November 25, 2024 • 19 mins
We’ve gone viral!
Join Dr George Moncrieff and Dr Roger Henderson as they discuss paraviral rashes, where the rash is an immune response to the virus.
They’ll be covering:
- Measles
- Rubella
- Fifth disease
- Pityriasis rosea
- Hand, foot and mouth disease
- Herpangina
Tune in to hear tips for diagnosis, the available treatment options and some potentially serious complications.
Plus, the two hosts will be discussing why they think the MMR vaccine uptake is falling, resulting in rising cases of measles.
Thank you to our kind sponsor AproDerm, who provide a comprehensive range of quality emollients designed for the management of dry skin conditions, including eczema, psoriasis and ichthyosis.
To simplify the process of finding the most suitable emollient for each patient, they have developed a remarkable solution: the AproDerm Emollient Starter Pack. This pack conveniently combines all four of their emollients in a single prescription, enabling patients to identify their ideal emollient more efficiently, aiding both compliance and adherence.
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The views expressed in this podcast are of Dr George Moncrieff and Dr Roger Henderson. Fontus Health has not influenced, participated, or been involved in the programme, materials, or delivery of educational content.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:08):
Hey George, can I tell you something?
If you must.
Out of all our Rash Decisions episodes,I really hope this one goes viral.
Oh dear.
I know, I had to say it.
Now, as mentioned in our last episodeon viral skin infections, I like to
think of viral rashes in two broadgroups, cytopathogenic and paraviral.
(00:31):
And in this week's episode, we'regoing to be delving into the paraviral
types, where the rash is due toan immune response to the virus.
So, we'll be covering key symptoms ofa range of conditions, including common
things like measles, herpangina, evenhand, foot and mouth disease, along with
a few treatment options for your patients.
So, without further ado, let'sget started and play that music.
(01:04):
So, welcome once again to thisRash Decisions podcast, where
we look at skin-related issues,conditions and treatments in an
interesting and informed way.
I'm Dr Roger Henderson.
I'm a GP with a long-standinginterest in this area of health.
And I'm Dr George Moncrieff.
I was also a GP, although I've retired nowfrom my practice and I'm a former Chair
of the Dermatology Council for England.
(01:27):
Now in the last episode, we discussedthe more common cytopathogenic viral
skin infections, where the virusdirectly causes the skin manifestations
and is present within the lesions.
Do have a listen to it as we exploredsome really intriguing diseases.
Didn't we George?
We did indeed, yeah.
And if two episodes isn't enough,don't worry [in] our final episodes on
(01:50):
viral skin infections, we'll be joinedby our very special guest, Dr Marina
Morgan, a Consultant Microbiologist atthe Royal Devon and Exeter Hospital,
who'll be telling us all about therarer viral forms that affect the
skin, such as Kawasaki disease,smallpox, and of course, Covid-19.
But back to today's topic where we'relooking at the paraviral skin rashes,
(02:13):
where the rash is a manifestationof the interaction between the
virus and the host's immune system.
So, George, let me put you in the hotseat and quiz you about what the big
eight childhood infectious rashes are.
This is a little bit unfair and probablygoing to take you back to your medical
school days, but your time starts now.
(02:34):
Thank you very much.
Well, back in 1905, I think it was,a French physician by the name of
Léon Cheinisse tried to classifychildhood infectious rashes, and he
actually numbered them one to five.
One being measles, two actuallybeing a bacteria, so scarlet fever,
(02:55):
three is German measles or rubella,four was something that he called
fourth, epidemic pseudo-scarlatinaor Filatov-Dukes disease.
Although that's not really consideredto be an entity nowadays at all.
And fifth disease, we've allheard of fifth disease, that's
erythema infectiosum, sometimescolloquially known as 'slapped cheek'.
(03:18):
Right, so, a quick five.
Now, what about the other three?
Well a few more have been addedin more recent times, including,
roseola infantum, sixth disease.
That used to be called exanthem subitum,and we'll be talking about that.
Seventh is Kawasaki diseaseand eighth is pityriasis rosea.
(03:41):
Congratulations, you win thepodcast goldfish and I now
consider myself educated.
But, I want to kick off witha reminder about measles.
I think one of the things that I'veseen that's concerned me as much as
anything over the last 20 years hasbeen the rise and rise of measles
because of the fall and fall in thevaccination uptake of the MMR vaccine.
