Infectious Disease

1
Infectious Disease

• Debbie King RN, MSN,FNP,PNP

2
Ill Children

• February 5, 2010 Rapid breathing, parental
  concern, and the clinician's instinct are among
  the red flags warning of serious infection in
  children in developed countries, according to the
  results of a systematic review reported online in
  the February 3 issue of The Lancet.

3
Fever

• Fever
• Occurs with rise in hypothalamic setpoint,
  responding to endogenously produced pyrogens
• Caused by conditions that either infections,
  malignancies, autoimmune diseases, metabolic
  diseases, chronic inflammatory conditions,
  medications, CNS abnormalities, exposure to
  excessive heat
• Most fevers are caused by self-limiting viral
  infections
• One of most common reasons for office visits, ER
  visits, and phone calls
• Is a temp of 100.4 or higher

4
Fever

• When to evaluate
• Immediately if
• Younger than 3 months
• Fever is over 40.6 C or 105 F
• Crying inconsolably or whimpering
• Crying when moved or touched
• Difficult to awaken
• Their neck is stiff
• Purple dots or spots are reported
• Breathing is difficlut
• Drooling
• They had a seizure
• ACTS OR LOOKS VERY SICK!

5
fever

• When to evaluate
• With in 24 hours
• Is 3-6 months old
• Unless they have had the DTaP with in 48 hours
• Fever is over 40 C or 104 F esp if under 3 years
  old
• Dysuria is present
• Fever present over 24 hours without an obvious
  cause
• Fever subsided for over 24 hours then returned
• Fever has been present for over 72 hours

6
Fever

• Fever evaluation
• History
• Duration
• How was the temp taken
• Maximum temp documented
• Associated symptoms
• Chronic medical problems
• Medications
• Fluid intake
• Urine output
• Parental concerns
• Examination
• VS- temp, HR, Resp, BP
• Complete physical
• Focus on neuro, hydration and toxicity

7
fever

• Work up
• CBC with diff
• Blood cultures
• Chest X-Ray
• Urine
• UA
• UC with sensitivities
• Obtain urine by cath if under 3 year
• LP if indicated
• Any other test indicated

8
West Nile

• Most important mosquito borne encephalitis in the
  US
• Birds are the reservoir
• Incubation is 3-12 days

9
West Nile

• Signs and symptoms- onset
• abrupt onset of fever
• head ache
• sore throat
• myalgia
• Retroocular pain
• conjunctivitis
• rash
• Adenopathy

10
West Nile

• Risk with infection
• Encephalitis
• Muscle weakness
• Flaccid paralysis
• Movement disorders

11
West Nile

• Diagnostic Test and results
• CBC with leukocytosis, lymphonenic
• LP with pleoytosis
• IgM-EIA serology positive in 2-3 days after CNS
  symptoms
• PCR less sensitive test
• Treatment
• Supportative

12
Septicemia (Sepsis)

• Definition A generalized systemic response to
  infection usually severe and associated with
  presence of pathogenic microorganisms or
  associated toxins (usually bacterial) in blood
  stream neonates are most susceptible due to
  immature immune system

13
Etiology/ Incidence

• Etiologic agents vary by age, immunologic status
  and mechanism of transmission
• Newborn (lt3 days) - placental transfer of
  pathogens from infected maternal blood stream or
  from vaginal mucosa during birth
• Group B streptococcus (GBS)-high mortality
• Escherichia coli-most common gram negative
  organism
• Listeria monocytogenes

14
Septicemia in neonates

• Postnatal (I to 3 weeks )-cross-contamination in
  nurseries or other crowded conditions poor hand
  washing and housekeeping
• Staphylococcus aureus-most common
• Klebsiella
• Enterococci P
• Pseudomonas

15
Septicemia

• Older infants in the community can be at
  increased risk for sepsis due to inadequate
  immunization status -Haemophilus influenzae type
  B
• Hospitalized immunosuppressed children at risk
  for nosocomial sepsis - cancer, post-operative,
  and patients with HIV/AIDS

16
Septicemia

• Leading cause of morbidity and mortality among
  hospitalized patients due to associated
  homodynamic changes affecting tissue perfusion
  and oxygenation if not treated, may lead to
  septic shock
• Increased risk of septicemia
• High risk, premature infants
• Malesgt females
• Invasive procedures-IV, intubations
• Bottle feeding-breast milk may be protective
• Immunocompromised children and adolescents

17
Signs and Symptoms

• Neonates-symptoms may be vague and non-specific,
  e.g., poor feeding, color changes (pallor,
  mottling), changes in muscle tone, apnea,
  cyanosis
• Other immunosuppressed children-fever may be only
  sign reports by caregiver that child "isn't him
  or herself'
• Older children (rarer) with normal immune
  function-fever, irritability, anorexia, general
  toxic appearance

18
Differential Diagnosis

• Viral sepsis
• Bacterial sepsis
• Fungal infection
• Rocky mountain spotted fever
• Toxic shock syndrome
• Non-infectious causes-hemorrhagic, anaphylactic,
  or neurogenic shock

19
Physical Findings

• Neonates-hyper or hypothermia bradycardia or
  tachycardia hepatosplenomegaly, jaundice
• Older children-irritability, stiff neck
• Later phase-lethargy, delayed capillary refill,
  hypotension and subsequent septic shock

20
Diagnostic Tests/ Findings

• CBC with differential - WBC gt 15,000 with
  increased neutrophils
• Chest radiograph to rule out pneumonia
• Positive blood cultures identifying source of
  infection
• Cerebral spinal fluid (CSF)-pleocytosis,
  decreased glucose, increased protein, positive
  culture
• Coagulation studies-prolonged prothrombin time
  decreased fibrinogen levels

