Transcript It`s Thursday…get excited!!

It’s Thursday…get excited!!
AM Report- Thursday, July 28th 2011
Our Patient…
Exanthem #1
Exanthem #2
Exanthem #3
Exanthem #4
Exanthem #5
Exanthem #6
Clue: This patient was recently treated with Ampicillin
Exanthem #7
Clue: This patient had a h/o 3 days of fever (that has since defervesced)
before the appearance of the rash
Exanthem #8
Exanthem #9
Clue: You might be more suspicious of this illness if this picture was a
hypotensive woman
Exanthem #10
Exanthem #11
Exanthem #12
Exanthem #13
Exanthem #14
Measles
Koplik Spots
Measles (Rubeola)
8-12d

24h
Exposure Fever, malaise Coryza, cough,
48h
2-3d
conjunctivits Koplik spots Exanthum
 Exanthem: red/ purple papules appear at
hairline, then spread downward (@ toes by
day 3)


Coalescence common on face and upper body
Fades in same fashion (headtoe)
Measles (Rubeola)

Control Measures
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
Isolation (airborne precautions)
Immunization/ Immune globulin

First determine who is susceptible
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<2 doses of MMR vaccine after the first birthday
Low titers in response to vaccine administration
No documentation of measles by a physician
If susceptible:


MMR vaccine within 72hours of exposure
Immune globulin to household contacts or
immunocompromised patients within 6 days of exposure if
vaccine not given within 72h
Coxsackie A
Hand, Foot, Mouth Disease
Enteroviruses

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Echoviruses, Coxsackie A&B, Polio
Primarily affect young children in the
summer
Accompanied by non-specific constitutional
symptoms
Exanthem displays impressive variability


Urticarial, petechial, purpuric, vesicular,
rubelliform, morbilliform, scarlatiniform
Dx: Culture, nucleic acid amplification
Rubella
Forchheimer Spots
Rubella (German Measles)

In 2005, the CDC announced that rubella had
been eliminated from the US
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But, it’s still on the Boards!!
Epidemiology
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Spread by person-to-person transmission of
infected droplets
Patients are infectious a few days before the rash
appears continuing through the first several days of
the rash
Peaks in late winter/ early spring
Rubella (German Measles)
14-21 d


Exposure Tender adenopathy (post-auricular,
posterior cervical, and occipital)
 Malaise, HA, low-grade fever, sore throat
1-5 d
 Exanthem (+/- Forchheimer spots)
Exanthem: rose-pink maculopapules on face that
spread quickly to involve trunk and then extremities


Day 2: rash on face disappears, truncal rash coalesces
Day 3: rash disappears
Congential
Rubella
Highest rate of infection
1st and 3rd trimesters,
morbidity associated with
1st trimester infection
Presentation:

TTP Blueberry
muffin lesions
Radiolucencies in
metaphyseal long bones
PDA (or ASD/VSD)
Sensorineural deafness
Cataracts/ glaucoma
HSM

Parvovirus B19 (Fifth’s Disease)
“Slapped cheek” appearance
Parvovirus B19 (aka: Fifth disease,
Erythema Infectiosum)


Seen most often in children 4-15 in winter
and spring
4-15 d
Exposure HA, coryza, low-grade fever,
7d
1-4 d
malaise “slapped cheek appearance”
erythematous, maculopapular rash on trunk
end
and ext central clearing with lacy/
reticular appearance periodic increases in
rash intensity (x1-3 wks)
Parvovirus B19 (aka: Fifth disease,
Erythema Infectiosum)
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Aplastic crisis in children with hemolytic
anemias
Chronic infection in immunocompromised
patients
Fetal infection
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Hydrops fetalis, fetal death, miscarriage
Highest risk during second trimester
Varicella (Chicken Pox)
Vesicular lesions in different stages of healing
Varicella
10-21d



24-48h
Exposure low-grade fever, malaise, HA
3-5 d
vesicular exanthem crusting
Exanthem: “dew drops on a rose petal,”
occurs most commonly on trunk and
extremities
Contagious 1-2 days before rash appears
and until all the lesions are crusted over
Varicella Immune Globulin

Consider immune globulin (within 96h) for
exposed susceptible children at risk for severe
dz:
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Immunocompromised children
Pregnant women
Newborns whose mothers had varicella<5 days
before delivery or <48h after
Hospitalized premature infants >/= 28 weeks born
to a varicella Ab-negative mother
Hospitalized premature infants </= 28 weeksor
<1000g
EBV (Mono)
Clue: This patient was recently treated with Ampicillin
HHV 6 (Roseola)
Clue: This patient had a h/o 3 days of fever (that has since defervesced)
before the appearance of the rash
HHV 6 (Roseola)