(04:07):
And we mustn't forget just howpotentially serious measles can be.
I know, so sad, isn't it?
It really is.
I think people forget how serious theseviral conditions can be, and we've
become quite complacent, but measles isa very serious viral infection, which
worldwide has a very high mortality.
In developed countries, death is rare,but it still has some potentially
(04:30):
very serious complications, includingencephalitis, pneumonitis, of course,
ear infections, and there are somereally nasty late neurological sequelae.
And of course, it is totally preventablewith an adequate immunisation
programme, which is just so sad.
It doesn't affect anyother animals, only humans.
And so if we just adhere to agood immunisation programme,
(04:53):
we wouldn't have this problem.
The incubation period is betweenone and two weeks, and it starts
with an initial coryzal illness.
And at that time, you might seelittle tiny spots on the buccal
mucosa, known as Koplik’s spots.
I used to think those were pathognomonicfor measles, but they're not.
You can get them in other things,including rubella, for example.
(05:15):
And then the rash appears, and the eyesbecome sore with a particularly nasty
bilateral conjunctivitis, making thechild look miserable and looking 'measly'.
Yes.
A really useful thing my trainertaught me 40 years ago, when measles
was actually more common, was that youcannot diagnose measles without a cough.
(05:36):
So, cough is a big part of that illness.
The rash, which is not itchy,typically starts behind the ears and
then over the next few days spreadsdown over the entire body, usually
sparing the palms and the soles.
You're contagious from a couple of daysbefore the onset of the rash during that
coryzal phase until around about fivedays or so after the rash has appeared.
(06:01):
If you have immunisation withtwo of the MMR vaccines, that
confers excellent immunity.
But we need the community, to haveimmunity to provide herd immunity.
To have a herd immunity that'seffective that needs to be
over 95% to prevent spread.
But unfortunately, for a variety ofreasons, such as scares over the risk
(06:23):
of autism or inflammatory bowel disease,as well as in the past concerns over
egg allergy, uptake has become reallypoor, especially in inner cities where
we're seeing immunisation rates ofunder 75% in children of school age.
Yeah.
That's not uncommon.
If someone gets measles, the thingsthat should make you anxious and the red
(06:48):
flags to consider include breathlessness,
a child who has a seizure oris drowsy in any way, or a
particularly uncontrolled fever.
It's not common in infants under onebut if an infant under one gets it, or
someone immune compromised, or indeed ifsomeone is pregnant when they get measles,
that can be very dangerous as well.
(07:10):
And of course, don't forget, measlesis a notifiable disease, so you're
under legal obligation to report it.
Yes, and that can sometimes be forgotten,but obviously patients sometimes
confuse measles with so called Germanmeasles, rubella, but this does have
some not only subtle differences, butnot too subtle differences as well.
(07:34):
But it certainly can confuse some patientssometimes if you don't explain these.
Yeah, rubella is quite different.
Yeah.
It's generally a very mild illness witha fairly faint rash, mostly on the trunk.
Typically with rubella, yousee enlargement of the swollen
posterior cervical glands.
Hmm.
That's a feature.
(07:54):
Interestingly, although the rash isdue to the immune response, virus
has been isolated from the skin rash.
So there are elements of this, that arecytopathogenic, but I think the rash
is largely due to the immune response.
But spread is through therespiratory tract, so coughing
and you have a viraemia.
But of course, the main concern withthis virus is that it is teratogenic.
(08:18):
We're all very aware of that problem.
The acute illness can include jointpain, so they can get an arthralgia.
Interestingly, there's ashort-lasting pure red cell
aplasia, which is rarely an issue.
But I had a child with Diamond-Blackfansyndrome, and he already had
a fairly low haemoglobin.
He dropped his haemoglobinto two with rubella.
Wow, that's one to remember.
(08:40):
I just want to touch on fifth diseasenext, George, because I sometimes think of
it as a sign that the weather's improvingbecause, it's caused by the human B19
parvovirus, and so we most commonly seeit in the early spring, but about half
the people with it are asymptomatic.
And in my experience, there's anincubation period of up to two
(09:00):
weeks, from sort of four to 14 days.
And then in that time, the patientdevelops this coryzal illness and a fever.
You touched on arthralgia and myexperience with fifth disease is
that some older children and adultscertainly can experience some arthralgia,
but obviously we've got the rash offifth disease, which we all know.