21
Management/ Treatment

• Medical referral for hospitalization
• Close observation, monitoring, and supportive
  care
• IV fluids to maintain hemodynamics
• Broad spectrum parenteral antibiotics for gram
  positive and negative organisms pending culture
  and sensitivities
• Vasoactive medication if septic shock ensues

22
Diphtheria

• Definition Highly contagious acute infection of
  the upper respiratory tract and/or trachea that
  is relatively rare in the U.S. but may still
  occur in under-immunized or un-immunized children
  

23
Etiology/ Incidence

• Caused by Corynebaccerium diphtheriae
• Transmission through direct contact with infected
  person, carrier, or contaminated food/objects
• Rare in the U.S. due to DTaP/dT immunization
  approximately 5 cases reported annually
• Increased risk among un-immunized children living
  in crowded conditions
• Fall/winter incidence most common

24
Signs and Symptoms

• Sore throat
• Low-grade fever
• Nasal discharge
• Bloody nose
• Hoarseness or cough
• Difficulty breathing (severe cases)

25
Differential Diagnosis

• Acute streptococcal pharyngitis
• Nasal foreign body
• Mononucleosis
• Viral croup
• Epiglottitis

26
Physical Findings

• Greyish-white pseudomembrane found at location of
  infection-nasopharynx, pharynx or trachea
• Other findings vary by location of membrane
• Toxin-related severe complications
  include-myocarditis, Guillain-Barre type neuritis
  and paralysis

27
Diagnostic Tests/ Findings

• Positive culture of C. Diphrheriae
• CBC - normal or slight leukocytosis and
  thrombocytopenia

28
Management/ Treatment

• Hospitalization
• Evaluation of sensitivity to horse serum if
  negative, single dose of equine antitoxin
• Antibiotic treatment--erythromycin or penicillin
  G antimicrobial treatment is not a substitute
  for antitoxin
• Respiratory isolation

29
Diphtheria

• Report to State health department
• Identification of contacts for follow-up care,
  immunization and treatment according to current
  American Academy of Pediatrics Red Book
  recommendations
• Prevention through universal immunization

30
Pertussis (Whooping Cough)

• Definition Highly contagious bacterial infection
  involving the respiratory tract characterized by
  prolonged coughing episodes ending in an
  inspiratory "whoop"

31
Etiology/ Incidence

• Caused by Bordetella pertussis
• Infection occurs following person to person
  contact via aerosolized droplets from respiratory
  tract
• 35 of cases occur in infants less than 6 months
  of age and these children have the highest
  mortality
• Incubation period is 6 to 20 days, usually 7 to
  10 days
• Infectivity is highest in catarrhal stage

32
Signs and Symptoms

• Catarrhal stage-mild URI symptoms with cough for
  approximately two weeks low-grade fever
• Paroxysmal stage-severe coughing episodes with
  inspiratory "whoops"that may persist for weeks
  vomiting, sucking or crying precipitates coughing
  episodes poor feeding

33
Differential Diagnosis

• Pneumonia (bacterial, viral, chlamydial)
• Acute bronchitis
• Croup
• Upper respiratory infection
• Foreign body aspiration
• Cystic fibrosis

34
Physical Findings

• Catarrhal stage - mild URI symptoms
• Paroxysmal stage-severe coughing episodes with
  inspiratory "whoops", cyanosis

35
Diagnostic Tests/ Findings

• Chest radiograph-may reveal thickened bronchi and
  evidence of atelectasis and bronchopneumonia
• WBC count reveals marked leukocytosis - usually
  presents during paroxysmal period and persists
  for 3 to 4 weeks
• Nasopharyngeal culture of direct fluorescent
  antibody stain (DFA) positive in initial phase of
  illness

36
Management/ Treatment

• Medical referral is necessary
• Antibiotic therapy-erythromycin (40 to 50
  mg/kg/day divided four times a day for 14 days
  maximum 2 g/day) Zithromax regular dosing may be
  used.
• Hospitalized children should remain in isolation
  until they have received five days of
  erythromycin

37
Pertussis

• Children receiving oral erythromycin at home
  should not attend day care or school until they
  have received five days of therapy
• Supportive treatment for children who cannot
  tolerate oral intake due to paroxysmal coughing
  episodes-intravenous hydration, oxygen
  supplementation, ventilatory support
• Report cases of pertussis to State health
  department

38
Pertussis

• Prevention
• Appropriate pertussis immunization according to
  schedule
• Children less than 7 years of age, with close
  contact with infected individual, who are
  unimmunized or have received fewer than four
  doses of pertussis vaccine, should complete the
  series with the minimal intervals
• If the third dose of vaccine was received six
  months or more prior to the exposure, should be
  given a fourth dose at time of exposure
• Children who have not received a vaccine within
  past three years or those 6 years of age,
  should receive a booster dose of pertussis
  vaccine at time of exposure
• Erythromycin (40 to 50 mg/kg/day divided four
  times a day for 14 days maximum 2 g/day) is
  recommended for all household contacts and other
  close contacts, regardless of vaccination status

39
Influenza

• Definition Highly contagious, viral illness
  characterized by sudden onset of fever, chills,
  malaise, headache, myalgia and dry cough

40
Etiology/ Incidence

• Epidemic influenza caused by types A and B
• Transmission occurs by direct person-to-person
  contact, via airborne droplet or by articles
  contaminated with nasopharyngeal secretions
• During outbreak, school-aged children are most
  frequently infected and infect household contacts

