Rashes among schoolchildren — 14 states, October 4, 2001-February 27, 2002

Morbidity and Mortality Weekly Report, March 1, 2002

Fourteen states (Arizona, Connecticut, Florida, Georgia, Indiana, Mississippi, New York, Ohio, Oregon, Pennsylvania, Texas, Virginia, Washington, and West Virginia) have reported investigations of multiple schoolchildren who have developed rashes. This report summarizes the investigation by state and local health departments of these rashes, which have occurred during October 2001 through February 2002, and provides examples for four states. Preliminary findings indicate that further investigation is needed to determine whether a common etiology for these rashes exists.

UNITED STATES

The first reported incident occurred October 4, 2001, in Indiana, followed by cases in Virginia that began November 20. Subsequent cases of rashes began in late January and occurred as recently as February 21. Rashes have been reported primarily from elementary schools but also among students in a few middle and high schools. The number of affected students in each state ranges from <10 to approximately 600. A few teachers and school staff have been affected, but rarely parents or siblings.

Characteristics of the rashes vary, but onset has generally been acute, typically with maculopapular eryrhemarous lesions--possibly in a reticulated pattern-on the face, neck, hands, or arms; duration of the rash varied but in most reports it was highly pruritic. The rashes were not attributed to a defined environmental exposure or infectious agent. Children with rashes were afebrile and usually had no other associated signs or symptoms. The rashes lasted from a few hours to 2 weeks and appeared to be self-limiting. Secondary transmission has not been reported, but in-school "sympathy" cases have reportedly occurred. Diagnoses by clinicians who have examined children have included viral exanthem, contact or atopic dermatitis, eczema, chemical exposure, impetigo, and poison ivy. Approximately 40 serum samples collected in four states have been PCR or IgM negative for parvovirus B19 (1); 22 nasal swab samples have been negative for enterovirus. Environmental assessments have not ideniified environmental causes.

CASE REPORTS

Indiana. During October 4--November 2, 2001, rashes appeared among 18 third-grade students in an elementary school of 390 students; one substitute teacher also developed rash. No rashes among family members were reported. The rash most often began on the face, then spread to the upper extremities; most rashes occurred on exposed skin. Clinical signs--including reddish welt-type itchy rash on face and upper extremities, swollen eyes, and smooth pink cheeks--degrees of coloration, and prominence of rash varied among the children. Diagnoses in the few children examined by family physicians varied and included contact dermatitis, chemical exposure, impetigo, and poison ivy. Because parvovirus B19 infection was diagnosed in one third-grade student on August 30, 2001, the Indiana State Department of Health collected serum specimens from four students with rashes to assess whether they had parvovirus 1319 infection. All specimens tested negative for the presence of IgM antibodies. Laboratory data analysis, interview s, a building survey, and examination of the children did not identify a cause for the rashes.

Pennsylvania. The initial report of rash occurred on January 31, 2002, among 54 elementary school students who had contact dermatitis diagnosed by a local health-care provider. To date, approximately 575 cases of rashes have been reported to the Pennsylvania Department of Health; 58 schools and child-care centers have reported cases (range: one-168 cases per facility). Most cases are in elementary and middle school students, with female cases outnumbering males. The rash has been characterized as bright-red, itchy or burning, and macular, occasionally with an urticarial or papular component. The rash may be evanescent, or remain for as long as 2 weeks; recurrent cases have been reported. There have been no other associated symptoms. Among the 54 students reported initially, serologies for parvovirus B19 were drawn on 13 cases; all were negative for IgM. PCR for parvovirus B19 was negative for 10 cases; results are pending for the remainder. Another health-care provider reported that results of nonserological (biopsy) specimens from his patients were consistent with viral exanthem. Environmental investigations at five schools have not yet identified an environmental source of the rashes. These investigations have included sampling for dust mite and cockroach allergens, solvents and cleaners, and fungal or bacterial culture growth. Air and surface cultures are still pending.

Oregon. During February 2002, outbreaks of rashes of acute onset and short duration occurred among students in two Oregon schools. Starting February 4, rashes were reported in 53 children and 11 adults in an elementary school of 589 students in southwestern Oregon; 54 (84%) were female. The rash, which appeared on cheeks and arms, was itchy and had a sunburned appearance but no systemic symptoms. A panel of dermatologists who examined 28 of the affected children reported that the rash resembled fifth disease but that several characteristics were not compatible with that diagnosis. Testing for parvovirus in two children was negative. Extensive questioning and environmental inspection did not uncover a source of the rash. Beginning February 21, rashes were reported by 84 children and seven adults in a middle school of 314 students in northwestern Oregon; 67 (74%) affected persons were female. No known links existed between the two schools. Rashes were characterized in a variety of ways, including eczema, and as a sunburned, itchy rash on face, arms, neck, and back; no other symptoms were reported. Tests for parvovirus in six persons were negative. An environmental evaluation of the school found no explanation for the rash.