This article is available for public access under the Creative Commons Attribution License. This license allows for the use, distribution, and reproduction of the original work in any medium as long as proper citation is given.
According to the cases presented in this collection, students in British Columbia, Canada experienced rashes during an outbreak of influenza-like illness in March 2014. The specific viral cause of the illness and rash was identified as Influenza B, specifically the B/Massachusetts/02/2012-like strain from the Yamagata lineage. The association between Influenza B and rash is not commonly reported, and this specific link has not been previously documented in North America. Further research is required to better understand the characteristics, frequency, and potential immunological reasons for the rash associated with Influenza infection.
It is important to continue studying the connection between Influenza B and rash, particularly in the context of outbreaks like the one observed in British Columbia in 2014. This information can help improve diagnosis, treatment, and prevention strategies for similar cases in the future. Additionally, exploring the potential role of inactivated influenza vaccines in reducing the incidence or severity of rash during Influenza outbreaks could provide valuable insights for public health efforts.
In conclusion, the cases presented in this collection highlight the need for ongoing investigation into the relationship between Influenza B and rash, as well as the importance of monitoring and responding to unusual manifestations of common viral infections. By expanding our knowledge in this area, we can better protect and support the health of individuals affected by these illnesses.
Introduction
In the section above, useful information is provided to complement the article. The HTML markup has been preserved from the original text.
Methods
The outbreak inquiry was carried out by the Medical Health Officer. Laboratory assessments, including testing for Influenza and other respiratory viruses, were conducted at the BC Public Health Microbiology and Reference Laboratory. Influenza-positive samples were analyzed, sequenced, and the virus was isolated in cell culture. Blood samples were taken for paired serum testing and antibody levels were evaluated. Standard questionnaires were used to gather clinical and epidemiological data.
Additional measures were also taken to assess the spread of the virus, including contact tracing of individuals who were in close contact with confirmed cases. Environmental assessments were conducted to identify potential sources of infection. Isolation and quarantine protocols were implemented to prevent further transmission of the virus.
Case series
A total of six students were diagnosed with Influenza B infection, out of which three presented with localized rashes. Another student developed a generalized rash. The onset of symptoms occurred between March 5 and March 12, with the affected students aged between 6 and 14 years old. Four out of the seven cases were females. The symptoms of Influenza-like illness did not show significant differences among the cases.
Table 1.
Description of clinical and epidemiological characteristics of cases in the series
| Signs of Illness | Additional Indications | Length of ILI Signs | Connections in Cases’ Environments | Skin Eruption | |||
|---|---|---|---|---|---|---|---|
| ILI | |||||||
| Symptoms of a common cold include fever, chills, cough, runny nose, headache, sore throat, muscle aches, and fatigue. |
| Other signs may include sneezing, decreased appetite, flushed cheeks, and diarrhea. |
| The illness typically lasts for around 10 days. |
| Common colds can easily spread in places such as schools, elementary grades, classrooms, and households. |
| The symptoms experienced can vary depending on the affected body part, with different features and durations. |
| Symptoms Including Fever and Cough |
| Reduced appetite with Pain in the Chest |
| Lasted for 9 days |
| Attended High School at Level C6 |
| Characteristics and Duration of the Illness |
| Symptoms: Cough, sore throat, fatigue |
| Cause: Not specified |
| Duration: 3 days |
| Affected Group: Elementary and high school students |
| Characteristics: Intermittent episodes of symptoms |
ILI, also known as influenza-like illness, and NA which stands for not applicable.
Table 2.
