Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Roseola (Exanthem Subitum)
An acute disease of infants and young children characterized by a high fever of 3to 4-day duration and the appearance of a faintly erythematous maculopapular rash after defervescence.
I. Etiology: Confirmation not available, but evidence suggests human herpesvirus 6 (HHV-6).
II. Incidence
A. Most commonly seen in the spring and fall, although it does occur year round.
B. Infants and preschoolers are the most susceptible, with 95% of the cases seen between 6 months and 3 years of life.
C. Peak incidence is between 6 and 24 months. Ninety percent of cases are seen in children under 2 years of age.
III. Incubation period: Estimated to be 7 to 17 days; average 10 days
IV. Communicability: Probably for duration of illness
V. Subjective data
A. Abrupt onset of high fever (up to 103F to 105F [39.4C to 40.5C]) for 3 to 7 days
B. Irritability
C. May present with a febrile convulsion
D. Generally, symptoms are minimal.
VI. Objective data
A. Child appears nontoxic.
B. Slight edema of eyelids
C. Mild pharyngitis
D. Suboccipital and cervical lymphadenopathy may be present.
E. Typical clinical course
1. Spiking high fever and irritability for 3 to 4 days
2. Fever falls by crisis to normal or subnormal.
3. Exanthem appears just before or shortly after temperature returns to normal. It is a faintly erythematous macular or maculopapular eruption, first appearing at the nape of the neck and behind the earlobes. Spreads mainly to the trunk, rarely on the face, and disappears within 24 hours.
F. Physical exam findings are generally unremarkable.
G. Laboratory findings.
1. Progressive leukopenia to 3,000 to 5,000 WBCs on the third to fourth day of illness with a relative lymphocytosis of up to 90%
2. Urinalysis and culture should be done to rule out urinary tract infection.
VII. Assessment
A. Diagnosis is based mainly on clinical findings, particularly if other cases are present in the community.
B. Differential diagnosis
1. Rubella: Prodromal period of mild catarrhal symptoms and lowgrade fever; rash concurrent with fever
2. Rubeola: Prodromal period with variable fever, which elevates to 103F to 104F (40C) with appearance of rash and remains elevated. Also, cough, coryza, and conjunctivitis are present during prodrome, and Koplik’s spots appear on second to fourth day of prodromal period.
3. Meningococcemia: Fever, chills, headache, nuchal rigidity, nausea, vomiting, and petechial rash are present. In children older than 2 years, Brudzinski’s and Kernig’s signs are positive. Lumbar puncture is positive.
4. Urinary tract infection (prior to onset of rash): Do urine culture.
5. Other acute febrile illnesses
VIII. Plan
A. Treatment is symptomatic.
B. Acetaminophen, 10 to 15 mg/kg every 4 hours, or ibuprofen, 5 to 10 mg/kg every 6 to 8 hours
C. Tepid baths
D. Encourage fluids.
IX. Education
A. Do not overdress child.
B. Try to keep environment calm and quiet.
C. Use tepid water for bath; allow to air dry, or rub skin briskly to increase skin capillary circulation, facilitating heat loss.
D. Bathe every 2 hours as necessary.
E. Keep child well-hydrated; encourage liquids. Do not worry about decreased appetite for solids.
F. Give small amounts of liquids frequently; try Popsicles, Jell-O, juice, sherbet.
G. Do not expose to other children until well.
H. One attack probably confers permanent immunity.
I. Disease is self-limited.
X. Follow-up: Maintain daily contact with parents until diagnosis is confirmed.
XI. Complications: Febrile convulsions
XII. Consultation/referral
A. Prolonged high fever (after rash appears)
B. Febrile convulsions
C. Signs of meningeal irritation
D. Child with immune deficiencies