41
Influenza

• Period of highest infectivity 24 hours prior to
  onset of symptoms and while symptoms are most
  severe
• Incubation period 1 to 3 days
• Influenza season mid-October through mid-February

42
Signs and Symptoms

• Fever
• Chills
• Malaise
• Headache, myalgia
• Dry cough
• Anorexia
• Rhinorrhea
• Sore throat

43
Differential diagnosis

• Upper respiratory infections
• Pneumonia

44
Physical Findings

• Listlessness
• Nonproductive cough
• Rhinorrhea
• Rigors
• Fever
• Conjunctivitis
• Pharyngitis

45
Diagnostic Tests/ Findings

• Nasopharyngeal cultures obtained within first 72
  hours of illness may reveal influenza
• Diagnosis is usually made based on clinical signs
  and available prevalence data

46
Management/ Treatment

• Management of influenza is primarily supportive
• Bed rest
• Acetaminophen or ibuprofen for fever (avoid
  aspirin-containing products due to risk of
  developing Reye's syndrome)
• Adequate hydration

47
Influenza

• Rimantadine and oseltarnivir diminishes severity
  of influenza A but is not effective in treatment
  of influenza B
• Not approved for use in infants lt 12 months of
  age
• CDC guidelines for children only use if
  necessary due to possible sever side effects
  including hallucinations. Ex exposure to
  immunosuppressed family member
• Dosages - Rimantadine 5 mg/kg/day (not to exceed
  150 mg/day for children 1 year to 9 years of age
  for children 10 years of age give 5 mg/kg/day
  if lt 40 kg, or 200 mg/day if 40 kg. Oseltamivir
  15 kg - 30 mg orally for 5 days 16-23 kg - 5
  mg orally for 5 days 24-40 kg - 60 mg orally for
  5 days Childrengt 40 kg and adults 75 mg orally
  for 5 days

48
Influenza

• Secondary bacterial infection may occur with
  influenza
• Persons in high risk groups (e.g., HIV, cancer,
  cystic fibrosis, sickle cell disease) should be
  vaccinated yearly, as should household contacts.
  The intranasal influenza vaccine is only intended
  for healthy children, adolescents and adults ages
  5 through 49

49
H1N1

• http//www.cdc.gov/h1n1flu/key_facts.htm
• is a respiratory disease of pigs caused by type
  A influenza virus that regularly causes outbreaks
  of influenza in pigs.
• cause high levels of illness and low death rates
  in pigs.
• may circulate among swine throughout the year,
  but most outbreaks occur during the late fall and
  winter months similar to outbreaks in humans.
• The classical virus (an influenza type A H1N1
  virus) was first isolated from a pig in 1930

50
H1N1

• There are four main influenza type A virus
  subtypes that have been isolated in pigs H1N1,
  H1N2, H3N2, and H3N1.
• Most of the recently isolated influenza viruses
  from pigs have been H1N1 viruses.
• Cases occur in persons with direct exposure to
  pigs (e.g. children near pigs at a fair or
  workers in the swine industry).
• There have been documented cases of one person
  spreading swine flu to others. For example, an
  outbreak of apparent swine flu infection in pigs
  in Wisconsin in 1988 resulted in multiple human

51
Key Flu Indicators May 21, 2010, 1100 AM Each
week CDC analyzes information about influenza
disease activity in the United States and
publishes findings of key flu indicators in a
report called FluView. During the week of May
9-May 15, 2010, nationally all key flu indicators
are low. Activity levels at this time are similar
to what is usually seen during the U.S. summer
months. Below is a summary of the most recent key
indicators Visits to doctors for influenza-like
illness (ILI) decreased from last week, and are
low nationally, with all 10 U.S. regions
reporting ILI below region-specific baseline.
Laboratory-confirmed hospitalizations rates have
leveled off.
52
The proportion of deaths attributed to pneumonia
and influenza (PI) based on the 122 Cities
Report remained about the same as last week. No
pediatric deaths were associated with flu were
reported this week. Since April 2009, CDC has
received reports of 338 flu laboratory-confirmed
pediatric deaths 282 due to 2009 H1N1, 53
pediatric deaths that were laboratory confirmed
as influenza A, but the flu virus subtype was not
determined, and three pediatric deaths that were
associated with seasonal influenza viruses.
(Laboratory-confirmed deaths are thought to
represent an undercount of the actual number. CDC
has provided estimates about the number of 2009
H1N1 cases and related hospitalizations and
deaths).
53
No states reported widespread or regional
influenza activity. This is the fifth consecutive
week that no states reported widespread or
regional flu activity. Most states are reporting
no activity or sporadic activity. The majority
of the influenza viruses identified so far
continue to be 2009 H1N1 influenza A viruses.
These viruses remain similar to the virus chosen
for the 2009 H1N1 vaccine and remain susceptible
to the antiviral drugs oseltamivir and zanamivir
with rare exception. All data are preliminary
and may change as more reports are received
54
H1N1

• The symptoms of H1N1 in people are expected to be
  similar to the symptoms of regular human seasonal
  influenza
• fever, lethargy, lack of appetite and coughing.
• May also have runny nose, sore throat, nausea,
  vomiting and diarrhea.

55
H1N1

• Diagnose
• respiratory specimen would generally need to be
  collected within the first 4 to 5 days of illness
  (when an infected person is most likely to be
  shedding virus). However, some persons,
  especially children, may shed virus for 7 days or
  longer. Identification as a swine flu influenza A
  virus requires sending the specimen to CDC for
  laboratory testing.