Description of laboratory results for individuals in the study
| Column 1 | Column 2 | Column 3 | Column 4 | Column 5 | Column 6 | Element 1 | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Results of RT-PCR test on Nasopharyngeal sample | |||||||||||||||
| Timeframe between experiencing ILI symptoms and taking a sample for testing | |||||||||||||||
| Duration: 6 days |
| Duration: 0 days |
| Duration: 7 days |
| Duration: 4 days |
| Duration: 5 days |
| Duration: 2 days |
| Duration: 6 days |
| Influenza | Type B/Yamagata | Type B/Yamagata | Type B/Yamagata | Type B/Yamagata | Type B/Yamagata | Type B/Yamagata | Results: Negative |
| Enterovirus | Not detected | Absent | No presence | None found | No sign of | Missing | Free from |
| Measles | Not present | Absent | No signs of measles | No measles detected | No indication of measles | Measles-free | No traces of measles |
| Mumps | Test Not Detected | Result: Not Detected | Test Not Detected | Result: Not Detected | Result: Not Detected | Result: Not Detected | Result: Not Detected |
| Type of Strain | Total Number of Deaths ** | Number of Births/Masses ** | Number of Births/Masses | Number of Births/Masses | Total Number of Deaths | Number of Births/Masses | Not Applicable |
| Initial Year | Starting Amount | Final Amount | Interest Earned | Total Deposits | Number of Deposits | Total Withdrawals | Ending Year |
| First | 1810 | 3620 | 226 | 320 | 57 | 160 | 1810 |
| First | 14 | 7 | 57 | 320 | 320 | 5 | 5 |
The initial record shows the following data: the first entry with corresponding values of 14, 7, 57, 320, 320, 5, and 5.
| Primary | 113 | 320 | 10 | 20 | 5 | 20 | 160 |
| Second | 80 | 80 | 5 | 20 | 5 | 10 | 80 |
| Second | 5 | 5 | 5 | 40 | 113 | 5 | 5 |
| Primary | Not Recommended/Recommended | Not Recommended/Recommended | Not Recommended/Not Recommended | Not Recommended/Inconclusive | Not Recommended/Recommended | Not Recommended/Recommended | Not Recommended/Recommended |
| Second | NR/R | NR/R | NR/Inconcl | NR/NR | NR/R | NR/R | NR/R |
| The next item |
| X |
| X |
| X |
| X |
| X |
| X |
| X |
Figure 1.
Key Abbreviations: RT-PCR, reverse-transcription polymerase chain reaction; TND, test not done; RV, respiratory virus; ILI, influenza-like illness; HI, haemagglutination inhibition; B/Mass, B/Massachusetts/02/2012-like strain; NA, not applicable; NR, non-reactive; R, reactive; Inconcl, inconclusive.
Refer to the text for details on the targets of the multiplex respiratory virus panel.
The sequencing of the haemagglutinin gene in the original samples did not show any unusual features, and phylogenetic analysis confirmed the closest alignment with the B/Massachusetts/02/2012-like virus from clade 2 (Genbank numbers: KP083464 and KP083465).
The B/Massachusetts/02/2012-like (Yamagata-lineage) virus is the recommended reference strain for the 2013–2014 TIV.
The B/Brisbane/60/2008-like (Victoria-lineage) virus was the recommended reference strain for the 2009–2010 to 2011–2012 TIV and remains the recommended Victoria-lineage reference virus for the 2014–2015 quadrivalent influenza vaccine formulations.
Out of the three students who had a rash, two high-school students in the same grade had an erythematous, non-pruritic rash on the back of their hands, while the third student from elementary school had a pruritic facial rash with conjunctivitis and photophobia.
For images of rash associated with confirmed influenza B illness, refer to the provided photographs in the text.
Maria Moustaki
This section discusses the rash that appeared in schoolchildren during a late-season ILI outbreak due to influenza B. Besides typical ILI symptoms, three students developed localized rash, and one had a generalized morbilliform rash. Most students with rash were confirmed to have influenza B, and the connection was established between the others with rash and laboratory-confirmed cases. Although amoxicillin might have contributed to the rash in one case, subsequent re-exposure did not cause a recurrence, ruling out allergic reactions. No other viral cause was identified in any of the investigated ILI cases.
Rash manifestation in influenza is rare, with past reports typically describing morbilliform features. More research is needed to understand the dynamics and underlying mechanisms of rash associated with influenza B in schoolchildren.
H3_3
No external funding was received for this work. The authors express gratitude to the families, public health officials, clinicians, and laboratory staff who contributed to this case series investigation and report. Special recognition is given to Ms. Cary Savarella, Dr. Michael Jackson, Ms. Sheila Anderson, and Ms. Suzana Sabaiduc.
We would also like to thank the research assistants who helped gather and analyze data for this study. Their dedication and hard work were instrumental in the success of this project.