(09:21):
So, they've got the face with thebright red cheeks and the sparing
around the vermilion border of themouth, and that's one of the giveaways.
You have that classical slappedcheek appearance, although
it's not always bilateral.
I mean, I think that's something that'sforgotten and you can get sometimes
a more subtle, reticulated lacy rash,that lasts for longer, sometimes on the
(09:43):
proximal upper limbs or the neck areas.
And we always think about fifth diseasein children, but adults are in the
firing line as well, in my experience.
Yes.
Worryingly over 40% of adultsin their twenties remain
susceptible to this infection.
Of course that's the age group,that's most likely to become pregnant.
(10:05):
And an acute infection with this viruscan cause a really significant pure
red cell aplasia in the unborn infant.
It can also cause a myocarditis in theunborn infant and that together with the
extreme anaemia that it can cause canresult in catastrophic heart failure with
(10:26):
hydrops and that can be really disastrous.
Things are further complicated bythe fact that once the rash appears,
the patient is no longer contagious.
So the most high risk individuals arethose who are just incubating the virus.
I think we also ought to mention at thispoint, roseola infantum, or sixth disease.
This is a common viral illness, and itusually presents in young toddlers aged
(10:50):
six months to around about three years.
How they present is they have thisspectacularly high temperature for a
few days, which rises and falls quitedramatically, rather like the Himalayas.
It goes right up and right down.
Often can trigger a febrile convulsion.
But at that stage, there's really verylittle to find to account for this
(11:11):
intermittently very high temperature.
And then, fairly suddenly, on about thethird or fourth day, a fairly subtle,
fine rash appears on their torso.
And once the rash appears, thechild rapidly begins to recover.
But this rapid appearance of the rashaccounts for the old fashioned name,
exanthem subitum, meaning suddenly.
(11:33):
And this illness is caused bythe human herpesviruses 6 & 7.
There's a really obscure quiz question,if we wanted it for the Christmas
podcast, which is, what do branand Christmas trees have in common?
And I'm thinking aboutpityriasis rosea here.
Well, absolutely.
The word 'pityriasis' comes from the Greekmeaning like a 'husk of bran', and it
(11:57):
describes that very fine scale we've seenaround the perimeter of these lesions.
We now know that pityriasis rosea iscaused by a resurgent of the previously
dormant human herpesviruses 6 & 7following their infantile roseola.
It's because of the resurgence of theirown virus, it accounts for the rather
sporadic nature of this rash, and thereason why we don't tend to see more
(12:18):
than one case of this clearly viralrash in a household at any one time.
I've only ever seen that once actually,two young medical students, brother
and sister, both had it at the sametime, but that's really unusual.
It typically presents in a youngadult who initially notices a large,
solitary, slightly pink lesion on theirtorso, the so called 'herald patch'.
(12:42):
And that's often mistaken for a fungalinfection because of that subtle
pityriasiform scale around the perimeter.
And then, within a couple of days,a more widespread rash develops with
large numbers of smaller, subtle pinkovoid lesions, mostly on the trunk.
And they're distributed in lines,rather like that Christmas tree you're
describing, called Langer's lines, givingthat Christmas tree like appearance.
(13:06):
With their long axis orientated sortof horizontally along these lines.
The rash can actually last forseveral weeks, and I'm not aware of
any treatment that can do anythingfor it, other than perhaps a simple
emollient, perhaps if it's itchy.
The illness though is altogethervery mild apart from the rash.
But there's an importantthing to raise here.
(13:27):
It doesn't have such a benignimpact when you're pregnant.
A recent paper showed that nearly twothirds of women who got it in the first
15 weeks of pregnancy aborted, and overallit resulted in a miscarriage rate of
about 13%, and the virus has been isolatedfrom both the fetus and the placenta.
(13:48):
So, not much we can do about it.
And it has this potentialproblem in pregnancy.
I used to think it was perfectlysafe in pregnancy, but we're
not so happy about it anymore.
Not very much you can do about that.
No, potentially tragic.
I suspect many healthcare professionalslistening to us will have a lot of empathy
with this next one because whenever I'mabout to mention the term hand, foot
(14:10):
and mouth disease to parents sittingin front of me, I know they're going to
start looking at me as if I've gone madbecause in their head, they hear foot and
mouth, at which point I have to gentlypoint out, I am a GP and not a vet and
it is hand, foot and mouth disease.
