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Infectious Diseases and Immunizations

Chapter 24

Introduction

Infectious diseases leading cause of illness in children

Viral infections most frequent/bacterial infections also common

Ability to distinguish serious infections from others an important skill for PCPs

Preventive education, vaccinations important

Pathogenesis of Infectious Diseases

Microbiome diversity in humans decreasing

Antibiotic use

Modern sanitation

Loss may account for increases in some diseases – asthma, allergies, diabetes, obesity

Inoculation with important bacteria occurs at birth during vaginal birth

Brain, spinal fluid, blood, urine, lungs, tissues are essentially sterile

Most bacteria are harmless/first line of defense against pathogens

Pathogenesis of Infectious Diseases

Viruses – sub-microscopic particles; need living host to multiply

Three criteria for virulence: inflict serious harm, go unrecognized by immune system, spread efficiently

Viruses can help control bacteria

Clinical Findings

Most infectious diseases in pediatrics diagnosed by history and physical examination

History

Present illness/presenting symptoms

Comprehensive past medical history

Current/recent medications

Immunizations

Family history/social history

Exposure history

Complete review of symptoms

Diet history

Clinical Findings

Physical examination

Vital signs

Irritability is nonspecific in children

Stiff/painful neck (meningitis)

New murmur

Refusal to walk

Skin/mucous membrane changes

Diagnostic Aids

Laboratory/imaging studies

Measures of “host-pathogen damage-response framework”

Pro-inflammatory cytokines activate acute-phase reactants – nonspecific

Quality of specimen affects reliability of results

Timing of sample collection affects accuracy

Certain volume/quantity often needed

Microbiologic specimens may require special handling

Diagnostic Aids

Complete blood count

WBC – leukocytosis/bacterial; leukopenia/viral

Differential WBC further focuses diagnosis

Platelet count

Thrombocytosis in active phase of acute infection

C-Reactive protein

Acute-phase reactant

Increases in presence of acute inflammation

Nonspecific

Diagnostic Aids

Procalcitonin

Biomarker for differentiating some viral from serious bacterial infections

Increased in bacteremia/can reflect severity

Erythrocyte sedimentation rate

Acute-phase reactant; nonspecific

Useful to evaluate therapy when antibiotics used

Cultures, stains, antimicrobial susceptibility testing

Bacterial, viral, fungal cultures

Susceptibility to antibiotics on cultures

Diagnostic Aids

Other technologies

DNA/RNA testing to assess for multiple organisms

Immunoserology

Detect antibodies to specific infectious organisms

Imaging techniques

Diagnosis of infections in bone, sinus, lung, skin, viscera, brain, heart

General Management Strategies

Preventing the spread of infection

Thorough, frequent hand washing

Alcohol-based rubs – ineffective against C. difficile

Use of antibiotics

Antibiotic-resistant infections increasing

Inappropriate use of antibiotics – when not needed, for wrong organisms

Prevention of Infection Through the Use of Vaccines

Mainstay of preventive disease control

Active immunization – live, attenuated virus or toxoid to induce antibody response

Passive immunization – exogenous antibody

Barriers to vaccination

Shortages, product recalls

Parental vaccine refusal/media misinformation

Complex immunization schedules

Prevention of Infection Through the Use of Vaccines

Barriers to vaccination (Cont.)

To help parents who are vaccine-hesitant:

Listen to/question reasons for refusal/delay

Be familiar with controversies/misconceptions

Infant/child system not overwhelmed by multiple vaccines

Emphasize risks/benefits of vaccines

Provide Vaccine Information Statement (VIS)

Document discussion about refusal/flag records of unimmunized children

Prevention of Infection Through the Use of Vaccines

Adverse reactions to vaccines

No causal relationship between thimerosol-containing/MMR vaccines and “pervasive developmental disorder”

No relationship between hepatitis B and demyelinating diseases of CNS/peripheral NS

No causal relationship between multiple vaccines and type 1 diabetes/serious infection

Prevention of Infection Through the Use of Vaccines

Adverse reactions to vaccines (Cont.)

MMR, varicella zoster, influenza, hepatitis B, meningococcal, and tetanus-containing vaccines can cause anaphylaxis

Injections can cause syncope, deltoid bursitis

Febrile seizure risk higher for 1 year after MMR

Vaccines for Children Program

PCPs can obtain all ACIP vaccines without cost

Provided for Medicaid-eligible, uninsured, Native-American, Alaska Native children <19 years

Prevention of Infection Through the Use of Vaccines

Vaccine shortages

CDC provides information about shortages

PCPs need to track patients who miss vaccines for these reasons

Vaccine safety and resources for providers

Informed consent

Documentation and reporting of adverse events

VAERS

Prevention of Infection Through the Use of Vaccines

Vaccines on the horizon

Shigella

Herpes simples types 1 and 2

Cytomegalovirus

Conjugate group B streptococcus for pregnant women

Acetaminophen prophylaxis after vaccination?

