Board review - Viral infections. Rubeola (nine-day or red measles) Prodromal symptoms - fever, malaise, dry (occasional croupy) cough, coryza, conjunctivitis

Board review - Viral infections

Rubeola (nine-day or red measles)

Prodromal symptoms - fever, malaise, dry (occasional croupy) cough, coryza, conjunctivitis c clear d/c, marked photophobia

1-2 days p prodromal symptoms - Koplik spots on the buccal mucosa

Koplik spots - tiny, bluish-white dots surrounded by red halos

rubeola (nine-day or red measles)

Day 3 or 4 - blotchy, erythematous, blanching, maculopapular exanthem appears

Rash begins at the hairline and spreads cephalocaudally and involves palms and soles

Rash typically lasts 5 - 6 days

Can see desquimation in severe cases


Patients can be systemically ill

Incubation period 9-10 days

Patients contagious from 4 days prior to the rash until 4 days after the resolution of the rash

Highly contagious - 90% for susceptible people


High morbidity and mortality common in children in underdeveloped countries

Peak season is late winter to early spring

Potential complications - OM, PNA, obstructive laryngotracheitis, acute encephalitis

Vaccination is highly effective in preventing disease


Rubella (german measles)

Little or no prodrome in children

In adolescents - 1-5 days of low-grade fever, malaise, headache, adenopathy, sore throat, coryza

Exanthem - discrete, pinkish red, fine maculopapular eruption - begins on the face and spreads cephalocaudally

Rash becomes generalized in 24 hours and clears by 72 hours

rubella (german measles)

Forchheimer spots - small reddish spots on the soft palate - can sometimes be seen on day 1 of the rash

Arthritis and arthralgias - frequent in adolescents and young women - beginning on day 2 or 3 lasting 5-10 days

Up to 25% of patients are asymptomatic - serology testing may be necessary to establish the diagnosis

rubella (german Measles)

Important in establishing the diagnosis if the patient is pregnant or has been in contact c a pregnant woman

Peaks in late winter to early spring

Contagious from a few days before the rash to a few days after the rash


Complications - rare in childhood - arthritis, purpura c or s thrombocytopenia, mild encephalitis

rubella (german Measles)

Varicella (chickenpox)

Caused by varicella-zoster virus

Highly contagious

Brief prodrome of low-grade fever, URI symptoms, and mild malaise may occur

Rapid appearance of puritic exanthem

varicella (chickenpox)

Lesions appear in crops - typically have 3 crops

Crops begin in trunk and scalp, then spread peripherally

Lesions begin as tiny erythematous papules, then become vesicles surrounded by red halos

Lesions began to dry - umbilicated appearance, then surrounding erythema fades and a scab forms


Hallmark - lesions in all stages of evolution

All scabs slough off 10-14 days

Scarring not typical unless superinfected

Cluster in areas of previous skin irritation

Puritic lesions on the skin

Painful lesions along the oral, rectal, and vaginal mucosa, external auditory canal, tympanic membrane


Occurs year-round, peaks in late autumn and late winter through early spring

Incubation period ranges from 10-20 days

Contagious 1-2 days prior to rash until all lesions are crusted over

Complications - secondary bacterial skin infections (GAS), pneumonia, hepatitis, encephalitis, Reye syndrome


Severe in the immunocompromised host - can be fatal

Can have severe CNS, pulmonary, generalized visceral involvement (often hemorrhagic)

Need to get varicella-zoster immunogloblin 96 hours post-exposure to possible varicella


Adenovirus

30 distinct types

Variety of infections including conjunctivitis, URIs, pharyngitis, croup, bronchitis, bronchiolitis, pneumonia (occ fulminant), gastroenteritis, myocarditis, cystitis, encephalitis

Can be accompanied by a rash - variable in nature

Typically can see - conjunctivitis, rhinitis, pharyngitis c or s exudate, discrete, blanching, maculopapular rash

adenovirus

Can see anterior cervical and preauricular LAD, low-grade fever, malaise

Peak season is late winter through early summer

Contagious during first few days


Coxsackie hand-foot-and-mouth disease

Brief prodome - low-grade fever, malaise, sore mouth, anorexia

1-2 days later, rash appears

Oral lesions - shallow, yellow ulcers surrounded by red halos

Cutaneous lesions - begin as erythematous macules then evolve to small, thick-walled, grey vesicles on an erythematous base

