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Good Morning! Happy Monday. Monday, July 22 nd , 2013. - PowerPoint PPT Presentation
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Good Morning! Happy Monday
Monday, July 22nd, 2013
4 yo female p/w 3 days of fever (tmax 102), 2 days of progressive non-pruritic rash on face/extremities, decreased PO/UOP, emesis x 1 (non-bloody,non-bilious), diarrhea x 2 (non-bloody), increasing fatigue x 5d, refusing to eat and walk
Meds: tylenol PRN Allergies: NKDA PMH: none FMH: neg Immunizations: received 4 yo shots several months ago Social: stays at home w/ mom, no travel history, older siblings
with cold like symptoms, no rash
Differential Dx Arthritis/Arthralgias Desquamation Lymphadenopathy Meningitis Enanthems (mucosal involvement) Ulcerative vesicular lesions Palm and Sole involvement Predominantly on extremities Respiratory Symptoms/Pulmonary infiltrates
Problem Definition Immunized 3 yo female with acute
onset of fever, progressive vesicular rash on extremities with oral mucosal involvement, mild N/V/D, non-toxic appearing
Enteroviruses** Single-stranded RNA viruses**
› Picornaviridae family Polioviruses Coxsackieviruses (Group A and B) Echoviruses Enteroviruses (serotypes 68-71)
“Summer viruses” **› *Increased prevalence in summer months
(May – October)› All year round in tropical climates (NOLA)
Transmission** Most cases involve children under age
5 Humans are only hosts Fecal-oral is most common route
› Then replicates in lymph nodes of respiratory and GI systems
› Initial viremia → heart, liver, skin› CNS infection usually the result of second
major viremia
Clinical Manifestations** Most patients are mildly ill & recover completely Most common → febrile illness, viral exanthem,
vomiting, diarrhea, and malaise Others:
› Hemorrhagic conjunctivitis› Pharyngitis› Herpangina› Hand-foot-and-mouth disease› Paralysis› Hepatitis› Myocarditis› Pericarditis› Encephalitis› Aseptic meningitis
A 6-day-old infant is brought to the ER in August with a 1-day history of decreased feeding, decreased activity, tactile fever, and rapid breathing. He was born at term. His mother reports that she had a nonspecific febrile illness 1 week before delivery for which she received no treatment. Her GBS screen was positive at 36 weeks' gestation, and she received two doses of ampicillin (>4 hours apart) during labor. The baby received no antibiotics and was discharged at 48 hours of age. Physical examination today reveals a toxic, lethargic infant who is grunting and has a temp of 39.4°C, HR of 180, and RR of 60. His lungs are clear, with subcostal retractions. He has a regular heart rhythm with gallop, his pulses are thready, his capillary refill is 4 seconds, and his extremities are cool.
Of the following, the MOST likely cause of this baby's illness isA. early-onset group B Streptococcus infection
B. echovirus 11 infectionC. herpes simplex virus infectionD. hypoplastic left heart syndromeE. respiratory syncytial virus infection
Neonates** High risk for developing disseminated
infection Severe manifestations:
› Fulminant Hepatitis› Myocarditis› Pneumonitis› Meningitis› Encephalitis› DIC› Multiorgan failure
Neonates** acquired from nurseries, or from
symptomatic mothers (fever 1 week prior to delivery)
Symptoms develop at 3-7 days of life Signs include
› mild listlessness, anorexia, transient respiratory distress, jaundice,
Diagnostic Tests** Viral culture**
› Stool, throat, blood, CSF, or tissue› 8 to 10 days
PCR**› Only small sample needed› Results in 24 hours
Serology› Based on increase in antibody titers› Too many enterovirus serotypes to be
practical
Diagnostic Tests (cont’d) Testing by PCR has been associated
with decreased IV abx use, ancillary testing, and hospital length of stay
Allows for patient isolation if necessary (ie, NICU)
Treatment Supportive care
Antivirals under investigation
IVIG may benefit immunodeficient patients› Also used in some with myocarditis or
persistant meningoencephalitis
Prevention
Contact precautions
HAND WASHING!!!
