Good Morning! Happy Monday
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Transcript of Good Morning! Happy Monday
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Good Morning! Happy Monday
Monday, July 22nd, 2013
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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
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Differential Dx Arthritis/Arthralgias Desquamation Lymphadenopathy Meningitis Enanthems (mucosal involvement) Ulcerative vesicular lesions Palm and Sole involvement Predominantly on extremities Respiratory Symptoms/Pulmonary infiltrates
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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
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Enteroviruses** Single-stranded RNA 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)
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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
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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
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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 isA. early-onset group B Streptococcus infection
B. echovirus 11 infectionC. herpes simplex virus infectionD. hypoplastic left heart syndromeE. respiratory syncytial virus infection
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Neonates** High risk for developing disseminated
infection Severe manifestations:
› Fulminant Hepatitis› Myocarditis› Pneumonitis› Meningitis› Encephalitis› DIC› Multiorgan failure
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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,
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Diagnostic Tests** Viral culture**
› 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
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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)
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Treatment Supportive care
Antivirals under investigation
IVIG may benefit immunodeficient patients› Also used in some with myocarditis or
persistant meningoencephalitis
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Prevention
Contact precautions
HAND WASHING!!!
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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
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Hand-Foot-and-Mouth Disease (cont’d)
Oral lesions
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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
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Hand Foot Mouth Disease Onychomadesis – proximal separation of
the nail plate from the nail bed
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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
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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
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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
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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)
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Herpangina Erythematous ring surrounds Puntate macules vesiclulate, ulcerate Anterior tonsillar pillars, soft palate,
posterior pharynx
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Herpangina Self-limited Resolve spontaneously within 1 week Supportive care
› Young children are at risk of dehydration
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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
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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
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Herpetic Gingivostomatitis
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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 72-96 hrs of disease, unable to drink or have significant pain
After resolution, reside in trigeminal ganglia
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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
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Apthous stomatitis
Topical creams may help
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Topical AnalgesiaUsually not recommended Benzocaine (orajel)
› associated with methemoglobinemia viscous lidocaine
› may cause problems if absorbed systemically
› may choke on secretions› may chew their buccal mucosa
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Hand, Foot, Mouth Disease
Herpangina Herpetic Gingivostomatitis
Aphthous Stomatitis
ages 1-4 yo 3-10 yo 6mos – 5 yo Older children , adultsIncubation 3-7 days 4-14 days 2 days – 2 weeks N/Aprodrome Malaise, sore throat,
mouth pain, anorexiaMalaise, HA, N/V, sore throat, mouth pain, anorexia
irritability, malaise, HA, anorexia, submandibular and cervical lymphadenitis
Usually none
fever Usually low grade Usually low grade Low-High grade fever Usually noneDescription of lesions
Mildly painful Vesicles surrounding erythema (may ulcerate)
Painful Vesicles/ulcers with surrounding erythema
Vesicles that ulcerate and coalesceBeefy red gingiva
Exquisitely painfulLarge 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 A16summer
Group A Coxsackie summer
HSV 1Year round
none
Duration and treatment
1 weekSymptomatic tx
1 weeksymptomatic tx
10-14 daysAcyclovir, symptomatic tx
Variable, can recur, symptomatic tx
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Picture QuizInfectious Exanthems
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Exanthem #1MEASLES
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Exanthem #2Coxsackie A - HFM
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Exanthem #3 Rubella
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Exanthem #4 Parvovirus B19- Fifth’s Disease- Erythema
Infectiosum
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Exanthem #5Varicella
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Exanthem #6RMSF
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Exanthem #7
Clue: This patient had a h/o 3 days of fever (that has since defervesced) before the appearance of the rash
HHV6- Roseola
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Exanthem #8 Scarlet Fever- Group A Strep
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Exanthem #9
Clue: You might be more suspicious of this illness if this picture was a hypotensive woman
Toxic Shock Syndrome
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Exanthem #10Staph Scalded Skin
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Exanthem #11 Steven-Johnson-Syndrome
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Exanthem #12Kawasaki Disease
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Exanthem #13 Meningococcemia
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Exanthem #14
Clue: This patient was recently treated with Ampicillin
EBV- mono
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BONUS ROUND Who can name the original 6 childhood
exanthems? (1st disease, etc)
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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)