Pediatric Infectious Disease - Clin Med

What does this refer to

• A 9-month-old girl presents to the pediatrician for a rash on her trunk.

• She had a high-grade fever for 3 days, and she has been receiving ibuprofen for the fever.

• She has been more irritable but has been eating and having sufficient diapers.

• This morning, she no longer had a fever but developed a pink rash over her chest and back.

• On physical exam, there is a blanching, light pink rash with macules and papules on the trunk and back.

• She also has erythematous papules on her soft palate.

• Her mother is reassured that this disease is self-limited and has no complication

Rosela

What does this refer to

• ______ Infantum

• Viral syndrome due to HHV-6

Roseola

What does this refer to

• More than 3 million cases every year

• MC in children 5yo and younger

• MC 9-12 month old infants

• Accounts for up to 45% of febrile illness in infants

Epidemiology of Roseola

What does this refer to

• Transmitted by direct contact (saliva)

• Primary infection with human herpes virus 6 (HHV-6)

  • HHV-6A (immunocompromised adults)

  • HHV-6B (roseola infantum)

• Recurrence is uncommon

Etiology of Roseola

What does this refer to

• May be asymptomatic

• May cause the exanthem subitum/roseola syndrome which consists of

  • Otitis

  • Gastroenteritis, Respiratory distress

  • Seizures

• Acute onset of high fever (40C/104F) with non-specific sx for 3 days

  • +/- febrile seizure

• Morbilliform exanthem rash

  • Diffuse and symmetric erythematous macules or small papules

• Conjunctivitis

• Acute otitis media

• Uvulopalatoglossal junctional macules or ulcers (Nagayama spots)

• Rhinorrhea

• Cough

• Vomiting

• Diarrhea (24 to 68 percent)

• Bulging fontanelle

Clinical history of Roseola

What does this refer to

• HHV-6 infection in AIDS patients

  • Viremia

  • Lymphadenopathy

  • Disseminated organ involvement

  • Active CNS infection

  • Retinitis

  • Death

• MC in people with AIDS compared to general population

Clinical history in patients with aids Roseola

What does this refer to

• After an abrupt loss of fever, the characteristic rash appears

• Generalized and subtle eruption of rash

• Discrete, small, pale pink papules or a blanchable, maculopapular exanthem that is 1-5 mm in diameter

• Starts on neck and trunk

  • Spreads to face and extremities

  • May last 2 days

• Typically a clinical dx based on hx and physical exam

Physical examRoseola

What does this refer to

• Rubeola (Measles)

• Rubella (German measles)

• Fever of unknown origin (FUO)

• Pneumococcemia

• Viral syndromes with fever and exanthem

Differential diagnosis Rosela

What does this refer to

Typically only in ill-appearing children

• CBC w/ diff

• BMP

• UA

• Blood cultures

• LP (cerebrospinal fluid examination)

• CXR

Workup for Roseola

What does this refer to

• Supportive care

• Alternate Acetaminophen (Tylenol) – Ibuprofen (Motrin) every 4-6 hours for fever​

• Hydration​

• Aspirin is contraindicated in viral illnesses

  • Reye syndrome

  • Exception to this C/I —> Kawasaki Disease

Clinical Management of Roseola

What does this refer to

Treatment of complications

• Gastroenterologic

• Respiratory

• Hematologic

• CNS

When to admit/dispositionRoseola

What does this refer to

• Recurrence is uncommon

• Immunocompetent survive roseola infantum without sequelae

• Patients who are immunosuppressed, multisystem complications

• No risk appears to be present to pregnant women exposed to roseola

  • Care must be taken to distinguish this from rubella

Prognosis of Roseola

What does this refer to

• A 30-year-old woman presents to the emergency room.

• She is a tourist from Southeast Asia and reports having a low-grade fever for several days.

• She also reports having arthralgias, especially in her wrists and knees.

• Additionally, she has a pink rash on her face and her chest.

• The rash appears to be spreading downward.

• She does not recall whether or not she had the measles, mumps, and rubella vaccine.

• Physical exam – lymphadenopathy in her postauricular and posterior cervical chains.

• Petechiae on her soft palate and uvula and a pink maculopapular rash on her face and trunk.

• Isolation precautions are indicated.