Hand-Foot-and-Mouth Disease
1-4 yo Incubation period 3 to 7 days Prodromal phase of malaise, sore
throat, mouth pain, anorexia and low grade fever
Coxsackie A16 virus
Hand-Foot-and-Mouth Disease (cont’d)
Oral lesions
Hand-Foot-and-Mouth Disease (cont’d)
Painful vesicles in mouth and on hands and feet› Surrounded by an
erythematous margin
Nonvesicular lesions on buttocks, GU and extremities less commonly
Hand Foot Mouth Disease Onychomadesis – proximal separation of
the nail plate from the nail bed
Hand-Foot-and-Mouth Disease (cont’d)
Most resolve spontaneously w/in 3d-1wk
Treatment is supportive Hydration and analgesics Magic Mouthwash
› Maalox› Benadryl› Viscous lidocaine
Hand-Foot-and-Mouth Disease (cont’d)
Moderately contagious Spread by direct contact with nasal
discharge, saliva, blister fluid, or stool Most contagious during the first week
of the illness› Can shed virus in stool for up to 8 weeks› No day care/school during the first few
days of illness and in setting of open lesions
HFM: Parental Guidance Analgesia: Avoid aspirin
(acetaminophen and ibuprofen are ok) Diet: cold, soft foods, dairy, nothing
spicy Prevent spread: wash hands often,
especially after using the bathroom Avoid others during the first week of
illness to prevent spread, avoid pregnant women
Herpangina Coxsackie group A Ages 3 -10 years Incubation period 4-14 days Prodromal phase
› Malaise, HA, N/V, myalgias, anorexia› sore throat and mouth pain 1-2 days prior
to lesions› Fever (low grade > high)
Herpangina Erythematous ring surrounds Puntate macules vesiclulate, ulcerate Anterior tonsillar pillars, soft palate,
posterior pharynx
Herpangina Self-limited Resolve spontaneously within 1 week Supportive care
› Young children are at risk of dehydration
Herpetic Gingivostomatitis Ages 6 mo – 5 yo (peaks at 2yo) Incubation 2 days – 2 weeks Prodrome: fever, irritability, malaise, HA,
PO, lymphadenopathy (cervical, submandibular)
Low to high grade fever
Herpetic Gingivostomatitis Red, edematous gingivae
› bleed easily Small vesicles ulcerate and coalesce
› Large ulcerations with erythema surrounding
Buckle mucosa, tongue, gingiva, hard palate, pharynx, lips, perioral skin
Herpetic Gingivostomatitis
Herpetic gingivostomatitis Diagnose with culture, PCR, or antigen
testing Resolve in 10 to 14 days Treatment is supportive
› Hydration and analgesics Acyclovir
› If patients present in the first 72-96 hrs of disease, unable to drink or have significant pain
After resolution, reside in trigeminal ganglia
Aphthous stomatitis Typically found in older children and
adults Not associated with infection Can be associated with autoimmune
disease (SLE, IBD) Exquisitely painful ulcers Large, yellow, pseudomembranous
slough with erythematous border
Apthous stomatitis
Topical creams may help
Topical AnalgesiaUsually not recommended Benzocaine (orajel)
› associated with methemoglobinemia viscous lidocaine
› may cause problems if absorbed systemically
› may choke on secretions› may chew their buccal mucosa
Hand, Foot, Mouth Disease
Herpangina Herpetic Gingivostomatitis
Aphthous Stomatitis
ages 1-4 yo 3-10 yo 6mos – 5 yo Older children , adultsIncubation 3-7 days 4-14 days 2 days – 2 weeks N/Aprodrome Malaise, sore throat,
mouth pain, anorexiaMalaise, HA, N/V, sore throat, mouth pain, anorexia
irritability, malaise, HA, anorexia, submandibular and cervical lymphadenitis
Usually none
fever Usually low grade Usually low grade Low-High grade fever Usually noneDescription of lesions
Mildly painful Vesicles surrounding erythema (may ulcerate)
Painful Vesicles/ulcers with surrounding erythema
Vesicles that ulcerate and coalesceBeefy red gingiva
Exquisitely painfulLarge Ulcers , yellow pseudomembranous with erythematous border
Location of lesions
Hands, feet, mouth (buccal mucosa and tongue), occasionally nonvesicular lesions on buttocks, genitals and extremities
Anterior tonsillar pillars, soft palate, posterior pharynx
Buccal mucosa, tongue, gingival, hard palate, pharynx, lips, perioral skin
lips, tongue, buccal mucosa
Most common virus, season
Coxsackie A16summer
Group A Coxsackie summer
HSV 1Year round
none
Duration and treatment
1 weekSymptomatic tx
1 weeksymptomatic tx
10-14 daysAcyclovir, symptomatic tx
Variable, can recur, symptomatic tx
Picture QuizInfectious Exanthems
Exanthem #1MEASLES
Exanthem #2Coxsackie A - HFM
Exanthem #3 Rubella
Exanthem #4 Parvovirus B19- Fifth’s Disease- Erythema
Infectiosum
Exanthem #5Varicella
Exanthem #6RMSF
Exanthem #7
Clue: This patient had a h/o 3 days of fever (that has since defervesced) before the appearance of the rash
HHV6- Roseola
Exanthem #8 Scarlet Fever- Group A Strep
Exanthem #9
Clue: You might be more suspicious of this illness if this picture was a hypotensive woman
Toxic Shock Syndrome
Exanthem #10Staph Scalded Skin
Exanthem #11 Steven-Johnson-Syndrome
Exanthem #12Kawasaki Disease
Exanthem #13 Meningococcemia
Exanthem #14
Clue: This patient was recently treated with Ampicillin
EBV- mono
BONUS ROUND Who can name the original 6 childhood
exanthems? (1st disease, etc)
Answer 1st disease: Rubeola, Measles 2nd disease: Scarlet Fever (s. pyogenes) 3rd disease: Rubella, German Measles 4th disease: Staph Scalded Skin Syndrome,
Filatow-Duke’s Disease, Ritter’s Disease 5th disease: Erythema Infectiousum (parvo) 6th disease: exanthem subitum, roseola
(HHV 6 or HHV 7)