine).
• Natural infection or vaccination give good
  immunity, but not solid, re-infection can happen.
• Booster, dose of Rubella vaccine is recommended
  for female at age of puberty (14-15 years), or
  before marriage.
• Contraindication of MMR
• Pregnancy must be avoided 1-3 months after
  vaccination
• Immunodeficiency patient
• Hypersensitivity to egg.

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Viruses Causing Maculopapular Rash (Continued)

• 3- PARVO-VIRUS B19 Erythema Infectiosum Fifth
  disease
• Parvovirus B19 replicates in erythroid cells of
  human bone marrow or erythroid cells of fetal
  liver.
• Parvovirus B19 is cytocytic for erythroid cells
  cause severe fall of Hb due to transient aplastic
  anemia especially in patient with chronic
  haemolytic disorder.
• Virology Aspects
• Family parvovirus
• The smallest DNA virus
• The only DNA virus with ssDNA
• Un-enveloped virus
• Only one serotype, infect only human.

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Viruses Causing Maculopapular Rash (Continued)

• 2- Clinical Syndromes
• Parvovirus in normal child
• The common form of the disease Fifth disease or
  Slapped Cheek, Erythema infectiosum.
• Is childhood disease, transmitted from child to
  child by respiratory droplets with I.P 4 10
  days, symptoms started as fever, sore throat,
  malaise, with decrease Hb. Due to transient
  arrest of erythropoiesis.
• Then followed by rash on the cheeks that look
  like person has been slapped, then rash spread to
  trunk and limbs with complete recovery within one
  week.

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Parvovirus B19 Slapped Cheek
Erythema Infectiosum
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Viruses Causing Maculopapular Rash (Continued)

• Parvovirus B19 in patient with chronic hemolytic
  anemia
• Infection in these group of patient e.g. sickle
  cell anemia, thalassemia can lead to severe
  aplastic crisis which can be fatal.
• Parvovirus B19 in adult
• Usually can lead to polyarthritis without
  appearing of rash especially in adult female.
• Parvovirus B19 in pregnant lady
• The virus can infect the fetus and kill
  erythrocyte precursors, causing anemia, and
  congestive heart failure hydrops
  fetalis.
• But No congenital abnormalities Not Teratogenic

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Viruses Causing Maculopapular Rash (Continued)

• Laboratory Diagnosis
• Detection of IgM Ab.
• Treatment and Prevention
• No specific treatment
• No way of prevention except we can screen the
  blood before transfusion especially if we give it
  to chronic heamolytic patient.

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Viruses Causing Maculopapular Rash (Continued)

• 4- HERPES VIRUS TYPE 6 Roseola infantum Sixth
  disease
• Exanthema subitum
• Virology Aspects
• Herpes virus type 6- Family Herpes virus
• Double stranded DNA. Enveloped virus.
• Has the characteristic of latency.
• latent virus persists for long period to be
  activated when immunity become less.

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Viruses Causing Maculopapular Rash (Continued)

• 2- Clinical Syndromes
• It is mainly a childhood disease
• It is transmitted by respiratory droplet
• Rapid onset of high fever, followed by
  generalized rash, with mild lymphadenopathy.
• Complete recovery after 3-5 days.
• 3- Treatment and Prevention
• No specific way of treatment or prevention
• No vaccine available