Yes, indeed, nor am I.
But foot-and-mouth is a highlycontagious aphthoviral infection,
(14:33):
a sort of picornavirus thataffects cloven-hoofed animals.
So humans are spared.
Um, they don't have cloven-hooves.
But yeah, in my experience, most peoplehave heard of hand, foot and mouth.
It's well known by mostparents of little children.
And it's a common infection,but it's not always mild.
(14:54):
Indeed, in a study from China,looking at over one million cases,
there were several hundred deaths.
So, it's usually, but not invariably,primary school children who develop
small grey vesicles on an erythematousbase, on the palms of their hands,
on their soles, and in and around themouth, so hence hand, foot, and mouth.
(15:16):
It is caused by a variety of viruses,but most commonly by Coxsackie A5,
10 or 16, very rarely outbreaksare caused by an enterovirus.
Back in 2010, a particularlynasty variant was described from
Taiwan caused by Coxsackie A6.
This caused a rash on the buttocks,and so I've heard other people
(15:39):
calling it, and I like callingit hand, foot, and butt disease.
And the important point here is thatadults are rarely immune to Coxsackie
A6, so it can affect them too.
And a measure of how severe thisillness can be, is the manifestation
of extreme Beau’s lines that cancommonly follow this illness.
You remember a Beau’s line is thathorizontal depression across the
(16:03):
nails due to interrupted nail growth.
So, all the nails just develop thishorizontal line across, which then
gradually grows out with the nail.
But if it's particularly severe, the wholeproximal edge of the nail can lift off.
A condition known as onychomadesis.
It's a proximal onycholysis, the nailsort of lifts off proximally, and this
(16:25):
pattern of proximal onycholysis issometimes seen a few weeks after the
adult has gone down with hand, foot, andbutt, because it's such a nasty illness.
More recently, just two years ago, in2022, another severe variant of hand,
foot, and mouth was described from India.
Initially, this was called 'tomato flu'because of the very large, painful,
(16:46):
red, bright red, even tomato-sizedblisters that develop around the
mouth and on the hands and feet.
But now it's known this is not flu at all.
This is caused by Coxsackie A16 and it'sjust considered to be the severe end of
the spectrum of hand, foot, and mouth.
Yeah, yeah, the variationsare really interesting.
Coming towards the end of the podcast,George, but before we do, I thought I'd
(17:09):
remind our colleagues about two conditionsthat we often forget about, if indeed
they're remembered in the first place,but I do think they're worth mentioning.
One's herpangina, and the nextis Gianotti-Crosti I hope you
think they're worth mentioning.
Absolutely, yeah.
Herpangina is a miserable illness thatpresents with small, painful ulcers
(17:30):
inside the mouth with a red base.
It's just a painful condition there.
It can be caused by a varietyof viruses, including the herpes
simplex virus, various Coxsackieviruses both A and B viruses, as
well as again that enterovirus 71.
Gianotti-Crosti or papulovesicularacrodermatitis of childhood,
(17:51):
is not uncommon, and it canbe confused with chickenpox.
But the distributionreally is quite different.
So, Gianotti and Crosti describedthis back in 1950, I think it was,
1957 But typically you have a notunwell child who presents with
non-tender, rather monomorphicpapular vesicles around their wrists,
their ankles, and on their buttocks.
(18:12):
So it's not on the palms and the soles,it's further back onto the skin there.
And the residual changes from thisrash can persist for many weeks.
When Gianotti and Crosti first describedit, from Italy, it was associated
with hepatitis B infection, and formany years they wouldn't allow us
to use their name for this conditionunless it was caused by hepatitis B.
(18:34):
But in the UK, that's very rare,and it's much more commonly
caused by cytomegalovirus.
I've seen that a few times.
EB virus can do it, as can CoxsackieA16, and we've seen very typical
Gianotti-Crosti caused by Covid-19.
It can cause so many things.
Yes, absolutely.
I hadn't seen it before Covidappeared, but once again, old
(18:55):
father time has beaten us, George.
So, we do hope you found this discussionabout viral infections that we so commonly
see in our patients, really helpful.
we also look forward to you joining usagain when our special guest, Dr Marina
Morgan will come along and give her expertviews on conditions, including Covid-19,
but also smallpox and Kawasaki disease.
