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Clin Med II Infectious Disease Lecture II—Viral Diseases, part 3/3.

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Presentation on theme: "Clin Med II Infectious Disease Lecture II—Viral Diseases, part 3/3."— Presentation transcript:

1 Clin Med II Infectious Disease Lecture II—Viral Diseases, part 3/3

2 Measles

3  Acute systemic paramyxovirus  Inhalation of infective droplets  Major worldwide cause of morbidity and mortality  750,000 deaths in 2000  197,000 deaths in 2007  Rising rates of intentional undervaccination—sporadic outbreaks  Highly contagious

4 Measles  Fever (40-40.6 C or 104-105 F)  Malaise, coryza, cough, conjunctivitis  Koplik spots  Rash appears about 4 days after oonset  Pinhead-sized papules  brick-red, irregular, blochy maculopapular rash  may become uniform erythema  Face and behind ears  trunk  extremities  Erythematous pharynx with yellowish tonsillar exudate  Coated tongue  Generalized lymphadenopathy  Splenomegaly

5 Measles


7  Labs—Leukopenia, thrombodytopenia, proteinuria  Can culture virus from nasopharyngeal washings and blood  IgM measles bodies or 4x rise in serum hemagglutination inhibition, fluorescent antibody staining of respiratory or urinary epithelial cells  Complications  CNS—postinfectious encephalomyelitis—multiple forms— read in text  Bronchopneumonia, bronchiolitis, bronchiectasis  Secondary bacterial infections  Immune reactivity  Gastroenteritis  Conjunctivitis, keratitis, otosclerosis

8 Measles—Treatment  General—isolation until week following rash onset; bed rest until afebrile  Antipyretics and fluids  High dose vitamin A—maintains GI and respiratory mucosa  Treatment of secondary bacterial infections  Encephalitis—symptomatic treatment only

9 Measles  Prevention—immunization (12-15 mo, 4-6 yrs)  Do not give in pregnancy or immunosuppression  Report all cases to public health. Refer in cases of HIV and pregnancy  Admit:  Meningitis, encephalitis, myelitis  Severe pneumonia  Diarrhea that compromises fluid balance

10 Mumps

11  Spread by respiratory droplets  Children are most commonly affected  Incidence highest in spring  Incubation 14-21 days  Up to 1/3 of infection-- asymptomatic

12 Mumps  Parotid tenderness, swelling  Trismus  Glands usually normal within 1 wk  Fever and malaise  Meningitis  Orchitis—most common extrasalivary site in adults  Pancreatitis—most common cause of pancreatitis in children

13 Mumps  Labs—mild leukopenia, amylasemia (from salivary glands), mild kidney function abnormalities  CSF—pleiocytosis, hypoglorrhachia  Diagnosis—usually characteristic clinical picture  Isolate of virus from swab of the duct of the parotid or other affected salivary gland  Can isolate virus from CSF early in aseptic meningitis  Nucleic acid amplification—more sensitive than viral culture but limited availability  Elevated IgM--diagnostic

14 Mumps  Treatment—isolate till swelling subsides, bed rest till afebrile; symptomatic relief  Topical compresses  IVIG—can try for complicated disease but no consensus  Meningitis—symptomatic; manage cerebral edema, airway, vital functions  Epididymoorchitis—scrotal support, ice bags, pain relief  Pancreatitis—symptomatic, hydration  Usually lasts no longer than 2 weeks  Prevention—live virus vaccine; routine immunization  Often in combination with measles, rubella and VZV

15 Rubella

16  Systemic disase— togavirus transmitted by inhalation of infective droplets  One attack usually confers permanent immunity  Difficult to distinguish from mono, measles, other viral illnesses— arthritis is more prominent in rubella  Principal importance— devastating effects on fetus in utero

17 Rubella  Fetal—devastating  Postnatally acquired—innocuous—up to 50% asymptomatic  Fever, malaise, tender suboccipital adenitis, coryza  Arthritis—fingers, wrists, knees  Early posterior cervical and postauricular lymphadenopathy  Erythema of palate and throat  Fine pink maculopapular rash on face, trunk and extremities in rapid progression (2-3 days) and fades quickly1 day in each area

18 Rubella

19  Labs—leukopenia  Diagnosis—elevated IgM antibody, isolation of virus, 4x or greater rise in IgG  False positive IgM—Epstein-Barr, CMV, parvovirus, RF  Exposure during pregnancy—immediate hemagglutination-binding rubella antibody level  Infection during 1 st trimester—congenital rubella in 80%  Evaluate immunization—titers fall to seronegativity in 10% of patients after about 12 yrs

20 Rubella  Congenital rubella—usually have wide variety of manifestations—eye disease, microphthatlmia, hearing deficits, psychomotor retardation, heart defects, organomegaly, maculopapular rash  Younger fetus at infection—more severe illness  Second trimester—deafness  Specific test for IgM rubella antibody  Postinfectious encephalopathy—mortality rate 20%