Insufficient evidence to show reduced vaccine protection

Prevention of Infection Through the Use of Vaccines

Active immunity

Inoculation with all or part of modified product from microorganism evokes immune response

Live-attenuated vaccines usually broader, longer-lived immunity than inactivated types

Systemic protection (IgG) may not ensure local mucosal (IgA) protection

Research on environmental factors affecting immunity (PCBs)

Three schedules: 0-6, 7-18, catch-up for 4 months-18 years

Prevention of Infection Through the Use of Vaccines

Maternal antibodies neutralize some vaccines

Vaccines from outside U.S. acceptable with reliable documentation; reimmunize if uncertain

ACIP guidelines

Doses may be given 4 days prior/later than specified date

Give live virus vaccines at least 28 days apart

Space vaccine injections 1″ apart; no need to aspirate

Reimmunization is not harmful

Prevention of Infection Through the Use of Vaccines

ACIP guidelines (Cont.)

Reduced doses should not be given

Recognize/respond to adverse reactions

Vaccine failure can occur with improper transport and storage

May have accelerated schedule for travel

Major contraindication is anaphylaxis

Considerations When Choosing Inactive Vaccines

Information about side effects, precautions, contraindications from CDC

Fever/local reactions within first 24-72 hours

Anaphylaxis to prior dose, neomycin, polymyxin B, streptomycin contraindication to IPV

Pregnancy contraindication for HPV

Allergies to vaccine components/yeast contraindication for HBV, IPV

Moderate to severe infection contraindication for HPV, Hib

Inactivated Vaccines

Diphtheria and tetanus toxoids with pertussis

DTaP – acellular pertussis – <7 years

Tdap – >7 years

Controlling pertussis in young infants may depend on giving boosters to older children/adults

Tetanus prophylaxis as part of wound care

Polio vaccine

Inactivated polio vaccine only in U.S. (IPV)

Inactivated Vaccines

Haemophilus influenzae type B vaccine

Pneumonia, meningitis, epiglottitis, others

Hepatitis A virus vaccine

Goal is to prevent transmission to adults

Other groups of high-risk individuals (CDC)

Hepatitis B virus vaccine

Given at birth/infancy

Other groups of high-risk individuals (CDC)

Inactivated Vaccines

Human papilloma virus

For females and males

Contraindicated in pregnancy

Influenza vaccine

Formulation based on epidemiologic data

Annual vaccine

Meningococcal vaccine

Neisseria meningitidis

Pneumococcal vaccine

PCV-13 covers 13 serotypes

PCV-23 for children >2 years at high risk of pneumococcal disease

Live Vaccines

Precautions regarding live vaccines

Consult with infectious disease specialist if giving to immunocompromised patients

Cannot give during IVIG therapy

Live Vaccines

Bacille Calmette-Guerin Vaccine

To prevent spread of tuberculosis

Not routinely used in U.S.

Measles-Mumps-Rubella vaccine

Measles vaccine – responsible for most adverse reactions

Mumps vaccine

Rubella vaccine – give to females >13 who do not have documented immunity

Varicella vaccine

Localized pain, erythema

May develop maculopapular rash

Live Vaccines

Post-exposure prophylaxis for varicella disease

VariZIG – if exposure causes significant risk

Table 24-3 – indications for prophylaxis

Administer varicella vaccine 5 months after

Rotavirus vaccine

History of intussusception or SCID is contraindication

Smallpox vaccine

Given only for risk of outbreak

Passive Immunity: The Immunoglobulins

Derived from sera of pooled human immunoglobulin (IG), illness-specific IG, antibodies from animals, or monoclonal antibodies

Reserved for those with immunodeficiencies or who have problems making antibodies

Given to nonimmunized or underimmunized patients exposed to certain infectious diseases

Respiratory Syncytial Virus Prophylaxis

Palivizumab – for infants at risk for adverse outcomes of RSV

Infants born before 29 weeks during RSV season until they are 12 months old

Children born <32 weeks who are <2 years and who have chronic lung disease

Infants up to 12 months old with hemodynamically significant cyanotic or complicated congenital heart disease

Infants up to 12 months old with neuromuscular disorder or congenital anomalies compromising respiratory secretions

Infections in Children in Child Care Settings

2-18 times more prone to infectious disease

More antibiotic treatment/more antibiotic-resistant infections

Table 24-4 – typical infections

Specific Viral Diseases

Enteroviruses – non-polio

10-15 serotypes account for most diseases

Most common cause of aseptic meningitis

Hand-foot-mouth, herpangina, acute hemorrhagic conjunctivitis, other

Primary invasion through GI tract

Transmitted via respiratory route

Transplacental transmission can occur

Infants have highest prevalence rate

Specific Viral Diseases

Enteroviruses – non-polio: clinical findings

History – mild URI; nonspecific febrile illness >3 days; onset within 2 weeks after delivery

Physical examination

Skin – macular, macular-papular, urticarial, vesicular, petechial

Herpangina – sudden onset of high fever; vesicular lesions on oropharynx, palate

Acute lymphonodular pharyngitis

Hand-foot-mouth disease – vesicles

Aseptic meningitis – fever, stiff neck, headache

Specific Viral Diseases

Enteroviruses – non-polio: clinical findings (Cont.)