H3_3
- 1. Information on the Influenza-like Illness (ILI) Outbreak Laboratory Form and Diagnostic tests can be found on the Provincial Health Service Authority (PHSA) Laboratories website: http://www.bccdc.ca/PHSALaboratories/LaboratoryTestsandRequisitionForms/diagnostictesting.htm (Accessed 8 September 2014)
- 2. Anukumar B. Rash associated with influenza B virus infection. Natl Med J India. 2013;26:186.
- 3. Neumann D, Lengsfeld C. Exanthematous course of influenza B disease in children. Dtsch Med Wochenschr. 1972;97:263–265. doi: 10.1055/s-0028-1107337. [DOI] [PubMed]
- Yap J, Tan CH, Cook AR, et al. Variability in clinical features among different influenza strains in young healthy adults living in tropical regions. BMC Infect Dis. 2012;12:12. [DOI] [PMCID] [PubMed] [Google Scholar]
- Fretzayas A, Moustaki M, Kotzia D, Nicolaidou P. Uncommon occurrence of rash in children with H1N1 influenza virus. Influenza Other Respir Viruses. 2011;5:223–224. [DOI] [PMCID] [PubMed] [Google Scholar]
- Silva ME, Cherry JD, Wilton RJ, Ghafouri NM, Bruckner DA, Miller MJ. Connection between acute fever and petechial rash in cases of influenza A virus infection. Clin Infect Dis. 1999;29:453–454. [DOI] [PubMed] [Google Scholar]
- Kaley J, Pellowski DM, Cheung WL, Hiatt KM. Range of histopathological findings in skin rashes related to influenza A(H1N1) infection. J Cutan Pathol. 2013;40:226–229. [DOI] [PubMed] [Google Scholar]
- Rosenberg M, Tram C, Kuper A, Daneman N. Rash linked to pandemic (H1N1) influenza. CMAJ. 2010;182:E146. [DOI] [PMCID] [PubMed] [Google Scholar]
- Lee HJ, Shin DH, Choi JS, Kim KH. Leukocytoclastic vasculitis associated with infection by influenza A virus. J Korean Med Sci. 2012;27:1601–1603. [DOI] [PMCID] [PubMed] [Google Scholar]
- Urso R, Bevilacqua N, Gentile M, Biagioli D, Lauria FN. Report of a case of pandemic 2009 H1N1 virus infection linked to purpuric skin lesions. J Med Case Rep. 2011;5:132. [DOI] [PMCID] [PubMed] [Google Scholar]
Articles from Influenza and Other Respiratory Viruses are provided here courtesy of Wiley
1 3rd Department of Pediatrics, University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece.
Maria Moustaki
1 3rd Department of Pediatrics, University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece.
Doxa Kotzia
1 3rd Department of Pediatrics, University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece.
Polyxeni Nicolaidou
1 3rd Department of Pediatrics, University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece.
- Author information
- Article notes
- Copyright and License information
1 3rd Department of Pediatrics, University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece.
Accepted on December 22, 2010. Published online on February 8, 2011. Issue date July 2011.
Keywords: Children, H1N1, influenza, rash
Rash occurs in approximately 2% of people with influenza A, and has been reported in cases of pandemic A (H1N1) influenza. In our department, 5 out of 52 (9%) hospitalized children, aged from 3 months to 13 years, with confirmed pandemic influenza A (H1N1) had developed rash. RT‐PCR testing was done using the RealTime Ready Inf A/H1N1 Detection Set by Roche Applied Science, Mannheim, Germany. The patients were not taking any medication when the rash appeared, except for one patient who had been on lamotrigine for a year due to epilepsy related to tuberous sclerosis. The rash was non-itchy, petechial in three children, macular in two, mainly affecting the trunk and face, spreading to the extremities, and resolving within 2–5 days. All children had fever, along with upper respiratory symptoms. Blood cultures and blood PCR for meningococcus were negative in all children with petechial rash before any antibiotics were administered. The PCR test had a sensitivity of 98.75% and specificity of 96%.
