Transcript Case 6:”Kutis Porcelana”

Case 6:
”Kutis Porcelana”
“Kutis Porcelana”
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Strawberry is an 8-year old very fair-complexioned girl
planned by her beauty-contest conscious mother to
become a future Mutya ng Pilipinas, brought to the
hospital because of pruritic red spots on her chest,
back and arms. Three days earlier, she complained of
low-grade fever (37.80C), headache, anorexia and
generalized body malaise. On PE, she had numerous
vesicular lesions on an erythematous base scattered
on the back, chest and arms. The rest of the physical
findings were essentially normal.
Guide Questions
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6.
What conditions present with vesiculopustular
eruptions?
How is the diagnosis of Varicella achieved?
What is the treatment for Varicella?
What are the complications of Varicella?
Which high risk patients should receive VZIG to
prevent Varicella?
What is responsible for prevention and control of
Varicella?
Q1:
What conditions
present with
vesiculopustular
eruptions?
Conditions that present with
Vesiculopapular/pustular eruptions
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Varicella
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Herpes zoster
Herpes simplex infections
Hand, foot and mouth Syndrome (Coxsackie A16)
Impetigo
Insect bites
Molloscum contagiosum
Scabies
1. Varicella
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A benign but highly contagious infection in
immunocompetent individuals
Contagious from a few days before the skin
lesions appear to 5-7 days after the
appearance of the lesions
Varicella-zoster infection
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A prodromal period is usually
absent.The rash & constitutional
symptoms occur simultaneously
The rash is characterized by:
Rapid evolution of macules to
papules to vesicles to crusts
Central distribution of lesions
which occur in crops
Presence of the lesions in all
stages in any one anatomic area
Involvement of the scalp and
mucous membranes
Eventual crusting of nearly all of
the lesions
Krugman’s Infectious Disease of Children
Varicella-zoster infection
• The pleomorphic rash of
varicella evolves very
rapidly through stages of
macule, papule, vesicle,
pustule and crust.
• Skin lesions are first
seen on the body and
inner aspects of the
thighs but spread quickly
to the face, scalp and
proximal parts of the
limbs
Varicella rashes
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Lesions emerge in crops at
irregular intervals up to a week
The rash is heaviest on the trunk
and diminishes in intensity
towards the periphery
Pruritus may be troublesome
during the first few days
Varicella
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Crusting to scarring
2. Herpes Zoster (Shingles)
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Due to reactivation of latent VZV
Herpes Zoster, Herpes Simplex
and Vaccinia occur without any
prodromal period
The lesions of herpes zoster are
unilateral and distributed along
the line of affected nerves.The
vesicles are grouped together
and tend to become confluent
Herpes Zoster
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Predominantly a disease of the
middle-aged & elderly. Less than
5% of attacks occur in children
below 10 yrs.
When zoster develops in very
young children, there is
frequently a history of an attack
in the mother during pregnancy.
Post-herpetic neuralgia is
seldom a problem in children
3. Herpes simplex Infection
Congenital herpes simplex group
of vesicles on arms and back
Eczema herpeticum
Herpes simplex labialis
4. Hand, Foot and Mouth Disease
5. Impetigo contagiosa & Impetigo
bullosa
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Impetigo contagiosa:
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The classic lesion begin as
erythematous papules in traumatized
areas. They quickly evolve into honeycolored crusted plaques with
surrounding erythema
GAS and S. aureus are the chief
causative agent
Impetigo contagiosa
Impetigo bullosa :
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Exclusively staphylococcal in origin
The characteristic lesion are caused by
epidermolytic toxin
Impetigo bullosa
Impetigo contagiosa & Impetigo
bullosa
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They differ from chickenpox in appearance and
distribution
They do not appear in crops, do not involve the
mucous membranes of the mouth and are not
accompanied by constitutional symptoms
The lesions of impetigo commonly involve the
nasolabial area because of the tendency for a
child to scratch with contaminated fingers
6. Molluscum Contagiosum
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A viral skin infection caused by a
large DNA virus (poxvirus).
The lesions are grouped pinpoint
papules that increase in size.
They are off white or pinkish-tan
and rounded and may have a
central umbilication
Most frequently occurs in children
There are no associated systemic
symptoms
No specific therapy is required
7. Insect bites, Papular urticaria
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Local reactions may resemble infectious
exanthems or may be secondarily infected.
