1. Infections with exanthems Mészner Zsófia dr. National Institute of Child Health Szent László Hospital Budapest

2. Which clinical syndromes?? „the classics” scarlet fever scarlet fever morbilli- measels morbilli- measels rubella-german measels rubella-german measels varicella varicella megalerythaema megalerythaema herpes herpes exanthema subitum exanthema subitum variola, vaccina, anthrax… variola, vaccina, anthrax…

3. Where is/what is this building?

4. What else? impetigo, SSS, STSS.. impetigo, SSS, STSS.. erythaema migrans (lyme) erythaema migrans (lyme) erythaema nodosum erythaema nodosum Hand-mouth-foot disease Hand-mouth-foot disease erysipelas erysipelas mucocutane candidiasis mucocutane candidiasis etc… etc…

5. Which syndromes are not typically of infectious origin? urticaria, atopic dermatitis urticaria, atopic dermatitis Drug induced exanthems (EBV + aminopenicillin)?? Drug induced exanthems (EBV + aminopenicillin)??  „Fix” exanthem Kawasaki disease?? Kawasaki disease?? ITP, other vasculitis sy ITP, other vasculitis sy IRA, SLE IRA, SLE Stevens-Johnson sy Stevens-Johnson sy

6. „Emergency” Meningococcus (Hib) sepsis – early signs Meningococcus (Hib) sepsis – early signs  Petechiae, fever, hyperacute start,  NO meningeal signs!!! Typhus abdominalis Typhus abdominalis  fever, roseola, splenomegaly

7. „Emergency” STSS – toxin mediaeted sy, ICU! STSS – toxin mediaeted sy, ICU! Cellulitis, deep necrotizing fasciitis Cellulitis, deep necrotizing fasciitis  varicella, surgical wounds, insect bites - superinfections Fever, neutropenia and cuteneous signs: Fever, neutropenia and cuteneous signs:  Pseudomonas aeruginosa, fungi

8. What activity is done here?

9. Epidemiology Vaccine preventible infections Vaccine preventible infections  Measels, rubella (MMR): extremly rare, imported cases  varicella (Varilrix) marked morbidity Other viral infections Other viral infections  megalerythaema, HHV-6,7, hand-mouth-foot disease

10. Vaccine preventible infections morbilli, rubella, (mumpsz) (MMR): extremly rare, imported cases morbilli, rubella, (mumpsz) (MMR): extremly rare, imported cases  1/500 exitus!!  no antiviral drug! varicella (Varilrix) marked morbidity varicella (Varilrix) marked morbidity  40-50 thousand cases/year (reported)

11. Other exanthemes Megalerythaema – exanthema infectiosum Megalerythaema – exanthema infectiosum  HPV B19 HHV-6,7,8 HHV-6,7,8 Hand-mouth-foot disease Hand-mouth-foot disease  enterovírusok

12. Which building?

13. Epidemiology again „purulent” infections „purulent” infections  Streptococcus pyogenes – angina, scarlat fever, STSS, AOM, mastoiditis, pneumonia, meningitis, rheumatic fever, poststreptococcal glomerulonephritis  Staphylococcus aureus – impetigo, scarlatoid, pneumonia, sepsis sy antropozoonozes antropozoonozes  Lyme (EM), hand-mouth-foot…

14. Morbilli - measels Characteristic signs and symptoms Characteristic signs and symptoms  highly contagious 96-98% (herd immunity!)  14-d incubation, wheezing prodrom  4.-day - exanthems  peeling  self-limiting immunsuppression (cellularis) Complications Complications  viral pneumonia (Hoechts), encephalitis, SSPE? No antiviral! No antiviral!

15. Kanyaró (morbilli)* 23 cases (1998), 2/3 in nurseries 23 cases (1998), 2/3 in nurseries  Imported cases from Romania, Ukrajna  no SSPE  Several epidemics all over Europe  MMR-autism – FALSE!  doctors don’t recognize it  No antiviral  WHO:eradication to 2010? (inf. Morbidity 8.) *EPINFO, Magyarország 1998. Évi járványügyi helyzete, 1999.november 23.