(19:15):
So, do make sure you join us.And as always, we must thank our
wonderful sponsor, AproDerm®, forall their help in putting these
Rash Decisions podcasts together.
We couldn't have done it without them.
Absolutely.
And if you like what you hear,and many of you are telling us
that you do, which is great.
Do take a moment to rate and review uswherever you've got your podcasts, because
it really does help us put together thecontent that you want to hear about.
(19:40):
But until the next time,it's goodbye from George.
Goodbye.
And it's goodbye from me.
Goodbye.
Hey George, can I tell you something?
If you must.
Out of all our Rash Decisions episodes,I really hope this one goes viral.
Oh dear.
I know, I had to say it.
Now, as mentioned in our last episodeon viral skin infections, I like to
think of viral rashes in two broadgroups, cytopathogenic and paraviral.
(00:31):
And in this week's episode, we'regoing to be delving into the paraviral
types, where the rash is due toan immune response to the virus.
So, we'll be covering key symptoms ofa range of conditions, including common
things like measles, herpangina, evenhand, foot and mouth disease, along with
a few treatment options for your patients.
So, without further ado, let'sget started and play that music.
(01:04):
So, welcome once again to thisRash Decisions podcast, where
we look at skin-related issues,conditions and treatments in an
interesting and informed way.
I'm Dr Roger Henderson.
I'm a GP with a long-standinginterest in this area of health.
And I'm Dr George Moncrieff.
I was also a GP, although I've retired nowfrom my practice and I'm a former Chair
of the Dermatology Council for England.
(01:27):
Now in the last episode, we discussedthe more common cytopathogenic viral
skin infections, where the virusdirectly causes the skin manifestations
and is present within the lesions.
Do have a listen to it as we exploredsome really intriguing diseases.
Didn't we George?
We did indeed, yeah.
And if two episodes isn't enough,don't worry [in] our final episodes on
(01:50):
viral skin infections, we'll be joinedby our very special guest, Dr Marina
Morgan, a Consultant Microbiologist atthe Royal Devon and Exeter Hospital,
who'll be telling us all about therarer viral forms that affect the
skin, such as Kawasaki disease,smallpox, and of course, Covid-19.
But back to today's topic where we'relooking at the paraviral skin rashes,
(02:13):
where the rash is a manifestationof the interaction between the
virus and the host's immune system.
So, George, let me put you in the hotseat and quiz you about what the big
eight childhood infectious rashes are.
This is a little bit unfair and probablygoing to take you back to your medical
school days, but your time starts now.
(02:34):
Thank you very much.
Well, back in 1905, I think it was,a French physician by the name of
Léon Cheinisse tried to classifychildhood infectious rashes, and he
actually numbered them one to five.
One being measles, two actuallybeing a bacteria, so scarlet fever,
(02:55):
three is German measles or rubella,four was something that he called
fourth, epidemic pseudo-scarlatinaor Filatov-Dukes disease.
Although that's not really consideredto be an entity nowadays at all.
And fifth disease, we've allheard of fifth disease, that's
erythema infectiosum, sometimescolloquially known as 'slapped cheek'.
(03:18):
Right, so, a quick five.
Now, what about the other three?
Well a few more have been addedin more recent times, including,
roseola infantum, sixth disease.
That used to be called exanthem subitum,and we'll be talking about that.
Seventh is Kawasaki diseaseand eighth is pityriasis rosea.
(03:41):
Congratulations, you win thepodcast goldfish and I now
consider myself educated.
But, I want to kick off witha reminder about measles.
I think one of the things that I'veseen that's concerned me as much as
anything over the last 20 years hasbeen the rise and rise of measles
because of the fall and fall in thevaccination uptake of the MMR vaccine.
(04:07):
And we mustn't forget just howpotentially serious measles can be.
I know, so sad, isn't it?
It really is.
I think people forget how serious theseviral conditions can be, and we've
become quite complacent, but measles isa very serious viral infection, which
worldwide has a very high mortality.
In developed countries, death is rare,but it still has some potentially
(04:30):
very serious complications, includingencephalitis, pneumonitis, of course,
ear infections, and there are somereally nasty late neurological sequelae.
And of course, it is totally preventablewith an adequate immunisation
programme, which is just so sad.