56
H1N1

• Treatment
• There are four different antiviral drugs that are
  licensed for use in the US for the treatment of
  influenza amantadine, rimantadine, oseltamivir
  and zanamivir. While most swine influenza viruses
  have been susceptible to all four drugs, the most
  recent H1N1 influenza viruses isolated from
  humans are resistant to amantadine and
  rimantadine

57
Rubella (German Measles)

• Definition An acute, contagious, viral disease
  characterized by a minor or absent prodrome,
  swelling of sub-occipital, post-auricular and
  cervical nodes

58
Etiology/ Incidence

• Caused by an RNA virus
• Postnatal transmission occurs via contact from
  nasopharyngeal secretions
• Incubation period ranges from 14 to 21 days
• Preventable by active immunization

59
Signs and Symptoms

• History of inadequate immunization
• Rash starts on face and spreads over trunk and
  extremities disappears by 3rd day
• Associated signs and symptoms
• Malaise, low-grade fever
• Transient joint pain
• Bruising (rare)

60
Differential Diagnosis

• Rubeola
• Scarlet fever
• Erythema infectiosum
• Adenovirus
• Rocky mountain spotted fever
• Roseola

61
Physical Findings

• Generalized erythematous, maculopapular discrete
  rash-usually first indication of illness
• Listlessness
• Post-auricular and sub-occipital lymphadenopathy
  -usually precedes rash
• Purpura/petechiae (rare)
• Meningeal signs (rare)

62
Diagnostic Tests/ Findings

• Presence of rubella specific IgM antibody
  indicates recent postnatal infection or
  congenital infection in newborn
• Refer to current American Academy of Pediatrics
  Red Book for further information on available
  assays for detecting rubella infection

63
Management/ Treatment

• Management of uncomplicated infection is
  primarily supportive-includes fever and pain (in
  lymph nodes) control with acetaminophen or
  ibuprofen
• Determine contacts that may require immunization
• Infected children should limit contact with
  susceptible persons, including women of
  childbearing age
• Educate adolescent females regarding teratogenic
  nature of rubella in pregnancy
• Educate caretakers regarding complications of
  arthritis, and rarely thrombocytopenia and
  encephalitis

64
Rubeola (Red measles)

• Definition An acute, highly contagious viral
  disease characterized by prodrome of upper
  respiratory manifestations followed by
  generalized maculopapular eruptions

65
Etiology/Incidence

• Caused by a morbilli virus, in Paramyxovirus
  family
• Transmitted by direct contact with infected
  secretions or via airborne droplets
• Infected individuals are contagious 3 to 5 days
  before appearance of rash, to four days after
  appearance of rash
• Increased incidence during winter and spring
• Preventable by active immunization

66
Signs and Symptoms

• History of inadequate immunization
• Acute Onset of fever, coryza, cough,
  conjunctivitis, malaise, anorexia
• Confluent, erythematous, maculopapular rash 3 to
  4 days after initial symptoms progresses in
  caudal direction

67
Differential Diagnosis

• Roseola or rubella
• Viral infections (e.g., echovirus,
  coxsackievirus, adenovirus)
• Infectious mononucleosis
• Scarlet fever
• Rickettsial diseases
• Serum sickness

68
Physical Findings

• Confluent, erythematous maculopapular rash after
  3 to 4 days, rash assumes a brownish appearance
• Profuse coryza
• Conjunctivitis
• Pulmonary findings (crackles, rhonchi)
• Koplik spots (red eruptions with white centers on
  buccal mucosa) prior to appearance of rash- are
  diagnostic

69
Diagnostic Tests/ Findings

• Presence of measles specific IgM antibody
  suggests recent infection

70
Management/ Treatment

• Medical referral necessary
• No specific antiviral therapy available
• Management of uncomplicated measles is primarily
  supportive-bedrest, adequate hydration
  acetaminophen or ibuprofen for fever
  anti-tussive therapy
• Otitis media is most common complication of
  measles infection- treated with same antibiotics
  as in standard otitis media
• Educate caretakers regarding complications
  including otitis media, encephalitis and
  pneumonia

71
Roseola (Exanthem Subitum)

• Definition An acute contagious disease
  characterized by high fever, and appearance of a
  rash with simultaneous decrease in fever

72
Etiology/Incidence

• Caused by human herpesvirus 6 (HHV -6)
• Mode of transmission not known
• Incubation period is 5 to 15 days
• Period of infectivity is thought to be during the
  febrile episode, prior to appearance of the rash
• Most commonly occurs in children 6 to 24 months
  of age
• Most cases occur in spring and Summer

73
Signs and Symptoms

• Abrupt onset of high fever (102 to 105 F)
  lasting 3 to 5 days
• Appearance of a rash follows resolution of fever
• Associated symptoms include irritability and
  swelling of eyelids .

74
Differential Diagnosis

• Rubeola
• Scarlet fever
• Rubella

75
Physical Findings

• Generalized erythematous, maculopapular rash
  starts on trunk and spreads to arms, and neck
  with less involvement of face and legs
• Irritability
• May have mildly inflamed edematous conjunctiva

76
Diagnostic Tests/ Findings

• Progressive leukopenia during febrile period

77
Management/ Treatment

• Acetaminophen or ibuprofen for fever
• Medical referral if meningeal signs appear, or if
  fever persists
• Education
• Potential for febrile seizures
• Reassurance that appearance of rash is sign of
  recovery

78
Fifth Disease (Erythema Infectiosum - EI)

• Definition A contagious, usually afebrile,
  exanthematous disease

79
Etiology/ Incidence

• Human parvovirus B19
• Typically seen in 5 to I4-year-old children
• Outbreaks occur most often during spring months
  Incubation period between 4 and 14 days
• Mode of transmission includes respiratory
  secretions and blood
• Patho
• Parvovirus B 19 replicates primarily in the
  erythroid progenitor cells, with
  reticulocytopenia occurring for about a week
  during the illness. This is not a problem in
  those with normal erythrocyte half life, but
  causes severe anemia in those with hemolytic
  disorders