Rubella

What does this refer to

• Contagious disease caused by a virus

• Usually have a mild illness, with symptoms that can include a low-grade fever, sore throat, and a rash that starts on the face and spreads to the rest of the body

Rubella

What does this refer to

• Last cases (endemic & congenital) reported in 2009 from the Americas region

• Fewer than 10 cases of _______ are reported each year in the US

  • Most due to the arrival of infected persons from other countries

  • 2015 - WHO declared the Americas region free of rubella and congenital rubella syndrome

• 2016 – added to the national vaccine regimen

Epidemiology for Rubella

What does this refer to

• Systemic disease caused by

  • Togavirus

    • Natural hosts include humans, mammals, birds, and mosquitoes

    • Transmitted by inhalation of infective droplets

• Through direct contact with the saliva or mucus of an infected person

• Through air by respiratory droplets (from coughing or sneezing)

• From pregnant woman to unborn baby

Etiology Rubella

What does this refer to

• Exposure 14–21 days before onset

• No prodrome in children and mild prodrome in adults

  • (Low grade) fever, malaise, coryza

  • Onset of rash

    • With onset of sx OR

    • 5 days prior to other sx

• Fine, pink, NON-CONFLUENT maculopapular rash of 3 days’ duration

  • Starts on face

    • Spreads to trunk and extremities

• Leukopenia, thrombocytopenia

Clinical history of Rubella

What does this refer to

• Fine pink, maculopapular rash

  • Typically lasts 3 days’ duration

  • Descending spread

    • Starts on face then spreads —> trunk —> extremities

• Lymphadenopathy

  • Posterior cervical/suboccipital

  • Postauricular is classic

• Petechial rash on soft palate (Forschheimer spots)

• Orchitis may be present in males

Physical examRubella

What does this refer to

• Roseola

• Erythema Infectiosum (5th disease)

• Rubella

• Meningitis

Differential diagnosis for rubella

What does this refer to

• CBC w/ diff

• CMP

• UA

• Serum or saliva

  • Elevated IgM antibody

  • At least 4x > rise in IgG antibody titers

  • Isolation of the virus

• RT-PCR from throat swabs, oral/nasopharyngeal secretions

  • Best if collected within the first 3 days

    • Within 3 months in case of congenital rubella syndrome.

Work up Rubella

What does this refer to

• Clinical diagnosis

• Serum or saliva confirms

  • Elevated IgM antibody

  • At least 4x > rise in IgG antibody titers

  • Isolation of the virus

OR

• RT-PCR virus detection

How Rubella is diagnosed

What does this refer to

• No specific treatment of the disease itself

• Treat the symptoms

  • Antipyretics

  • Analgesics

  • Hydration

• High dose vitamin A supplement x 2 days for children to reduce morbidity and mortality

Clinical management for Rubella

What does this refer to

• Complications are rare

• Polyarticular arthritis and arthralgia MC adult women

  • Involves fingers, wrists, and knees

  • Usually subside within 7 days

    • May persist for weeks

• Hemorrhagic manifestations MC in children

• Hepatitis has been reported

• Encephalitis (rare)

  • More common in adults

  • High mortality rate

• Vertical transmission to fetus —> congenital rubella syndrome

• Thrombocytopenic purpura (TTP)

• Guillain-Barre syndrome

Complications of Rubella

What does this refer to

• Vaccination

  • MMR

  • 1st dose – age 12-15 months

  • 2nd dose – age 4-6 years (prior to starting school)

• Check immune status of pregnant women

  • Antibody titers fall about 10% within 12 years of vaccination

• Per UpToDate, the MMRV vaccination is contraindicated in pregnancy

• Vaccine C/I in solid organ transplant patients

Prevention for Rubella

What does this refer to

• Devastating effects on the fetus in utero

  • May cause fetal death, preterm delivery, and teratogenic effects

• Severity of symptoms is directly related to the gestational age

  • 1st trimester leads to congenital rubella in at least 80% of fetuses

• Manifestations of congenital rubella syndrome

  • Transient

  • Permanent

  • Developmental

Congenital rubella syndrome (CRS)Rubella

What does this refer to

• Low birth weight, and hepatosplenomegaly

• Early-onset cataracts and glaucoma

• Microphthalmia

• Hearing deficits

• Psychomotor retardation

• Congenital heart defects

  • Patent ductus arteriosus

  • Branch pulmonary artery stenosis

Manifestations of Congential rubella

When do you admit/disposition for Rubella

• Complications

  • Meningitis

  • Encephalitis

  • Myelitis

• Severe pneumonia

• Diarrhea that significantly compromises fluid or electrolyte status

What does this refer to

• Pregnancy

• Meningitis/encephalitis

• Significant vaccination reactions

• Suspect cases should be reported to public health authorities

Referral/Consult for Rubella

What does this refer to

• Mild illness and rarely lasts more than 3–4 days

• Congenital rubella has a high fetal mortality rate

  • Associated congenital defects are permanent

• Infants with CRS can transmit virus for up to 1 year after birth

Prognosis for Rubella

What does this refer to

• A 2-year-old child presents to the pediatrician’s office for a rash.