Physical examination (Cont.)

Acute hemorrhagic conjunctivitis – sudden eye pain, photophobia, erythema

Pleurodynia

Orchitis – similar to mumps

Myocarditis/pericarditis – mild to severe

Respiratory symptoms – wheezing, asthma exacerbation, apnea, distress

Specific Viral Diseases

Enteroviruses – non-polio: clinical findings (Cont.)

Diagnostic studies – PCR highly sensitive; cultures from throat, stool, CSF, blood

Differential diagnosis – viral/bacterial causes

Management – supportive care

Specific Viral Diseases

Enteroviruses – poliomyelitis virus

Asymptomatic illness to severe CNS involvement

Fecal-oral/respiratory transmission

Worldwide incidence low; reemergence occurs

Nonspecific febrile illness, aseptic meningitis, paralytic symptoms

Viral culture from stool/throat – two samples 24 hours apart

Exclude other illnesses with paralytic symptoms

Management is supportive

Specific Viral Diseases

Hepatoviruses – hepatitis A virus

Causes primary infection in liver

Person-to-person; fecal-oral transmission

<10% of young children develop jaundice; only 30% are symptomatic – allows for rapid spread

Clinical findings

Preicteric phase – acute febrile illness; malaise, nausea, anorexia, vomiting, digestive complaints; may have RUQ pain

Icteric phase – jaundice, dark urine, clay-colored stools; feel sick; poor weight gain in infants

Specific Viral Diseases

Hepatoviruses – hepatitis A virus (Cont.)

Fulminant disease rare; complete recovery in 1-2 months; occasional relapses up to 6 months

Diagnostic studies – serologic testing

Differential diagnosis

Infancy – physiologic jaundice, hemolytic disease, galactosemia, hypothyroidism, biliary disorders, hypervitaminosis A

Older infants, children, adolescents – hemolytic-uremic syndrome, Reye syndrome, others

Specific Viral Diseases

Hepatoviruses – hepatitis A virus (Cont.)

Management, complications, prevention

Supportive care

Good hand hygiene, especially with diaper changes

Immunoglobulin or HAV vaccine within 2 weeks of exposure

Good personal hygiene; safe drinking water

Routine HAV vaccine

Specific Viral Diseases

Hepatoviruses – hepatitis B virus

Highly contagious – severe liver damage

Blood/body fluids transmission

Perinatal transmission can occur

>90% of infants will develop chronic illness if untreated

Clinical findings

Asymptomatic seroconversion to fulminant disease

Most at early age are asymptomatic

Fever, nausea, mild hepatomegaly

Later, more severe icteric phase

Specific Viral Diseases

Hepatoviruses – hepatitis B virus (Cont.)

Diagnostic studies

Serologic tests

Changes in liver enzymes to evaluate degree of injury

Differential diagnosis – any cause of jaundice

Management

Acute infection – supportive care

Active and passive vaccination

Specialist referral for chronic management

Five medications approved for use in children

Specific Viral Diseases

Hepatoviruses – hepatitis C virus

Chronic disease; spread through blood

15% to 25% will not develop chronic disease; will resolve spontaneously without treatment

High rate of chronic disease, liver damage

Perinatal transmission major route for children

Most common route of transmission in U.S. is IV drug use

Clinical findings

Incubation 2 weeks to 6 months

Onset of symptoms insidious

Fulminant infection uncommon

Specific Viral Diseases

Hepatoviruses – hepatitis C virus (Cont.)

Diagnostic studies – no serologic marker; IgG antibody enzyme immunoassay, but may have false negatives; LFT when disease occurs

Differential diagnosis – HAV, HBV

Management

Supportive treatment

Interferon for chronic disease

HAV, HBV vaccines to prevent further complications

Complications/prevention – course generally mild

Specific Viral Diseases

Hepatoviruses

Hepatitis D

Uncommon in children

Parenteral, percutaneous, mucosal contact with infected blood

No vaccine for HDV, but vaccination with HBV is protective because HDV requires comorbidity with HBV

Hepatitis E

Human, nonhuman hosts

Fecal-oral transmission; contaminated water

Asymptomatic/mild symptoms in children

Chronic infection rare; recovery usually complete

Specific Viral Diseases

Herpes family of viruses – herpes simplex virus

Widely disseminated in humans

HSV-1 – orolabial lesions

HSV-2 – genital lesions

Both types associated with oral/genital infections

Both types devastating to newborns

Type 1 most common in children as gingivostomatitis

Type 2 usually result of sexual activity

Specific Viral Diseases

Herpes family of viruses – herpes simplex virus (Cont.)

