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Crash Course on Common Viral Exanthems (now with CASES!) Vincent Patrick Tiu Uy, MD PGY-2 Pediatrics St. Barnabas Hospital, Bronx Define Exanthem VS Enanthem Short and Sweet case Identification of the disease and causative agent Chronology of Signs and Symptoms Incubation & Period of contagiousness Work-up Treatment and Prophylaxis Pointers A 7 year old male with a rash was seen in the Emergency room and was diagnosed with a single-stranded Togavirus from direct PCR of nasopharyngeal swabs. The ER resident who examined the child is 2 weeks pregnant. What should she be concerned of? A. She will get a similar rash B. She will have lymphadenopathy C. Her joints will hurt D. Her baby will have congenital malformations E. She should worry after she goes for her first prenatal check-up Causes: Single stranded Togavirus Transmission: Respiratory droplets Incubation period: 14-23 days Pathophysiology: Nasopharynx Reticuloendothelial system Viral particles deposit in skin, synovium, CNS and placenta PRODROME (1-5 days) Malaise Fever (low-high grade) Anorexia Rhinorrhea Headaches (in older children) Conjunctivitis +/- Lymphadenopathy No work-up is necessary in otherwise healthy children Pregnant women: MUST determine immune status. First 2 months of life. Risk increases even more up to 5 months of life. Risk increases towards the final trimester Serum IgM to Rubella is useful in newborns suspected of having congenital rubella syndrome Arthropathies of the fingers Thrombocytopenia (rare) Congenital Rubella Syndrome IUGR CHD (PDA, PPAS) Hearing defects Glaucoma, Cataracts Neonatal purpura (“blueberry muffin rash”) Hepatomegaly and Jaundice Meningitis and Encephalitis “Celery-stalking” lesions on long bones Treatment: Supportive MMR vaccines for children at 12 months and school age DO NOT VACCINATE NON-IMMUNE PREGNANT WOMEN (MMR is a live vaccine) Single Stranded Togavirus 2-3 weeks incubation period First and last trimester of pregnancy high risk of CRS Characteristic rash + Lymph nodes Forchheimer spots MMR at 12 months and 4-6 years Know about Congenital Rubella Syndrome A 21 year old fertile female caught measles for the first time, cause she was unvaccinated as a child. The virus ran it’s course with no complications. It’s now 1 week after the rash disappeared. She is not pregnant now, but she plans to be in the next 4-5 months. What’s a girl to do ? A. She should start taking multivitamins and folic acid B. She should receive IVIG as soon as possible C. She should be reassured only D. She should see her obstetrician ASAP E. She should have herself tested for measles antibodies Cause: Rubeola virus (Morbillivirus) family of Paramyxoviridae Appears late winter to spring Incubation: 7-14 days Transmission: Droplets Patient is contagious 4 days before the exanthem and 4 days after it’s disappearance Pathophysiology: Delayed type hypersensitivity IL-12 response Other infections PRODROME (up to 7 days): High fevers (>38.0C) Malaise 3 “C’s” of Measles Photophobia and Edema of the eyelids Myalgias Usually unnecessary Suspected cases should be reported to the DOH Atypical presentations: Measles IgM peaks by day 3 of the rash and still seropositive 4-11 days after that Meases IgG may indicate immunity; stays positive after exposure/vaccination. Useful in SSPE and for screening purposes High risk to develop Otitis Media, Pneumonia, Croup and reactivation of latent TB (immunosuppression) Encephalitis may ensue as a result of immunosuppression Subacute Sclerosing Panecephalitis SSPE For uncomplicated cases, treatment is generally supportive with attention to hydration Vitamin A Supplementation MMR vaccine at 12 months of age + 4-6 years of age Post-exposure prophylaxis: Unvaccinated Within 3 days of exposure Ribavirin immunocompromised patients or in the setting of SSPE Human IVIG Consider IVIG in the following situations: Immunosuppressed individuals (ex. Chronic systemic glucocorticoids, HIV) Children < 6 months to a year (especially if mom is not immune) Pregnant women (since vaccine will be contraindicated) Usually a benign condition with a classic clinical course Know the typical course Contagious 4 days before and 4 days after the rash Complications increase in immunocompromised people SSPE Vitamin A supplementation MMR 3 days after exposure IVIG A child was brought to the emergency department for a simple febrile seizure. He was discharged and three days later, he had a rash which appeared to be roseola infantum. How old is this child? A. 1 month old B. 10 months old C. 2 years old D. 7 years old E. 15 years old Cause: Human Herpes Virus 6a, 6b and 7 Peak onset: 9-12 months Route: Saliva Pathophysiology: Remains in lymphocytes and monocytes cytopathic changes Diminished regulation of the host immune system Previously