Transcript Lymphadenopathy in Children

Common Viral Infecions
Measles
Mumps
Rubella
Chicken pox
Erythema infectiousum (Fifth Disease)
Roseola infantum(Sixth Disease)
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.
Vesicular:
Raised hemispherical lesions,<0.5 cm diameter,contain
clear fluid.ex chicken pox
Pustular/bullous:
Raised hemispherical lesions,>0.5cm diameter,contain
clear or purulent fluid.
ex Imptigo
Desquamation:
Dry and flaky loss of surface epidermis, often
peripheries. ex Kawasaki disease.
Measles
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RNA Virus
Incubation Period: 6 – 12 days
Clinical Features.fever,rash,coryza
Complications:
• Respiratory: pneumonia,om
• Neurological:febrile
conv.encephalitis,SSPE
• Others:diarrhoea,hepatitis
• Treatment;symptomatic
• Isolation & Infectivity: 2 days
before till 6 days after rash
CLINICAL MANIFESTATIONS
• 1.Incubation period is approximately 6~18days,10days is
the most common.
(3-4weeks)
• 2 .predromal phase 3~4 days.
1. Fever.
2. Catarrhal inflammation of URT.
3. Koplik’s spots: white spots in the inner cheeks that
appears after 24-48 hours of the infection. It’s the first to
appear.
4. Transient prodromal rashes ( rash does not appear
from the 1st day )
• 3. Eruption stage
1. Time: the 3~5 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.
course:10-14 days
COMPLICATIONS : the disease itself is not severe but
its complications are serious.
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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.
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.
DIAGNOSIS.
• 1 .Epidemiologic data.
• 2 .Clinical manifestations.
• 3. Laboratory findings:
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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
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
season:winter and spring
age:6 months to 5 years old ( seen in young age group )
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.
Mumps
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RNA Virus
Incubation Period: 14 – 21 days
Clinical Features: fever, swelling
Complications:
• Glandular
• Non glandular
• Isolation & Infectivity: 9 days after
onset of parotid swelling
Clinical manifestation of mumps are:
• Parotid inflammation (or parotitis) in 60–70% 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).
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.
Rubella
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RNA Virus
Incubation Period: 14 – 21 days
Clinical Features: fever ,rash.
Complications:
• Acquired ;arthritis,encephalitis,
• Congenital:fetal damage.
• Isolation & Infectivity: 7 days from
onset of rash
– Congenital Rubella: until 1 year of age
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. It’s 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.
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.
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)
Rubella, Smallpox, Chickenpox
Poliovirus
• Incubation Period: 7 – 21 days
• Clinical Features: <1% classical
paralytic polio
• Complications: aseptic
meningitis.
• Treatment
• Isolation & Infectivity: several
weeks
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.
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.
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.
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.
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
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.
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.
Croup
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Parainfluenza any strain
Incubation Period: 2 – 6 days
Clinical Features
Complications
Treatment
Isolation & Infectivity: contact
precaution in hospital, infective
up to 3 weeks
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
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
Diagnosis
• The first step is to exclude other obstructive
conditions of the upper airway, especially
epiglottitis (it’s a more serious infection than
croup, once suspected you can’t examine the
patient, you do x-ray (thumb sign) and intubate),
an airway foreign body, subglottic stenosis,
angioedema, retropharyngeal abscess, and
bacterial tracheitis.
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
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
Bronchiolitis
• Respiratory Syncytial Virus
• Incubation Period: 2 – 8
days
• Clinical Features
• Complications
• Treatment
• Isolation & Infectivity: 3 – 8
days (up to 4 weeks in
infants)
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.
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).
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.
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. They’re 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
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.
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
Roseola
• Typically the disease affects a child between six months
and two years of age, and begins with a sudden high fever
(39–40 °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
Infectious Mononucleosis
• Epstein-Barr Virus
• Incubation Period: 30 – 50 days
• Clinical Features : fever
,tonsillopharngitis. exudative membrane,
cervical lymphadenopathy, generalized
maculopapular rash.
• Complications:
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Hepatitis
Hemolytic Anemia
GBS
Splenic rapture
Myocarditis
Malignacy
• Treatment no treatment might get
complicated with a secondary strept
infection
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.
Continue….
• Group A streptococcus:
• Direct effect: tonsillitis, osteomyelitis, otitis media,
cellulitis
• Toxin mediated: toxic shock like syndrome, scarlet
fever
• Post infectious: rheumatic fever,
glomerulonephritis.
Haemophilus influenzae type b (Hib)
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Clinical Features
Complications
Treatment
Isolation & Infectivity:
droplet precautions for 24
hours after starting
antimicrobial therapy
• Vaccine
Cerebrospinal fluid culture positive
for Hib (Gram stain)
Pertusis
(Whooping
Cough)
Bordetella Pertusis
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• Incubation Period: 7 – 14 days (IP is
reduced by treatment)
• Clinical Features
• Complications:
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Pneumonia & Bronchiectasis
Haemorrhage
Hernia
Hypoxia
• Treatment
• Isolation & Infectivity: up to 6 weeks,
but with treatment => 5 days after
starting therapy
• Vaccine
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
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
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
Complications
Children
Adults
Hypoxia
Pneumonia
Apnea
Rib Fracture
Pneumonia
Weight Loss
Seizures
Hernias
Urinary Incontinence
Treatment
• Antibiotic Therapy- Macrolides
– Erythromycin
– Azithromycin
– Clarithromycin
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.
Diphtheria
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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
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.
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.
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 <10 kg and 600,000 U/d for those
weighing >10 kg).
– Patients with allergies to penicillin G or erythromycin can use
rifampin or clindamycin.
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
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.
• 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.
Guide to Tetanus Prophylaxis in Routine Wound
Management
History of Adsorbed
Tetanus Toxoid (Doses)
Clean, Minor Wound
All Other Wounds*
Td
TIG
Td
TIG
Unknown or <3
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
• 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
Thrush
• Candida Albicans
• Clinical Features: cheesy like
material. Don’t 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
Kawasaki disease
• Affect infant and young children
• Clinical criteria
– Fever >5days and 4 of the following
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Conjunctival injection
Red mucous membrane
Cervical lymphadenopathy
Rash
Oedema of palms & soles with peeling
Feature
Hepatitis A
Hepatitis B
Hepatitis C
Hepatitis D
Hepatitis E
Virus
HAV
HBV
HCV
HDV
HEV
Genome
RNA
DNA
RNA
RNA
RNA
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
Rare
Uncommon
Uncommon
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
0.1-0.2 %
0.5-2 %
1-2 %
2-20 %
1-2 %
Incubation
Sequelae:
Fulminant
liver failure
Carrier
Chronic
hepatitis
Mortality
Further Reading
• READ BOOK by Report of the committee on
Infectious Diseases.