1. Good Morning! Happy Monday
Monday, July 22nd, 2013

2. 4 yo female p/w 3 days of fever (tmax 102), 2 days of progressive non-pruritic rash on face/extremities, decreased PO/UOP, emesis x 1 (non-bloody,non-bilious), diarrhea x 2 (non-bloody), increasing fatigue x 5d, refusing to eat and walk
Meds: tylenol PRN
Allergies: NKDA
PMH: none
FMH: neg
Immunizations: received 4 yo shots several months ago
Social: stays at home w/ mom, no travel history, older siblings with cold like symptoms, no rash

4. Differential Dx Arthritis/Arthralgias Desquamation Lymphadenopathy
Meningitis
Enanthems (mucosal involvement)
Ulcerative vesicular lesions
Palm and Sole involvement
Predominantly on extremities
Respiratory Symptoms/Pulmonary infiltrates

5. Problem Definition
Immunized 3 yo female with acute onset of fever, progressive vesicular rash on extremities with oral mucosal involvement, mild N/V/D, non-toxic appearing

8. Enteroviruses** Single-stranded RNA viruses** “Summer viruses” **
Picornaviridae family
Polioviruses
Coxsackieviruses (Group A and B)
Echoviruses
Enteroviruses (serotypes 68-71)
“Summer viruses” **
*Increased prevalence in summer months (May – October)
All year round in tropical climates (NOLA)

9. Transmission** Most cases involve children under age 5
Humans are only hosts
Fecal-oral is most common route
Then replicates in lymph nodes of respiratory and GI systems
Initial viremia → heart, liver, skin
CNS infection usually the result of second major viremia
Specifically infants less than one yr of age become infected at rates that far exceed those of older children and adults
Males > females by up to 50%

11. Clinical Manifestations**
Most patients are mildly ill & recover completely
Most common → febrile illness, viral exanthem, vomiting, diarrhea, and malaise
Others:
Hemorrhagic conjunctivitis
Pharyngitis
Herpangina
Hand-foot-and-mouth disease
Paralysis
Hepatitis
Myocarditis
Pericarditis
Encephalitis
Aseptic meningitis
Treatment is symptomatic for most of these, no documented use for acyclovir. IVIG has been used in myocarditis and persistent meningoencephalitis

12. A 6-day-old infant is brought to the ER in August with a 1-day history of decreased feeding, decreased activity, tactile fever, and rapid breathing. He was born at term. His mother reports that she had a nonspecific febrile illness 1 week before delivery for which she received no treatment. Her GBS screen was positive at 36 weeks' gestation, and she received two doses of ampicillin (>4 hours apart) during labor. The baby received no antibiotics and was discharged at 48 hours of age. Physical examination today reveals a toxic, lethargic infant who is grunting and has a temp of 39.4°C, HR of 180, and RR of 60. His lungs are clear, with subcostal retractions. He has a regular heart rhythm with gallop, his pulses are thready, his capillary refill is 4 seconds, and his extremities are cool.
Of the following, the MOST likely cause of this baby's illness is
A. early-onset group B Streptococcus infection
B. echovirus 11 infection
C. herpes simplex virus infection
D. hypoplastic left heart syndrome
E. respiratory syncytial virus infection

13. Neonates** High risk for developing disseminated infection
Severe manifestations:
Fulminant Hepatitis
Myocarditis
Pneumonitis
Meningitis
Encephalitis
DIC
Multiorgan failure
Most common are Fulminant hepatitis and myocarditis – signs of hypotension, bleeding, jaundice, organ failure

14. Neonates**
acquired from nurseries, or from symptomatic mothers (fever 1 week prior to delivery)
Symptoms develop at 3-7 days of life
Signs include
mild listlessness, anorexia, transient respiratory distress, jaundice,
Can be acquired from nurseries, or from symptomatic mothers (who are febrile the last week of pregnancy) – but may be exposed to virus positive cervical secretions or viremic maternal blood, not believed to be passed via the placenta
Outcomes related to exposure to passive immunization – related to timing of maternal infection, and development and passage of IgG
Most affected develop symptoms between 3-7 days of life
Can be mild listlessness, anorexia, transient respiratory distress, biphasic – apparent well being between initial symptoms and more serious manifestations
Most common are Fulminant hepatitis and myocarditis – signs of hypotension, bleeding, jaundice, organ failure