healthy child Abrupt onset of high fevers (usually 40 C) Febrile seizures (15%) Diagnosis is clinical; work-up is not necessary Consider work-up only in immunocompromised hosts Treatment is mainly supportive, ensuring adequate hydration Dehydration is the most common reason for admission; complex febrile seizures may also be another. Isolation is not necessary No prophylaxis necessary for close contacts Self-limiting condition Fever Rash clinical course Nagayama’s spots HHV6B most common etiology in children Isolation not necessary A four year old girl with HIV was seen in the ED because she was exposed to a boy in daycare who had vesicular lesions suspicious for chicken pox. Because she had HIV borderline CD4 counts, the parents were worried that she may obtain a catastrophic form of chicken pox. What should be done? A. Obtain titers of Varicella antibodies B. Vaccinate her immediately C. Passive immunization within 96 hours D. Reassurance. It’s ok for her to get the disease and get it over with E. Give her a bath with betadine so she does not develop lesions Cause: VZV (Herpesviridae) Transmission: Respiratory droplets, direct contact to skin lesions Incubation: 10-21 days Contagious Period: 1-2 days before the onset of the rash and 5-6 days after (until lesions “crust”) Pathophysiology: 2-4 days: Virus replicates in the lymph nodes 4-6 days: Primary viremia (RES) 7 days: Secondary viremia PRODROME (up to 4 days) Fever Abdominal Pain Headache Cough and Respiratory Distress ** Not necessary, diagnosis is generally clinical in straightforward cases Blood counts may show leukopenia in the first 3 days LFT’s show elevated ALT For unclear cases, a Tzanck smear may be done Secondary bacterial infections Acute Postinfectious Cerebellar Ataxia Varicella pneumonia 3-4 days Encephalitis Hepatitis, eye disorders, HSP, myocarditis, GN, appendicitis and Pancreatitis Neonatal Varicella Reye’s Syndrome Mainly supportive; maintain adequate hydration; break the itch-scratch cycle Acyclovir Reserved for immunocompromised patients Treatment for Varicella pneumonia and Encephalitis Treatment of Neonatal Varicella Oral forms may be considered in primary infection of adolescents Varicella Deterrence Varicella Vaccine PEP: Given within 36-72 hours of exposure Recommended in children 12 months of age; booster at school age IM VZIG post-exposure prohylaxis Should be considered for the following: Newborns who are at increased risk Leukemia/Lymphoma HIV Immunosuppressed patients on Steroids Pregnant women Characteristic pattern of the rash Common complications of chicken pox Contagious 1-2 days before the rash until all lesions “crust” Humoral + Cellular immunity Lifelong immunity Indications for pre-exposure and post-exposure prophylaxis Breakthrough varicella ~42 days from vaccination A child was seen in clinic and diagnosed with “fifth’s disease”. He has the classic rash on the face and a lacy rash on the arms for 3 days now. What anticipatory guidance should be given? A. Keep the child away from sun and heat exposure B. Patient may go to daycare C. Patient should wear loose fitting clothes and apply petroleum jelly on the face D. Clothes should be washed in hot water E. Child should be admitted for IVIG Cause: Parvovirus B19 Transmission: Respiratory droplets, fomites, blood transfusions & transplacentally Incubation: 7-10 days (but up to 21 days) Pathophysiology: Skin Joints Erythroid Progenitor cells PRODROME (2-3 days) Headaches Fever Sore Throat Pruritus Cough Coryza Abdominal Pain Diagnosis is often made clinical Patients with a history of anemia or leukemia - CBC Bone marrow suppression Arthritis Hydrops Fetalis Severe Aplastic Anemia Generally supportive; Pay attention to hydration Indication for IVIG Aplastic Crisis Consider in immunosuppressed patients – consult with ID first Vaccine Parvovirus B19 is the only Parvovirus that causes human disease Affinity and cytotoxic to erythroid progenitors bone marrow suppression/aplastic anemia 10% have Arthritis and arthralgias 3 phases of exanthem No longer infectious when rash appears IVIG only for aplastic crisis/immunocompromised A previously healthy 3 year old male was seen in the ER for fever and sore throat. He was diagnosed with Hand Foot and Mouth disease. Mom wants to know how he got the infection. Which of the following is NOT a means of transmission for coxsackievirus? A. Feco-oral route B. Oral secretions C. Respiratory droplets D. Skin to skin contact E. Daycare attendance Causes: Picornaviridae Coxsackievirus A16/A5/A/9/A10/B2/B5 Enterovirus 71 Neurologic Involvement Incubation: 7 days Summer months Transmission: Feco-oral, Salivary, skin contact Pathophysiology: virus cell Sore Throat High Fevers +/- Vomiting Malaise No work-up necessary not unless patient has neurologic manifestations CSF samples may be needed