It Always Has To Be Viral?

1. It Always Has To Be Viral? Crash Course on Common Viral Exanthems (now with CASES!) Vincent Patrick Tiu Uy, MD PGY-2 Pediatrics St. Barnabas Hospital, Bronx

2. Outline for Discussion • Define Exanthem VS Enanthem • Short and Sweet case • Identification of the disease and causative agent • Chronology of Signs and Symptoms • Incubation & Period of contagiousness • Work-up • Treatment and Prophylaxis • Pointers

3. Case 1 • A 7 year old male with a rash was seen in the Emergency room and was diagnosed with a single-stranded Togavirusfrom direct PCR of nasopharyngeal swabs. The ER resident who examined the child is 2 weeks pregnant. What should she be concerned of? • She will get a similar rash • She will have lymphadenopathy • Her joints will hurt • Her baby will have congenital malformations • She should worry after she goes for her first prenatal check-up

4. Rubella

5. Rubella

6. Rubella • Causes: Single stranded Togavirus • Transmission: Respiratory droplets • Incubation period: 14-23 days • Pathophysiology: Nasopharynx  Reticuloendothelial system Viral particles deposit in skin, synovium, CNS and placenta

7. Clinical Course PRODROME (1-5 days) Malaise Fever (low-high grade) Anorexia Rhinorrhea Headaches (in older children) Conjunctivitis +/- Lymphadenopathy

8. Work-up • No work-up is necessary in otherwise healthy children • Pregnant women: MUST determine immune status. • First 2 months of life. • Risk increases even more up to 5 months of life. • Risk increases towards the final trimester • Serum IgM to Rubella is useful in newborns suspected of having congenital rubella syndrome

9. Complications • Arthropathies of the fingers • Thrombocytopenia (rare) • Congenital Rubella Syndrome • IUGR • CHD (PDA, PPAS) • Hearing defects • Glaucoma, Cataracts • Neonatal purpura (“blueberry muffin rash”) • Hepatomegaly and Jaundice • Meningitis and Encephalitis • “Celery-stalking” lesions on long bones

10. Treatment and Prophylaxis • Treatment: Supportive • MMR vaccines for children at 12 months and school age • DO NOT VACCINATE NON-IMMUNE PREGNANT WOMEN (MMR is a live vaccine)

11. Pointers for Rubella • Single Stranded Togavirus • 2-3 weeks incubation period • First and last trimester of pregnancy  high risk of CRS • Characteristic rash + Lymph nodes • Forchheimer spots • MMR at 12 months and 4-6 years • Know about Congenital Rubella Syndrome

12. Case 2 A 21 year old fertile female caught measles for the first time, cause she was unvaccinated as a child. The virus ran it’s course with no complications. It’s now 1 week after the rash disappeared. She is not pregnant now, but she plans to be in the next 4-5 months. What’s a girl to do ? • She should start taking multivitamins and folic acid • She should receive IVIG as soon as possible • She should be reassured only • She should see her obstetrician ASAP • She should have herself tested for measles antibodies

13. Measles

14. Measles • Cause: Rubeola virus (Morbillivirus) family of Paramyxoviridae • Appears late winter to spring • Incubation: 7-14 days • Transmission: Droplets • Patient is contagious 4 days before the exanthem and 4 days after it’s disappearance • Pathophysiology: Delayed type hypersensitivity IL-12 response Other infections

15. Clinical Course PRODROME (up to 7 days): High fevers (>38.0C) Malaise 3 “C’s” of Measles Photophobia and Edema of the eyelids Myalgias

16. Work-up • Usually unnecessary • Suspected cases should be reported to the DOH • Atypical presentations: • Measles IgM  peaks by day 3 of the rash and still seropositive 4-11 days after that • Meases IgG  may indicate immunity; stays positive after exposure/vaccination. Useful in SSPE and for screening purposes

17. Complications • High risk to develop Otitis Media, Pneumonia, Croup and reactivation of latent TB (immunosuppression) • Encephalitis may ensue as a result of immunosuppression • Subacute Sclerosing Panecephalitis SSPE

18. Treatment and Prophylaxis • For uncomplicated cases, treatment is generally supportive with attention to hydration • Vitamin A Supplementation • MMR vaccine at 12 months of age + 4-6 years of age • Post-exposure prophylaxis: • Unvaccinated • Within 3 days of exposure • Ribavirin  immunocompromised patients or in the setting of SSPE • Human IVIG

19. Treatment and Prophylaxis • Consider IVIG in the following situations: • Immunosuppressed individuals (ex. Chronic systemic glucocorticoids, HIV) • Children < 6 months to a year (especially if mom is not immune) • Pregnant women (since vaccine will be contraindicated)

20. Pointers for Measles • Usually a benign condition with a classic clinical course • Know the typical course • Contagious 4 days before and 4 days after the rash • Complications increase in immunocompromised people • SSPE • Vitamin A supplementation • MMR 3 days after exposure • IVIG

21. Case 3 A child was brought to the emergency department for a simple febrile seizure. He was discharged and three days later, he had a rash which appeared to be roseolainfantum. How old is this child? • 1 month old • 10 months old • 2 years old • 7 years old • 15 years old

22. RoseolaInfantum

23. RoseolaInfantum • Cause: Human Herpes Virus 6a, 6b and 7 • Peak onset: 9-12 months • Route: Saliva • Pathophysiology: • Remains in lymphocytes and monocytes  cytopathic changes • Diminished regulation of the host immune system

24. Clinical Course Previously healthy child Abrupt onset of high fevers (usually 40 C) Febrile seizures (15%)

25. Work-up • Diagnosis is clinical; work-up is not necessary • Consider work-up only in immunocompromised hosts

26. Treatment and Prophylaxis • Treatment is mainly supportive, ensuring adequate hydration • Dehydration is the most common reason for admission; complex febrile seizures may also be another. • Isolation is not necessary • No prophylaxis necessary for close contacts

