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Board review - Viral infections

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

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Board review - Viral infections

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  1. Board review - Viral infections

  2. 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

  3. 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

  4. rubeola (nine-day or red measles) • 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

  5. rubeola (nine-day or red measles) • 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

  6. rubeola (nine-day or red measles)

  7. 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

  8. 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

  9. 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 • Incubation period 14-21 days • Complications - rare in childhood - arthritis, purpura c or s thrombocytopenia, mild encephalitis

  10. rubella (german Measles)

  11. 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

  12. 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

  13. varicella (chickenpox) • 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

  14. varicella (chickenpox) • 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

  15. varicella (chickenpox) • 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

  16. varicella (chickenpox)

  17. 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

  18. 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 • Incubation period 6-9 days

  19. 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

  20. Coxsackie hand-foot-and-mouth disease • Highly contagious • Incubation period 2-6 days • Lasts 2-7 days • Peak season summer through early fall • If no cutaneous lesions - herpangina • less painful and less intense than herpes gingivostomatitis

  21. 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

  22. erythema infectiosum (fifth disease) • 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

  23. erythema infectiosum (fifth disease)

  24. 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

  25. roseola infantum (exanthem subitum) • 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

  26. roseola infantum (exanthem subitum)

  27. 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

  28. Infectious mononucleosis • 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

  29. Infectious mononucleosis • 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

  30. Infectious mononucleosis • Complications: • pneumonia • hemolytic anemia and thrombocytopenia • icteric hepatitis • acute cerebellar ataxia, encephalitis, aseptic meningitis, myletis, Guillain-Barre • rarely myocarditis and pericarditis

  31. Infectious mononucleosis • 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

  32. Infectious mononucleosis • 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

  33. Infectious mononucleosis • 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

  34. 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

  35. 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

  36. 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

  37. 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

  38. 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

  39. primary herpes simplex infections • 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

  40. primary herpes simplex infections • 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

  41. 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

  42. Eczema herpeticum (kaposi varicelliform eruption) • 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

  43. Eczema herpeticum (kaposi varicelliform eruption)

  44. 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

  45. 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

  46. 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)

  47. herpes zoster (shingles) • 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

  48. herpes zoster (shingles) • 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

  49. herpes zoster (shingles)

  50. 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

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