• Her mother is against vaccines, so the child had not received any childhood vaccines. Her father, however, is worried about her lack of vaccination and asks the doctor if this is measles or rubella. On physical exam, she has a high fever as well as a confluent maculopapular rash. She also has blue-white spots on her buccal mucosa. The family is instructed to take isolation precautions and to bring in the child’s siblings who are also unvaccinated.

Rubeola

What does this refer to

• Paramyxoviral infection that occurs acutely

• Serious Infection that has a high incidence of morbidity and death

Rubeola

What does this refer to

• ______ virus

• Highly contagious

• Transmission

  • Inhalation of Respiratory droplets

Etiology of Rubeola

What does this refer to

Pediatric patients infected annually result in almost a million deaths

Very contagious

• Especially before the onset of rash and the

• Catarrhal stages (until the rash subsides)

Number of cases in the US has been increasing over the past decade

• 2019 – 1282 cases dx in US

Risk factors

• Lack of vaccination

• Travel to endemic areas

Epidemiology of Rubeola

What does this refer to

Prodrome Symptoms

• (High grade) fever (high Fever 104)

• Coryza

• Rash –occurs 5 days or less once symptoms occur

• Cough

• Conjunctivitis

• Koplik spots

Clinical history for Rubeola

What does this refer to

• Koplik spots are pathognomonic

  • Tiny bluish-white spots with red background

    • on buccal mucosa opposite the molars

• Palms and soles are spared from rash

• Rash blanches in the first few days

Physical exam for Rubeola

What does this refer to

• Onset 3-5 days after sx begin

• Small papules (pinhead size)

• Progresses to brick red, irregular blotchy maculopapular rash

  • Face and ears downward to (trunk) and outward to (limbs)

  • RARELY effecting the palms and soles

• Coalesces can occur if severe

• Other symptoms

  • Lymphadenopathy

  • Reddened Pharynx

  • Yellow colored exudate on the tonsils

  • Splenomegaly

Physical exam of Rubeola

What does this refer to

• These groups developed hypersensitivity rather than protective immunity

• Vaccinated with the inactivated measles vaccine from 1963-1968

• Received live measles vaccine before 12 months of age

Atypical measles

What does this refer to

• More prolonged and severe than regular measles

• Marked by

  • Prolonged high fever

  • Pneumonitis

  • (Varying) rash begins peripherally

    • Urticarial

    • Maculopapular

    • Hemorrhagic

    • and/or vesicular

Physical exam of atypical (wild) measles

What Nagayama spots refer to

Roseola

What does Koplik’s spot refer to

Rubeola (Measles)

What does Forschheimer’s spots refer to

Rubella (German measles)

What does this refer to

• CBC w/ diff

• CMP

• Virus culture can be done thru nasopharyngeal secretions

• Measle antibodies (IgM) or IgG or virus detection on RT-PCR

• Fluorescent antibody screening

  • Eval for presence of IgM antibodies in blood

• Lymph node bx (rarely needed)

  • Wartin-Finkeldey giant cells

    • Fused lymphocytes with paracortical hyperplasia

Workup for Rubeola

What does this refer to

• Contour

• Heart

• Effusion

• Symmetry

• Trachea

Reading a chest x-ray

What does this refer to

Pneumonitis of atypical measles

What does this refer to

• Drug reactions

• Parvovirus B19

• Roseola

• Rubella

• Less likely

  • Kawasaki Disease

  • Dermatologic Manifestations of Viral hemorrhagic fever

  • Epstein Barr Virus (causes Mononucleosis)

  • Scarlet fever

Differential of Rubeola

What does this refer to

• ISOLATION for a week following the onset of rash

• Bedrest until afebrile

• Antipyretics and fluids

• Vitamin A may be used

• Treat secondary bacterial infections

Clinical Management of Rubeola

What does this refer to

• VACCINATION with MMR, MMRV

• Children first vaccinated at 12-15 months and then again at 4-6 years before entering school system

• Unvaccinated –outbreak more likely

Prevention for Rubeola

What does this refer to

• Pregnancy

• Void of fetal abnormalities

• Risk to the pregnancy

  • May result in spontaneous abortion or premature birth

Measles and pregnancyRubeola

What does this refer to

• Encephalitis

• Lung infections

• Secondary Bacterial Infections

• GI Complications

Complications of Rubeola

What does this refer to

• A 2-year-old girl is brought to her pediatrician’s office for a new rash on the palms and soles that developed yesterday.