It doesn't affect anyother animals, only humans.
And so if we just adhere to agood immunisation programme,
(04:53):
we wouldn't have this problem.
The incubation period is betweenone and two weeks, and it starts
with an initial coryzal illness.
And at that time, you might seelittle tiny spots on the buccal
mucosa, known as Koplik’s spots.
I used to think those were pathognomonicfor measles, but they're not.
You can get them in other things,including rubella, for example.
(05:15):
And then the rash appears, and the eyesbecome sore with a particularly nasty
bilateral conjunctivitis, making thechild look miserable and looking 'measly'.
Yes.
A really useful thing my trainertaught me 40 years ago, when measles
was actually more common, was that youcannot diagnose measles without a cough.
(05:36):
So, cough is a big part of that illness.
The rash, which is not itchy,typically starts behind the ears and
then over the next few days spreadsdown over the entire body, usually
sparing the palms and the soles.
You're contagious from a couple of daysbefore the onset of the rash during that
coryzal phase until around about fivedays or so after the rash has appeared.
(06:01):
If you have immunisation withtwo of the MMR vaccines, that
confers excellent immunity.
But we need the community, to haveimmunity to provide herd immunity.
To have a herd immunity that'seffective that needs to be
over 95% to prevent spread.
But unfortunately, for a variety ofreasons, such as scares over the risk
(06:23):
of autism or inflammatory bowel disease,as well as in the past concerns over
egg allergy, uptake has become reallypoor, especially in inner cities where
we're seeing immunisation rates ofunder 75% in children of school age.
Yeah.
That's not uncommon.
If someone gets measles, the thingsthat should make you anxious and the red
(06:48):
flags to consider include breathlessness,
a child who has a seizure oris drowsy in any way, or a
particularly uncontrolled fever.
It's not common in infants under onebut if an infant under one gets it, or
someone immune compromised, or indeed ifsomeone is pregnant when they get measles,
that can be very dangerous as well.
(07:10):
And of course, don't forget, measlesis a notifiable disease, so you're
under legal obligation to report it.
Yes, and that can sometimes be forgotten,but obviously patients sometimes
confuse measles with so called Germanmeasles, rubella, but this does have
some not only subtle differences, butnot too subtle differences as well.
(07:34):
But it certainly can confuse some patientssometimes if you don't explain these.
Yeah, rubella is quite different.
Yeah.
It's generally a very mild illness witha fairly faint rash, mostly on the trunk.
Typically with rubella, yousee enlargement of the swollen
posterior cervical glands.
Hmm.
That's a feature.
(07:54):
Interestingly, although the rash isdue to the immune response, virus
has been isolated from the skin rash.
So there are elements of this, that arecytopathogenic, but I think the rash
is largely due to the immune response.
But spread is through therespiratory tract, so coughing
and you have a viraemia.
But of course, the main concern withthis virus is that it is teratogenic.
(08:18):
We're all very aware of that problem.
The acute illness can include jointpain, so they can get an arthralgia.
Interestingly, there's ashort-lasting pure red cell
aplasia, which is rarely an issue.
But I had a child with Diamond-Blackfansyndrome, and he already had
a fairly low haemoglobin.
He dropped his haemoglobinto two with rubella.
Wow, that's one to remember.
(08:40):
I just want to touch on fifth diseasenext, George, because I sometimes think of
it as a sign that the weather's improvingbecause, it's caused by the human B19
parvovirus, and so we most commonly seeit in the early spring, but about half
the people with it are asymptomatic.
And in my experience, there's anincubation period of up to two
(09:00):
weeks, from sort of four to 14 days.
And then in that time, the patientdevelops this coryzal illness and a fever.
You touched on arthralgia and myexperience with fifth disease is
that some older children and adultscertainly can experience some arthralgia,
but obviously we've got the rash offifth disease, which we all know.
(09:21):
So, they've got the face with thebright red cheeks and the sparing
around the vermilion border of themouth, and that's one of the giveaways.
You have that classical slappedcheek appearance, although
it's not always bilateral.
I mean, I think that's something that'sforgotten and you can get sometimes
a more subtle, reticulated lacy rash,that lasts for longer, sometimes on the
(09:43):
proximal upper limbs or the neck areas.
And we always think about fifth diseasein children, but adults are in the
firing line as well, in my experience.
Yes.