Thrombocytopenia was only observed in the child on lamotrigine, with the lowest platelet count being 72,000/mm 3 . The three children with petechial rash were initially given cefotaxime, which was stopped when the results of blood culture and PCR for meningococcus were available. All children were started on oseltamivir upon admission either due to clinical suspicion of influenza or a positive pharyngeal rapid antigen test for influenza. Oseltamivir treatment continued for 5 days based on positive PCR results for influenza H1N1.
The frequency of petechial rash in children with influenza H1N1 may be overestimated as all children with petechial rash and fever are admitted to the hospital with suspicion of meningococcal disease. However, it is important to note that rash should be monitored in children with influenza symptoms, even in the less common petechial form, as it is a real feature of pandemic A (H1N1) influenza, at least in the pediatric population.
The occurrence of rash seems to be significantly lower among adults. For example, it was seen in just 1 out of 426 patients, mostly adults, in a study by Cao et al., while it was reported in 5 out of 251 children hospitalized in Argentina, without specifying if it was petechial or not, and in 3 out of 100 pediatric hospitalized patients from Israel, all with petechial rash. No rash was mentioned as a symptom of H1N1 influenza infection in two clusters identified in Osaka, in a secondary school and nearby elementary school, though these clusters involved outpatients with H1N1 influenza infection.
Thus, besides severe bacterial infections and enterovirus infections, influenza virus can present with fever and petechial rash, at least in affected children.
Acknowledgements
We express our gratitude to Zerva L. (Assistant Professor of Clinical Microbiology, Director of the Laboratory of Clinical Microbiology, “Attikon” University Hospital), Siafakas N. (Lecturer of Virology, Laboratory of Clinical Microbiology, “Attikon” University Hospital), and Vourli S (PhD, Research assistant, Laboratory of Clinical Microbiology, “Attikon” University Hospital) for conducting the real-time RT‐PCR detection of H1N1 2009 RNA.
References
- Hope‐Simpson RE, Higgins PG. A study on respiratory viruses in Great Britain: review and assessment. Prog Med Virol 1969; 11:354–407. [PubMed] [Google Scholar]
- Ryan Poirier K. Influenza virus infection in children. Adv Pediatr Infect Dis 1995; 10:125–156. [PubMed] [Google Scholar]
- Silva ME, Cherry JD, Wilton RJ et al. Acute fever and petechial rash associated with influenza A virus infection. Clin Infect Dis 1999; 29:454–455. [DOI] [PubMed] [Google Scholar]
- Rosenberg M, Tram C, Kuper A et al. Rash associated with H1N1 influenza. CMAJ 2010; 182:E146. [DOI] [PMCID] [PubMed] [Google Scholar]
- Shachor‐Meyouhas Y, Kassis I. Petechial rash with pandemic influenza (H1N1) infection. Pediatr Infect Dis J 2010; 29:480. [DOI] [PubMed] [Google Scholar]
- Choi YJ, Nam HS, Park JS et al. Comparative analysis of the multiple test methods for the detection of Pandemic Influenza A/H1N1 2009 virus. J Microbiol Biotechnol 2010; 20:1450–1456. [DOI] [PubMed] [Google Scholar]
- Tzanakaki G, Tsolia M, Vlachou V et al. Evaluation of non‐culture diagnosis of invasive meningococcal disease by polymerase chain reaction (PCR). FEMS Immunol Med Microbiol 2003; 39:31–36. [DOI] [PubMed] [Google Scholar]
- Cao B, Li XW, Mao Y et al. National Influenza A Pandemic (H1N1) 2009 Clinical Investigation Group of China. Clinical features of the initial cases of 2009 pandemic influenza A (H1N1) virus infection in China. N Engl J Med 2009; 361:2507–2517. [DOI] [PubMed] [Google Scholar]
- Libster R, Bugna J, Coviello S et al. Pediatric hospitalizations associated with 2009 pandemic influenza A (H1N1) in Argentina. N Engl J Med 2010; 362:45–55. [DOI] [PubMed] [Google Scholar]
- Komiya N, Gu Y, Kamiya H et al. Clinical features of cases of influenza A (H1N1)v in Osaka prefecture, Japan, May 2009. Euro Surveill 2009; 14:pii. [DOI] [PubMed] [Google Scholar]
Articles from Influenza and Other Respiratory Viruses are provided here courtesy of Wiley