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Clin Med II Infectious Disease

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

2 Measles

3 Measles 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

6 Measles

7 Measles 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 Mumps Spread by respiratory droplets
Children are most commonly affected Incidence highest in spring Incubation 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 Rubella 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 Rubella 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 1st 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 Roseola 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 Influenza 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

35 Human Papilloma Virus— Condyloma Acuminata

36 Human Papilloma Virus Cervical dysplasia— koilocyotic cells—HPV (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 HIV 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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