Neonatal HSV-2 from mother during delivery

Conjunctivae, nose/mouth, broken skin

Can occur with C-section, asymptomatic shedding

Postnatal transmission, inoculation from fathers, lateral transmission from other infants may occur

Period of communicability 2 days to 2 weeks

Some congenital infections occur >6 weeks

Can transmit from primary/recurrent infection

Specific Viral Diseases

Herpes family of viruses – herpes simplex virus (Cont.)

Clinical findings – determined by port of entry, age, health, immune competence

Neonatal infection – always symptomatic

Disseminated – multiple organ failure; encephalitis – day 10-12 of life

CNS – focal/generalized seizures, lethargy, irritability, poor feeding, herpetic lesions – day 16-19 of life

Skin, eye, mouth – limited to these sites – day 10-12 of life

Specific Viral Diseases

Herpes family of viruses – herpes simplex virus (Cont.)

Traumatic herpetic infection

Localized to area of abrasion, teething, laceration; inoculated by parent who kisses site

Fever, constitutional symptoms, regional lymphadenopathy

Acute herpetic meningoencephalitis

Recurrent infection – virus is dormant; recurrent infections are common

Specific Viral Diseases

Herpes family of viruses – herpes simplex virus (Cont.)

Diagnostic studies

Intrapartum cultures mother/child; within 12-24 hours after delivery

Differential diagnosis

Coxsackievirus if viral stomatitis

Always suspect HSV with neonatal respiratory distress/sepsis

Management

Parenteral acyclovir with life-threatening/neonatal infection

Oral acyclovir for 6 months after parenteral treatment

Specific Viral Diseases

Herpes family of viruses – herpes simplex virus (Cont.)

Complications

Most cases mild; may have secondary bacterial infection

Refer all children with ocular involvement

Patient and family education

Toddlers/infants with gingivostomatitis should be kept out of day care if drooling; “fever blisters” – may go to school

Wrestlers should not compete until lesions cleared

Ask all pregnant women about HSV during labor

Specific Viral Diseases

Herpes family of viruses – infectious mononucleosis syndrome

Epstein-Barr virus (EBV)

Young children often have subclinical disease

Older children/adolescents common

Specific Viral Diseases

Herpes family of viruses – infectious mononucleosis syndrome (Cont.)

Clinical findings

Lymphoid tissue enlargement – spleen, nodes, tonsils, liver

Atypical lymphocytes in peripheral blood

Prodrome – mild; malaise, fatigue

Acute – fever, sore throat, malaise, fatigue, rash, organomegaly

Resolution – gradual resolution with organomegaly taking 1-2 months to resolve

Specific Viral Diseases

Herpes family of viruses – infectious mononucleosis syndrome (Cont.)

Diagnostic studies

CBC (>10% atypical lymphocytes)

Elevated liver enzymes

Monospot, serum heterophile test

Differential diagnosis – GABHS, CMV, rubella, SLE, leukemia, toxoplasmosis

Specific Viral Diseases

Herpes family of viruses – infectious mononucleosis syndrome (Cont.)

Management – supportive, bed rest, OTC analgesics, fluids, calories; return-to-play guidelines after hepatosplenomegaly

Complications – few in healthy children

Patient and family education

No blood/organ donation after recent infection

Avoid sharing food/drinks

Specific Viral Diseases

Herpes family of viruses – roseola infantum

Human herpesvirus (HHV-6; HHV-7)

Likely spread via oral, nasal, conjunctival routes

Associated with encephalitis

Rare in children <3 months, >4 years; most common between 7-24 months

Clinical findings

Sudden onset of fever for 3-7 days without seeming ill

At defervescence, rose-colored maculopapular rash

Specific Viral Diseases

Herpes family of viruses – roseola infantum (Cont.)

Diagnostic studies – usually made on presentation

Differential diagnosis – other viral rashes, scarlatina, drug hypersensitivity

Management and complications

Supportive; acetaminophen

No practical means of prevention

Rare complications – febrile seizures, meningoencephalitis

Specific Viral Diseases

Herpes family of viruses – varicella

Highly contagious – chickenpox primary illness

Shingles – (herpes zoster) reactivation from latent VZV acquired during varicella infection

Direct contact, droplets, airborne transmission

Victims of shingles infectious – can cause primary varicella illness

Incubation period – 10-21 days

Communicability is 1-2 days before rash erupts until lesions crusted over (3-7 days)

Specific Viral Diseases

Herpes family of viruses – varicella (Cont.)

