Roseola differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Omodamola Aje B.Sc, M.D. [2]

Overview

Roseola must be differentiated from other diseases that cause fever and rash, such as Rubella (german measles), Rubeola (measles), hand foot and mouth disease caused by coxakie virus, erythema infectiosum caused by parvovirus B19, scarlet fever and even drug allergy.

Differential diagnosis

Roseola, also known as Exanthem subitum must be differentiated from all other childhood diseases that cause rash, and fever. The following table summarizes the differential diagnosis for roseola.

Differential Diagnosis of fever and rash.

Disease	Cause	Typical Age	Prodrome	Fever	Duration of the rash (days)	Workup	Treatment
Roseola Infantum (exanthem subitum)	Human herpes virus type 6	6 months to 2 years	None	High	1-2; it follows defervescence	Discrete erythematous macules, rarely involves face, begins as fever ends	Lymphadenopathy, irritability
Measles	Paramyxovirus Measles virus	1 to 20 years	2-4 days of cough, conjunctivitis, and coryza	High	5 - 6	Erythematous, irregular size, maculopapular; starts on temples and behind ears; progresses down from face; fades to brownish	Koplik's spots: C blue-white papules (salt grains) on bright red mucosa opposite premolar teeth
Rubella	Togavirus	7 months to 29 years	0 - 4 days; mild malaise, fever; absent in children	Low grade	1 - 3	Discrete, rose-pink, diffuse, maculopapular; progresses downward from face, may change quickly	Arthralgia (usually in adults), tender posterior cervical and suboccipital lymphadenopathy, malaise, petechiae on soft palate
Erythema Infectiosum (Fifth Disease)	Human parvovirus type B19	5 - 10 years	None, usually in children, may occur in adults	None to low-grade	2 - 4	Starts as “slapped cheek”, maculopapular; progresses to reticular (lacy) pattern; can recur with environmental changes such as sunlight exposure	Arthralgia/arthritis in adults, adenopathy
Infectious Mononucleosis	Epstein-Barr Virus	10 - 30 years	2 - 5 days of malaise and fatigue	Low to high	2 - 7	Trunk and proximal extremities. Rash common if Ampicillin given	Pharyngitis, lymphadenopathy, splenomegaly, malaise
Kawasaki disease	Unknown	< 5 years	3 days of abrupt fever	High; fever of 5 days is a diagnostic criteria	5 - 7	Erythematous, morbilliform, maculopapular or scarlatiniform, central distribution; erythematous, indurated palms and soles	Acute: dry, fissured and injected lips, strawberry tongue; irritability; cervical lymphadenopathy; conjunctival injection; peripheral edema; Subacute: finger-tip desquamation; Complications: arthritis, carditis
Scarlet Fever	ß-hemolytic streptococci	> 2 years	0 - 6 day, marked	Low to high	2 - 7	Scarlet "sunburn" with punctate papules "sandpaper", circumoral pallor, increased intensity in skin folds, blanches stars face/head, upper trunk and progresses downward	Sore throat, exudative tonsillitis, vomiting, abdominal pain, lmphadenopathy, white then red strawberry tongue
Enterovirus	Echovirus Coxsackie virus	Mainly childhood	0 - 1 day fever and myalias	Low to high	1 - 5	Fine, pink, always affects face; variant is Boston exanthem (large ~ 1 cm, discrete maculopapules)	Sore throat, headache, malaise, no lymphadenopathy, gastroenteritis
Dengue Fever	Flavivirus Dengue virus types 1 - 4		None	High	1 - 5	Generalized maculopapular rash after defervescence; spares palms and soles	Headache, myalgia, abdominal pain, pharyngitis, vomiting
Drug induced rash	Many	Any	Possible due to underlying illness	Possible	Varies	Typically diffuse but may be concentrated in diaper area, typically no progression, erythema multiform rash can progress over a few days	Possibly due to underlying illness or complications
Pharyngoconjunctival Fever	Adenovirus types 2, 3, 4, 7, 7a	< 5 years		Low to high	3 - 5	Starts on face and spreads down to trunk and extremities	Sore throat, conjunctivitis, headache, anorexia

Table adapted from CDC Pinkbook.