Common Viral Infecions

1
Common Viral Infecions

• Measles
• Mumps
• Rubella
• Chicken pox
• Erythema infectiousum (Fifth Disease)
• Roseola infantum(Sixth Disease)

2
Rashes caused by childhood infections.

• Macular/papular /maculopapular
• Macules-red/pink discrete flat areas,blanch on
  pressure ex rubella,measles..ect
• Papules solid raised hemispherical
  lesions,usually tiny ,also blanch on perssure.ex
  scarlet fever,kawasaki disease.
• Purpuric/petechial
• Non-blanching red/purple spots.ex meningococcal.

3

• Vesicular
• Raised hemispherical lesions,lt0.5 cm
  diameter,contain clear fluid.ex chicken pox
• Pustular/bullous
• Raised hemispherical lesions,gt0.5cm
  diameter,contain clear or purulent fluid.
• ex Imptigo
• Desquamation
• Dry and flaky loss of surface epidermis, often
  peripheries. ex Kawasaki disease.

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Measles

• RNA Virus
• Incubation Period 6 12 days
• Clinical Features.fever,rash,coryza
• Complications
• Respiratory pneumonia,om
• Neurologicalfebrile conv.encephalitis,SSPE
• Othersdiarrhoea,hepatitis
• Treatmentsymptomatic
• Isolation Infectivity 2 days before till 6
  days after rash

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CLINICAL MANIFESTATIONS

• 1.Incubation period is approximately
  618days,10days is the most common.
• (3-4weeks)
• 2 .predromal phase 34 days.
• 1. Fever.
• 2. Catarrhal inflammation of URT.
• 3. Kopliks spots white spots in the
  inner cheeks that appears after 24-48 hours of
  the infection. Its the first to appear.
• 4. Transient prodromal rashes ( rash does
  not appear from the 1st day )

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• 3. Eruption stage
• 1. Time the 35 days after fever but the
  4th day is most common
• 2 . Shape maculopapular
• 3. Sequence behind the ear?along the
  hairline?face?neck?chest?back?abdomen?limbs?hand
  and feet(palm , sole)
• ( rash starts in the face then the trunk then on
  the periphery )
• 4 . The temperature rise continuously and
  accompanied with the toxic symptoms .
• 4 . Convalescent stage
• brown staining.
• fine desquamation.
• course10-14 days

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COMPLICATIONS the disease itself is not severe
but its complications are serious.

• 1 .Bronchopneumonia.
• 2 .Myocarditis.
• 3 .Laryngitis.
• 4 .Neurologic complications
• Encephalitis and SSPE .
• subacute sclerosing panencephalitis
• Persistent infection of the brain.
• Rare,psychologic.neuro deterioration.
• Personality changes,seziure,coma. It happens
  7-10 years after the infection.

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Measles vs. Scarlet fever
Both measles and scarlet fever cause
maculopapular rash but in scralet fever the rash
appears from the 1st day and has a sand like
appearance and occurs all over the body but not
in the palms and soles. Scarlet comes with a
strawberry tongue white cirumoral lesions and is
caused by strep infection.
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DIAGNOSIS.

• 1 .Epidemiologic data.
• 2 .Clinical manifestations.
• 3. Laboratory findings
• 1 .Multinucleated giant cells are detected
  in nasopharyax mucosa secretions.
• 2 .Measles virus can be isolated in tissues
  culture.
• 3 . Antibody titer. specific antibody IgM.
• 4 . Other Ag and multinucleated giant cells

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EPIDEMIOLOGY

• 1.Source of infection
• The patients are the only source of
  infection.
• 2 .Routes of transmission
• air-borne ( highly infectious ) by
  sneezing and cough.
• 3. Susceptibility of population
• 1 . All age person is susceptible 90 of
  contact people acquire the disease.
• 2 .The permanent immunity acquire after
  disease.
• 4.Epidemic features
• seasonwinter and spring
• age6 months to 5 years old ( seen in young
  age group )

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DIFFERENTIAL DIAGNOSIS

• 1 .Rubella (German measles)
• 2. scarlet fever.
• 3 .Roseola infantum (infant subitum,exanthem
  subitum)
• 4. Drug rashes. In drug rash there will be no
  fever, conjuctivitis, congestion or cough.