Clinical findings

Prodrome – not always present; low-grade fever, anorexia, mild abdominal pain

Rash

Centripetal, in crops of pruritic lesions

Progresses from macular spots to teardrop vesicles

Vesicles break open and crust over

All forms can be present at once

High fever

Lesions can be present on all mucosal tissues

Specific Viral Diseases

Herpes family of viruses – varicella (Cont.)

Diagnostic studies – PCR or direct fluorescent antibody testing; serology for IgG

Differential diagnosis – rash is classic; impetigo, cigarette burns, insect bites

Management

Supportive; usually benign

Antihistamines, oatmeal baths for itching

Acetaminophen for fever

Topical antibiotics for bacterial superinfection

Intravenous acyclovir for immunocompromised patients

Oral acyclovir not routinely recommended

Specific Viral Diseases

Herpes family of viruses – varicella (Cont.)

Complications

Pyoderma – streptococcus/staphylococcus

Pneumonia, CNS complications, glomerulonephritis, hepatitis

Patient and family education

May attend school up to one week after exposure unless signs of illness

Immune globulin for immunocompromised patients; should receive vaccine within 5 months

Specific Viral Diseases

Influenza viral infection

Orthomyxovirus – three types: A, B, C

Typical influenza

Epidemics in winter months in temperate climates; year-round close to equator

Mortality rate 0.5-1/1000

Incubation period 1-4 days; infectious 24 hours before symptoms until 7 days after onset

Specific Viral Diseases

Influenza viral infection (Cont.)

Clinical findings

Sudden onset of high fever, headache, chills, coryza, vertigo, sore throat, myalgia, dry cough

Young children may have N/V, croup

Infants will appear septic

Conjunctival infection, epistaxis, myocarditis common

Lower respiratory tract involvement in severe infection

Diagnostic studies

Rapid diagnostic tests have limited sensitivity

Viral cultures confirm diagnosis

Specific Viral Diseases

Influenza viral infection (Cont.)

Differential diagnosis – other viral URI, allergic croup, bacterial pulmonary infections

Management and complications

Supportive – bed rest, OTC antipyretics, fluids

Observe for worsening symptoms

Viral resistance to amantadine/rimantadine – need reliable susceptibility

Antiviral therapy for immunocompromised or those with chronic diseases at risk for complications

Complications – Reye syndrome, respiratory infections, acute myositis, myocarditis, asthma/CF exacerbations

Patient and family education

Annual influenza vaccine

Human Immunodeficiency Virus

Retrovirus – RNA viruses; must make DNA copy of RNA to replicate

Two serotypes – clinically indistinguishable

Worldwide burden high – especially in Africa

In U.S., overall rates declined, but increased rates in 13- to 14-year-olds and 20- to 29-year-olds

Transmission greatest for male-to-male sexual contact

Vertical transmission (mother to infant) higher in non-Hispanic African-Americans

Humans only known reservoir

Transmission from accidental needle sticks rare

Human Immunodeficiency Virus

Virtual elimination of mother-to-infant transmission in U.S. due to:

Rigorous antenatal screening

Use of cART, cesarean births, not breastfeeding

Elective C-section, with zidovudine for mother and infant reduces risk by 87%

Risk factors for increased transmission:

Maternal drug use

Premature rupture of membranes

Low birth weight; birth <34 weeks

Human Immunodeficiency Virus

Transmission through breastmilk depends on:

Maternal status, symptoms, CD4+ cell count

Length of time breastfeeding

Infant co-infections

Breast abscesses, mastitis, cracked nipples

Incubation period variable – can occur as early as 5.2 months in untreated infant

Human Immunodeficiency Virus

Clinical findings

Influenza-like symptoms for 2-4 weeks

Asymptomatic infection for months to 15 years

Newborn examinations usually normal

Lymphadenopathy, hepatomegaly occur first

FTT, diarrhea, pneumonia, recurrent infections

Those with high viral load have earlier symptoms

Opportunistic diseases occur – Mycobacterium avium, severe CMV, EBV, VZV, histoplasmosis, TB

Human Immunodeficiency Virus

Clinical findings (Cont.)

Children – more recurrent bacterial infections, parotid gland swelling, lymphoid interstitial pneumonitis

Malignancies common in pediatric AIDS

Diagnostic studies

Newborn HIV screening – 30-40% detected within 48 hours; 93% by 2 weeks

Refer to pediatric HIV specialist if screening normal, but high suspicion remains

Differential diagnosis – other immune deficiencies

Human Immunodeficiency Virus

Management

Follow current CDC AIDSinfo guidelines

Treatment in consultation with HIV specialist

Treatment goals:

Suppressing viral replication to undetectable levels

Restoring/preserving immune function

Reducing HIV-associated sequelae

Minimizing drug toxicity

Promoting normal growth and development

Promoting treatment adherence

Improving quality of life

Human Immunodeficiency Virus

Management (Cont.)

