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Okay, next is rubella. This is a long incubation period disease which, for children, is 17 days from exposure to onset of rash. Now with adults you have considerable prodrome, which goes unrecognized in children. Adults will tell you they have pain on lateral gaze, and they will have headache and sometimes photophobia. Also lymphadenopathy, subauricular and posterior auricular. Adults may not recognize it but they will just tell you it hurts when they comb their hair. The rash is erythematous, maculopapular but the lesions are discreet. They start centrally, spread peripherally and a very important thing is the rash, particularly in older people, is pruritic. Therefore it frequently, since they have minimal fever, it gets written off as a contact dermatitis. A number of years ago we had circumstances where an obstetrician got rubella but because his rash was pruritic his colleagues said, “Don’t worry about it. It’s contact dermatitis.” Then two nurses got it 17 days later and all told 240 pregnant women were exposed. So when you think of contact dermatitis, particularly in a pregnant woman, make sure it’s not rubella.
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So this is an adolescent. His chest is erythematous, maculopapular and discreet. This is another patient with a little bit more marked lesions, and this is showing posterior auricular lymphadenopathy. Adults very frequently have both arthralgias and arthritis as well.
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The next is varicella and this also is a long incubation period disease, with about 16 days to the onset of rash. Now you’ll see in textbooks about a 1-2 day prodrome but I really don’t think there is much of a prodrome. Usually the first lesion is rash but it’s frequently overlooked because it’s only one or two lesions. So the patients are contagious when they have rash, they are not contagious before they have a rash. The rash starts centrally, spreads peripherally. The main manifestation are vesicles but the vesicles start out as papules and maculopapule vesicles and scabbing over. And there are more lesions centrally than peripherally. At any one time you’ll see lesions at various stages. This is a young adult with mild disease. Here are the lesions at different stages. Here are some more classic teardrop-like lesions. This is an old fashioned Zenk-prep showing giant cells. The reason I show this is that the diagnosis of varicella is not always easy, and frequently it is over-diagnosed and this creates havoc if you have immunocompromised patients exposed. So you need to make a diagnosis and the way to do that today is direct antigen test on a lesion. Now if the laboratory … if the people in the lab aren’t very sophisticated you may get back a negative result when actually it was not an adequate preparation. So any negative result, you want to make sure that the lab reports cells. If they don’t report epithelial cells then the test is not valid and so in a way, old Zenk was good because it was very clear. You had to see cells and you had to see abnormal cells. So if you get a test, a direct antigen test on a vesicle, and they don’t tell you there were cells there, you should question them about that.
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