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Mumps

• RNA Virus
• Incubation Period 14 21 days
• Clinical Features fever, swelling
• Complications
• Glandular
• Non glandular
• Isolation Infectivity 9 days after onset of
  parotid swelling

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Clinical manifestation of mumps are

• Parotid inflammation (or parotitis) in 6070 of
  infections and 95 of patients with symptoms
  Parotitis causes swelling and local pain,
  particularly when chewing. It can occur on one
  side (unilateral) but is more common on both
  sides (bilateral) in about 90 of cases.
• Fever
• Headache
• Pancreatitis inflammation of the affected
  pancreas.
• Orchitis painful inflammation of the testicles
  might affect the future fertility (most important
  complication).

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Diagnosis

• Person infected with mumps is contagious from
  approximately 6 days before the onset of symptoms
  until about 9 days after symptoms start.
• Usually the disease is diagnosed on clinical
  grounds and no confirmatory laboratory testing is
  needed, you might ask for amylase.

15
Rubella

• RNA Virus
• Incubation Period 14 21 days
• Clinical Features fever ,rash.
• Complications
• Acquired arthritis,encephalitis,
• Congenitalfetal damage.
• Isolation Infectivity 7 days from onset of
  rash
• Congenital Rubella until 1 year of age

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Rubella

• Symptoms include low grade fever, swollen
  glands (sub occipital posterior cervical
  lymphadenopathy), joint pains, headache and
  conjunctivitis.
• The swollen glands or lymph nodes can persist
  for up to a week and the fever rarely rises above
  38 C (100.4 F) therefore no toxic appearance
  unlike measles.
• The rash (blueberry muffin rash) of German
  measles is typically pink or light red. The rash
  causes itching and often lasts for about three
  days. It starts severe and starts improving on
  the 3rd day on the face (unlike measles), but is
  still present on extremities. Its seen in the
  face and trunk but more prominent in the
  peripheries.
• 1st patient to get infected has the best
  presentation, whereas the last has the worst
  presentation.

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Congenital rubella syndrome

• Rubella can cause CRS in the newly born, whch is
  the most serious. The syndrome (CRS) follows
  intrauterine infection by the Rubella virus and
  comprises cardiac (PDA), cerebral (microcephaly),
  ophthalmic (cataract) and auditory defects.
• It may also cause prematurity, low birth weight,
  and neonatal thrombocytopenia, anaemia and
  hepatitis.
• The risk of major defects or organogenesis is
  highest for infection in the first trimester.

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Chicken Pox (Varicella)

• DNA Virus(VZV).
• Incubation Period 10 21 days very contagious
  especially in the first 48 hours from the rash.
  Almost 99.
• Clinical Features Generalized macules, Papules-
  vesicles- pusules-crust and then it scales. The
  rash has no specific sequence all present at the
  same time and do not differ from day to day as in
  rubella. The zoster rash has a dermatomal
  distribution.
• Complications
• 2nd bacterial infection staph.strep causing
  cellulitis
• Neurological cerebellitis, encephalitis (a week
  after the infection)
• Reye syndrome
• Disseminated immunocompromised
• Treatment (Acyclovir- to decrease symptoms in
  measles and rubella there is no need for
  treatment).
• ZIG (zoster immunoglobulin) given for 2 day to
  immuno-compromised patients who are exposed.
• Isolation Infectivity 2 days before rash till
  all skin lesions have crusted (6th day of rash)

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Rubella, Smallpox, Chickenpox
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Poliovirus

• Incubation Period 7 21 days
• Clinical Features lt1 classical paralytic polio
• Complications aseptic meningitis.
• Treatment
• Isolation Infectivity several weeks

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What is Poliomyelitis?

• polio gray matter
• Myelitis inflammation of the spinal cord
• This disease result in the destruction of motor
  neurons caused by the poliovirus.
• Polio is causes by a virus that attacks the nerve
  cells of the brain spinal cord although not all
  infections result in severe injuries and
  paralysis.

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How is polio transmitted?

• Poliovirus is transmitted through both oral and
  fecal routes with implantation and replication
  occurring in either the oropharyngeal and/or in
  the intestine of mucosa ( highly contagious )
• Polio cases are most infective for 7-10 days
  before and after clinical symptoms begin.

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What are the symptoms?

• Many include fever, pharyngitis, headache,
  anorexia, nausea, and vomiting. Illness may
  progress to aseptic meningitis and
  menigoencephalitis in 1 to 4 of patients. These
  patients develop a higher fever, myalgia and
  severe headache with stiffness of the neck and
  back.

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Can it cause paralytic disease?

• Paralytic disease occurs 0.1 to 1 of those who
  become infected with the polio virus.
• Paralysis of the respiratory muscles or from
  cardiac arrest if the neurons in the medulla
  oblongata are destroyed.
• Patients have some or full recovery from
  paralysis usually apparent with proximally 6
  months
• Physical therapy is recommended for full recovery.