Coxsackie hand-foot-and-mouth disease

Highly contagious


Lasts 2-7 days

Peak season summer through early fall

If no cutaneous lesions - herpangina

less painful and less intense than herpes gingivostomatitis

erythema infectiosum (fifth disease)

Caused by Parvovirus B19

Affects preschool and young school aged children

Peak incidence in late winter and early spring, but it is seen year round

Characterized by rash - large, bright red, erythematous patches over both cheeks - warm, but non-tender


Facial rash fades, then see a symmetrical, macular, lacy, erythematous rash on the extremities

Resolution occurs within 3-7 days of onset

Transmitted by respiratory secretions, replicates in the RBC precursors in the bone marrow

Can cause aplastic crisis in patients with sickle cell disease, other hemogloblinopathies, and other forms in hemolytic anemia


roseola infantum (exanthem subitum)

Febrile illness affecting children 6-36 months

Human herpesvirus 6 is causative agent

Symptoms include:

fever, usually >39

anorexia

irritability

these symptoms subside in 72 hours


As fever defervenscences, usually an erythematous, maculopapular rash that appear on the trunk and then spread to the extremities, face, scalp, and neck

Occurs year-round

More common in late fall and early spring

Incubation period thought to be 10-15 days


Infectious mononucleosis

Acute self-limiting illness of children and young adults

Caused by EBV

Transmission by oral contact, sharing eating utensils, transfusion, or transplantation

Incubation period 30-50 days (shorter, 14-20 days, in transfusion-acquired infection)

Don’t usually see “classic mono” in young children


Prodrome - fatigue, malaise, anorexia, HA, sweats, chills lasting 3-5 days

Symptoms

fever - can have wide daily fluctuations

pharyngitis c tonsillar and adenoidal enlargement c or s exudate, halitosis, palatal petechiae

LAD - anterior cervical and posterior cervical - in classic cases, generalized LAD toward end of wk 1


Symptoms cont:

splenomegaly - develops in 50% of patients in 2nd-3rd wk

hepatomegaly in 10% of patients

exanthem - erythematous, maculopapular, rubelliform rash in 5-10% of patients


Complications:

pneumonia

hemolytic anemia and thrombocytopenia

icteric hepatitis

acute cerebellar ataxia, encephalitis, aseptic meningitis, myletis, Guillain-Barre

rarely myocarditis and pericarditis


Complications cont:

upper airway obstruction from tonsillar and adenoidal enlargement

seen more often in younger patients

children < 5 yrs of age c obstruction are more likely to have secondary OM, recurrent bouts of OM, tonsillitis, and sinusitis

splenic rupture


Diagnosis:

classic finding - lymphocytosis (50% or more) c 10% atypical lymphocytes

80% or more of patients c elevated liver enzymes

Monospot - detects heterophil antibodies - specific, not as sensitive - 85% of adolescents + and fewer younger patients

specific EBV antibody titers and PCR


DDx

If fever and exudative tonsillitis predominate

GAS, diphtheria, viral pharyngitis

If LAD and splenomegaly predominate

CMV, toxo, malignancy, drug-induced mono

If severe hepatic involvement

viral hepatitis, leptospirosis

herpes simplex infections

Primarily involve the skin and mucous surfaces

Can be disseminated in neonates and immunocompromised hosts

Produces primary infection - enters a latent or dormant stage, residing in the sensory ganglia - can be reactivated at any time

herpes simplex infections

HSV-1

>90% of primary infections caused by HSV-1 are subclinical

more common

HSV-2

usually the genital pathogen

usual pathogen of neonatal herpes

herpes simplex infection

Diagnosis

usually made clinically

can scrap base of vesicle and a special stain - Giemsa-stained (Tzanck)

