Infectious diseases with exanthema syndrome

1. Infectious diseases with exanthema syndrome Lecturer: GorishnaIvannaLubomyrivna

2. Plan of the lecture • Clinical, epidemiological peculiarities, differential diagnosis, treatment and prevention of Measles • Clinical, epidemiological peculiarities, differential diagnosis, treatment and prevention of Rubella • Clinical, epidemiological peculiarities, differential diagnosis, treatment and prevention of Scarlet fever • Clinical, epidemiological peculiarities, differential diagnosis, treatment and prevention of Pseudotuberculosis • Clinical, epidemiological peculiarities, differential diagnosis, treatment and prevention of Chickenpox

3. Measles • Etiology: Measles virus - RNA virus, that belongs to the Paramyxoviridae family, Morbillivirus genus.

4. Transmission • Source of infection – infected person during last 2 days of incubation period, catarrhal period, and 4 days period of eruption (in case of complications –10 days period of eruption). • Infection is spread by inhalation of large and small airborne droplets. • Susceptible organism - no immunized persons, older than 6 month, which never had measles.

5. Pathophysiology • Local replicationin the respiratory epithelium. • Viremia - virus is spread by leukocytes to the reticuloendothelial system. • necrosis of leukocytes, a secondary viremia occurs. • specific antibody and cell-mediated responses - the illness resolves. • Measles causes an immune suppression. It may predispose individuals to severe bacterial infection, particularly bronchopneumonia, a major cause of measles-related mortality among younger children.

6. Clinical presentation The incubation period 9 - 17 (21!) days. • Prodromal period - 3 - 5 days. • Temperature is usually high at first day. • The classic three “C’s” (cough, coryza, conjunctivitis). • the enanthema orKoplik’s spots. They usually disappear by the second day of the exanthema.

7. Measles conjunctivitis

8. Koplik’s spots

9. Measles enanthema

10. Exanthema period: 3-4 days • Second increase of temperature. • Initial lesions on the forehead and face. • During 3-4 days they spread downward • The rash is red maculopapular, initially discrete then confluent. • Ctarrhal signs progress • Koplick’s spots and enanthema remain for 1-2 days Pigmentation period (1-1.5 weeks) • Pigmentation progresses in the same fashion as the rash, than desquamation (microscalling) • Normalisation of the temperature • Ctarrhal signs resolves

11. Measles, typical rashes, 1st day

12. Measles, typical rashes, 2nd day

13. Measles, hemorrhagic rashes

14. Measles, pigmentation period

15. Classification • By the form: • typical, by the severity: • mild; • moderate; • severe (without hemorrhagic syndrome, with hemorrhagic syndrome); • Atypical - • abortive; • mitigious; • hyperreactive; • subclinical; • asymptomatic; • measles in vaccinated; • measles in person who receive antibiotics and hormones. • By the course: • smooth (uncomplicated); • not smooth, uneven (complicated).

16. Complications • By the time of development: • early (in prodromal and rashes period) • late (in pigmentation period). • By the localization: • respiratory system; • digestive system; • nervous system; • eyes; • ears; • skin; • urinary system.

17. Complications:primary (viral) • laryngotracheitis (croup), • bronchitis, • encephalitis, • Giant-cell pneumonia • diarrhea • keratoconjunctivitis • Rare complications include • hepatitis, encephalitis.

18. Complications:secondary bacterial • otitis media, • pneumonia, • gingivostomatitis, • pyelonephritis, • diarrhea, • dermatitis.

19. Peculiarities of measles in infants • Atypical (mitigious) forms • Shortened periods of the disease • Mild clinical signs (catarrhal phenomena, fever, small rash with the shortened appearing and pigmentation) • Complications are more frequent.

20. Laboratory work-up • common laboratory tests are non-specific. • leukopenia, lymphocytosis, eosynophylia, and thrombocytopenia (may be) • serological test (DHAR, PHAR), Immune enzyme analysis • virus isolation (nasopharyngeal smears) is technically difficult • Cytoscopic examination presence of typical multinuclear giant cells

21. Differential diagnose • scarlet fever, • Epstain-Barr viral infection, • meningococcal sepsis, • pseudotuberculosis, • Stevens-Johnson syndrome, • adenovirus, • enterovirus infection.

22. Scarlet fever, localisation of rashes

23. Allergic rashes

25. Meningococcemia

26. Stevens-Johnson syndrome

27. Adenovirus infection

28. Treatment • Adequate hydration, bed rest; vitaminized food; • Antipyretics for fever control: • paracetamol 10-15 mg/kg not often than every 4 hours or ibuprophen 5-10 mg/kg per dose, not often than every 6 hours. • Nasal decongestants not more than 3 days, in infants before 6 mo physiologic saline solution • Mucosolvents and cough supressors; • Vitamin A 200 000 Units orally daily • Care for oral cavity, conjunctiva.