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Vaccine

• Polio vaccine first appeared to be licensed in
  the United States in 1955.
• Advantages
• Ease to administration
• Good local mucosal immunity
• Disadvantage
• Strict cold shipping (it gets destroyed by heat)
  storage requirements
• Multiple doses required to achieve high humeral
  conservation rates against all virus types

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Vaccine (continuation)

• Babies are given 4 doses throughout their
  infancy.
• Adolescents and adults should get vaccinated as
  well. Adolescents younger than 18 should receive
  the routine four doses.
• You should get it if you travel outside places
  where polio is still an epidemic.

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Treatment

• Supportive treatment bed rest with close
  monitoring of respiratory and cardiovascular
  functioning is essential during the acute stage
  of poliomyelitis along with fever control and
  pain relievers for muscle spasms.
• No antiviral medications.
• If respiratory failure must be hospitalized for
  mechanical ventilation, respiratory therapy may
  be needed depending of the severity of patients.

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Croup

• Parainfluenza any strain
• Incubation Period 2 6 days
• Clinical Features
• Complications
• Treatment
• Isolation Infectivity contact precaution in
  hospital, infective up to 3 weeks

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Croup (or laryngotracheobronchitis)

• Is a respiratory condition that is usually
  triggered by an acute viral infection of the
  upper airway.
• The infection leads to swelling inside the
  throat, which interferes with normal breathing
  and produces the classical symptoms of a
  "barking" cough, stridor, and hoarseness

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croup

• Croup is characterized by a "barking" cough,
  stridor, hoarseness, and difficult breathing
  which usually worsens at night.
• The "barking" cough is often described as
  resembling the call of a seal or sea lion.
• The stridor is worsened by agitation or crying,
  and if it can be heard at rest, it may indicate
  critical narrowing of the airways. As croup
  worsens, stridor may decrease considerably

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Diagnosis

• The first step is to exclude other obstructive
  conditions of the upper airway, especially
  epiglottitis (its a more serious infection than
  croup, once suspected you cant examine the
  patient, you do x-ray (thumb sign) and intubate),
  an airway foreign body, subglottic stenosis,
  angioedema, retropharyngeal abscess, and
  bacterial tracheitis.

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Diagnosis

• A frontal X-ray of the neck is not routinely
  performed, but if it is done, it may show a
  characteristic narrowing of the trachea, called
  the steeple sign, because of the subglottic
  stenosis, which is similar to a steeple in shape

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Croup treatment

• Corticosteroids (inhaled or nebulized), such as
  dexamethasone and budesonide, have been shown to
  improve outcomes in children with all severities
  of croup, single dose is usually all that is
  required.
• Moderate to severe croup may be improved
  temporarily with nebulized epinephrine

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Bronchiolitis

• Respiratory Syncytial Virus
• Incubation Period 2 8 days
• Clinical Features
• Complications
• Treatment
• Isolation Infectivity 3 8 days (up to 4
  weeks in infants)

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Bronchiolitis

• most often affects infants and young children
  because their small airways can become blocked
  more easily than those of older kids or adults (
  in older group children and adults it causes
  URTI)
• typically occurs during the first 2 years of
  life, with peak occurrence at about 3 to 6 months
  of age
• is more common in males, children who have not
  been breastfed, and those who live in crowded
  conditions.
• Its more common in premature babies.

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Signs Symptoms

• Sudden breathing difficulty, usually preceded by
  fever and a mild common cold and cough, and
  characterized by the following
• Wheezing.
• Rapid, shallow breathing (60 to 80 times a
  minute).
• Retractions (seesaw movements) of the chest and
  abdomen, and nasal flaring.
• Fever (occasionally).
• Blue discoloration of skin or nails (severe
  cases).

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Treatment General Measures

• Keep the humidity in the child's room as high as
  possible, preferably with an ultrasonic cool-mist
  humidifier. Clean humidifier daily. If you don't
  have a humidifier, run cold or hot water in the
  shower with windows and doors closed to produce a
  high-humidity room. Hold the child in this room
  for 20 minutes several times a day, especially at
  bedtime. If the child awakens at night with
  wheezing or shortness of breath, repeat the
  process.
• Sometimes they give ventolin but its not very
  effective.

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Erythema Infectiosum(Fifth Disease) might come
as a picture in the exam

• Parvovirus B19 (imp MCQ)
• Incubation Period 4 21 days
• Clinical Features fever, slapped cheek rash.
  Theyre not that sick.
• Complications aplastic crises especially in SCA
  and other hemoglobinopathies by shutting down the
  BM.
• No Treatment
• Isolation Infectivity droplet precautions for
  7 days

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Fifth disease symptoms

• Bright red cheeks are a defining symptom of the
  infection in children (hence the name "slapped
  cheek disease"). Occasionally the rash will
  extend over the bridge of the nose or around the
  mouth.
• In addition to red cheeks, children often develop
  a red, lacy rash on the rest of the body, with
  the upper arms and legs being the most common
  locations.