80
Signs and Symptoms

• No prodromal symptoms
• Rash
• Begins as bilateral erythema on cheeks ("slapped
  cheek" appearance)
• Spreads to upper arms, legs, trunk, hands and
  feet
• Palms and soles are spared
• Lacy-reticular exanthem appears as facial
  erythema begins to diminish
• May reappear when skin is exposed to sunlight,
  temperature extremes
• Rash lasts from 2 to 39 days, average 11 days

81
Fifths disease

• Low grade fever may occur
• Can cause aplastic crises in young children, and
  in patients with hemolytic diseases
• Can cause miscarriage in first trimester of
  pregnancy
• Arthritis is a possible complication, with adults
  and older adolescence lasting up to 6 weeks
• Is under study for possible cause of
  collagen-vascular diseases, neurologic syndromes,
  hepatitis, and myocarditis

82
Differential Diagnosis

• Drug reactions
• Rubella, atypical measles
• Enteroviral diseases
• Systemic lupus erythematosus

83
Physical Findings

• Early-bilateral erythema on cheeks ("slapped
  cheek" appearance)
• Late - erythematous rash on upper arms and legs,
  trunk, hands and feet palms and soles are spared
  
• Late - lacy-reticular exanthem appears as facial
  erythema begins to diminish

84
Tests/ Findings

• Parvovirus B19 IgM antibody confirms current
  infection, or infection within past several
  months
• 2. Parvovirus B19 IgG antibody indicates previous
  infection and immunity

85
Management/ Treatment

• None indicated
• Reassure parent of benign nature of disease
• Avoid sunlight as exposure may exacerbate the
  condition
• Period of high infectivity in persons with EI is
  prior to onset of symptoms unlikely to be
  infectious after rash develops conversely
  patients with aplastic crises are highly
  contagious prior to the onset of symptoms and
  through week of onset, or longer
• Patients with aplastic crisis may need a
  transfusion

86
Varicella-Zoster Virus (VZV) (Chickenpox)

• Definition An acute contagious disease caused by
  a herpesvirus characterized by a short or absent
  prodrome and usually a sequential rash consisting
  of papules, vesicles, pustules and crusts

87
Etiology/ Incidence

• VZV is a herpesvirus
• Transmission occurs by direct contact with
  varicella lesions or by airborne droplet
  infection
• Susceptible individuals can contract chickenpox
  from patients with varicella zoster (shingles)
• Incubation period between 10 and 21 days
• Infected individual contagious for 24 to 48 hours
  prior to outbreak of lesions, until lesions have
  crusted over
• Most cases occur between ages of 5 and 10 years
• VZV occurs commonly in late winter and early
  spring

88
Signs and Symptoms

• Early lesions appear as faint erythematous
  macules that progress to papules, followed by
  appearance of vesicles primarily on trunk, scalp,
  face lesions eventually crust over
• Lesions continue to erupt for 3 to 4 days and may
  be present in various stages, may have as many as
  5 crops
• Associated symptoms may include fever, pruritus,
  malaise, anorexia, joint pain

89
Differential Diagnosis

• Herpes zoster
• Bullous impetigo
• Insect bites
• Urticaria

90
Physical Findings

• Crops of skin lesions that may appear as
  maculopapular (early), vesicular, pustular with
  eventual crusts many maculopapular lesions may
  progress to vesicular stage and resolve without
  crusting
• Rash usually present On scalp, face, trunk and
  extremities most lesions on face and trunk
• Hepatomegaly (rare)
• Meningeal signs (rare)
• Pulmonary findings-crackles, wheezes (rare)

91
Diagnostic Tests/ Findings

• None routinely performed

92
Management/ Treatment

• VZV is a self-limited disease lasting 7 to 10
  days
• Supportive treatment
• Control of pruritus with oatmeal baths,
  diphenhydramine, calamine lotion
• Acetaminophen for fever (avoid aspirin-containing
  products due to risk of developing Reye's
  syndrome)
• Oral acyclovir is beneficial in reducing duration
  of new lesion formation, and total number of
  lesions (20 mg/kg/dose, four times a day maximum
  800 mg four times a day) should be started
  within 24 hours of onset for maximum benefit

93
Chickenpox

• Oral acyclovir not usually recommended in healthy
  children with uncomplicated varicella
• Varicella-zoster immune globulin (VZIG) should be
  given to immune suppressed contacts to provide
  passive protection
• Medical referral necessary for immune suppressed
  children

94
Varicella

• Education
• Avoid contact with elderly, pregnant women,
  neonates and immunocompromised children
• Live-attenuated varicella vaccine is available in
  U.S. and is recommended for all healthy children
  and adults age 12 months and up who lack a
  reliable history of varicella, with a booster now
  recommended.
• Signs and symptoms of complicated varicella
  infection - meningeal signs, respiratory
  distress, dehydration, ocular involvement,
  secondary bacterial infection, thrombocytopenia,
  pneumonia
• Signs and symptoms of Reye's syndrome-persistent
  vomiting, lethargy, agitation, disorientation,
  combativeness, coma

95
Mumps

• Definition A contagious, systemic, viral disease
  characterized by swelling of the salivary glands