21 Rubella  Treatment—symptomatic (acetaminophen)  Prognosis—mild—rarely lasts more than 3-4 days  Congenital—high mortality rate and permanent defects  Prevention—live attenuated rubella virus vaccine—often in combination with measles, mumps, and varicella  Try to immunize girls prior to menarche  Do not give immunization during pregnancy  In US—80% of 20-year-old women are immune to rubella

22 Roseola

23  Human herpesvirus 6—principal cause of exanthema subitum  Primary HHV6—children under 2 years; major cause of infantile febrile seizures  May also see encephalitis and acute liver failure  HHV6 encephalitis—hippocampus, amygdala, limbus  Symptomatic HHV6 is rare in immunocompetent adults— mono-like illness (primary) or encephalitis (reactivated)  Can see infection during pregnancy / congenital transmission  Reactivated disease—mainly in immunocompromised adults— associated with graft rejection, graft-versus-host disease  May cause fulminant hepatic failure and acute decompensation of chronic liver disease in children

24 Roseola

25 Influenza

26  Highly contagious—respiratory droplets  3 types of viruses—Type A infects many mammals and birds, Types B and C infect humans almost exclusively  Type A—subtypes from hemagglutinin (H) and neuraminidase (N)  Annual epidemics in fall and winter—10-20% of global population each year  Pandemics—longer intervals (decades)—major genetic reassortment of virus or mutation of animal virus  Main current viruses—H1N1 and H3N2 subtypes and type B.

27 Influenza  Types A and B—clinically indistinguishable infections  Type C—minor  Abrupt onset—Fever, chills, malaise, myalgias, cough substernal soreness, headache, nasal stuffiness, nausea  Elderly—may present with only lassitude, confusion  Mild pharyngeal infection, flushed face, conjunctival redness, cervical lymphadenopathy  Labs—leukopenia, may see leukocytosis; proteinuria; isolate virus from throat swasbs, nasal washings, cell cultures  Rapid assays—nasal or throat swabs—60-80% sensitivity

28 Influenza  Complications—necrosis of respiratory epithelium—secondary bacterial infections  Bacterial enzymes activate influenza viruses  Frequent complications— sinusitis, otitis media, purulent bronchitis, pneumonia  Young children, pregnant women, elderly, LTC facility patients, patients with comorbidities— higher risk of complications  Read—Reye Syndrome

29 Influenza  Treatment—bed rest, analgesics, cough medicine  Treat - suggestive clinical infection or laboratory confirmed influenza and high risk for complications  No proven benefit of antivirals after 48 hrs, but should consider if patient is hospitalized  Neuraminidase inhibitors—inhaled zanamivir or oral oseltamivir—equally effective in treatment  reduce duration of symptoms and secondary complications  do not reduce hospitalizations or mortality  Adamantanes—amantadine and rimantadine—high levels of resistance and not recommended for treatment  Prognosis—uncomplicated lasts 1-7 days; excellent prognosis in healthy, nonelderly adults  Prevention—annual administration of influenza vaccine  Read—information on flu vaccine including contraindications

30 HPV

31 Human Papilloma Virus  Skin Warts—flat (superficial) or plantar (deep growths)— typically regress over time—HPV 1-4  Benign Head and Neck Tumors—  single oral papillomas—pedunculated with stalk and rough papillary appearance  Laryngeal papillomas—most often caused by HPV-11—most common benign epithelial tumors of larynx; can cause airway obstruction in children  Condyloma Acuminata—almost exclusively on squamous epithelium of external genitalia and perianal areas  90% due to HPV 6 and HPV 11

32 Human Papilloma Virus— Skin Warts

33 Human Papilloma Virus— Oral papilloma

34 Human Papilloma Virus— Condyloma Acuminata


36 Human Papilloma Virus  Cervical dysplasia— koilocyotic cells—HPV 16-18 (70%)  Dysplasia—40-70% of lesions spontaneously regress  Progressive changes from mild (CIN I) to moderate (CIN II) to severe (CIN III) dysplasia, carcinoma in situ, or both

37 HPV Diagnosis  wart can be confirmed microscopically by histologic appearance—hyperplasia of prickle cells and excess keratin  HPV infection—koilocytoctic (vaculolated) squamous epithelia cells that are rounded and occur in clumps  HPV virions on electron microscopy  Molecular probes for HPV DNA—establish in cervical swab and tissue  HPV does not gro in cell cultures  HPV antibodies—rarely used

38 Human Papilloma Virus  Treatment—spontaneous disappearance of warts is the rule; may take months to years  Cryotherapy, Electrocautery, Chemical  Recurrences are common  See guidelines for follow-up on cervical dysplasia  Prevention—HPV quadrivalent vaccine (Gardasil)  Types 6,11,16,18

39 HIV

40 Whole chapter of its own—I suggest you read! You should know:  Major risk factors/Modes of transmission  Presenting symptoms (Hallmark of symptomatic HIV?) and major complications  Prevention measures  HIV risk for health care professionals  Major pathogens that need prophylaxis  Indications for antiretroviral therapy

41 Questions?

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