Roseola also known as exanthema subitum or Sixth disease is a viral infection caused by human herpesvirus 6 (HHV-6) common in infants and young children. The pathognomonic sign of roseola infantum is the development of acute high fever and febrile seizure. Commonly after defervescence, a rubelliform eruption or rash occurs. A clinical exam is needed to diagnose roseola and the treatment is symptomatic (Caserta, 2014). To patients who are immunosuppressed, HHV-6 is a major cause of morbidity and mortality. HHV-6B can also cause CNS disease in these immunocompromised patients ("Roseola Infantum", 2016).
Pathophysiology
The transmission of the HHV-6 is airborne, mainly from mother to child. The virus is often secreted in the saliva of health adults having antibody to HHV-6. The two types of HHV-6 are A and B. HHV-6B is the main cause of roseola. The cell receptor for the virus is CD46. In primary infection, the virus replicated in salivary glands and in leukocytes. Latent infection often follows primary infection. If a patient is immunosuppressed, the latent infection can be reactivated. The site of latent infection could be monocytes or macrophages. Seroepidemiological studies have shown that almost all children are infected with HHV-6 about 6-24 months after birth (Yamanishi, 1992).
In primary infection, high fever of 39.5 to 40.5° C occurs for 3 to 5 days. This is the body’s response to infection. Exogenous pyrogens which are commonly microbes or products of microbes induce release of endogenous pyrogens (Tunkel, 2016). Cervical and posterior auricular lymphadenitis develops often. The presence of seizures is due to the affectation of the CNS by early invasion of HHV-6. Blood-brain barrier dysfunction occurs because of high serum levels of matrix metalloproteinase 9 and tissue inhibitor of metalloproteinases 1 in infants infected with HHV-6leads to febrile seizures. After defervescence, a rash starts on the chest, back and abdomen then spreads to the extremities. The rubelliform eruption is usually flat and pink (2 mm to 5 mm in diameter). The rash lasts about three days. Molecular mimicry by producing functional chemokine and chemokine receptors is one of the several mechanisms of the HV-6. This is how it down-regulates the host immune system ("Roseola Infantum", 2016). Occuring after an acute primary infection, the virus remains latent in lymphocytes and monocytes. The virus has also been found in low levels in certain tissues. Immunosuppression in certain conditions such as AIDS, organ or marrow transplantation may reactivate the virus.
Epidemiology
In the United States, HHV-6 has been reported to cause 10-45 percent of cases of febrile illness in infants. In a population based study in 2005, it revealed that 40 percent of HHV-6 infection occur by age 12 and 77% occur by age 24 months. By 9-21 months, a majority of infants acquire primary HHV-6 infection. HHV-6 infection is almost universal according to serologic tests ("Roseola Infantum", 2016). Internationally, there are some variations in seroprevalence. In Zambia, there suggests an endemic because of the strong association of HHV-6A in Zambian children with febrile illness ("Roseola Infantum", 2016). Females and having older siblings are associated with HHV-6 acquisition ("Roseola Infantum", 2016). During the spring time and autumn incidence is higher. It is usually a mild illness that affects one third of all children ("Roseola Infantum", 2014).
Diagnosis
Clinical evaluation is done to diagnose Roseola Infantum. It is usually based on clinical history. For example when the typical symptoms occur a week after contact with another child with the condition, the doctor will rule in Roseola Infantum. The signs of meningitis must be rule out. Laboratory testing is not done routinely but if the diagnosis is uncertain, serologic or culture tests can confirm the diagnosis and exclude other potentially serious causes (Caserta, 2014).
Management
The management given is supportive care. The treatment is made to treat the symptoms such as fever. This can prevent a febrile convulsion from occurring. The following are the usual treatments for patients with roseola infantum:
Facilitating adequate or plenty cool fluids intake.
Administering antipyretics such as acetaminophen to relieve the fever. Do not give acetylsalicylic acid (ASA) to children less than 18 years of age as this may lead to Reye’s syndrome.
Promote rest.
Tepid sponge bath to lower the temperature of the child.
Removing excess clothing to aid in proper thermoregulation.
For immunosuppressed patients with severe disease, antiviral agents such as foscarnet or ganciclovir is used for treatment. For patients taking these drugs, frequent monitoring of minerals and electrolyte must be done as alterations in plasma minerals and electrolytes are associated with foscarnet treatment. Frequent monitoring of serum creatinine should be made for changes in renal function (Caserta, 2014).
Follow-up Care
Roseola infantum does not usually cause complications. If symptoms subside, follow-up with the doctor is necessary when complications develop such as febrile seizures, encephalitis, meningitis, and hepatitis (Lewis, 2015). HHV-6 and HHV-7 may persist after the primary infection. It may be reactivated in immunosuppressed conditions. It may also have a role in the flare and severity of drug-induced hypersensitivity syndromes (Lewis, 2015).
According to Leininger (2002), “Culture refers to the learned, shared and transmitted knowledge of values, beliefs, and lifeways of a particular group that are generally transmitted intergenerationally and influence thinking, decisions, and actions in patterned or in certain ways” (Leininger and McFarland, 2002). In the care of a patient with Roseola infantum, being cognizant of the perception of health of the parents or caregivers is key to providing culturally competent care. As the nurse, I have to know about the language and culture of the patient, parents and caregivers in general. The belief systems differ among cultural groups. The patient’s parent or caregiver might believe that the disease is not due to natural causes but do to supernatural causes, it is important as the nurse that I health educate them.
It is also essential that I allow and respect the family’s religion. Maybe the parents don’t believe in taking medications to treat the fever and prefer their child to take herbal or alternative medicine. It is important that I respect their beliefs but at the same time make sure that these alternatives don’t cause any harm to the patient. As the nurse, I must take into consideration whose needs are priority. Some may prioritize the family over the patient, so health-related decision making and problem solving always involve the family. Some may favor independent problem solving. Nurses must always consider the health literacy, culture and language when caring for culturally diverse patients or families.
References
Caserta, M. (2014). Roseola Infantum. Merck Manuals Professional Edition. Retrieved 1 July 2016, from https://www.merckmanuals.com/professional/pediatrics/miscellaneous-viral-infections-in-infants-and-children/roseola-infantum
Leininger, M., & McFarland, M. (2002). Transcultural nursing: Concepts, theories, research, and practice. 3rd edition. New York: McGraw-Hill.
Lewis, L. (2015). Roseola Infantum in Emergency Medicine Follow-up: Deterrence/Prevention, Complications, Prognosis. Emedicine.medscape.com. Retrieved 2 July 2016, from http://emedicine.medscape.com/article/803804-followup#e3
Roseola Infantum. (2016). Emedicine.medscape.com. Retrieved 1 July 2016, from http://emedicine.medscape.com/article/1133023-overview#a5
Roseola infantum. (2014). Medquarterly.net. Retrieved 2 July 2016, from http://www.medquarterly.net/mq88/index.php/n-paediatric/article/13-roseola-infantum#section3
Singleton, K. & Krause, E. (2009). Understanding Cultural and Linguistic Barriers to Health Literacy. Online Journal Of Issues In Nursing, 14(3). Retrieved from http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol142009/No3Sept09/Cultural-and-Linguistic-Barriers-.html
Tunkel, A. (2016). Fever. Merck Manuals Professional Edition. Retrieved 1 July 2016, from http://www.merckmanuals.com/professional/infectious-diseases/biology-of-infectious-disease/fever
Yamanishi, K. (1992). Pathogenesis of human herpesvirus 6 (HHV-6). Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/1365539