• For the past few days, she has had low-grade fevers and a slight cough, and of note, her 6-year-old sister had similar symptoms.

• Upon further questioning, she and her sister have had all routine childhood vaccinations.

• Physical exam

  • Multiple 2-3-mm grey vesicular lesions on the bilateral palms and soles and several vesicles and ulcers on the oral mucosa.

Hand-foot-mouth disease (HFMD)

What does this refer to

• Common pediatric viral illness causing sores in/on/around the mouth, and palms and soles

Hand-Foot-Mouth Disease (HFMD)

What does this refer to

• MC young children

• Risk Factors

  • Exposure to others

  • Daycare centers

  • Poor hygiene

  • Finger sucking

Epidemiology of Hand-Foot-Mouth-Disease (HFMD)

What does this refer to

• Coxsackie virus

• Type A*

  • HFMD

  • Herpangina

• Type B

  • Nonspecific prodrome

  • Myocarditis

  • Pericarditis

• Once infected —> lymph nodes >>> prodromal sx

Etiology of Hand-Foot-Mouth-Disease (HFMD)

What does this refer to

• Flu-like sx

• Low-grade fever

• Cough

• Malaise

• Mouth sores

• Rash

Clinical history of Hand-Foot-Mouth-Disease (HFMD)

What does this refer to

• Grayish-yellow vesicles or erythematous papules on the palms and soles

• Vesicles and ulcers in oral mucosa and around the mouth

Physical exam Hand-Foot-Mouth Disease (HFMD)

What does this refer to

• Rickettsia rickettsi

• Chickenpox

• Diagnosis is often clinical, but can be confirmed with labs

Differential diagnosis of Hand-Foot-Mouth Disease (HFMD)

What does this refer to

Workup for Hand-Foot-Mouth Disease (HFMD)

What does this refer to

• Coxsackievirus-specific immunoglobulin A +

• Viral culture

How to diagnose Hand-Foot-Mouth Disease (HFMD)

What does this refer to

Supportive care

• Antipyretics

• Analgesics

• Hydration

Clinical Intervention of Hand-Foot-Mouth Disease (HFMD)

What does this refer to

“No specific pharmacologic therapy”

Clinical pharmacotherapeuticsHand-Foot-Mouth Disease (HFMD)

What does this refer to

Prognosis/prevention for Hand-Foot-Mouth-Disease (HFMD)

What does this refer

“Most patients have full, spontaneous recovery”

Prognosis of Hand-Foot-Mouth Disease (HFMD)

What does this refer to

• Acute, febrile medium vessel vasculitis

• Also known as Acute Systemic Vasculitis

Kawasaki Disease

What does this refer to

• A 5-year-old boy presents to the emergency room with 5 days of fevers, ranging from 102-104°F (38.9-40°C).

• His mother reports that he also has a bad rash that developed on day 3.

• Physical exam

  • Bilateral conjunctivitis

  • Extensive morbilliform rash on his trunk with desquamation

  • Bright red tongue

  • Swollen hands and feet

• Labs

  • Elevated C-reactive protein, white blood cell count, and erythrocyte sedimentation rate.

Kawasaki Disease

What does this refer to

• MC peds < 5yo

• MC Asian descent

• Risk Factors

  • Family hx

  • Asian or Pacific Islander descent

Epidemiology of Kawasaki Disease

What does this refer to

• No known specific etiology

• Combination infectious, environmental, immunologic, and genetics

Etiology of Kawasaki Disease

What does this refer to

• General arthralgias

• High fever

Clinical history of Kawasaki Disease

What does this refer to

Physical exam of Kawasaki Disease

What does this refer to

• Fever for 5 or more days (burn) PLUS

• Must have 4 of 5 CRASH sx

  • Conjunctival injection

  • Rash

  • Adenopathy

  • Strawberry tongue

  • Hand and foot rash

Diagnostic Criteria for Kawasaki Disease

What does this refer to

• Takayasu arteritis

• Scarlet fever

• Staphylococcal scalded skin syndrome

Differential diagnosis of Kawasaki Disease

What does this refer to

Workup for Kawasaki Disease

What does this refer to

“Vaccinations if not up to date (UTD)”

Clinical interventionKawasaki Disease

What does this refer to

• Intravenous Immunoglobulin (IVIG)

• High-dose aspirin (ASA) with taper to lower dose

  • DC if imaging confirms no coronary vessel abnormalities weeks after onset of disease

• Anticoagulation (warfarin (coumadin) often drug of choice)

• ↓ risk of thrombosis

• + thrombocytosis

• Monitor INR if taking warfarin

Clinical pharmacotherapeuticsKawasaki Disease

What does this refer to

Prognosis/preventionKawasaki Disease

What does this refer to “Most cases are self-limited and resolve with treatment”

Prognosis for Kawasaki Disease

What does this refer to

• 4-year-old boy presents to the urgent care clinic for a new rash.