Worryingly over 40% of adultsin their twenties remain
susceptible to this infection.
Of course that's the age group,that's most likely to become pregnant.
(10:05):
And an acute infection with this viruscan cause a really significant pure
red cell aplasia in the unborn infant.
It can also cause a myocarditis in theunborn infant and that together with the
extreme anaemia that it can cause canresult in catastrophic heart failure with
(10:26):
hydrops and that can be really disastrous.
Things are further complicated bythe fact that once the rash appears,
the patient is no longer contagious.
So the most high risk individuals arethose who are just incubating the virus.
I think we also ought to mention at thispoint, roseola infantum, or sixth disease.
This is a common viral illness, and itusually presents in young toddlers aged
(10:50):
six months to around about three years.
How they present is they have thisspectacularly high temperature for a
few days, which rises and falls quitedramatically, rather like the Himalayas.
It goes right up and right down.
Often can trigger a febrile convulsion.
But at that stage, there's really verylittle to find to account for this
(11:11):
intermittently very high temperature.
And then, fairly suddenly, on about thethird or fourth day, a fairly subtle,
fine rash appears on their torso.
And once the rash appears, thechild rapidly begins to recover.
But this rapid appearance of the rashaccounts for the old fashioned name,
exanthem subitum, meaning suddenly.
(11:33):
And this illness is caused bythe human herpesviruses 6 & 7.
There's a really obscure quiz question,if we wanted it for the Christmas
podcast, which is, what do branand Christmas trees have in common?
And I'm thinking aboutpityriasis rosea here.
Well, absolutely.
The word 'pityriasis' comes from the Greekmeaning like a 'husk of bran', and it
(11:57):
describes that very fine scale we've seenaround the perimeter of these lesions.
We now know that pityriasis rosea iscaused by a resurgent of the previously
dormant human herpesviruses 6 & 7following their infantile roseola.
It's because of the resurgence of theirown virus, it accounts for the rather
sporadic nature of this rash, and thereason why we don't tend to see more
(12:18):
than one case of this clearly viralrash in a household at any one time.
I've only ever seen that once actually,two young medical students, brother
and sister, both had it at the sametime, but that's really unusual.
It typically presents in a youngadult who initially notices a large,
solitary, slightly pink lesion on theirtorso, the so called 'herald patch'.
(12:42):
And that's often mistaken for a fungalinfection because of that subtle
pityriasiform scale around the perimeter.
And then, within a couple of days,a more widespread rash develops with
large numbers of smaller, subtle pinkovoid lesions, mostly on the trunk.
And they're distributed in lines,rather like that Christmas tree you're
describing, called Langer's lines, givingthat Christmas tree like appearance.
(13:06):
With their long axis orientated sortof horizontally along these lines.
The rash can actually last forseveral weeks, and I'm not aware of
any treatment that can do anythingfor it, other than perhaps a simple
emollient, perhaps if it's itchy.
The illness though is altogethervery mild apart from the rash.
But there's an importantthing to raise here.
(13:27):
It doesn't have such a benignimpact when you're pregnant.
A recent paper showed that nearly twothirds of women who got it in the first
15 weeks of pregnancy aborted, and overallit resulted in a miscarriage rate of
about 13%, and the virus has been isolatedfrom both the fetus and the placenta.
(13:48):
So, not much we can do about it.
And it has this potentialproblem in pregnancy.
I used to think it was perfectlysafe in pregnancy, but we're
not so happy about it anymore.
Not very much you can do about that.
No, potentially tragic.
I suspect many healthcare professionalslistening to us will have a lot of empathy
with this next one because whenever I'mabout to mention the term hand, foot
(14:10):
and mouth disease to parents sittingin front of me, I know they're going to
start looking at me as if I've gone madbecause in their head, they hear foot and
mouth, at which point I have to gentlypoint out, I am a GP and not a vet and
it is hand, foot and mouth disease.
Yes, indeed, nor am I.
But foot-and-mouth is a highlycontagious aphthoviral infection,
(14:33):
a sort of picornavirus thataffects cloven-hoofed animals.
So humans are spared.
Um, they don't have cloven-hooves.
But yeah, in my experience, most peoplehave heard of hand, foot and mouth.
It's well known by mostparents of little children.
And it's a common infection,but it's not always mild.
(14:54):
Indeed, in a study from China,looking at over one million cases,
there were several hundred deaths.