for neurologically symptomatic patients For infections with coxsackievirus, generally none Myocarditis Enterovirus 71 Aseptic meningitis Encephalitis and encephalomyelitis Cerebellar ataxia Acute Transverse Myelitis Guillaine-Barre Syndrome Opsoclonus-Myoclonus Syndrome Mainly supportive Pay attention to child’s hydration Cold liquids Avoid spicy/sour foods Systemic and topical analgesia Magic mouthwash NSAIDS Avoid Aspirin Deter by appropriate oral hygiene and hand washing Coxsackievirus and Enterovirus Type A16 is the most common! Routes of transmission Herpangina vs HFMD A 15 year old male was determined to have pityriasis rosea by his PMD. Patient has been tried on topical steroids which did not provide relief of symptoms. The rash is now becoming vesicular. What should be advised? A. Refer to Dermatology for topical retinoids B. Refer to Dermatology for UV therapy at 80% of the dose C. Refer to Dermatology for laser treatments D. Refer to Dermatology for Dapsone treatments E. Trial of oral acyclovir Causes: Any virus; HHV-7? Usually in the Spring Fall Transmission: Close contacts Photosensitive variant Localization of the exanthem Inverse pityriasis Unilateral variant For younger children, there is no need for work-up For sexually active teenagers, r/o syphillis and HIV “Prozone” Phenomenon Generally none Pityriasis Lichenoides Chronica >3 months without resolve Risk of miscarriage Mothers who develop it within the first 15 weeks of pregnancy. Relief of pruritus Judicious use of topical steroids Oatmeal baths Anti-pruritic lotions Ultraviolet light (UV-B) at 80% of the erythrogenic dose may be considered for chronic cases If there are vesicles, Dapsone may be considered Caused by many viruses Herald patch mutliple macules and patches with Christmas tree appearance Always rule out HIV and syphilis if clinically indicated Treat by itch relief. Steroid responsive A 10 year old male with terrible eczema was diagnosed with vesicular rashes over the areas of eczema around the eyes, the lips and along the cleavage of the arms and legs. He refused to eat or drink anything, but was not in dehydration on exam. The PMD was concerned and sent him to the ED. Initial management should include the following except? A. Ask the nurse to start IV fluids B. Place a line and give him IV acyclovir C. Admit and perform urinalysis and some basic labs D. Refer to ophthalmology E. Perform a PCR immediately Causes: HSV-1 HSV-2 Coxsackievirus A16 Vaccinia virus Transmission: Direct contact Proposed mechanism: Systemic immune defects involving both cell-mediated and humoral immunity, as well as impairment in cutaneous immune responses that are interrelated with the defective mechanical barrier properties of affected skin in person with AD. Viral cultures and direct observation using DFA is the best test to use A Tzanck smear may also be used but this is nonspecific Atypical eruptions PCR Bacterial cultures if superinfection is suspected Multisystemic viremia Secondary bacterial infection and sepsis Keratoconjunctivitis and possible blindness Patients with Eczema herpeticum should be admitted and treated with Acyclovir Foscarnet Trifluridine/Vidabarin – eye drops Valacyclovir No vaccine available for HSV You are seeing a 1 year old girl who recently immigrated. She is new to your practice at 2021 GC. You give her MMR and Varicella vaccines in your clinic to update her vaccine. Three days later, she comes in as a sick visit with a rash on the face and arms with relative sparing of the trunk. Dr. Cochran diagnoses her with Giannotti-Crosti Syndrome. What is the treatment? A. Prescribe hydrocortisone and benadryl gel and she should see you in two weeks. B. Prescribe diphenhydramine PRN and ask the patient to follow up in 2 weeks C. Oral prednisolone at 2 mg/kg/day for 5 days D. Admit to the hospital for IVIG E. Refer to Dr. Purice or Dr. Ledesma Infantile Papular Acrodermatitis Papular Acrodermatitis of Childhood Causes: Different kinds of viruses; Hepa B? EBV? Immunizations Pathophysiology: Local Type IV hypersensitivity reaction Often unecessary Consider a biopsy if diagnosis is unclear Transaminitis may be found: HBV? EBV? DFA and electron microscopy may fail to produce answers Reassure parents Rash stays for 2-4 weeks and can last up to 4 months Anti-pruritics Steroids? Antihistamines? Consults: Dermatology Gastroenterology Truncal sparing May mimic other disease like zinc deficiency History of acute infection with EBV or HBV Post immunization Face, buttocks, and extremities No treatment necessary Infectious Mononucleosis Adenovirus Infection Papular Purpuric Glove Socks Syndrome Unilateral Laterothoracic Exanthem (Assymetric Periflexural Exanthem) Filatov-Duke’s Disease First Disease? Second Disease? Third Disease? Fourth Disease? Fifth Disease? Sixth Disease? Egg! FEED ME…