Infectious diseases

Viral Infections in Children and Adolescents

Eczema Herpeticum

Warren Clinic, Tulsa, Oklahoma

The parents of this 8-year-old girl sought a second opinion about the rash on their daughter’s face. The condition was unresponsive to antibiotics that had been prescribed by another practitioner.

The child was febrile and appeared somewhat ill. She complained that the lesions tingled, itched, and burned. The acute papulovesicular eruption was superimposed on long-standing atopic dermatitis.


The mother reported that her daughter had had a small cold sore on the lip immediately before the rash erupted. A culture of material from one of the rash lesions showed herpes simplex virus and confirmed the suspected diagnosis of eczema herpeticum, or Kaposi varicelliform eruption. Staphylococcus folliculitis and contact dermatitis also had been considered in the differential.

Typically, eczema herpeticum is seen superimposed on a preexisting atopic dermatitis. Other predisposing dermatoses include seborrheic dermatitis and Darier disease, or keratosis follicularis.

A course of oral acyclovir successfully resolved this child’s infection.


Hand-Foot-and-Mouth Disease

Morgan City, Louisiana

This nearly 4-year-old boy’s symptoms began with a low-grade fever; multiple small, shallow ulcers on his tongue; and a fever blister–type lesion on the right upper lip that rapidly spread periorally (A and B). Simultaneously, punctate, reddened vesicles developed on the right ear helix, palms, and the dorsi of the feet (C, D, and E).

hand foot mouth

He complained of pain with pressure on the balls of the feet. Anterior cervical lymph nodes were enlarged and tender. Because of a parental history of recurrent herpes labialis, a culture of the patient’s tongue was obtained to rule out herpes simplex of the mouth; no herpes simplex virus was found.

hand foot mouth

An outbreak of hand-foot-and-mouth disease, which typically affects children younger than 10 years, was reported in this child’s preschool class. Horizontal spread of this disease, generally caused by coxsackievirus A16, is common. The patient was treated symptomatically, and his condition improved over several days; however, similar symptoms developed in a younger sibling.

hand foot mouth

As the disorder’s name implies, eruptions on the buccal mucosa, palate, and extremities are characteristic. This child’s ear lesions and extensive perioral involvement are relatively uncommon for this viral exanthem and enanthem complex.

Roseola Infantum

Morgan City, Louisiana

Human herpesvirus 6 has been identified as the predominant cause of roseola infantum, an infection that affects children between the ages of 6 months and 3 years.

A sudden rise in temperature that may persist for as long as 5 days heralds the onset of the disease. The temperature can range from 39.5°C (103°F) to 40.5°C (105°F) and may trigger convulsions. Physical findings usually are nonexistent or too minor to explain the significant fever.

roseola infantum

Typically, the child remains active, and eating habits and behavior are normal. As the fever wanes, a pink macular or maculopapular rash—as seen on the 16-month-old infant pictured here—generally erupts. The rash is most prominent on the back and trunk and to a lesser degree on the face and extremities. There is no pruritus or desquamation, and the lesions resolve within 2 days.

Roseola infantum frequently occurs in the spring and fall and may provoke a minor epidemic. These factors, along with the exclusion of other common causes of pyrexia in very young children, suggest the diagnosis. Laboratory tests are rarely necessary to confirm the diagnosis.

Antipyretics may be used, particularly in those children who are prone to febrile seizures. Otherwise, no specific treatment is required for children with roseola infantum.

Gianotti-Crosti Syndrome

Eagan, Minnesota

La Mesa, California

Flesh-colored to red-brown nonpruritic papules developed most prominently on the elbows, forearms, and knees of a 2½-year-old boy. The rash was preceded by a low-grade fever and mild, upper respiratory tract symptoms.

On physical examination, no hepatosplenomegaly was detected. A clinical diagnosis of Gianotti-Crosti syndrome, or papular acrodermatitis, was made.

gianotti crosti syndrome

Gianotti-Crosti syndrome is self-limited. It is seen in children, particularly those between 2 and 5 years of age who have viral infections, including those caused by Epstein-Barr virus, coxsackievirus, and hepatitis B virus. If hepatic symptoms are present at the initial diagnosis, reexamine the child in 4 to 6 weeks; patients without liver involvement need routine follow-up to monitor for the development of hepatic disorders.

Mild postinflammatory hyperpigmentation may follow rash resolution; generally, it will fade in a few months. Corticosteroids usually are of no benefit in treating this condition. Reassure the patient (and parents) that the disease is self-limited and will resolve in approximately 2 months. This young boy’s symptoms cleared 7 weeks after they first appeared.


Morgan City, Louisiana

Throat pain of 1 day’s duration sent this 17-year-old boy for medical evaluation. He had no fever and no other symptoms.

Injection of the posterior palate with multiple 1- to 2-mm pustules was evident. The patient’s cervical glands were enlarged but not tender. A culture of material from these lesions showed no evidence of herpes simplex virus. A diagnosis of herpangina was made.


Herpangina, caused by group A or B coxsackievirus or other enteroviruses, generally occurs in epidemics and predominately affects younger children. Fever, headache, and body pain may accompany the sore and vesiculated throat. The differential diagnosis includes aphthous stomatitis, herpetic stomatitis, and hand-foot-and-mouth disease.

The herpangina cleared following the patient’s assiduous use of mouthwash containing tetracycline and triamcinolone.