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

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…

Where is/what is this building?

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…

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

„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

„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

What activity is done here?

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

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  thousand cases/year (reported)

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

Which building?

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…

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!

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 Évi járványügyi helyzete, 1999.november 23.

Where are we now?

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!!

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 Évi járványügyi helyzete, 1999.november 23.

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

No local treatment, please!!

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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

Religions?

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 !! „slapped face” only on day !! Arthritis in women Arthritis in women Heatlabil, spectacularexanthem – not contagious!! Heatlabil, spectacularexanthem – not contagious!! Serodiagnostics Serodiagnostics

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

Where are – were - we now?

Kawasaki disease (KD) Magyarországon First recognised case in H.: prf. Nyerges Gábor First recognised case in H.: 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

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, ;

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;

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;

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

Thank you for your attention!