1. Infectious diseases with exanthema syndrome
Lecturer:
Gorishna Ivanna Lubomyrivna

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 replication in 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 (21!) days.
Prodromal period days.
Temperature is usually high at first day.
The classic three “C’s” (cough, coryza, conjunctivitis).
the enanthema or Koplik’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: By the localization:
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 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 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 % 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-pink maculopapular 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 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. Clinical presentation
incubation period to 21 days
contagious period to 2 days before the rashes erupt until all of the lesions have crusted (5 days after the last rashes have appeared)
Prodrome 1 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.

51. Phlegmona

52. Rare complications idiopathic thrombocytopenic purpura, nephritis,
myocarditis,
arthritis.

53. Laboratory investigations
In CBC: leucopenia, lymphocytosis, normal ESR.
Vesicle scrapings contain multinucleated giant cells, and vesicle fluid contains virus
Immune enzyme method
Serological reactions: CBR, IHAR
CSF investigation – in case of meningoencephalitis.

54. Treatment antiseptic fluids for skin lesions;
antihistamines for itching;
Gurgling with oral antiseptic fluids after the food intake
paracethamol or ibuprophen for fever control.
Acyclovir
for immune compromised children, generalized forms, thrombocytopenia, neonatal varicella – (IV 10 mg/kg 3 t.d. for 7 days or up to 48 hours after the last elements)
Severe forms - orally 80 mg/kg/day 4 t.d. for children elder than 2 years and teenagers.
Also for severe cases in neonates – varicella-Zoster immune globulin (0.2 ml/kg).

55. Prevention Nonspecific
To isolate ill person until the 5 day after the last vesicles has appeared.
To isolate contact persons from 9 till 21 day after exposure.
Specific passive - VZ immune globulin in immunecompromised children within 72 hours of exposure.
Specific active - VZ-vaccine

56. Scarlet fever
Scarlet fever is an acute infectious disease, that is caused by group A β-hemolytic streptococcus

57. Epidemiology:
a source of infection – ill person not only with scarlet fever, but another forms of GABHS-infections (sore throat, tonsillitis, erysipelas, streptodermia).
– Infection is spread by inhalation of infected airborne droplets.
– Susceptible organism – children 2-9 years old.

58. Pathogenesis Incubation period is short, not more than 7 days
has three lines:
1. Toxic (toxic damage of cardiovascular, central nervous, endocrine systems).
2. Septic (tonsillitis, secondary bacterial complications).
3. Allergic (depression of immunity leads to allergic complications).
Incubation period is short, not more than 7 days

59. Clinical presentation:
acute onset
fever (often above 39C),
sore throat (often with dysphagia),
Erythema and enanthema on the soft palate.
purulent tonsilar exudates.
Anterior cervical lymph nodes are tender and enlarged.
Coated than swollen, red tongue (strawberry tongue).
Other features are nausea and vomiting, headache, abdominal discomfort.

60. Scarlet fever, pharyngitis, enanthema

61. Scarlet fever, pharyngi-tis, tonsillitis

62. Strawberry tongue

63. a rash appears 1-2 days after the onset.
first on the neck and then on the trunk and extremities through 24 hours.
dusky red, blanching tiny papules that have a rough texture ("sand paper" sign).
flushing face with circumoral pallor (Filatov’s sign).
the rash is intensified in skin folds and at sites of pressure.
Pastia’s lines: In the antecubital and axillary fosses linear petechiae with accentuation of the erythema.
Papules are usually absent at palms, and soles

64. Scarlet fever, localisation of rashes

65. Scarlet fever, morphology of rashes

66. Scarlet fever, intensive rashes in the sites of pressure

67. Filatov’s sign

68. Pastia’s lines

69. The exanthema lasts 4 - 5 days
then desquamate, first on the face last on the palms and soles.
Pharyngitis usually resolves in 5 to 7 days.

70. Desquamation of the skin

71. Classification 1. Form: typical; atypical: subclinical;
extra pharyngeal (burns, wounds, post-natal, after operations, delivery);
with aggravated symptoms (hypertoxic, hemorrhagic).
2. Severity:
mild;
moderate;
severe: toxic, septic, toxic-septic.
3. Course:
smooth;
uneven (relapses, complications).

72. Purulent Complications:
otitis media,
lymphadenitis,
perytonsilar abscess,
necrotizing tonsillitis,
sepsis,
Pneumonia,
Sinusitis,
Meningitis,
Bone or joint problems (osteomyelitis or arthritis)

73. Necrotizing tonsillitis

74. Perytonsillitis

75. Perytonsillar absces

76. Streptodermia, strawberry tongue

77. Allergic Complications
rheumatic fever,
myocarditis,
arthritis,
nephritis.

78. Laboratory tests 1. The diagnose is confirmed by throat culture
2. Serology (antistreptolizin O, antideoxyribonuclease B) may be useful for documenting recent GABHS infection.
3. The CBC: WBC is higher 12.5 * 109/L with left shift, eosynophilia, elevated ESR

79. Treatment: Bed rest during an acute period. Etiological treatment :
In the mild case: The course of treatment is 10 days.
penicillin orally 50, ,000 EU/kg/day divided in 3-4 doses or:
Erythromycin (or another macrolides) is alternative antibiotic (30 –50 mg/kg/day).
In the moderate case: The course of treatment is days.
penicillin intramuscularly, the same dose
In the severe case: intravenously for days
cefalosporins of the 1st-2nd generation, or
klindamycin, or vancomycin.