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Roseola (Sixth Disease)

• HHV-6
• Incubation Period 9 10 days
• Clinical Features fever followed by macular
  rash as fever wanes.
• Complications associate e febrile convulsion
• Treatment

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Roseola

• Typically the disease affects a child between six
  months and two years of age, and begins with a
  sudden high fever (3940 C 102.2-104 F) that
  persists up to 5 days.
• This can cause, in rare cases, febrile
  convulsions (also known as febrile seizures or
  "fever fits") due to the sudden rise in body
  temperature, but in many cases the child appears
  normal. To prevent this, we need to give regular
  antipyretics.
• After a few days, the fever subsides, and just as
  the child appears to be recovering, a red rash
  appears. This usually begins on the trunk,
  spreading to the legs and neck. The rash is not
  itchy and may last 1 to 2 days

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Infectious Mononucleosis

• Epstein-Barr Virus
• Incubation Period 30 50 days
• Clinical Features fever ,tonsillopharngitis.
  exudative membrane, cervical lymphadenopathy,
  generalized maculopapular rash.
• Complications
• Hepatitis
• Hemolytic Anemia
• GBS
• Splenic rapture
• Myocarditis
• Malignacy
• Treatment no treatment might get complicated with
  a secondary strept infection

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COMMON BACTERIAL INFECTIONS

• Staphylococcal and Group A streptoccocal
  infections.
• By direct effect abscess, celluitis, imptigo,
  orbital celluitis.
• Toxin mediated toxic shock syndrome
• Toxic epidermial necrolysis.

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Continue.

• Group A streptococcus
• Direct effect tonsillitis, osteomyelitis, otitis
  media, cellulitis
• Toxin mediated toxic shock like syndrome,
  scarlet fever
• Post infectious rheumatic fever,
  glomerulonephritis.

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Haemophilus influenzae type b (Hib)

• Clinical Features
• Complications
• Treatment
• Isolation Infectivity droplet precautions for
  24 hours after starting antimicrobial therapy
• Vaccine

Cerebrospinal fluid culture positive for Hib
(Gram stain)
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Pertusis (Whooping Cough)

• Bordetella Pertusis
• Incubation Period 7 14 days (IP is reduced by
  treatment)
• Clinical Features
• Complications
• Pneumonia Bronchiectasis
• Haemorrhage
• Hernia
• Hypoxia
• Treatment
• Isolation Infectivity up to 6 weeks, but with
  treatment gt 5 days after starting therapy
• Vaccine

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Diagnosis

• Isolation by culture
• Media Regan-Lowe, Bordet-Gengou, or charcoal
  agar
• Polymerase Chain Reaction PCR
• Kids Children
• Direct fluorescent antibody (DFA)
• NO Freezer or Refrigeration of samples

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Route of Transmission

• Spread through direct contact of respiratory
  secretions.
• Most contagious during first few stages of
  infection
• Resides in upper airway pathways, mostly the
  trachea and bronchi.
• Very contagious

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Progression of Whooping Cough

• Incubation period 4-21 days
• 3 Stages
• 1st Stage- Catarrhal Stage 1-2 weeks
• runny nose, sneezing, low fever, and a mild cough
  (common mistaken for cold)
• 2nd Stage- Paroxysmal Stage 1-6 weeks
• whooping cough, which consists of bursts or
  paroxysms of numerous, rapid coughs, severity of
  the infection is at its greatest. The is a
  contagious phase.
• 3rd Stage- Covalescent Stage weeks-months
• gradual recovery starts

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Complications
Adults Pneumonia Rib Fracture Weight
Loss Hernias Urinary Incontinence
Children Hypoxia Apnea Pneumonia Seizures
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Treatment

• Antibiotic Therapy- Macrolides
• Erythromycin
• Azithromycin
• Clarithromycin

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Prevention
Good hygiene

• CDC recoomends children be given the
  Diphtheria, Tetanus, and Pertussis (DTaP) vaccine
  as early as 6 weeks but no later than 6 y/o.