• His mother reports that the rash started on both his cheeks yesterday, but since then he has developed a rash on his trunk.

• On physical exam, he has a slapped cheeks appearance and has a maculopapular rash on his trunk with some areas having a lacy or reticular appearance.

• The physician advises him to stay home while he is still contagious and to stay away from pregnant women.

Erythema infectiosum (5th disease)

What does this refer to

• Viral illness parvovirus B19

• Can cause a variety of illnesses (depending on patient population)

Erythema Infectiosum (5th disease)

What does this refer to

• Highest incidence in winter and spring

• Children > adults

• Risk Factors

  • Sickle cell disease

  • Thalassemia

  • Hereditary spherocytosis

  • Close proximity to others

Epidemiologyof Erythema Infectiosum (5th disease)

What does this refer to

• Parvovirus B19

• Variety of illnesses

• Aplastic crisis – red blood cell disorders

• Pure RBC aplasia in adults

• Rheumatoid arthritis-like sx in adults

• Erythema infectiosum (5th disease) in children

• Hydrops fetalis

  • Maternal exposure

• Transmission —> respiratory droplets

EtiologyErythema Infectiosum (5th disease)

What does this refer to

Peds

• Prodromal flu-like sx

Fetus

• Fetal death in pregnant women

Adults

• Polyarthropathy may be only sx

Clinical history of Erythema Infectiosum (5th disease)

What does this refer to

• First appears as “slapped cheeks”

• Followed by erythematous maculopapular rash on trunk and limbs

  • Lacy or reticular

Physical exam of Erythema Infectiosum (5th disease)

What does this refer to

• Measles (Rubeola)

• German Measles (Rubella)

Differential Diagnosis of Erythema Infectiosum (5th disease)

What does this refer to

Workup for Erythema Infectiosum (5th disease)

What does this refer to

• History and physical exam

• Parvovirus-specific IgM +

• PCR + for parvovirus

How Erythema Infectiosum (5th disease) is diagnosed

What does this refer to

Supportive care

• Analgesics

• Hydration

Clinical interventionErythema Infectiosum (5th disease)

Only use aspirin for

Kawasaki disease

What does this refer to “No antiviral therapy indicated”

Clinical pharmacotherapeuticsErythema Infectiosum (5th disease)

What does this refer to

Prognosis/preventionErythema Infectiosum (5th disease)

What is the prognosis of erythema infectiosum (5th disease)

Usually self-limiting

What does this refer to

• An 8-year-old boy is brought by his parents to the pediatrician with complaint of a fever and sore throat for the past few days.

• He says that he has felt tired and that his "neck is sore."

• Physical examination is notable for the finding seen in the image.

• Heterophile antibody test is negative

Cytomegalovirus (CMV) Peds

What does this refer to

• CMV (HHV-5)

• Causes CMV mononucleosis

• Can cause congenital CMV

Cytomegalovirus (CMV) Peds

What does this refer to “Congenital infection 1% of all births”

EpidemiologyCytomegalovirus (CMV) Peds

What does this refer to

CMV (HHV-5) transmission

• Sexual

• Transplacental —> congenital

• Breast milk

• Respiratory droplets

• Blood transfusions

EtiologyCytomegalovirus (CMV) Peds

What does this refer to

Clinical history of Cytomegalovirus (CMV) Peds

What does this refer to

• Cervical lymphadenopathy

• Petechial (“blueberry muffin”) rash

Physical examCytomegalovirus (CMV) Peds

What does this refer to

• Congenital toxoplasmosis

• EBV mononucleosis

Differential Diagnosis of Cytomefalovirus (CMV) Peds

What does this refer to

DiagnosticsCytomegalovirus (CMV) Peds

What does this refer to

• Supportive care

• ID consult

Clinical interventionCytomegalovirus (CMV) Peds

What does this refer to

1st line therapy

• Ganciclovir (Cytovene)

• Cidofivir (Vistide)

• Foscarnet (Foscavir)

Clinical pharmacotherapeuticsCytomegalovirus (CMV) Peds

What does this refer to

PrognosisCytomegalovirus (CMV) Peds