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)

Have a Great Day!Noon Conference