Current cART – at least three oral ARV drugs from at least two drug classes

Some diagnosed as infants living into 3rd or 4th decade of life

Refer infants born to HIV-positive mothers

Box 24-1 – prophylaxis protocol for HIV-exposed newborn >35 weeks’ gestation

Treat associated conditions with IVIG, antifungals, antivirals, antimycobacterials, nutrition counseling

Human Immunodeficiency Virus

Management (Cont.)

Treatment of children only in concert with HIV specialist

Adolescents present noncompliance risk

PCP should boost adherence rates, monitor drug side effects

Complications

HIV becomes a multi-systemic/multi-organ disease

Human Immunodeficiency Virus

Prevention and reduction of perinatal HIV

Improve access to ART for HIV-infected women/children

Improve access to testing

Increase blood/tissue/surgical/injection safety

Expand maternal/newborn/child health care

Expand sexual/reproductive health education

Strengthen infant nutrition support

Use cesarean delivery if indicated

Promote exclusive breastfeeding with cART

Increase availability of chemoprophylaxis until status known

Human Immunodeficiency Virus

Pre-exposure prophylaxis for high-risk

Male-to-male anal sex without condom

Those having sex with HIV-positive partner

Injection drug users

Post-exposure prophylaxis after nonoccupational exposure

Follow CDC guidelines for counseling/screening

Measles (Rubeola)

Rash indicating viremia; serious disease

Most U.S. cases from unvaccinated persons exposed to outbreaks in other countries

Disease in areas with low herd immunity

Respiratory secretions, blood, urine are sources

90% of susceptible individuals will develop disease when exposed

Incubation period – 8-12 days

Contagious 1-2 days before onset of symptoms to 4 days after appearance of rash

Measles (Rubeola)

Clinical findings

Incubation period – no symptoms

Prodromal period – 4-5 days

URI symptoms

Low to moderate fever

Cough, coryza, conjunctivitis

Koplik spots – bluish-white granules on erythematous background

Rash stage – on 3rd or 4th day

Maculopapular rash behind ears/on forehead

Papules enlarge, coalesce, progress downward

High fever; respiratory symptoms worse day 3 of rash

Rash may become hemorrhagic – DIC

Measles (Rubeola)

Diagnostic studies – IgM or viral isolation; measles is a reportable disease

Differential diagnosis – any viral rash

Management – supportive care

Refer immunocompromised children or those with severe symptoms to infectious disease specialist

Vitamin A therapy to prevent complications

Care of exposed individuals – vaccine within 72 hours or IG to prevent/modify disease

Complications – bacterial superinfections, myocarditis, purpura fulminans, encephalitis

Mumps

Acute viral disease; painful enlargement of salivary (usually parotid) glands

Contact with saliva, respiratory secretions

Incubation – 12-25 days

Communicability – 1-2 days before swelling up to 5 days after onset of symptoms

Lifelong immunity after infection

Mumps

Clinical findings

Prodromal stage – rare; fever, headache, anorexia, neck pain, malaise

Swelling stage – one or both parotid glands; orchitis in males after puberty

Diagnostic studies – viral detection, serologic tests; leukopenia

Differential diagnosis – lymphadenitis, CMV, HIV, enteroviruses, tumor, suppurative parotits

Mumps

Management – supportive care; corticosteroids or NSAIDs

Complications – meningoencephalitis, orchitis, epididymitis, oophoritis, myocarditis, deafness

Erythema Infectiosum

“Fifth disease” – parvovirus B19

Vertical transmission, respiratory secretions, percutaneous exposure

Disease of childhood – 5-15 years

Incubation – 4-21 days; rash 2-3 weeks after exposure

Communicable – before appearance of rash

Erythema Infectiosum

Clinical findings

Prodrome – mild fever, myalgia, headache, malaise, URI symptoms

Rash – 7-10 days after prodromal stage

Slapped cheek with circumoral pallor

Lacy, maculopapular rash – may last a month

Rash subsides

Diagnostic studies – not usually indicated

Differential diagnosis – other viral exanthems

Erythema Infectiosum

Management and complications

No antiviral treatment

IVIG for immunocompromised patients

Children may attend school

Pregnant women may develop fetal hydrops with death or IUGR

Parainfluenza Virus

Similar to influenza virus; important cause of laryngotracheobronchitis, bronchitis, bronchiolitis, pneumonia

Nasopharyngeal secretions/fomites

Incubation – 2-6 days; contagious 4-6 days before symptoms/7-21 days after resolution

Diagnostic studies – RT-PCR testing from nasopharyngeal secretions

Parainfluenza Virus

Differential diagnosis – other viral URI

Management and complications

Supportive; most uncomplicated

Antibiotics if secondary bacterial infection

Complications infrequent

Rubella (German Measles)