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Etiology/ Incidence

• Caused by paramyxovirus
• Spread by direct contact via respiratory airborne
  droplet and fomites contaminated with infected
  saliva
• Incubation period between 12 to 25 days after
  exposure
• Infected individual is contagious for as many as
  7 days prior to, and as long as 9 days after
  onset of symptoms
• Infection occurs throughout childhood rarely
  during adulthood
• More common in late winter and spring

97
Signs and Symptoms

• History of inadequate immunization
• Swelling of salivary glands (specifically parotid
  gland), pain with swallowing
• Malaise, fever
• Scrotal swelling and pain

98
Differential Diagnosis

• Submandibular or preauricular lymphadenitis
• Salivary duct obstruction
• Infectious mononucleosis
• Epididymitis

99
Physical Findings

• Swelling of salivary glands (specifically parotid
  gland)
• Listlessness
• Scrotal swelling and pain

100
Diagnostic Tests/ Findings

• Serum for complement fixation (CF) - positive
  test for complement-fixing antibody against mumps
  virus suggests recent infection

101
Management/ Treatment

• Acetaminophen for pain and fever
• Warm compresses for salivary gland swelling
• Soft or liquid diet
• Education
• Complications include pancreatitis, oophoritis,
  meningitis, orchitis
• May return to day care or school when all
  symptoms have resolved or 9 days after onset of
  symptoms
• Report cases to State health department

102
Cat Scratch Disease (CSD)

• Definition An infection characterized by
  regional lymphadenopathy in an otherwise healthy
  person, following contact with an infected cat,
  as a result of a cat bite or scratch, or contact
  with cat saliva on broken skin or the
  conjunctivae of the eye

103
Etiology/ Incidence

• Most cases are caused by Bartonella spp., which
  include the former genus Rochalimaea
• More than 24,000 cases per year occur in the U.S.

104
Signs and Symptoms

• Mild systemic symptoms
• History of cat exposure
• Usually do not appear ill
• Swollen lymph nodes
• May have low-grade fever general malaise
  headache
• Anorexia
• May have rash

105
Differential Diagnosis

• Bacterial lymphadenitis
• Lymphoma
• Tularemia

106
Physical Findings

• Papule or pustule at site of cat scratch or bite,
  followed in 1 to 3 weeks by enlargement of an
  associated lymph node
• Lesion may be present for several days to several
  months

107
Diagnostic Tests/ Findings

• May have elevated ESR
• Immunofluorescence assay (IFA) detects antibody
  to CSD
• Warthin-Starry silver stain used to identify CSD
  in lymph node, skin or conjunctival tissue

108
Management/ Treatment

• CSD is a self-limited disease lasting 2 to 4
  months
• Now is treated with z-max
• Supportive Treatment
• Analgesics for discomfort and fever
• Limited activity
• Needle aspiration of painful, suppurative nodes
  questionable may result in chronic draining
  sinus tract
• No treatment required for animal that transmitted
  CSD

109
Rocky Mountain Spotted Fever (RMSF)

• Definition A systemic, febrile illness with
  characteristic petechial or purpuric rash

110
Etiology/ Incidence

• Caused by Rickettsia rickettsii
• Transmitted to humans via tick bites
• Usually occurs in persons younger than 15 years
  of age
• Widespread in U.S. most prevalent in southern
  States
• Incubation period ranges from I to 14 days

111
Signs and Symptoms

• Fever, myalgia, nausea and vomiting precede
  appearance of rash
• Erythematous, macular rash (usually appearing
  before the sixth day of illness), on wrists,
  ankles, spreading within hours to the trunk
• In some cases rash fails to develop, or develops
  late in the illness
• Disease can last 3 weeks with multisystem
  involvement (e.g., CNS, cardiac, pulmonary, GI,
  renal)

112
Differential Diagnosis

• Rubeola
• Rubella
• Lyme disease
• Septicemia
• Meningococcemia

113
Physical Findings

• Characteristic petechial, erythematous, macular
  rash
• Neurologic deficits
• Heart murmur
• Pulmonary findings (crackles)
• Decreased urine output
• Jaundice

114
Diagnostic Tests/ Findings

• Culture is not attempted due to transmission risk
  for laboratory personnel
• Renal failure
• Elevated liver enzymes
• Increase in antibody titer as established by
  serologic testing indirect hemagglutination
  (IHA) and microimmunofluorescence (micro-IF) are
  most sensitive .

115
Management/ Treatment

• Medical referral
• Doxycycline or tetracycline is given until
  patient is afebrile for 2 to 3 days
• Tetracycline not routinely given to children less
  than 18 years of age doxycycline is drug of
  choice
• Education includes preventive measures such as
  use of tick repellent and protective clothing in
  tick-infested areas
• Patients with multi-system organ involvement may
  require rehabilitative services
• Report cases to State health department

116
Cytomegalovirus

• Definition herpesvirus transmitted by many
  routes. It may be transmitted by many routes.
• In utero
• May be teratogenic
• Postpartum from birth secretion
• From breast milk
• Saliva
• Sexually transmitted
• Blood transfusions

117
Cytomegalovirus

• Primary infection
• Minor illness or asymptomatic in young children
• Mono like syndrome with pharyngitis in older
  children
• Congenital infection most serious
• Growth retardation
• Microcephaly- seizures
• Retinitis and encephalitis
• Hepatosplenomegaly with thrombocytopenia
• Blueberry muffin rash
• Blueberry muffin is a petechial, purpuric,
  magenta
• colored macules, papules, and plaques as
  well as
• blueberry colored ecchymoses, which
  resolve
• gradually over a period of several days
  to weeks.4
• Sensorineural deafness