15. Diagnostic Tests** Viral culture** PCR** Serology
Stool, throat, blood, CSF, or tissue
8 to 10 days
PCR**
Only small sample needed
Results in 24 hours
Serology
Based on increase in antibody titers
Too many enterovirus serotypes to be practical
Culture – is labor intensive and expensive, but it allows typing of the isolate for clinical/epidemiological/research purposes

16. Diagnostic Tests (cont’d)
Testing by PCR has been associated with decreased IV abx use, ancillary testing, and hospital length of stay
Allows for patient isolation if necessary (ie, NICU)

17. Treatment Supportive care Antivirals under investigation
IVIG may benefit immunodeficient patients
Also used in some with myocarditis or persistant meningoencephalitis
IVIG in myocarditis= better LV function
IVIG injected directly into ventricles
Also used to use an experimental drug that is no longer available (pleconaril)

18. Prevention
Contact precautions
HAND WASHING!!!

19. Hand-Foot-and-Mouth Disease
1-4 yo
Incubation period 3 to 7 days
Prodromal phase of malaise, sore throat, mouth pain, anorexia and low grade fever
Coxsackie A16 virus

20. Hand-Foot-and-Mouth Disease (cont’d)
Oral lesions

21. Hand-Foot-and-Mouth Disease (cont’d)
Painful vesicles in mouth and on hands and feet
Surrounded by an erythematous margin
Nonvesicular lesions on buttocks, GU and extremities less commonly

22. Hand Foot Mouth Disease
Onychomadesis – proximal separation of the nail plate from the nail bed

23. Hand-Foot-and-Mouth Disease (cont’d)
Most resolve spontaneously w/in 3d-1wk
Treatment is supportive
Hydration and analgesics
Magic Mouthwash
Maalox
Benadryl
Viscous lidocaine

24. Hand-Foot-and-Mouth Disease (cont’d)
Moderately contagious
Spread by direct contact with nasal discharge, saliva, blister fluid, or stool
Most contagious during the first week of the illness
Can shed virus in stool for up to 8 weeks
No day care/school during the first few days of illness and in setting of open lesions
Can take any form – urticaria (coxsackie), petechiae/purpura (echovirus 9) – confusing if someones meningitic appearing, maculopapular (echo) or vesicular (coxsackie)
Recent severe cases of HFM – enterovirus 71  cns disease, pulm edema and hemorrhage and heart failure, temp paralysis that resolved

25. HFM: Parental Guidance
Analgesia: Avoid aspirin (acetaminophen and ibuprofen are ok)
Diet: cold, soft foods, dairy, nothing spicy
Prevent spread: wash hands often, especially after using the bathroom
Avoid others during the first week of illness to prevent spread, avoid pregnant women
Enteroviruses don’t cross placenta, but there are rare cases of infant death associated with echovirus, coxsackie virus – not proven cause,
Advise pregnant women to avoid contact with patients suspected of having an enteroviral illness

26. Herpangina Coxsackie group A Ages 3 -10 years
Incubation period 4-14 days
Prodromal phase
Malaise, HA, N/V, myalgias, anorexia
sore throat and mouth pain 1-2 days prior to lesions
Fever (low grade > high)
Can be caused by Group B coxsackie viruses and echoviruses occasionally
Can be elevated up to 105.8

27. Herpangina Erythematous ring surrounds
Puntate macules  vesiclulate, ulcerate
Anterior tonsillar pillars, soft palate, posterior pharynx
Typically 2-6 lesions, but as many as can be present
Posterior oropharynx is minimally erythematous

28. Herpangina Self-limited Resolve spontaneously within 1 week
Supportive care
Young children are at risk of dehydration

29. Herpetic Gingivostomatitis
Ages 6 mo – 5 yo (peaks at 2yo)
Incubation 2 days – 2 weeks
Prodrome: fever, irritability, malaise, HA, PO, lymphadenopathy (cervical, submandibular)
Low to high grade fever

30. Herpetic Gingivostomatitis
Red, edematous gingivae
bleed easily
Small vesicles ulcerate and coalesce
Large ulcerations with erythema surrounding
Buckle mucosa, tongue, gingiva, hard palate, pharynx, lips, perioral skin