Postnatal or congenital forms

Spread through nasopharyngeal secretions or transplacentally

Maternal rubella in 1st trimester – 61% occurrence of congenital defects; 26% if infection in 2nd trimester

Prolonged, repeated contact to become infected

Incubation – 14-21 days

Rubella (German Measles)

Clinical findings – 25% are subclinical

Prodrome – mild fever, GI upset, sore throat, eye pain, arthralgia, malaise, headache

Lymphadenopathy – postauricular, posterior, posterior occipital lymph nodes; splenomegaly

Rash – enanthem (small, rose-colored spots on soft palate) may occur, then rubella rash with complete remission by 3rd day

Diagnostic studies – clinical signs; RT-PCR; IgG, IgM antibodies

Rubella (German Measles)

Differential diagnosis – other viral, bacterial rashes; difficult to diagnose unless epidemic

Management and complications

Supportive, antipyretics

Keep home from day care/school

Mosquito-Borne Viruses

West Nile Virus

Spread globally 1999

Mosquito-borne; rare human-to-human

Symptoms 2-14 days after bite; >10 years

Mortality higher in immunocompromised, older adults

Clinical findings

Mimics influenza, GI infection

Mild symptoms will resolve in 1 week

Severe – neuroinvasive involvement

Diagnostic studies – IgM antibody capture enzyme linked immunosorbent assay (MAC-ELISA)

Mosquito-Borne Viruses

West Nile Virus (Cont.)

Differential diagnosis – mild viral/influenza, GI viral infection, aseptic meningitis, polio, GBS, dengue fever, chikungunya, St. Louis encephalitis

Management and complications

Supportive treatment for mild cases

Hospitalization with meningitis, encephalitis, severe muscle weakness/paralysis, dysphagia, dysarthria

Antiretrovirals not indicated

Mosquito-Borne Viruses

West Nile Virus (Cont.)

Patient and family education

Use insect repellant with DEET, oil of lemon eucalyptus, or soybean oil

Do not use DEET on skin/clothing of infants <2 months

Avoid combination DEET-sunscreen

Minimize standing water

Tight-fitting screens

Report dead birds to health agencies

Mosquito-Borne Viruses

Dengue Virus

Clinical findings – question about travel; ask about 24-hour fluid intake, dizziness, urinary output, diarrhea

Febrile phase – rapid rise; 2-7 days; 2 or more of: headache, retro-orbital pain, photophobia, body ache, myalgia, arthralgia, facial flushing, maculopapular or morbilloform rash, injected oral pharynx, leukopenia, anorexia, N/V, diarrhea, other

Critical phase – mild to severe plasma leak – dengue hemorrhagic fever: prior fever for 2-7 days, spontaneous bleeding, platelet count <100,000/mm3, anemia; progression to “shock syndrome”

Mosquito-Borne Viruses

Dengue Virus (Cont.)

Recovery phase

Reabsorption of extravascular fluid over 48-72 hours

Diagnostic studies

CBC, platelets, hematocrit are crucial

Serum urea >4.0 mmol/L (dehydration) and total protein <67.0 g/L (plasma leakage) signify high risk for hemorrhagic shock

Viral, serology, molecular tests

Mosquito-Borne Viruses

Dengue Virus (Cont.)

Differential diagnosis – other hemorrhagic diseases, sepsis, meningitis, HSP, other viral diseases

Management – correct diagnosis/rapid treatment; hospitalize or follow daily during febrile phase

Complications – dehydration, fever can cause neurological disturbances/febrile seizures

Patient and family education – prevention similar to West Nile

Hantavirus Pulmonary Syndrome

Rare in U.S.; exposure to rodents

Abrupt fever, chills, myalgia of shoulders, lower back, upper legs, N/V, headache followed by pulmonary edema, cardiac decompensation, hypotension

Early thrombocytopenia/leukocytosis

Hospitalize for management of pulmonary edema, hypoxemia, hypotension

Differentiate from rickettsial disease, other

Avoidance or rodent wastes

Additional Noteworthy Viruses

Metapneumovirus

Acute respiratory infection

Human calicivirus – norovirus, sapovirus

Gastroenteritis; occur in closed populations

Coronaviruses

Respiratory tract infections

SARS a coronavirus

Potential Emerging and Re-emerging Viruses on the Horizon

Middle-Eastern Respiratory Syndrome (MERS)

Countries near Arabian peninsula

Monitoring the global spread of viruses

Global Viral Initiative

One goal to increase bank of genetic information to develop vaccines

Parasitic-Caused Disease: Malaria

Spread by mosquito – worldwide

Febrile, nonspecific illness from 7 to 30 days after exposure

High fever, chills, rigor, sweats, headache

May progress in severity to neurologic compromise and death

Diagnostic studies – anemia, thrombocytopenia, elevated bilirubin, aminotransferases; may identify parasite microscopically

Parasitic-Caused Disease: Malaria

Treatment and preventive measures in epidemic regions

Insecticide-treated nets

Intermittent preventive treatment in pregnant women and infants

Indoor residual spraying

Antimalarial drugs for travelers

Tick-borne diseases

Lyme Disease

Growing epidemic in U.S.

