EMERGING VECTOR-BORNE DISEASES IN CHILDREN

EMERGING VECTOR-BORNE DISEASES IN CHILDREN

DR SV PATIL PROF AND HEAD PAEDIATRICS BLDE-UNIVERSITY SRI BM.PATIL MEDICAL

COLLEGE BIJAPUR

EMERGING VECTOR - BORNE DISEASES IN CHILDREN

DR SV PATIL PROF AND HEAD PAEDIATRICS

• Dengue fever• Ricketsial fever

• Chickungunya fever• Japanese encephalitis• Malaria

Dengue fever

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Case

• Rahul, 4 year male child presents with– Fever high grade, vomiting for 4 days– Treated with paracetamol but little response– Monsoon time and a case of dengue in neighborhood

reported recently – How will you proceed in such a case?

• Ask • Look • Test

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Ask for ……• Localizing symptoms:

– Cough, cold, ear ache: Tonsillitis, AOM, Sinusitis– Loose stools: Rotaviral, bloody diarrhea– Urinary symptoms: UTI– Boils: SSTI

• Without focus: – Pattern of fever, Well between fever spikes, history in

contacts, coryza, systemic symptoms (myalgia) – Vaccination: Hib, typhoid, measles, MMR

• Danger symptoms: Lethargy, refusal of feeds, irritability, oliguria, convulsion, cold extremities (Serious infections)

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Look for …..

• Vitals: Pulse, CRT, BP/Pulse pressure, Tourniquete test, Skin rash

• Focus like: – Liver/spleen/LN, ascitis – Resp: Conj congestion, Coryza, Throat/Otoscopy,

RR, Grunt, retractions, effusions – CNS: Alertness, FND, meningeal signs – Other systems

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Test for …..

• Test for (now or later?) – CBC, PS for MP (repeat if no response) – Urine analysis – culture SOS– Blood culture?? – X ray chest (If resp signs)– Repeat tests (CBC) SOS– Others: CRP, SGOT, SGPT, Widal, Dengue serology,

RMT ????

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Case continues ….

• Rahul’s tests done show: • CBC:

– Hb 13 gm%, HCT 40%, – WBC 3200, P 40, L 56 E 3, M1– Platelets: 1.2 lakhs

• PS for MP: Negative• Urine analysis: Albumin nil, Pus cells 2-3/hpf• X ray chest: Normal

DD: Malaria, Dengue, Viral fever, Enteric fever, Leptospirosis etc

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Case continues …..

• Rahul’s fever is persistent • He now has some rash on his body• He seems to have body ache and restlessness • His mother repeats his investigations

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Case continues ….Day 4 Day 6

Hb 13 15

HCT 40 45

WBC 3200 2200

DC P40, L56, E3, M1 P34, L60, E5, M1

Platelets 120,000 70,000

PS for MP -ve -ve

Urine Routine Normal Normal

Mother wants to know whether it is dengue and whether she should ask for dengue tests?

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Which laboratory tests?

• Test for confirming dengue– NS1 Antigen, ELISA for IgG & IgM

• Need, timing, interpretation

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Interpretation of dengue serologyNS1 antigen IgM IgG Interpretation

+ve -ve -ve Early (< 4dys)

-ve/+ve +ve -ve Primary

-ve +ve +ve low titers Current/Recent

-ve/+ve +ve +ve high titer Secondary

-ve -ve +ve High titers Secondary

-ve -ve +ve low titers Past infection

• Most important for preventing morbidity and mortality is serial clinical monitoring and CBC

• Do not withhold fluid therapy pending labs/-ve labs

*

* Exception being congenital dengue (in 1st 3 months of life)

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• Rahul is drinking and eating though less than before

• His fever is better with paracetamol• He has passed urine 3-4 times since morning• Mother wants to know whether she should

admit Rahul in hospital?

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Course of dengue illnessCritical phase:

Falling WBC & Platelets

Plasma leak & Rising HCT – 3rd spacing

Shock, organ dysf., Acidosis, DIC

Severe bleeding with HCT & in WBC

Severe shock, organ damage & death.

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WHO classification of dengueDF grade Clinical criteria Laboratory criteria

DF Fever with 2 or more of following signs:

Headache, retro-orbital pain, myalgia, arthralgia

Leukopenia, occasionally thrombocytopenia with no plasma leakage

DHF I Above signs plus

+ve tourniquete test

HCT rise > 20%

platelets < 100,000

DHF II Above signs plus

spontaneous bleeding

HCT rise > 20%

platelets < 100,000

DHF III

(DSS)

Above signs plus

circulatory failure

HCT rise > 20%

platelets < 100,000

DHF IV

(DSS)

Profound shock with undetectable BP and pulse

HCT rise > 20%

platelets < 100,000

Not suitable in all situation; severe dengue in absence of criteria

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Suggested dengue classification

Criteria for dengue +/- warning signs

Without

With warning signs

1) Severe plasma leakage 2) Severe hemorrhage 3) Severe organ impairment

Dengue +/- warning signs Severe Dengue

Criteria for severe dengue

Probable dengue

Live in/travel to dengue endemic area. Fever and 2 of the following criteria

• Nausea, vomiting • Rash • Aches and pains • +ve tourniquete test • Leukopenia • Any warning sign

Warning signs• Abd. Pain & tenderness

• Persistent vomiting

• Clinical fluid accum.