80. Treatment: Detoxication therapy: Antihistamines (in average doses)
Medicine which strengthens vascular wall (vit. C and PP: ascorutin, galascorbin)
Control of fever
Local treatment with antiseptic fluids (gurgling), UV-insolation.
Patient may go home from infection department not earlier the 10th day of the illness, in 10 days blood analysis, urinalyses, ECG must be repeated.

81. Prevention:
isolation of the patient for 10 days, but he mustn’t visit school until 22 day of the disease.
Contract persons (children before 8 years) should be isolated for 7 days (period of incubation).

82. Pseudotuberculosis (mesenteric adenitis)
Etiology: Yersinia pseudotuberculosis belongs to the family Enterobacteriaceae, genus Yersinia

83. Epidemiology:
source of infection - wild and home animals (rats, dogs, foxes, cats and other);
Way of transmitting – alimentary;
Susceptible organism – children (not infants), adults.
Incubation period is 3-18 days

84. Pathogenesis: Entering the bacilli to gastrointestinal tract.
Inocculation of them in enterocytes.
Regional lymphadenitis (regional infection).
Generalization (bacteriemia, toxemia).
Parenhymatous phase (fixation of pathogen by liver and spleen).
Immunological response, recovering from disease.
May be secondary bacteriemia (exacerbations and relapses).

85. Clinical criteria
Complaints: malaise, fatigue, headache, sleepless, anorexia, arthralgias, muscle pain, sore throat, nausea, abdominal pain, dyspepsia.
Rash: maculopapulous (like in scarlet fever), may be erythematous.
The eruption is characterized by dusky red, tiny papules. The rash is present on face, intensified periorbitally, on the neck (“glasses” symptom, “hood” symptom); on the body the rash is intensified in skin folds, at the sites of pressure, on the hands, feet, (“gloves”, “socks” symptom), round the joints. The exanthema usually lasts 4 to 5 days and then begins to desquamate, first on the face and last on the palms and soles.

86. “hood” symptom

87. “socks” symptom

88. Erythema nodosum

89. Desquamation on buttocks

90. Desquamation on palms

91. catharral syndrome - pharyngeal and tonsilar erythema conjunctivitis, rhinitis
“strawberry” tongue Abdominal syndrome; tenderness during the palpation of abdomen, may be acute appendicitis.
Dyspepsia: nausea, vomiting, liquid feces.
Hepatomegaly, rare – splenomegaly, lymphadenopathy.
Hepatitis with or without the jaundice.
Arthritis of knees, elbows, foot and hand joints or arthralgia.
Toxic myocarditis.
Toxic nephritis, pyelonephritis.
Bronchitis or pneumonia may also develop.

92. “strawberry” tongue

93. Complications: Appendicitis, Bacteriemia,
Diffuse ulceration and inflammation of the small intestine and colon,
Intussusception,
Meningitis,
Osteomyelitis,
Peritonitis.

94. Laboratory findings CBC: Bacteriological – Serological –
leucocytosis, neutrophilia with left shift, eosynophilia, ESR is enlarged.
Bacteriological –
Yersinia Pseudotuberculosis may be found in feces, urine, blood and throat mucus.
Serological –
(AR, IHAR with diagnostic tires 1:200 and more).
Immune-enzyme analysis
Specific antibodies Ig M are positive in an acute phase of the disease.

95. Treatment Regime and diet
Etiologic: -by chloramphenicol mg/kg 3 or 4 times per day during all period of pyrexia and plus 3 days (no less then 14 days). Alternative antibiotics: cefalosporins of the 3rd-4th generation. In severe case combination together with aminoglycosides of the 3rd generation (IM, IV).
Pathogenetic:
detoxication oral or parenteral;
corticosteroids 1-3 mg/kg with a short course (in severe cases, in case of carditis)
Antipyretics
NSAIDs in case of arthritis, carditis, nodular erythema (ibuprophen, aspirin, voltaren, indomethacin in average doses)

96. Prevention:
Eliminate reservoirs and minimize the contamination of food products.
Always institute enteric precautions in the care of patients hospitalized with infection.
Avoid unpasteurized milk and raw pork, particularly chitterlings, which often are consumed during the holiday season.
Supervision for persons from the epidemic focus for 18 days with fecal bacteriological test.