31. Herpetic Gingivostomatitis

32. Herpetic gingivostomatitis
Diagnose with culture, PCR, or antigen testing
Resolve in 10 to 14 days
Treatment is supportive
Hydration and analgesics
Acyclovir
If patients present in the first hrs of disease, unable to drink or have significant pain
After resolution, reside in trigeminal ganglia
Previously not recommended, few studies now that show decreased length of oral lesions, less time with mouth pain, less time with difficulty eating/drinking, decreased incidence of new lesions
Acyclovir - 15mg/kg 5x per day for 5-7 days
Topical acyclovir therapy not recommended

33. Aphthous stomatitis Typically found in older children and adults
Not associated with infection
Can be associated with autoimmune disease (SLE, IBD)
Exquisitely painful ulcers
Large, yellow, pseudomembranous slough with erythematous border

34. Apthous stomatitis
Topical creams may help

35. Topical Analgesia Usually not recommended Benzocaine (orajel)
associated with methemoglobinemia
viscous lidocaine
may cause problems if absorbed systemically
may choke on secretions
may chew their buccal mucosa

36. Hand, Foot, Mouth Disease Herpangina Herpetic Gingivostomatitis
Aphthous Stomatitis
ages
1-4 yo
3-10 yo
6mos – 5 yo
Older children , adults
Incubation
3-7 days
4-14 days
2 days – 2 weeks
N/A
prodrome
Malaise, sore throat, mouth pain, anorexia
Malaise, HA, N/V, sore throat, mouth pain, anorexia
irritability, malaise, HA, anorexia, submandibular and cervical lymphadenitis
Usually none
fever
Usually low grade
Low-High grade fever
Description of lesions
Mildly painful Vesicles surrounding erythema (may ulcerate)
Painful Vesicles/ulcers with surrounding erythema
Vesicles that ulcerate and coalesce
Beefy red gingiva
Exquisitely painful
Large Ulcers , yellow pseudomembranous with erythematous border
Location of lesions
Hands, feet, mouth (buccal mucosa and tongue), occasionally nonvesicular lesions on buttocks, genitals and extremities
Anterior tonsillar pillars, soft palate, posterior pharynx
Buccal mucosa, tongue, gingival, hard palate, pharynx, lips, perioral skin
lips, tongue, buccal mucosa
Most common virus, season
Coxsackie A16
summer
Group A Coxsackie
HSV 1
Year round
none
Duration and treatment
1 week
Symptomatic tx
symptomatic tx
10-14 days
Acyclovir, symptomatic tx
Variable, can recur, symptomatic tx

37. Picture Quiz
Infectious Exanthems

38. Exanthem #1
MEASLES
Koplik spots

39. Exanthem #2
Coxsackie A - HFM

40. Exanthem #3
Rubella
Forscheimer spots

41. Parvovirus B19- Fifth’s Disease- Erythema Infectiosum
Exanthem #4
Parvovirus B19- Fifth’s Disease- Erythema Infectiosum

42. Exanthem #5
Varicella

43. Exanthem #6
RMSF

44. Exanthem #7 HHV6- Roseola
Clue: This patient had a h/o 3 days of fever (that has since defervesced) before the appearance of the rash

45. Scarlet Fever- Group A Strep
Exanthem #8
Scarlet Fever- Group A Strep

46. Exanthem #9 Toxic Shock Syndrome
Clue: You might be more suspicious of this illness if this picture was a hypotensive woman

47. Exanthem #10
Staph Scalded Skin

48. Steven-Johnson-Syndrome
Exanthem #11
Steven-Johnson-Syndrome

49. Exanthem #12
Kawasaki Disease

50. Exanthem #13
Meningococcemia

51. Exanthem #14
EBV- mono
Clue: This patient was recently treated with Ampicillin

52. BONUS ROUND
Who can name the original 6 childhood exanthems? (1st disease, etc)

53. Answer 1st disease: Rubeola, Measles
2nd disease: Scarlet Fever (s. pyogenes)
3rd disease: Rubella, German Measles
4th disease: Staph Scalded Skin Syndrome, Filatow-Duke’s Disease, Ritter’s Disease
5th disease: Erythema Infectiousum (parvo)
6th disease: exanthem subitum, roseola (HHV 6 or HHV 7)

54. Have a Great Day!
Noon Conference