The eruption on the mucous surfaces is very slight; Sticker has observed a mottled appearance of the mucous membrane of the mouth, Pospischill an annular, Heiman a macular exnanthem. The writer has twice seen on the fourth clay of the disease small petechite on the hard palate (also on the skin of the lower part of the face).
The lymph-glands may become enlarged in connection with the disease, at the angle of the jaw, in the neck, under the lobe of the ear, also on the elbow. Pospischill has found the spleen in all cases more or less enlarged—once or twice among my own cases a spleen tumor was present. There may be pains in the joints, once even fluctuation over the patella is said to have occurred. F. v.ller reports severe attacks of sciatica. There is a tendency to constipation and the pulse sometimes is rapid and somewhat irregular. In my own cases I have frequently noticed indicanuria. In a four-year-old there was present on the fourth day a polynuclear leucocytosis (27,200). As for complications, Tripke claims to have seen one case of hemorrhagic and one of catarrhal nephritis.
Course and eruption, which is often the only symp tom, may, as already mentioned, temporarily subside and reappear. During these latent stages of the disease, especially in dispensary cases, one may make the mistake of regarding the disease as at an end.
The duration of the disease (according to observation in the dis pensary), is said to be 3 to 5 clays (Sticker, Berberich); for a longer duration the patient's carelessness may be responsible; other clinicians, myself included, estimate the total duration S to 10 days.
After that the disease always or almost always terminates in recov ery. It is extremely rare for the disease to run a different, more severe course or end fatally.
The following is noteworthy: I. The morbilloid (resembling measles) type of the disease in chil dren under three years of age according to observations of Pospischill and Trumpp the erythema infectiosum in very young children deviates from the type described above. The younger the patient the more closely does the clinical picture resemble that of measles. The eruption can not be differentiated from that of measles, the catarrhal symptoms of measles are present, so that the diagnosis at first sight is that of measles. Koplik spots, however, are absent, the temperature soon falls to normal after the prodromal symptoms, and, furthermore, annular, net- or map-like figures make their appearance on the trunk and extremities.
II. Pospischill describes another type of erythema infectiosum, the "Scarlatinoid" (probably identical with the Scarlatinois of Trainnier). In place of the formation of rings, there is seen on the trunk, shoulders, but tocks, forearms and thighs a diffuse redness or abundant e flioreseences typ ical of scarlatina, only somewhat larger, while the distal parts remain free. There is no angina. The peculiar (wheal-like) puffiness and redness of the cheeks and the rapid fall of temperature aid in the differential diagnosis.
III. One very severe case with fatal termination is said to have occurred during the epidemic described by Sticker: Ilalbay reports t he case in Berberich's work: Two sisters came down with the disease at the same time; in the one its course was typical, in the other assumed a grave form (li,emor rhagic), accompanied by persistently high temperature, appearance of bluish-red isolated and confluent spots, the size of a nickel, formation of vesicles, desquamation, bluish-black discoloration of the skin, swelling of the skin on hands and feet. Finally a black, bloody crust covered
the whole body. Death on the twelfth day.
Two cases of Tripke proved fatal, but the erythema infectiosum occurred in patients having pneumonia.
In the differential diagnosis, the following diseases are to be considered: I. Erythema Exsudativam Multiforme. From this disease erythema infectiosum differs in that it runs its course as a rule without fever, pain and severe constitutional disturbance, the eruption begins on the face, the back of hands and feet remaining free, it does not become vesicular, bullous or like herpes, is hot to the touch and as a rule does not last longer than ten days and shows no tendency to relapse. Cases belonging to the group of erythema exsudativum may also occur in epidemics (pellagra, acrodynia, erysipelas).
II. Pityriasis rosea is accompanied by itching and followed by desquamation, does not involve the face and runs a chronic course.
HI. In scarlatina, aside from the severe constitutional symptoms, the trunk quite early in the disease is the seat of the eruption. The characteristic punctate rash of scarlatina is perhaps never seen in ery thema; the same is true of the desquamation in leaves.
IV. Differentiation from measles is easy, when as is the there is no prodromal fever and absence of the catarrhal symptoms and eruption on the mucous membranes. Another differential point is that the eruption in erythema infectiosum involves the forehead, scalp and sides of thorax either quite late in the disease or not at all.
V. Erythema infectiosum is perhaps most frequently mistaken for R&heln (rubella). One distinct feature about the eruption is its marked tendency to become confluent, to form rings and net-like figures, to appear on the forearms and legs before it involves the trunk, where, ofttimes, it is entirely missing. Rubella eruption rarely occurs in large spots and does perhaps never lead to the formation of map-like figures, it remains out only 2 to 4 days and has a period of incubation from 2 to 3 weeks.
The persistence of the large spots as also the character of the exan them serve to distinguish it from the "fourth disease." infectiosum is a disease per se, not identical with measles, scarlatina, rubella and the "fourth disease." Having passed through these exanthemata no immunity is afforded against infection with erythema infectiosum. All observers state that it has occurred in children who previously had scarlatina and measles. Bei- bet-kb, Schmid and the writer have also seen it attack children who had had rubella. One attack of erythema infectiosum usually confers per manent immunity from subsequent attacks.
Treatment.—Keeping the patient in the room and bed, perhaps on a fever diet, is all that is required.