Download Red Book: 2009 Report of the Committee on Infectious Diseases.

Pediatric Infectious
Diseases cont’d...
Case 1
• 15 month old Aboriginal male
• rash, fever, irritability
• 2 sibs with same rash, uncomplicated
• PMHx: well
• meds: none
• NKDA
• Imm: 2P, 4P, 6O, 12O
Case 1
• Physical exam:
• febrile,
unwell
• rash
Case 1
• Management:
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•
•
•
•
kept in negative pressure room
FSWU done - neg U/A and LP
covered with vancomycin
wound culture grew MRSA
stayed 4 days in hospital, discharged on Septra x 2
weeks
Case 2
• 12 month old Hutterite male
• rash + fever 12 days ago, then sore
right knee x 10 days
• PMHx: well
• meds: none
• NKDA
• Imm: 2P, 4P, 6P, 12O
Case 2
• Physical exam:
• afebrile, well
• MSK: R distal thigh swollen, warm,
not red; decreased ROM of knee (o
o
10 flexion, -10 extension); N ROM
hip and ankle
Case 2
• Labs:
•
•
•
•
•
WBC: N
CK: N
ESR: 62
CRP: 130.4
BC drawn
(grew Staph
aureus)
• Imaging:
Case 2
• Management:
•
•
•
covered with cloxacillin
admitted to hospital
further work-up:
•
•
•
•
bone scan +
U/S: thigh abscess
taken to OR for drainage
f/u X-ray abN
Case 2
•
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MRI: confirmed
osteomyelitis, and
revealed a distal femoral
epiphyseal abscess
abscess drained in OR
discharged after 19 day
hospital stay
iv cloxacillin
recommended for 6
weeks
What was the
underlying illness?
What was the
underlying illness?
Varicella Zoster Virus
Pathophysiology
human herpesvirus family
causes 2 diseases:
Pathophysiology
human herpesvirus family
causes 2 diseases:
varicella (chickenpox)
zoster (shingles)
Pathophysiology
Pathophysiology
direct contact
infected respiratory
tract secretions
airborne droplets
Pathophysiology
direct contact
infected respiratory
tract secretions
airborne droplets
exposure to
mucosa of upper
respiratory tract or
conjunctiva
Pathophysiology
incubation 10-23
days (avg, 14 days)
direct contact
infected respiratory
tract secretions
airborne droplets
exposure to
mucosa of upper
respiratory tract or
conjunctiva
Pathophysiology
incubation 10-23
days (avg, 14 days)
direct contact
infected respiratory
tract secretions
airborne droplets
exposure to
mucosa of upper
respiratory tract or
conjunctiva
Pathophysiology
incubation 10-23
days (avg, 14 days)
direct contact
contagious 1-2 days
before rash until all
lesions crusted over
infected respiratory
tract secretions
airborne droplets
exposure to
mucosa of upper
respiratory tract or
conjunctiva
Pathophysiology
incubation 10-23
days (avg, 14 days)
direct contact
contagious 1-2 days
before rash until all
lesions crusted over
infected respiratory
tract secretions
airborne droplets
exposure to
mucosa of upper
respiratory tract or
conjunctiva
90% risk of
disease
after
exposure
•
•
Clinical
Manifestations
mild-moderate in
children, more severe
in adults
short or absent
prodrome
Clinical
Manifestations
• mild-moderate in
children, more
severe in adults
• short or absent
prodrome
•
•
•
•
macules g papules
g vesicles g
pustules g scabs
evolves as series of
“crops” over 3-4 days
concentrated on trunk
and head
250-500 lesions
Clinical
Manifestations
• variable
severity
Clinical issues in
pregnancy
Clinical issues in
pregnancy
• VZV in first 20 weeks:
•
•
fetal death, or
congenital varicella syndrome:
•
T1 and T2
•
•
•
•
1-2% risk if mum gets
varicella
limb hypoplasia
cutaneous scarring
eye abnormalities
CNS damage
Clinical issues in
pregnancy
• VZV in second 20
weeks:
•
T2 and T3
children can develop
inapparent varicella and
subsequent zoster
earlier in life without
extrauterine varicella
Clinical issues in
pregnancy
•
VZV peripartum:
•
T3
•
varicella infection can be fatal in
the neonate if mother develops
varicella 5 days before or 2 days
after delivery
if mum develops varicella >5
days before and if infant >28
wks GA, severity of disease
modified by transplacental
maternal IgG antibody
Prevention once
exposed
• Postexposure immunization:
•
•
varicella vaccine, to people without evidence of
immunity 12 months or older, within 72 hours of
exposure (possibly up to 120 hours)
contraindicated in:
•
•
pregnant women