• Mucosal bleeds

• Lethargy, restlessness

• > 2 cm liver enlarged

• Lab: HCT with rapid in platelets

Severe plasma leakage• Shock (DSS) • Fluid accumulation with respiratory distress

Severe bleeding As evaluated by clinician

Severe organ involvement • Liver: AST/ALT > 1000 • CNS: Impaired consc. • Heart & other organs

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Management principles

Step 1. Overall assessment: History, examination, labs

Step 2. Diagnose & assess phase/severity of disease

Step 3. Management:• Disease notification• Management decisions:

• Group A (to be sent home)• Group B (in-hospital management)• Group C (emergency treatment & referral)

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• Rahul is drinking and eating though less than before

• His fever is better with paracetamol• He has passed urine 3-4 times since morning• Mother wants to know whether she should

admit Rahul in hospital?

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Group 1 (Home care)

• It includes those who: – Can tolerate adequate volume of oral fluids– Pass urine 4-5 times in 24 hours– No warning signs

• Rx: 5-6 glasses of ORS, Juices, other fluids, Paracetamol (NO NSAIDs/Mefenimic acid)

• FU: Daily FU till defervescence period is over at home by care taker and at clinic by medical professional for – Intake, output, repeat CBC, look for warning signs,

response to therapy, deterioration or warning signs

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• Rahul is now sick looking• He has vomited several times and is not able

to drink well• He has developed cold hands and feet• He is irritable and restless • He has not passed urine for 8 hours• Mother wants to know whether she should

admit the child?

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Group 2 (In-hospital Rx)

• Includes those with warning signs:• Abd. Pain & tenderness • Clinical fluid accum. • Lethargy, restlessness • Lab: HCT/ in platelets

• High risk for complications like pregnancy, infancy, old age, obesity, diabetes mellitus, renal failure, chronic hemolytic diseases

• Difficult social situation (far away/living alone)

• Persistent vomiting • Mucosal bleeds • > 2 cm liver enlarged

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5-7 ml/Kg/hr x 1-2 hr



Clinical/CBC monitoring

Taper over 24-48 hr

Response seen

Worsening


Clinical/CBC monitoring

Response seen Worsening

Severe shock

Monitoring: Clinical q 1-4 hr; Urine output q 4-6 hr; CBC q 6-12 hr; Organ function tests sos

Management of Group 2 with danger signs

Refer to 30 care

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Group 3 (Referral to tertiary care)

• Includes those with severe dengue (DSS):– severe plasma leakage leading to dengue shock

and/or fluid accumulation with respiratory distress

– severe hemorrhages– severe organ impairment (hepatic damage, renal

impairment, cardiomyopathy, encephalopathy or encephalitis)

Need access to intensive care, blood products and colloids

Dr. Nitin Shah 25

Compensated shock (systolic pressuremaintained but has signs of reduced perfusion)O2, Fluid resuscitation with isotonic crystalloid

5–10 ml/kg/hr over 1 hour

Improvement

IV crystalloid 5–7 ml/kg/hr for 1–2 hours, then:

to 3–5 ml/kg/hr for 2–4 hours; to 2–3 ml/kg/hr for 2–4 hours.Improvement - fluid further.

Monitor HCT 6–8 hourly.Not stable, act according to

HCT levels:if HCT , consider bolus

or increase fluid administration;if HCT , consider

fresh whole blood transfusion.Stop at 48 hours.

No improvement

HCT or high HCT low

Check HCT

Significant Bleeding

– consider Fresh whole

blood transfusion

2nd bolus 10-20 ml/Kg

for 1 hr

Improvement

No improvement Fluids to

7–10 ml/kg/hr for 1–2 hoursthen further

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Hypotensive shock O2, Fluid resuscitation with isotonic crystalloid

or colloid @ 20 ml/kg over 15 min

Improvement

IV cryst./colloid 10 ml/Kg x 1 hrIV cryst. 5–7 ml/kg/hr x 1–2 hours

3–5 ml/kg/hr x 2–4 hours2–3 ml/kg/hr x 2–4 hours.

Improvement - fluid further.Monitor HCT 6–8 hourly.

Not stable, act according to HCT levels:

if HCT , consider bolus or increase fluid administration;

if HCT , consider fresh whole blood transfusion.

Stop at 48 hours.