16. Where are we now?

17. Rubeola – rubella – german measels Signs-symptoms Signs-symptoms  Highly contagious  Incubation:17-21 d  Mild course  CRS – index of susceptibility complications complications  encephalitis  CRS No antiviral!! No antiviral!!

18. Rubeola*  Practically nonexistant?  1998.: 125 confirmed cases (+25% 1997.)*  67,2% <15 mo  15,2% > older, unvaccinated  2 cases of CRS in 1998(!) *EPINFO, Magyarország 1998. Évi járványügyi helyzete, 1999.november 23.

19. ?

20. VZV infections chickenpox chickenpox  varicella - chickenpox  övsömör - herpes zoster – shingles Smallpox??? – Vaccinia?? Smallpox??? – Vaccinia??

23. No local treatment, please!!

24. ?

25. The difference… VZV VZV  No,or short (1-2d) prodrom  Polymorh picture:3- 4. day macules,- papules, vezikules pustules  Crusts are not infectious  1-2 week courses on average Smallpox  5-7 d prodrom  Deeply seated vesicles on face and extremities  No polymorphism  Haemorrhagic laesions  Crusts are infectious  Average course 3 weeks

26. Religions?

27. Megalerythaema No good Hungarian name No good Hungarian name HPV B19 HPV B19 Multiplicates in proerythrocytes – haemolyzis Multiplicates in proerythrocytes – haemolyzis No clear incubation - 14 from case to case No clear incubation - 14 from case to case Highly contagiosus Highly contagiosus Infants, school kids Infants, school kids „slapped face” only on day 14-17.!! „slapped face” only on day 14-17.!! Arthritis in women Arthritis in women Heatlabil, spectacularexanthem – not contagious!! Heatlabil, spectacularexanthem – not contagious!! Serodiagnostics Serodiagnostics

28. Megalerythaema Risk groups Risk groups  Pregnancy  Early sptaneous abortions (AB testingt!)  Immunhydrops foetus  Hematology patients  Aplastic crizis – ovalocytosis, spherocytosis  Immunocompromised patients  Prolonged cytopenia (fvs, thr)  IVIG

29. Where are – were - we now?

30. Kawasaki disease (KD) Magyarországon First recognised case in H.: 1977. prf. Nyerges Gábor First recognised case in H.: 1977. prf. Nyerges Gábor Not registered – no data Not registered – no data Significance: leading cause of acquired heart disease in childhood Significance: leading cause of acquired heart disease in childhood disease? syndrom? disease? syndrom? Kawasaki’s original article Kawasaki’s original article

31. A KD diagnostic criteria (by Kawasaki) Bilateral (dry) conjunctivitis Bilateral (dry) conjunctivitis Mucosal signs (ips, tonque, oral cavity) Mucosal signs (ips, tonque, oral cavity) fever in spite of AB treatment (1-2 weeks) fever in spite of AB treatment (1-2 weeks) Skin signs: palmar-plantar redness, oedema, peeling Skin signs: palmar-plantar redness, oedema, peeling polymorh (non vezikular) exanthem Acute,non purulent cervical lymph node < 1,5 cm Acute,non purulent cervical lymph node < 1,5 cm forrás: Pediatrics, 1974. 3; 271-6.

32. KD AHA diagnostic criteria I. min. 5-day fever min. 5-day fever min. 4: min. 4: Extremities, polymorph exanthem, bilateral conjunctivitis, cheilitis, glossitis, cervical lymphnode Exclusion of other syndromes/diseases Exclusion of other syndromes/diseases forrás: Circulation 1993, 87; 1776-80.

33. KD AHA diagnostic criteriaI II. (atypical) Less than 4 typical signs Less than 4 typical signs Echography: a. coronaria dilatation/aneurysm Echography: a. coronaria dilatation/aneurysm No other known etiology No other known etiology forrás: Circulation 1993, 87; 1776-80.

34. Anthrax? Anthrax: antropozoonozis  Does not spread from person to person!!!  Skin: „pokolvar”: necrotic, deep ulcer  Intestinal: haemorrhaege  „respiratory” – haemorrhagic mediastinitis

35. Thank you for your attention!