ballooned epithelial cells c intranuclear inclusions and multinucleated giant

viral cultures take 24-72 hours

Primary herpes simplex infections

Herpetic gingivostomatitis

high fever, irritability, anorexia, mouth pain, drooling in infants and toddlers

gingivae becomes intensely erythematous, edematous, friable and tends to bleed

small yellow ulcerations c red halos seen on buccal and labial mucosa, tongue, gingivae, palate, tonsils

primary herpes simplex infections

Herpetic gingivostomatitis

yellowish white debris builds on the mucosal surfaces causing halitosis

vesiculopustular lesions on perioral surfaces

anterior cervical and tonsillar LAD

symptoms last 5-14 days, but virus can be shed for weeks following resolution


Skin infections

fever, malaise, localized lesions, regional LAD

direct inoculation (usually cold sores)

lesions are deep, thick-walled, painful vesicles on an erythematous base - usually grouped, but may be single

lesions evolve over several days - pustular, coalesce, ulcerate, then crust over


Skin infections

most common sites are lips and fingers or thumbs (herpes whitlow)

eyelids and periorbital tissue infection can lead to keratoconjunctivitis - dx by dendritic ulcerations on slit lamp exam

can lead to visual impairment - consult ophtho

Eczema herpeticum (kaposi varicelliform eruption)

Onset of high fever, irritability, and discomfort

Lesions appear in crops in areas of currently or recently affected skin (for those with atopic eczema or chronic dermatitis)

Lesions begin as pustules, then rupture and crust over the course of a couple of days

Lesions can become hemorrhagic


Multiple crops can appear over 7-10 days (like varicella)

Can be mild or fulminant, depending (in part) on the underlying dermatitis

If area of involvement is large, can be lots of fluid loss and potentially fatal

Treat promptly c acyclovir

Risk of secondary bacterial infections


Recurrent herpes simplex infection

Triggers include fever, sunlight, local trauma, menses, emotional stress

Seen most commonly as cold sores

Prodrome of localized burning, itching or stinging before eruption of grouped vesicles

recurrent herpes simplex infection

Vesicles contain yellow, serous fluid and are often smaller and less thick-walled than the primary lesions

Vesicular fluid becomes cloudy after 2-3 days, then crusts over

Regional, tender LAD

herpes zoster (shingles)

Caused by varicella-zoster virus

After primary infection, virus lies dormant in genome of sensory nerve root cell

Postulated triggers include mechanical and thermal trauma, infection, debilitation as well as immunosuppression

Lesions are grouped, thin-walled vesicles on an erythematous base distributed along the course of a spinal or cranial nerve root (dermatome)


Lesions evolve from macule to papule to vesicle then crusted over a few days

May have associated nerve root pain - not common in pediatrics - usually short-lived unless it involves a cranial nerve root dermatome

+/- fever or constitutional symptoms

Regional LAD common


Thoracic, cervical, trigeminal, lumbar, facial nerve dermatomes (order of frequency)

If cranial nerve involvement - prodrome of severe HA, facial pain, or auricular pain prior to the eruption

Affected patients can transmit varicella, but less of a problem b/c lesions are often covered by clothing and the o/p is not involved in most cases


gianotti-crosti syndrome

Papular acrodermatitis

Associated c amicteric hepatitis B, EBV, echovirus, coxasckievirus, parainfluenza virus, CMV, and RSV

Most patients between 1-6 years old (range 3 months to 15 years)

Prodrome of low-grade fever and malaise

May be associated c generalized LAD, hepatomegaly, URI symptoms, and diarrhea


Lesions appear within a few days - discrete, firm, lichenois papules c flat tops ranging from 1-10 mm (larger in infants and smaller in older children)

Papules can be flesh colored, pink, red, dusky, coppery, or purpuric

Distributed symmetrically over extremities (including palms and soles), buttocks, and face - relative sparing of the trunk and scalp

No mucosal involvement and non-purtitic


Usually clears in 2-3 weeks, but can last for 8 weeks or more

Lab studies are generally non-specific, but liver enzymes should be obtained and if abnormal - hepatitis B or EBV serology should be done

Treatment is supportive

Steroid creams contraindicated b/c they can make the rash worse


Documents

Board review - Viral infections. Rubeola (nine-day or red measles) Prodromal symptoms - fever, malaise, dry (occasional croupy) cough, coryza, conjunctivitis