27. Pointers for RoseolaInfantum • Self-limiting condition • Fever  Rash clinical course • Nagayama’s spots • HHV6B  most common etiology in children • Isolation not necessary

28. Case 4 • A four year old girl with HIV was seen in the ED because she was exposed to a boy in daycare who had vesicular lesions suspicious for chicken pox. Because she had HIV borderline CD4 counts, the parents were worried that she may obtain a catastrophic form of chicken pox. What should be done? • Obtain titers of Varicella antibodies • Vaccinate her immediately • Passive immunization within 96 hours • Reassurance. It’s ok for her to get the disease and get it over with • Give her a bath with betadine so she does not develop lesions

29. Chicken Pox

30. Chicken Pox • Cause: VZV (Herpesviridae) • Transmission: Respiratory droplets, direct contact to skin lesions • Incubation: 10-21 days • Contagious Period: 1-2 days before the onset of the rash and 5-6 days after (until lesions “crust”) • Pathophysiology: • 2-4 days: Virus replicates in the lymph nodes • 4-6 days: Primary viremia (RES) • 7 days: Secondary viremia

31. Clinical Course PRODROME (up to 4 days) Fever Abdominal Pain Headache Cough and Respiratory Distress **

32. Work-up • Not necessary, diagnosis is generally clinical in straightforward cases • Blood counts may show leukopenia in the first 3 days • LFT’s show elevated ALT • For unclear cases, a Tzanck smear may be done

33. Complications • Secondary bacterial infections • Acute Postinfectious Cerebellar Ataxia • Varicella pneumonia  3-4 days • Encephalitis • Hepatitis, eye disorders, HSP, myocarditis, GN, appendicitis and Pancreatitis • Neonatal Varicella • Reye’s Syndrome

34. Treatment and Prophylaxis • Mainly supportive; maintain adequate hydration; break the itch-scratch cycle • Acyclovir • Reserved for immunocompromised patients • Treatment for Varicella pneumonia and Encephalitis • Treatment of Neonatal Varicella • Oral forms  may be considered in primary infection of adolescents

35. Treatment and Prophylaxis • Varicella Deterrence • Varicella Vaccine • PEP: Given within 36-72 hours of exposure • Recommended in children 12 months of age; booster at school age • IM VZIG post-exposure prohylaxis • Should be considered for the following: • Newborns who are at increased risk • Leukemia/Lymphoma • HIV • Immunosuppressed patients on Steroids • Pregnant women

36. Pointers for Varicella • Characteristic pattern of the rash • Common complications of chicken pox • Contagious 1-2 days before the rash until all lesions “crust” • Humoral + Cellular immunity  Lifelong immunity • Indications for pre-exposure and post-exposure prophylaxis • Breakthrough varicella ~42 days from vaccination

37. Case 5 • A child was seen in clinic and diagnosed with “fifth’s disease”. He has the classic rash on the face and a lacy rash on the arms for 3 days now. What anticipatory guidance should be given? • Keep the child away from sun and heat exposure • Patient may go to daycare • Patient should wear loose fitting clothes and apply petroleum jelly on the face • Clothes should be washed in hot water • Child should be admitted for IVIG

38. Erythema Infectiosum

39. Erythema Infectiosum • Cause: Parvovirus B19 • Transmission: Respiratory droplets, fomites, blood transfusions & transplacentally • Incubation: 7-10 days (but up to 21 days) • Pathophysiology: Skin Joints Erythroid Progenitor cells

40. Clinical Course PRODROME (2-3 days) Headaches Fever Sore Throat Pruritus Cough Coryza Abdominal Pain

41. Work-up • Diagnosis is often made clinical • Patients with a history of anemia or leukemia - CBC

42. Complications • Bone marrow suppression • Arthritis • Hydrops Fetalis • Severe Aplastic Anemia

43. Treatment and Prophylaxis • Generally supportive; Pay attention to hydration • Indication for IVIG • Aplastic Crisis • Consider in immunosuppressed patients – consult with ID first • Vaccine

44. Pointers for Fifth’s Disease • Parvovirus B19 is the only Parvovirus that causes human disease • Affinity and cytotoxic to erythroid progenitors  bone marrow suppression/aplastic anemia • 10% have Arthritis and arthralgias • 3 phases of exanthem • No longer infectious when rash appears • IVIG only for aplastic crisis/immunocompromised

45. Case 6 A previously healthy 3 year old male was seen in the ER for fever and sore throat. He was diagnosed with Hand Foot and Mouth disease. Mom wants to know how he got the infection. Which of the following is NOT a means of transmission for coxsackievirus? • Feco-oral route • Oral secretions • Respiratory droplets • Skin to skin contact • Daycare attendance

46. Hand Foot and Mouth Disease

47. Hand Foot and Mouth Disease • Causes: Picornaviridae • Coxsackievirus A16/A5/A/9/A10/B2/B5 • Enterovirus 71  Neurologic Involvement • Incubation: 7 days • Summer months • Transmission: Feco-oral, Salivary, skin contact • Pathophysiology: cell virus

48. Clinical Course Sore Throat High Fevers +/- Vomiting Malaise

49. Work-up • No work-up necessary not unless patient has neurologic manifestations • CSF samples may be needed for neurologically symptomatic patients

50. Complications • For infections with coxsackievirus, generally none • Myocarditis • Enterovirus 71 • Aseptic meningitis • Encephalitis and encephalomyelitis • Cerebellar ataxia • Acute Transverse Myelitis • Guillaine-Barre Syndrome • Opsoclonus-Myoclonus Syndrome