Non-specific rubelliform eruption
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Central distribution (trunk, face, proximal
extremities)
Follows 3-5 days of spiking fevers in a
young child
Child looks well
Scarlet Fever (Group A Strep)
Strawberry Tongue
Sandpaper rash
Scarlet Fever (Group A Strep)

Acute streptococcal pharyngitis with fine,
diffuse red rash
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“Sandpaper rash”
Usually appears 24-48h after illness begins, but
can be the presenting symptom
Begins on neck and upper chest and spreads
Lasts ~1wk, fades with subsequent
desquamation of trunk, hands and feet
Toxic Shock Syndrome
Clue: You might be more suspicious of this illness if this picture was a
hypotensive woman
Staph Scalded Skin
S.Aureus- Cutaneous Manifestations
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Impetigo
Abscess
Staph scalded skin
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Caused by exfoliating toxin
Fever common, +/- bacteremia
+Nikolsky sign
Toxic Shock Syndrome
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Hypotension, fever, diarrhea, hypocalcemia
Scarlatiniform erythroderma (within 24 h of fever),
hyperemia of MM and conjuntivae
Can also be caused by Group A Strep (pyogenes)- postop and with chicken pox
Stevens-Johnson Syndrome
Stevens-Johnson Syndrome

Major causes:
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Drugs: Abx (BACTRIM!!), anticonvulsants, NSAIDS
Infectious: Herpes virus, Mycoplasma
Prodrome of fever and malaise erythematous
or purpuric macules or plaques sloughing
Mucous membrane involvement:

Erythema Multiforme (0) SJS (<10%) TEN
(>30%)
Kawasaki Disease
Bright red diaper
area with
desquamation
Red, cracked
lips;
conjuntivitis
Red palms
Kawasaki Disease

Clinical criteria:
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Fever lasting >/= 5days plus 4 of the following:
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Bilateral bulbar conjunctival injection
Oral mucous membrane changes
Peripheral extremity changes
Polymorphous rash (greatly variable)
Cervial LAD (with at least 1 LN> 1.5cm in diameter)
Meningococcemia
~Caused by Neisseria meningitidis
~Usually seen in patients < 2yo
~Penicillin G is treatment of choice (once Neisseria is
confirmed)
~Hearing loss is a common complication of meningococcal
meningitis
Rocky Mountain Spotted Fever
Rocky Mountain Spotted Fever
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Caused by the Gm- coccobacillus Rickettsia
rickettsii, which is transmitted by tick bite
Usually seen in Southeastern US
Clinical course
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Abrupt onset of fever, HA, myalgias
After 2-5 days, exanthem appears
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Maculopapular
Distribution involves flexural areas of wrists and ankles
then spreads toward the center
Becomes petechial within 1-3 days, then confluent and
hemorrhagic with areas of necrosis
Rocky Mountain Spotted Fever

Have a low threshold to treat
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Doxycycline for all ages
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A 6-day-old infant is brought to the emergency department in August
with a 1-day history of decreased feeding, decreased activity, tactile
fever, and rapid breathing. He was born at term by normal
spontaneous vaginal delivery and weighed 3,742 g. His mother reports
that she had a nonspecific febrile illness 1 week before delivery for
which she received no treatment. Her group B Streptococcus screen
was positive at 36 weeks' gestation, and she received two doses of
ampicillin (>4 hours apart) during labor. The baby received no
antibiotics and was discharged at 48 hours of age. Physical
examination today reveals a toxic, lethargic infant who is grunting and
has a temperature of 39.4°C, heart rate of 180 beats/min, and
respiratory rate of 60 breaths/min. His lungs are clear, with subcostal
retractions. He has a regular heart rhythm with gallop, his pulses are
thready, his capillary refill is 4 seconds, and his extremities are cool.
Of the following, the MOST likely cause of this baby's illness is:
A. early-onset group B Streptococcus infection
B. echovirus 11 infection
C. herpes simplex virus infection
D. hypoplastic left heart syndrome
E. respiratory syncytial virus infection

A 13-year-old girl presents with a 2-day history of fever, sore throat, and a rash
that began on her arms and legs and spread to her chest and back. Physical
examination reveals pharyngeal exudate; bilateral cervical adenopathy; and a
"sandpapery" rash over her arms (Item Q157), legs, and trunk. A rapid
diagnostic test for group A Streptococcus yields negative results. At 48 hours, a
throat culture is growing small colonies with narrow bands of hemolysis on
sheep blood agar.
Of the following, the MOST appropriate antibiotic for treating this patient is
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A. ceftazidime
B. erythromycin
C. penicillin
D. tetracycline
E. trimethoprim-sulfamethoxazole