Atypical viral exanthems associated with community-acquired respiratory viruses in immunocompromised pediatric patients: a case series

Abstract

Atypical viral exanthems can pose significant diagnostic challenges in immunocompromised pediatric patients, where rashes may mimic drug reactions, infections, or graft-versus-host disease-conditions that require different and sometimes conflicting management strategies. These fragile patients, immunocompromised because of their underlying disease or treatment, require accurate and timely diagnosis to guide appropriate care. When the etiology is infectious, recognition also has public health and infection control implications. We describe four cases of atypical exanthems in children with oncohematologic diseases or solid tumors associated with community-acquired respiratory viruses-rhinovirus or respiratory syncytial virus (RSV)-confirmed by molecular diagnostics. The rashes were transient, nonpruritic or mildly pruritic, and predominantly involved the trunk and extremities. All rashes resolved spontaneously with no change in current therapy and no invasive procedures were required. These findings underscore the role of respiratory viruses such as rhinovirus and RSV in cutaneous manifestations and highlight the utility of noninvasive molecular testing to avoid misdiagnosis and overtreatment. Reports of such viral exanthems remain scarce in the literature. Our case series expands the clinical spectrum of rashes associated with rhinovirus and RSV and underscores the importance of a multidisciplinary approach to cutaneous manifestations in pediatric oncology patients.

Keywords: atypical viral exanthem; community-acquired respiratory viruses; immunocompromised pediatric patients; skin rash; urgent care.

Figure 1

Clinical presentation of Patient 1: A 10-year-old boy with acute lymphoblastic leukemia and post-HSCT status, presenting with a papulo-erythematous rash due to rhinovirus. The rash predominantly affected the legs (A), arms (B), and face.

Figure 2

Clinical presentation of Patient 2: A 3-year-old girl undergoing reinduction therapy for acute lymphoblastic leukemia, presenting with a papulo-erythematous rash caused by rhinovirus. The rash involved the cheeks (A), trunk, and limbs (B).

Figure 3

Clinical presentation of Patient 3: A 10-year-old girl with stage 3B renal cell carcinoma, showing a diffuse erythematous maculopapular rash associated with respiratory syncytial virus. The rash affected the trunk (A), limbs and hands (B,C).

Figure 4

Clinical presentation of Patient 4: A 3-year-old girl with a history of aplastic anemia post-HSCT, presenting with a papulo-erythematous rash caused by respiratory syncytial virus. The rash involved the trunk (A), extremities and palms (B).