Fourth disease
Filatov-Dukes disease
Fourth disease, also known as Filatov-Dukes disease, is the least defined of the classical childhood exanthems. Initially proposed as a distinct paediatric rash illness in the late 19th century, it was believed to lie somewhere between rubella and scarlet fever.
The condition was described independently by Russian paediatrician Nil Filatov in 1885 and by English physician Clement Dukes in 1894. Both observed a non-specific erythematous rash, with mild constitutional symptoms and lacking the distinguishing features of the better-defined exanthems.
Despite early interest, fourth disease was never conclusively linked to a unique pathogen or clinical syndrome. With time, most cases were reclassified as atypical presentations of scarlet fever, rubella, or viral exanthems. By the mid-20th century, “fourth disease” had largely fallen out of clinical use.
In 1979, Keith Powell controversially proposed that Filatov-Dukes disease may have represented staphylococcal scalded skin syndrome (SSSS), caused by epidermolytic toxin-producing Staphylococcus aureus. However, modern consensus largely rejects fourth disease as a distinct entity, considering it a historical artefact of nosological enthusiasm and overlapping symptomatology.
Synonyms: Filatov-Dukes Disease, Staphylococcal Scalded Skin Syndrome, Ritter disease, Fourth disease
English physician Clement Dukes (1845–1925) introduced the numbering system for childhood exanthems in 1900. He categorised them by clinical presentation into: First: measles; Second: scarlet fever; Third: rubella; and Fourth: Filatov-Dukes disease. Later additions – Fifth: erythema infectiosum (1905, Cheinisse); and Sixth: roseola infantum (1910, Dreyfus)
History of Fourth Disease (Filatov-Dukes disease)
1885 – Nil Filatov (1847–1902), Russian paediatrician described a rash he termed rubeola scarlatinosa as distinct from measles and rubella. Published in Archiv für Kinderheilkunde in 1886, his work is retrospectively cited as the first account of “Fourth Disease.”
1894 – Clement Dukes (1845–1925): English school physician described an epidemic roseola-like rash distinct from measles, scarlet fever, and rubella in The Lancet, terming it “epidemic roseola.” He later published further differentiation between rubella types.
I have found that rose-rash in its epidemic form is not only distinct from scarlet fever and measles, but that it may also be confused with a form of rubella. I am led to believe it constitutes a distinct disease.
1900 – Dukes formally proposes “Fourth Disease”: Building on outbreaks at Rugby School in 1892, 1896, and 1900, Dukes postulated a unique exanthem distinct from existing conditions, publishing in The Lancet. He referred to earlier observations as “the scarlet fever variety of rubella,” but ultimately concluded they were a sui generis entity.
Early 1900s: The name “Filatov-Dukes disease” emerged as textbooks and case reports began listing “Fourth Disease” alongside measles, scarlet fever, and rubella as a separate paediatric exanthem.
1930s–1960s: The diagnosis gradually waned in acceptance, lacking a defined aetiologic agent or consistent clinical features. Eventually dropped from medical texts.
1979 – Keith Powell resurrects the hypothesis: Suggested Filatov-Dukes disease might have been staphylococcal in origin, namely Staphylococcal scalded skin syndrome (SSSS) caused by epidermolytic toxin-producing Staphylococcus aureus. Compared Dukes’ cases with those described by Melish and Margileth.
1991 – Morens and Katz declare Fourth Disease nonexistent: In a landmark epidemiological reassessment (Am J Epidemiol), concluded that cases ascribed to “Fourth Disease” were misdiagnosed rubella or scarlet fever.
We conclude that fourth disease never existed… Misidentification is attributed to failures in the critical abilities of the medical and scientific communities at the time.
2001 – Martin Weisse reflects on the controversy: Reviewed historical and modern interpretations in The Lancet, noting the enduring intrigue but current consensus that “Fourth Disease” is a historical curiosity, possibly SSSS in retrospect.
Associated Persons
- Nil Fyodorovich Filatov (1847-1902)
- Clement Dukes (1845-1925)
References
Historical references
- Filatow N. Zur frage betreffs der Selständigkeit der Rubeola scarlatinosa. Archiv für Kinderheilkunde 1886; 7: 241-247.
- Dukes C. On the features which distinguish epidemic roseola (rose-rash) from measles and from scarlet fever. Lancet 1894; 143(3683): 791-795
- Dukes C. On the confusion of two different diseases under the name of rubella (rose-rash). Lancet 1900; 156(4011): 89-95
Eponymous term review
- Marsden RW. Fourth disease. Lancet 1902; 160(4120): 435-438
- Melish ME, Glasgow LA. Staphylococcal scalded skin syndrome: the expanded clinical syndrome. J Pediatr 1971; 78: 958–67
- Margileth AM. Scalded skin syndrome: diagnosis, differential diagnosis, and management of 42 children. South Med J 1975; 68: 447–54
- Powell KR. Filatow-Dukes’ disease. Epidermolytic toxin-producing staphylococci as the etiologic agent of the fourth childhood exanthem. Am J Dis Child. 1979 Jan;133(1):88-91.
- Morens DM, Katz AR. The “fourth disease” of childhood: reevaluation of a nonexistent disease. Am J Epidemiol. 1991 Sep 15;134(6):628-40.
- Weisse ME. The fourth disease, 1900-2000. Lancet 2001; 357(9252): 299-301
eponymictionary
the names behind the name
