Good Morning! Happy Monday

1. Good Morning! Happy Monday Monday, July 22nd, 2013

2. 4yo 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 yoshots several months ago • Social: stays at home w/ mom, no travel history, older siblings with cold like symptoms, no rash

4. Differential Dx • Arthritis/Arthralgias • Desquamation • Lymphadenopathy • Meningitis • Enanthems (mucosal involvement) • Ulcerative vesicular lesions • Palm and Sole involvement • Predominantly on extremities • Respiratory Symptoms/Pulmonary infiltrates

5. 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

8. 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)

9. 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

11. 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

12. 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 is A. early-onset group B Streptococcus infection B. echovirus 11 infection C. herpes simplex virus infection D. hypoplastic left heart syndrome E. respiratory syncytial virus infection

13. Neonates** • High risk for developing disseminated infection • Severe manifestations: • Fulminant Hepatitis • Myocarditis • Pneumonitis • Meningitis • Encephalitis • DIC • Multiorgan failure

14. 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,

15. 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

16. 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)

17. Treatment • Supportive care • Antivirals under investigation • IVIG may benefit immunodeficient patients • Also used in some with myocarditis or persistantmeningoencephalitis

18. Prevention • Contact precautions • HAND WASHING!!!

19. 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

20. Hand-Foot-and-Mouth Disease (cont’d) Oral lesions

21. Hand-Foot-and-Mouth Disease (cont’d) • Painful vesicles in mouth and on handsand feet • Surrounded by an erythematous margin • Nonvesicular lesions on buttocks, GU and extremities less commonly

22. Hand Foot Mouth Disease • Onychomadesis – proximal separation of the nail plate from the nail bed

23. 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

24. 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

25. 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

26. 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)

27. Herpangina • Erythematous ring surrounds • Puntatemacules vesiclulate, ulcerate • Anterior tonsillar pillars, soft palate, posterior pharynx

28. Herpangina • Self-limited • Resolve spontaneously within 1 week • Supportive care • Young children are at risk of dehydration

29. 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

30. 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

31. Herpetic Gingivostomatitis

32. 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

33. 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

34. Apthous stomatitis • Topical creams may help

35. Topical Analgesia Usually not recommended • Benzocaine (orajel) • associated with methemoglobinemia • viscous lidocaine • may cause problems if absorbed systemically • may choke on secretions • may chew their buccal mucosa

37. Picture Quiz Infectious Exanthems

38. Exanthem #1 MEASLES

39. Exanthem #2 Coxsackie A - HFM

40. Exanthem #3 Rubella

41. Exanthem #4 Parvovirus B19- Fifth’s Disease- Erythema Infectiosum

42. Exanthem #5 Varicella

43. Exanthem #6 RMSF

44. Clue: This patient had a h/o 3 days of fever (that has since defervesced) before the appearance of the rash Exanthem #7 HHV6- Roseola

45. Exanthem #8 Scarlet Fever- Group A Strep

46. Clue: You might be more suspicious of this illness if this picture was a hypotensive woman Exanthem #9 Toxic Shock Syndrome

47. Exanthem #10 Staph Scalded Skin

48. Exanthem #11 Steven-Johnson-Syndrome

49. Exanthem #12 Kawasaki Disease

50. Exanthem #13 Meningococcemia