118
Cytomegalovirus

• Differentials
• Toxoplasmosis
• Rubella
• Herpes simplex
• Syphilis

119
Cytomegalovirus

• Laboratory findings
• Lymphocytosis
• Atypical lymphocytes
• Anemia
• Thrombocytopenia
• Abnormal LFTs
• Increased levels of CMV antibody
• In infants
• Diffuse interstitial pneumonitis

120
Cytomegalovirus

• Treatments
• Is self limited and requires no treatment in most
  cases
• In infants
• O2, intubations, ganciclovir

121
Lyme Disease

• Definition
• An immune-mediated, inflammatory response
• Affects multiple organ systems
• Transmitted primarily via the deer tick

122
Etiology/ Incidence

• Caused by a spirochete Borrelia burgdorferi is
  most often transmitted via the deer tick
• Most often seen in Northeast from Massachusetts
  to Maryland the Midwest, primarily Wisconsin and
  Minnesota and in California primarily in
  heavily wooded areas
• Persons of all ages and both sexes are affected
• Most cases occur during June and July
• Incubation period is between 3 to 32 days

123
Signs and Symptoms

• Appearance of well-circumscribed, erythematous,
  annular rash with central clearing (erythema
  chronicum migrans) at site of recent tick bite
• Fever, malaise, headache, arthralgia,
  conjunctivitis, or mild neck stiffness
• May initially present as flulike illness if
  erythema migrans does not occur, or not
  recognized

124
Lyme Disease late symptoms

• Late signs and symptoms (weeks to months later)
• Migratory pain in joints, muscles and bones
• Transient, but severe, headaches and stiff neck
• Poor memory, mood changes, somnolence
• Muscle weakness and poor coordination
• Chest pain, cardiac abnormalities
• Dizziness/fainting
• Facial palsies
• Joint stiffness

125
Differential Diagnosis

• Tinea corporis (ringworm)
• Insect bite
• Cellulitis
• Acute rheumatic fever
• Influenza
• Aseptic meningitis
• Juvenile rheumatoid arthritis
• Henoch-Schöenlein purpura

126
Physical Findings

• Well-circumscribed, erythematous, annular rash
  with central clearing
• Malar rash, diffuse erythema or urticaria
• Heart murmur
• Neurologic findings - seventh cranial nerve palsy

127
Diagnostic Tests/ Findings

• Enzyme-linked immunosorbent assay (ELISA) -
  detects antibodies against B. burgdorferi
• Western blot-used to validate a positive or
  equivocal ELISA
• Serum immunoglobulins - lgM, IgG elevated
• Culture of erythema migrans lesion - expensive,
  time to isolation may take four weeks
• White blood cell count-normal or elevated
• Erythrocyte sedimentation rate (ESR)-elevated

128
Management/ Treatment

• Medical referral is necessary
• Early disease
• Children gt 8 years of age - amoxicillin or
  doxycycline
• Children 8 years of age - amoxicillin or
  penicillin V
• For penicillin-allergic patients - cefuroxime or
  erythromycin may be used, although erythromycin
  may be less effective
• Late disease for persistent arthritis, carditis,
  neurologic disease-parenteral ceftriaxone or
  penicillin G

129
Lyme Disease

• Education/prevention
• Ticks that carry Lyme disease are 4 to 5 mm in
  diameter
• Prompt removal of ticks from the skin and use of
  tick repellent decreases the incidence of Lyme
  disease
• Use blunt-end tweezers to grasp tick as close to
  skin surface as possible wear rubber gloves
• Disinfect skin where tick bite occurred
• Early intervention leads to improved prognosis
• Wear protective clothing in heavily wooded areas,
  check skin closely after outdoor activities
• Report cases of Lyme disease to State health
  department

130
Infectious Mononucleosis

• Definition An acute disease characterized by
  fever, exudative pharyngitis, lymphadenopathy,
  hepatosplenomegaly and atypical lymphocytosis

131
Etiology/ Incidence

• Caused by Epstein-Barr virus (EBV), a herpesvirus
  
• Contact with infected secretions is required for
  transmission
• Incubation period is 30 to 50 days - Commonly
  diagnosed in adolescents and young adults

132
Signs and Symptoms

• Fever, malaise, fatigue
• Severe sore throat
• Rash especially with administration of ampicillin
  derivatives
• Tender lymph nodes

133
Differential Diagnosis

• Streptococcal pharyngitis
• Hepatitis
• Influenza or viral illness
• Measles
• Blood dyscrasias, especially leukemia

134
Physical Findings

• Exudative pharyngitis
• May have hepatosplenomegaly
• Lymphadenopathy
• May have jaundice
• May have erythematous, macular, papular rash
• Tender posterior cervical nodes

135
Diagnostic Tests/ Findings

• Positive monospot, or positive Epstein-Barr virus
  titer
• WBC count reveals leukocytosis, 10,000 to 20,000
  cells/mm3, with 60 lymphocytes and 20 to 40
  atypical lymphocytes
• Rapid strep test and throat culture-identifies
  presence of B-hemolytic streptococcal infection,
  if present

136
Management/ Treatment

• IM is a self-limited disease lasting 2 to 3 weeks
  
• Supportive treatment
• Bedrest during acute phase
• Pain control for pharyngitis and lymphadenitis
• Saline gargles for sore throat
• Avoid contact sports until spleen is no longer
  palpable
• Antibiotic therapy as needed for
  pharyngitis-avoid use of ampicillin derivatives
  such as amoxicillin, and other penicillins may
  result in rash
• Orapred 15/5 2mg/kg B.I.D for 5 days or
  Prednisone 30 mg bid x 5 days if over 90 lbs

137
Tetanus (Lockjaw)

• Definition A neurologic disease characterized by
  severe muscle spasms that can be fatal