The lesions do not have a typical vesicular
appearance and do not involve the scalp or
mucus membranes
8. Scabies
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Typical lesions are papules,
vesicles, and burrows that tend to
occur in some areas of predilection
e.g. interdigital folds
Because of itching and scratching,
the rash becomes excoriated,
crusted, eczematized and
secondarily infected
The differential points of scabies are
the same as those of insect bites.
The burrows between the fingers
and toes and the microscopic
identification of Sarcoptes scabiei
help confirm the diagnosis
Q2:
How is the diagnosis
of
Varicella achieved?
VZV Diagnosis
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Diagnosis is usually made clinically
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The presence of a herpesvirus can be demonstrated
by a Tzanck smear that demonstrates inclusions
Infection can be confirmed by acute and
convalescent titers of VZV antibody
Q3:
What are the
complications
of Varicella?
Complications
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Secondary bacterial superinfection particularly with
Group A streptococcus, the most frequent
Encephalitis
Viral or bacterial Pneumonia
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Recognized chiefly in otherwise healthy adults and
immunocompromised children
Hepatitis
 DIC (rare) with purpura fulminans
**Complications occur more frequently in
immunocompromised patients and adults
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Neonatal Chickenpox
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Severe disseminated
and fatal varicella in 5-10
day old infants
resembling that in
leukemic children may
occur in offspring whose
mothers have varicella 5
days before delivery to 2
days after delivery.
Maternal varicella near term: effect
on the newborn infant (50 cases)
Onset
Maternal varicella, 5 or
more days before delivery;
baby’s varicella age 0-4
days
Maternal varicella. 4 days or
less before delivery;
Baby’s varicella, age 5-10
days
Effect
27 of 27 survived
16 of 23 survived (7 died of
diseminated varicella. 2 had
severe disease with survival
Gershon AA.,”Infections of the fetus and newborn infant”,1975
Varicella in the
immunocompromised
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Neonates whose mothers are not
immune and patients with
leukemia may suffer severe,
prolonged or fatal chickenpox
(Disseminated or Progressive
Varicella)
The mortality rate of untreated
primary infection in
immunocompromised children is
7-14% and may approach 50%
in adults
Q4:
What is the treatment
for Varicella?
Treatment
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IV Acyclovir should be given to immunocompromised
patients with Varicella or Herpes zoster
Oral acyclovir given to healthy children with varicella
within 24 hrs of the rash results in diminution and
duration of skin lesions. Should be considered in
adolescents and adults with varicella
VZIG should be given with 96 hrs of exposure to
susceptible high risk patients for severe or complicated
Varicella
Q5:
Which High Risk
Patients should
receive VZIG to
prevent Varicella?
High Risk Patients who should
receive VZIG
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Immunocompromised, susceptible children without history of
varicella or varicella immunizations (who have had household
exposure, shared a hospital room or played indoors for at least 1
hour with children with contagious VZV)
Normal susceptible adults, especially pregnant women
Newborn infant of a mother who had onset of Chickenpox within 5
days before or48 hours after delivery
Hospitalized premature infant (>28 wks gestation) whose mother
has not had chickenpox
All hospitalized premature infants <28 wks gestation or weighing
<1,000 gms.regardless of maternal hx of varicella
Q6:
What is responsible
for prevention and
control of Varicella?
Prevention and control of Varicella
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Varicella vaccine for susceptible children aged 12
months to 12 years
Live-attenuated preparation of serially propagated and
attenuated wild Oka strain
Dose: 0.5 ml subcutaneously(recommended) or IM,
one dose for children <12 yrs or younger and 2 doses
4-8 weeks apart for individuals older than 12 yrs of age
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95% immunogenic for immunized healthy children between 12
mos and 12 yrs of age with humoral and CMI response
78-82% after 1 dose and 99% after 2 doses for people 13 yrs
or older
Duration of immunity: at least 11 yrs (USA); 20 yrs (Japan
studies)
Key Learning Points
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Although a benign disease, Varicella can have disastrous
effects on the immunocompromised
The herpesviridae family e.g. Herpes zoster manifest a
propensity for latency or inactivity but may be reactivated
following immunosuppression or other stress factors
Maternal varicella can result in a congenital varicella
syndrome, Herpes zoster or neonatal varicella which can
have disastrous or fatal effects on the fetus
The most effective prevention against Varicella is thru
immunization with a live attenuated vaccine
VZIG is an effective tool to prevent dire consequences to the
unprotected host
Case 6:
”Kutis Porcelana”