So, it's usually, but not invariably,primary school children who develop
small grey vesicles on an erythematousbase, on the palms of their hands,
on their soles, and in and around themouth, so hence hand, foot, and mouth.
(15:16):
It is caused by a variety of viruses,but most commonly by Coxsackie A5,
10 or 16, very rarely outbreaksare caused by an enterovirus.
Back in 2010, a particularlynasty variant was described from
Taiwan caused by Coxsackie A6.
This caused a rash on the buttocks,and so I've heard other people
(15:39):
calling it, and I like callingit hand, foot, and butt disease.
And the important point here is thatadults are rarely immune to Coxsackie
A6, so it can affect them too.
And a measure of how severe thisillness can be, is the manifestation
of extreme Beau’s lines that cancommonly follow this illness.
You remember a Beau’s line is thathorizontal depression across the
(16:03):
nails due to interrupted nail growth.
So, all the nails just develop thishorizontal line across, which then
gradually grows out with the nail.
But if it's particularly severe, the wholeproximal edge of the nail can lift off.
A condition known as onychomadesis.
It's a proximal onycholysis, the nailsort of lifts off proximally, and this
(16:25):
pattern of proximal onycholysis issometimes seen a few weeks after the
adult has gone down with hand, foot, andbutt, because it's such a nasty illness.
More recently, just two years ago, in2022, another severe variant of hand,
foot, and mouth was described from India.
Initially, this was called 'tomato flu'because of the very large, painful,
(16:46):
red, bright red, even tomato-sizedblisters that develop around the
mouth and on the hands and feet.
But now it's known this is not flu at all.
This is caused by Coxsackie A16 and it'sjust considered to be the severe end of
the spectrum of hand, foot, and mouth.
Yeah, yeah, the variationsare really interesting.
Coming towards the end of the podcast,George, but before we do, I thought I'd
(17:09):
remind our colleagues about two conditionsthat we often forget about, if indeed
they're remembered in the first place,but I do think they're worth mentioning.
One's herpangina, and the nextis Gianotti-Crosti I hope you
think they're worth mentioning.
Absolutely, yeah.
Herpangina is a miserable illness thatpresents with small, painful ulcers
(17:30):
inside the mouth with a red base.
It's just a painful condition there.
It can be caused by a varietyof viruses, including the herpes
simplex virus, various Coxsackieviruses both A and B viruses, as
well as again that enterovirus 71.
Gianotti-Crosti or papulovesicularacrodermatitis of childhood,
(17:51):
is not uncommon, and it canbe confused with chickenpox.
But the distributionreally is quite different.
So, Gianotti and Crosti describedthis back in 1950, I think it was,
1957 But typically you have a notunwell child who presents with
non-tender, rather monomorphicpapular vesicles around their wrists,
their ankles, and on their buttocks.
(18:12):
So it's not on the palms and the soles,it's further back onto the skin there.
And the residual changes from thisrash can persist for many weeks.
When Gianotti and Crosti first describedit, from Italy, it was associated
with hepatitis B infection, and formany years they wouldn't allow us
to use their name for this conditionunless it was caused by hepatitis B.
(18:34):
But in the UK, that's very rare,and it's much more commonly
caused by cytomegalovirus.
I've seen that a few times.
EB virus can do it, as can CoxsackieA16, and we've seen very typical
Gianotti-Crosti caused by Covid-19.
It can cause so many things.
Yes, absolutely.
I hadn't seen it before Covidappeared, but once again, old
(18:55):
father time has beaten us, George.
So, we do hope you found this discussionabout viral infections that we so commonly
see in our patients, really helpful.
we also look forward to you joining usagain when our special guest, Dr Marina
Morgan will come along and give her expertviews on conditions, including Covid-19,
but also smallpox and Kawasaki disease.
(19:15):
So, do make sure you join us.And as always, we must thank our
wonderful sponsor, AproDerm®, forall their help in putting these
Rash Decisions podcasts together.
We couldn't have done it without them.
Absolutely.
And if you like what you hear,and many of you are telling us
that you do, which is great.
Do take a moment to rate and review uswherever you've got your podcasts, because
it really does help us put together thecontent that you want to hear about.
(19:40):
But until the next time,it's goodbye from George.
Goodbye.
And it's goodbye from me.
Goodbye.
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