138
Etiology/ Incidence

• Caused by neurotoxin produced by anaerobic
  bacterium Clostridium tetani in contaminated
  wounds
• Occurs throughout the world neonatal tetanus is
  common in countries where women are not immunized
  
• Incubation period 2 days to 2 months with an
  average of 10 days 5 to 14 days in neonates
• More common in warmer climates and months
• Has dramatically decreased with advent of tetanus
  vaccine

139
Signs and Symptoms

• Incomplete tetatus immunization series
• History of deep puncture wound, laceration
• Insidious onset
• Muscle spasms aggravated by stimuli
• Muscle rigidity
• Increased oral secretions
• Respiratory compromise

140
Differential Diagnosis

• Muscle spasms
• Amyotrophic lateral sclerosis (Lou Gehrig's
  disease)
• Hypocalcemic tetany
• Phenothiazine reaction
• Strychnine poisoning

141
Physical Findings

• Muscle spasms aggravated by stimuli
• Muscle rigidity
• Increased oral secretions
• Respiratory compromise

142
Diagnostic Tests/ Findings

• Diagnosis made clinically

143
Management/ Treatment

• Medical referral
• Supportive management-treatment of muscle spasms,
  intravenous fluids, respiratory support
• Minimize external stimuli (e.g., loud noise,
  bright light) to prevent aggravating muscle
  spasms
• Tetanus immune globulin (TIG) given to prevent
  circulating toxin from binding to central nervous
  system sites
• Infection with tetanus does not confer immunity
  patient should be re-immunized in convalescent
  period to prevent future infection
• Education-educate family regarding potential
  complications from tetanus including respiratory
  compromise, inability to speak

144
streptococcus pneumoniae

• causes a range of illnesses such as
• ear infections
• pneumonia
• bloodstream infections
• meningitis

145
WASHINGTON (Dow Jones)--The Food and Drug
Administration on February 24, 2010 approved a
new version of the widely used childrenaposs
vaccine Prevnar. The current Prevnar vaccine is
given to infants and toddlers to prevent seven
strains of bacteria known as streptococcus
pneumoniae that cause a range of illnesses like
ear infections, pneumonia, bloodstream infections
and meningitis, an infection of the covering of
the brain and spinal cord
146
The other strains in Prevnar 13 should protect
against an additional 25 of current disease. He
said the company is ready to start shipping the
new vaccine immediately. Children who
havenapost been fully vaccinated with the
original Prevnar can finish their vaccination
schedule with the new Prevnar. FDAaposs
approval of the vaccine came just before a
Centers for Disease Control and Prevention
Advisory vaccine advisory panel met to discuss
and vote on Prevnar 13. The Advisory Committee on
Immunization Practices sets vaccine-use policies
and positive votes on vaccines typically trigger
private-insurance companies to pay for vaccines.
Prevnar 13 will also be included in a federal
program that pays for vaccines for uninsured or
low-income children up to age 19. The panel said
doctors should start switching over to the new
vaccine and that children age 15 months to five
years of age whoaposve already received four
shots of the original Prevnar can receive one
shot of the new vaccine.
147
Lead Poising

• Lead Poisoning the facts
• The presence of serum lead levels that cause
  toxic effects on multiple organ systems
• Major pathway is ingestion
• Affects heme production, competes with calcium
  mediated process, affects certain enzyme
  functions and damages the nervous system
• Effects brain development as it inhibits the
  normal pruning process that eliminates multiple
  intercellular connections
• Environmental exposure is linked with conditions,
  diseases and also with reading problems, school
  failure, delinquent behavior, tooth decay,
  spontaneous , renal disease, cardiovascular
  disease
• Children are more likely to be exposed via hand
  to mouth behaviors and is more absorbed when
  nutritional deficiencies are present
• Lead level considered to be toxic is 10mcg/dL or
  higher, but impairments can be seen at 7 mcg/dL

148
Lead Poising

• Epidemiology
• Is decreased in the US, but is still estimated
  that more than 500,000 children ages 1-5 years
  have lead levels above 10
• Major source is dust and chips from deteriorating
  paint on interior surfaces
• Before 1950 50 of white house paint was lead and
  50 was linseed oil
• Limits on lead content began in 1955 and was
  increased in 1971 and again in 1977
• Houses build between 1960 and 1977 had 14 to 23
  times the hazard of homes built between 1978 and
  1998
• Children are at greatest risk in older homes with
  chipping or peeling paint
• Other sources of lead are lead using industries
  and smelters, lead pipes, brass fixtures, food
  from soil containing lead, pottery, lead crystal,
  some dyes used in paper, fishing weights,
  cosmetics, folk medicine

149
Lead Poising

• Signs and symptoms in young children
• May have no s/s
• May have severe gastrointestinal problems
  including pain, constipation, anorexia, vomiting
• Impaired hearing
• Agitation or clumsiness
• Headache
• Decreased cognitive functions
• Delayed growth and development
• Increased behavior problems
• Seizures/comas are late symptoms
• Differentials diagnosis
• GI infections
• Anemia (of other causes)
• ADHD
• CNS infections
• Physical exam
• No physical findings are expected in the early
  process

150
Lead Poising

• Work up
• Blood lead using venous blood
• Check for iron deficiency including ferritin and
  low ratio of serum iron to iron binding capacity
• Treatment
• Management involves preventing the continued
  exposure
• Treating for toxicity/hospitalize for IV
  chelation
• Monitoring lead levels
• Correcting dietary deficiencies
• Removing lead from the environment
• Testing and treating other children exposed
• Do follow up testing!!