Cover mouth/nose when coughing and sneezing.
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Diphtheria

• Corynebacterium diphtheriae
• Incubation Period 2 7 days
• Clinical Features
• Complications
• Thrombocytopenia
• Myocarditis
• Vocal cord paralyses
• Treatment
• Isolation Infectivity up to 6 weeks, but with
  treatment communicable for fewer than 4 days
• Vaccine

54
Diphtheria

• Is an upper respiratory tract illness caused by
  Corynebacterium diphtheriae, a facultative
  anaerobic, Gram-positive bacterium.
• It is characterized by sore throat, low fever,
  and an adherent membrane (a pseudomembrane) on
  the tonsils, pharynx, and/or nasal cavity.

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Case classification

• Probable a clinically compatible case that is
  not laboratory-confirmed and is not
  epidemiologically linked to a laboratory-confirmed
  case
• Confirmed a clinically compatible case that is
  either laboratory-confirmed or epidemiologically
  linked to a laboratory-confirmed case
• Empirical treatment should generally be started
  in a patient in whom suspicion of diphtheria is
  high.

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Treatment

• Antibiotics are used in patients or carriers to
  eradicate C. diphtheriae and prevent its
  transmission to others. The CDC recommends
  either
• Metronidazole
• Erythromycin (orally or by injection) for 14 days
  (40 mg/kg/day with a maximum of 2 g/d), or
• Procaine penicillin G given intramuscularly for
  14 days (300,000 U/d for patients weighing lt10 kg
  and 600,000 U/d for those weighing gt10 kg).
• Patients with allergies to penicillin G or
  erythromycin can use rifampin or clindamycin.

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Tetanus

• Clostridium tetani
• Incubation Period 2 days to months, most within
  14 days
• Clinical Features very sick, they come with
  arched back due to spasm
• Complications
• Lock jaw
• Neonatal mortality
• Generalized muscle spasm
• Treatment
• Isolation no person to person transmission
• Vaccines

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Tetanus

• Medical condition characterized by a prolonged
  contraction of skeletal muscle fibers.
• The primary symptoms are caused by tetanospasmin,
  a neurotoxin produced by the Gram-positive,
  rod-shaped, obligate anaerobic bacterium
  Clostridium tetani.
• Infection generally occurs through wound
  contamination and often involves a cut or deep
  puncture wound. As the infection progresses,
  muscle spasms develop in the jaw (thus the name
  "lockjaw") and elsewhere in the body.
• Neonates may develop it by using infected
  instruments to cut the umbilical cord after
  delivery.

59

• The wound must be cleaned. Dead and infected
  tissue should be removed by surgical debridement.
  Administration of the antibiotic metronidazole
  decreases the number of bacteria but has no
  effect on the bacterial toxin.
• Penicillin was once used to treat tetanus, but is
  no longer the treatment of choice, owing to a
  theoretical risk of increased spasms.

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Guide to Tetanus Prophylaxis in Routine Wound
Management
History of Adsorbed Tetanus Toxoid (Doses) Clean, Minor Wound Clean, Minor Wound All Other Wounds All Other Wounds
History of Adsorbed Tetanus Toxoid (Doses) Td TIG Td TIG
Unknown or lt3 Yes No Yes yes
3 No" No No No
" yes if more than 10 years since last dose yes
if more than 5 years since last dose
61

• Tetanus can be prevented by vaccination with
  tetanus toxoid.
• The CDC recommends that adults receive a booster
  vaccine every ten years, and standard care
  practice in many places is to give the booster to
  any patient with a puncture wound who is
  uncertain of when he or she was last vaccinated,
  or if he or she has had fewer than three lifetime
  doses of the vaccine

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Thrush

• Candida Albicans
• Clinical Features cheesy like material. Dont
  stop feeding the child.
• Complications if the baby is healthy its not
  complicated, if the baby is immunocompromised it
  might cause throat infection.
• Treatment nystatin

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Kawasaki disease

• Affect infant and young children
• Clinical criteria
• Fever gt5days and 4 of the following
• Conjunctival injection
• Red mucous membrane
• Cervical lymphadenopathy
• Rash
• Oedema of palms soles with peeling

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Feature Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E
Virus HAV HBV HCV HDV HEV
Genome RNA DNA RNA RNA RNA
Incubation 15-50 days 45-160 days 7-9 weeks 2-8 weeks 15-60 days
Onset Acute Insidious Insidious Acute Acute
Transmission Oral Parenteral Perinatal Parenteral Parenteral Oral
Sequelae Fulminant liver failure Carrier Chronic hepatitis Rare No No Uncommon Yes Yes Uncommon Yes Yes Yes Yes Yes Yes No No
Mortality 0.1-0.2 0.5-2 1-2 2-20 1-2
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Further Reading

• READ BOOK by Report of the committee on
  Infectious Diseases.