a. First Disease: Rubeola (Otherwise known as Measles)

Historically, it was considered the greatest killer of children. (1).  It still causes more than 1 million deaths worldwide (especially in developing countries). (1).  Although the child fatality rate in industrialized nations is only 0.1%-0.2%, in developing countries, the fatality rate can be as high as 10%.  It is highly transmissible, with an infectivity rate of 76%.  It is classically identified as cough, coryza, and conjunctivitis.  Children may also have photophobia and fever.  Patients will also have Koplik spots in the mouth. Infection leads to a prolonged immunosuppression, which accounts for the morbidity and mortality.  According to a CDC report form 1999, measles is no longer indigenous to the US (1).

Measles is contagious just before the prodromal symptoms until four days after the onset of the rash.

The rash begins on the fourth or fifth day of symptoms, and begins on the face and behind the ears. It then spreads to the trunk and extremities.

Summary of Symptoms:
Days 0-1:  Prodrome begins
Days 2-3 Koplik spots appear
Day 4-5:  Morbilliform rash begins
Days 6: Koplik spots regress
Days 7-8:  Rash is most intense
Day 10:  Rash begins to resolve

Treatment is generally supportive with attention to hydration, and quarantine until no longer infectious.  The WHO also recommends supplementation with Vitamin A (because these levels drop during the infection, and in developing countries these levels may already be very low. Additionally, there is a higher rate of blindness associated with vitamin A deficiency. (1)

The most common serious and sometimes fatal complications from measles usually occur in developing countries, and include:  dehydration (from diarrhea), pneumonia, vitamin A deficiency (leading to corneal ulceration and blindness) and immunosuppression. (1)

Suspected cases of measles are reportable to the public health department, and a blood sample from the patient should be obtained for confirmatory testing. (1)

b. Second Disease:  Scarlett Fever

Scarlet Fever is caused by group a beta-hemolytic streptococcal infection.  It is spread by airborne respiratory droplets, and the infection rate is increased in crowded situations (schools, dorms, etc.) (2)

Although the disease today is usually benign, if a nephrogenic strain is causing the infection, glomerulonephritis can occur in 10-15% of children.  Risk of acute rheumatic fever following untreated strep infection is estimated at 0.3-3%.  The peak incidence is children 4-8 yrs old, and by the time children are 10, about 80% have developed lifelong antibodies against streptococcal exotoxins.  Interestingly, scarlet fever is rare in children younger than 2 because of maternal anti-exotoxin antibodies.

Scarlet Fever has a 1-4 day incubation period, and the illness tends to start with an abrupt fever, sore throat, vomiting, abdominal pain and myalgias.  Rash usually appears 12-48 hours after fever.

Physical exam may reveal:
White strawberry tongue (white coating on the tongue with reddened papillae projecting through).
Rash appears as a fine sandpaper rash, and is accentuated in the skin folds (neck, axillae, antcubital fossae, and inguinal and popliteal areas).
Circumoral pallor may also be seen.
As the rash resolved, the patient may have desquamation of the palms, fingers and toes. This may also occur in the axillae and groin.

Penicillin remains the treatment of choice. (2). The child should not return to school until after 24 hours of antibiotic therapy.

c. Third Disease: Rubella (Sometimes called German Measles)

This is a viral infection that primarily causes morbidity and mortality (to the fetus) through teratogenic effects when pregnant women contract the disease (especially in first trimester). (3)  Fortunately, with vaccination, congenital rubella syndrome is rarely seen in the US. (3).

The virus is spread via aerosolized particles from the respiratory tract. Nearly half of the infected individuals are asymptomatic.  If there are symptoms, they are mild and include conjunctivitis, sore throat, headache, low grade fever, and lymphadenopathy (tender).  Patients may also complain of pain on lateral and upward eye movement.  The maculopapular rash may be pruritic (especially in adults). Some have nicknamed this rash the ‘3-day Measles’ because the rash (which starts on the face, travels to the trunk and extremities) disappears on the 3rd day.

Congenital rubella syndrome results in growth delay, mental retardation, hearing loss, congenital heat disease (PDA or pulmonary artery stenosis in 50%), eye and neurologic abnormalities. (3)

Treatment is supportive.


d. Fourth Disease:  Sometimes called Dukes Disease.

No specific cause has ever been identified.   Many believe Dukes disease was actually a nonspecific viral rash.  Some believe ‘’fourth disease is actually an infection related to endotoxin-producing Staphylococcus Aureus. (4).

e. Fifth Disease:   Sometimes called Slapped Cheek disease is identified as Erythema Infectiosum.

This infection is actually caused by the Parvovirus B-19.  It usually occurs in children 3-15 yrs old. Everyone has an easy time remembering this disease if you’ve seen it once.  Up to 1/3 will have a fever.  The eruption of the rash signals the end of the contagious period, so children can attend school once the rash develops.

The rash has 3 phases: The slapped cheeks, then in 1-4 days a malar rash and macular to Morbilliform rash on the extremities occurs.  Finally the rash will fade into a lacy bd pattern.  The lacy rash may last for 3 days to 3 weeks.

Most cases are self-limited and require no treatment. (5)  Adult women are more likely to develop a self-limited acute arthropathy (sometimes without cutaneous eruption).  Individuals at risk for severe problems are those patients who are immunocompromised, and sickle cell anemia patients who are at risk for transient aplastic crisis.  In fact, Parvovirus B-19 infection is the only infectious cause of transient aplastic crisis and is believed to be the cause of over 80% of patients with sickle cell disease. (6)

f. Sixth Disease: Roseola Infantum

It is caused by a herpes virus (type 6). (7) This infection presents with fever, fussiness, diarrhea which lasts for 3 days. When the fever breaks, the characteristic rash appears. By the time children reach 1 year old, 86% will have acquired antibodies to this infection. Roseola peaks in the spring and fall. Because of the fevers, the major morbidity is seizures, which occurs in 6-15% of children. (7)

2. Is there a Sixth disease?

Yes, see question #1.  Sixth disease is Roseola!

3. What are the treatments for these six diseases?

For the majority it is simply supportive treatment, except Scarlet Fever (Treatment with Penicillin).  Prevention of Measles is through vaccination and herd immunity.