No improvement

HCT or high HCT lowCheck 1st HCT

Significant Bleeding

– Fresh whole blood transfusion

2nd bolus colloid 10-20 ml/Kg

for ½-1 hr

Improvement No improvement

Check 2nd HCTHCT or high HCT low

3rd bolus colloid 10-20 ml/Kg over 1 hr

Improvement No improvement

Check 3rd HCT

Fluid refractory shock

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• Rahul was admitted in hospital and treated with IV fluids and he responded well

• His serial CBC showed platelets of only 30,000• He has some skin rash and mild epistaxis• Mother insists on giving platelet transfusion to

Rahul

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Use of blood products • At risk:

– Profound shock, hypotension, NSAIds, Trauma (procedures), liver disease

• Recognition: – Falling HCT on fluid resuscitation with unstable

hemodynamics, – Overt bleeding irrespective of HCT – Refractory/hypotensive shock, worsening metabolic

acidosis • Treatment:

– Fresh PRBC or whole blood (Rarely platelets, FFP) – No role of prophylactic platelets!!!!

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• Rahul is now well• He is eating and drinking well• He is passing urine well• It is 8 days and he is afebrile for 2 days• His CBC shows Hb of 11 gm%, WBC 4200,

P40,L56, E4, Platelets of 90,000• Mother wants to know when can Rahul go

home?

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Criteria for discharge

• All of the following must be present• Clinical:

– No fever for 48 hours– Improvement in clinical status (general well-being,

appetite, haemodynamic status, urine output, no respiratory distress)

– Time frame for critical phase over

• Laboratory:– Increasing trend of platelet count– Stable hematocrit without intravenous fluids

RICKETTSIAL INFECTIONS

Rickettsial Infections

• Symptoms-- FEVER headache myalgia rash and eschar

generalized lymphnodes,and hepatosplenomegaly

RASH-PALMS AND SOLES

• GI- symptoms-Nausea,Vomiting Abd pain, Diarrhoea

• RS-Cough, Distress,• CNS-Dizziness,Disorientation, Photphobia and

Visual disturbances• Others include-periorbital edema,conjunct

congestion Epistaxis,hearing loss and arthralgia

SEVERE SYMPTOMS

• Interstitial Pneumonia, Pulmonary edema• CNS-Meningoencephalitis syndrome• Renal-ARF • Disseminated Intravascular

Coagulation,Hepatic failure and Myocarditis.

Laboratory findings

• Hematology-TLC-is low and leucocytosis• Platelets less in 60% ESR is high• Hyponatremia,,Hypoalbunemia,Thrombocyto

penia• SGOT- elevated• Weil Felix test (5-7) days• PCR- Immunoflorescence(gold standard)

Diagnosis

• Fever-PUO- Fever with rash(palms and soles)• Tick bite and exposure• Epidemiological data• Lab findings-• Defervescence with antibiotics• DD-Measles,Dengue,Inf mono,Malaria

Typhoid TSS and CVD

Treatment

• Tetracyclin,Doxycyclin Chloromycetin, Macrolides and Quinolines

• 5mg/kg in 2 doses min 5-7 days, and• Supportive therapy.

JAPANESE ENCEPHALITIS

JAPANESE ENCEPHALITIS

Case Definition of Suspected case:• - Acute onset of fever, not more than 5-7 days

duration.• - Change in mental status with/ without• New onset of seizures (excluding febrile seizures)• (Other early clinical findings . may include irritability,

somnolence• or abnormal behavior greater than that seen with

usual febrile• illness)

JE

JE- CONTD• Laboratory-Confirmed case : A suspected case with any

one of the following markers:• Presence of lgM antibody in serum and/ or CSF to a

specific virus including• JE/Entero Virus or others• Four fold difference in lgG antibody titre in paired sera• Virus isolation from brain tissue• Antigen detection by immunofluroscence• Nucleic acid detection by PCR• In the sentinel surveillance network, AES/JE will be

diagnosed by lgM Capture ELISA, and• virus isolation will be done in National Reference

Laboratory.

CHICKUNGUNYA FEVER

• Triad of fever, rash and joint manifestations• Clinically-fever>38.5,severe

arthralgia(possible)• Epidemiological-visit epidemic area 15 days

prior to symptoms.(probable)• Lab-isolation virus, PCR IgM AND IgG

(confirmed)

• Caused by-chik virus, aedes aegypti vector (human-mosq-human)-post mansoon• Monkeys rodents birds and others.• Symptoms-fever(92%),arthralgia(87%),back

ache(67%) and head ache(62%)• Differs from adults-

Common Infrequent Rare in adults but seensometimes in children

Fever Rash Photophobia

Arthralgia Stomatitis Retro-orbital pain

Backache Oral ulcers Vomiting

Headache HyperpigmentationExfoliative dermatitis

DiarreaMeningeal syndromeAcute encephalopathy

SEQUELAE

• Arthralgia resolves in 87%,3.7% episodic stiffness and 2.8% persistent stiff

• Lab diagnosis–virus isolation PCR IgM antibody and rising IgG titres

• Differential diagnosis –Leptospirosis,dengue fever,malaria,meningitis and rheumatic fever

Management

• First contact-Differential diagnosis should be thought

• Assess dehydration(severe,mild to moderate)• Total leucocyte count->10,000-leptospira, and

<50,000 –dengue fever peripheral smear-MP• Paracetamol -50-60mg/kg/day• Exercise and physiotherapy

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Thank you all!

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EMERGING VECTOR-BORNE DISEASES IN CHILDREN