29. bacterial complications – antibacterial therapy • severe episodes– corticosteroids (1-2 mg/kg for 2-3 days). • croup: mist tent with 25-30 % oxygen inhalation, antianxiety medicines, steroids and mechanical ventilation in severe cases. • meningitis: steroids, dehydrates, parenteral detoxication (albumin, plasma), anticonvulsants.

30. Prevention • Specific active immunization by MMR vaccine (measles, mumps, rubella) at age 12 months. Revaccination at 6 years. • Specific passive postexposure prophylaxis with serum immune globulin in a dose of 0.25 ml/kg, within 3 days of exposure. • Nonspecific • isolation of ill person until 5th day of the exanthema period, • isolation of contact person from 8th to 21st day after exposure.

31. Rubella (German measles) • It is caused by RNA rubella virus, which belongs to the Togaviridae family, Rubivirus genus.

32. Transmission • the source of infection is a patient or carrier • the mechanism of transmission is air-droplet, transplacental • receptivity is common, especially high in children 2-9 years

33. Pathophysiology: • Acquired Rubella: • The primary cite of infection (atrium) - mucus membranes of nasopharynx, replication. • hematogenous distribution (viremia). • Damage of organs and systems. • Immunological response, recovery. • Congenital Rubella: • Transplacental infection of the fetus. • destruction of the cells by the virus (cytotoxic defect), violation of the organs’ development. • Forming of the congenital defects.

34. CLINICAL PICTURE of the Acquired Rubella Incubation period is 14-21days Prodromal phase: 1-2 days before the onset of rash: • Headache; Low-grade fever; Chills; Anorexia; Nausea; • Eye pain, Conjunctivitis; • Sore throat; • Tender lymphadenopathy (particularly posterior auricular and suboccipital lymph nodes); • Forchheimer sign- pinpoint or larger petechiae that usually occur on the soft palate

35. Exanthema phase (period): • a discrete rose-pinkmaculopapular rash ranging from 1- 4 mm covers all the body through 1 day • More intensive on external surfaces of the body • Disappears in 2-3 days without pigmentation and scalling • Temperature: Fever usually is not higher than 38.5°C. • Lymph nodes: Enlarged posterior auricular and suboccipital lymph nodes. • Mouth: The Forchheimer sign may still be present.

36. Rubella

37. Diagnostic criteria of the congenital Rubella Classical Triad: • Cataract • Congenital heart disease (patent ductus arteriosus, aortic valves defect, aortic stenosis, coarctation of the aorta, ventricular septal defect, pulmonary stenosis, atrial septal defect, transposition of the main arteries) • Deafness

38. Classification of the acquired Rubella • By the type: • typical forms • atypical forms (effaced, asymptomatic) • By the severity: • Mild • Moderate • Severe • By the course: • smooth (uncomplicated) • uneven (complicated) • Specific complications: meningitis, encephalitis, synovitis

39. Treatment • Basic therapy: • Hygienic regime, often room ventilation • Control of fever – as in measles

40. Prevention: • Isolation: for 4 days after the onset of rash in patients with acquired rubella. • Contact isolation for children with congenital rubella infection until 1 year unless nasopharyngeal swab and urine cultures after age 3 months are repeatedly negative. • Specific active –– MMR vaccine. • The first dose of MMR at 12-15 months. • The second dose of MMR at 6 years. • Girls of 15 years if were not vaccinated before – Rubella monovaccine. Specific Passive prophylaxis for seronegative pregnant.

41. Chickenpox (Varicella) Etiology: Varicella–zoster virus from Herpesvirus family Transmission: Source of infection - ill person Chickenpox or Herpes zoster Is transmitted by respiratory route or by the direct contact. Susceptible organism - everyone, who didn’t ill before. Lifetime immunity.

42. Pathogenesis Inoculation of virus and it’s replication in epithelial cells of upper respiratory tract. Regional lymphadenitis. Viremia. Damage of the skin epithelium and mucosa epithelium. Generalization of the infection in immunecompromised persons. Damage of the nervous system (cerebellum).

43. Clinicalpresentation incubation period11 to 21 days contagious period1 to 2 days before the rashes erupt until all of the lesions have crusted (5 days after the last rashes have appeared) Prodrome1 to 2 days fever, headache, malaise, and anorexia.

44. rashes,often pruritic, maculae  papule  vesicle  crusted lesion. first appear on the face or trunk are more numerous centrally than distally. erupt in crops for 3 to 4 days Polymorphism Lesions on the mucous membranes do not crust but form a shallow ulcer.

45. Chickenpox

46. Chickenpox, typical localization of rashes

47. Chickenpox, rashes on mucus membranes

48. Classification • By the type: • typical forms • atypical forms (subclinical, bullous, hemorrhagic, gangrenous, generalized) • By the severity: • Mild • Moderate • Severe • By the course: • smooth (uncomplicated) • uneven (complicated)

49. Hemorrhagic form

50. Complications secondary bacterial - Staphylo- or streptodermia otitis, pneumonia Viral: pneumonia croup Encephalitis (involvement of the cerebellum, or cerebrum) less common – Guillain-Barre syndrome, transverse myelitis, optic neuritis, and facial nerve palsy.