immunocompromised patients, including those on
high dose daily systemic steroids
Prevention once
exposed
• Passive immunization:
•
•
VZIG/VariZIG, given IM, within 96 hours of exposure
decision to give depends on:
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•
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likelihood exposed person has no immunity
likelihood exposure will lead to infection
likelihood infection will lead to complications
at risk populations:
•
•
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immunocompromised
pregnant women
certain neonates (mum develops rash -5 days to +2 days of
delivery)
Diagnostic Tests
Diagnostic Tests
• PCR or DFA
•
• virus culture less •
sensitive
• sites:
•
•
•
•
vesicle base
saliva or buccal mucosa
CSF (PCR)
rarely from respiratory
secretions
•
serology:
Ig M unreliable
significant increase in IgG from
acute and convalescent serum
for retrospective diagnosis
Treatment
Treatment
• no treatment in otherwise healthy
children
• consider oral acyclovir in patients at risk
of moderate to severe varicella:
•
•
•
•
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> 12 years
chronic cutaneous or pulmonary disorders
on long-term salicylate therapy
on steroids (short, intermittent, or aerosolized courses)
pregnant, esp 2nd and 3rd trimesters
Treatment
• intravenous acyclovir in
immunocompromised patients:
•
•
•
on chronic corticosteroids
immunodeficient, eg. HIV
immune-suppressed, eg. leukemia on chemo
Complications
• bacterial
Complications
superinfection of
skin lesions
• MSK infections
(arthritis,
osteomyelitis,
necrotizing fasciitis)
• CNS involvement
(acute cerebellar
ataxia, encephalitis,
stroke)
•
•
•
•
•
•
pneumonia
glomerulonephritis
hepatitis
thrombocytopenia
sepsis
etc.
Complications
• “The burden of varicella
complications before the introduction
of routine varicella vaccination in
Germany.”
• JG Liese, V Grote, E Rosenfeld, R Fischer, BH Belohradsky,
R vKries, ESPED Varicella Study Group
•
Pediatr Infect Dis J 2008;27: 119-124
Complications
• prospective review of varicella-related
hospital admissions in Germany
(which has no universal vaccination)
Complications
Complications
Complications
• Reasons for hospitalization:
Complications
• Types of complications:
Complications
Complications
Complications
• permanent sequelae in 15 (1.7%)
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•
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severe scarring (10)
ataxia (1)
mitral valve insufficiency from endocarditis (1)
visual restriction from retinal necrosis (1)
liver transplantation due to liver failure NYD (1)
hemiparesis from cerebral infarct (1)
Complications
• possible permanent sequelae in 78
(8.7%)
•
•
•
•
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severe scarring (19)
ataxia/coordination disorder (17)
epilepsy (4)
cerebral nerve paralysis (3)
other (35)
Complications
• death in 10 (1.1%)
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•
•
congenital varicella (2)
4 immunocompromised patients (3 with ALL, 1 with IgG
deficiency)
4 immunocompetent patients (cardiocirculatory failure
from myocarditis, severe bacterial superinfection and
sepsis x 2, multiorgan system failure - pneumonia,
meningoencephalitis, hemorrhagic complications)
Summary
• VZV:
• still out there
• importance of immunization history
• multiple complications, often in
previously
children
• preventable!
healthy
References
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•
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American Academy of Pediatrics. Varicella-Zoster Infections. In:
Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book:
2009 Report of the Committee on Infectious Diseases. 28th ed. Elk
Grove Village, IL: American Academy of Pediatrics;2009. (electronic
access)
Gershon AA. Varicella-Zoster Virus Infections. Pediatr Rev 2008;29:
5-11.
Heininger U, Seward JF. Varicella. Lancet 2006;368: 1365-76.
Liese JG, Grote V, Rosenfeld E, Fischer R, Belohradsky BH, vKries
R, ESPED Varicella Study Group. The burden of varicella
complications before the introduction of routine varicella vaccination
in Germany. Pediatr Infect Dis J 2008;27: 119-124.