Prevalence highest in northeast, mid-Atlantic, Wisconsin, Minnesota, Northern California

Clinical findings

Stage 1 – typical rash – erythema migrans, or “bull’s eye”; may resemble nummular eczema; some may have flu-like symptoms

Stage 2 – early disseminated disease – secondary annular lesions, neurologic signs, cardiac signs, generalized manifestations – 2 weeks to 2 years

Stage 3 – late disease – pauciarticular arthritis weeks to months after bite

Lyme Disease

Diagnostic studies

Clinical/epidemiological history; presence of EM is diagnostic with no serologic testing necessary

IgM antibodies not positive for 2-4 weeks; IgG for 4-6 weeks

High rate of false-positive serologic results

CDC – 2-step approach:

ELISA from blood sample; if negative, no further tests

IgG and IgM Western blot if symptoms >30 days

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Lyme Disease

Differential diagnosis

Other rashes – eczema, tinea, granuloma annulare, cellulitis, insect bites

Osteomyelitis, WNV, mycoplasma, septic arthritis, other spirochete diseases

Management and complications

Prophylactic doxycycline/amoxicillin

Amoxicillin or doxycycline in early localized disease

Early or late disseminated disease – consult with ID

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Lyme Disease

Post-Lyme disease syndrome

Subjective symptoms after treatment

May be a chronic form or may be from persistent immune-mediated inflammation

Patient and family education

Avoid tick-infested areas; take precautions when outdoors

Teach how to remove ticks safely

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Erlichiosis and Anaplasmosis

Both caused by obligate intracellular bacteria

Tick-borne; erlichiosis common in southeast, south-central, west Texas; anaplasmosis common in northeast, midwest, same areas as Lyme disease

Both infections – fever headache, myalgia, malaise, chills, nausea, anorexia

Erlichiosis – rash: petechial, macular, maculopapular

Diagnosis by IFA assay

Treatment – doxycycline for all ages

Systemic complications – pulmonary infiltrates, bone marrow hypoplasia, respiratory failure, encephalopathy

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Rocky Mountain Spotted Fever

Found in all contiguous states except Maine and Vermont

Prompt removal of ticks lowers risk of infection

Clinical findings

Fever, chills, myalgia, GI symptoms, photophobia, altered mental state

Focal neurologic deficits with disease progression

Maculopapular rash – wrists, forearms, ankles; spreads to trunk

Diagnostic studies

PCR testing or IFA

Thrombocytopenia, hyponatremia, leukocytosis, anemia

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Rocky Mountain Spotted Fever

Differential diagnosis

Enteroviral/adenoviral infections, meningococcemia, sepsis, others

Management

Antibiotics prior to onset of rash

Disease may progress rapidly

Doxycycline for 7-10 days; all ages

Complications and patient/family education

Neurologic deficits

20% fatality if untreated

Prevention – tick precautions

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Bacterial infection

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Community-Acquired Methicillin-Resistant Staphylococcus Aureus

Know prevalence in community

Pneumonia, cellulitis, osteomyelitis, myositis, bacteremia, endocarditis, TSS, deep tissue abscess, necrotizing fasciitis

Clinical clues:

Boil, abscess without pus; rapid onset

Fails treatment with beta-lactam agent

Other family members have similar infections

Neonate with skin/soft tissue infection

History of recurrent small, non-tender, maculopapular lesions; multiple lesions

Ethnic minority or lower socioeconomic status

History of hospitalization in past year

Attends day care; is <2 years old

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Community-Acquired Methicillin-Resistant Staphylococcus Aureus

Management

Superficial skin lesions – topical antibiotic

Widespread impetigo – oral/IV antibiotics

Management strategies

I&D/culture for nondraining, fluctuant abscess; antibiotics not needed if mild

Refer immunocompromised patients to ID specialist

Gram stain, culture/sensitivity, “d-test”

Warm compresses to localize pus in nonfluctuant

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Cat-Scratch Disease

Common cause of chronic, persistent lymphadenopathy in children

Most inoculation from cat scratches

Clinical findings

3-5 mm erythematous papules which heal; lymphadenopathy in 1-4 weeks; persists up to 1 year

Parinaud oculograndular syndrome – painful nonsuppurative conjunctivitis/preauricular lymphadenopathy in small percentage

Immunocompromised patients – recurrent fevers, bacteremia, weight loss

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Cat-Scratch Disease

Diagnostic studies – IFA for serum antibodies; CBC – mild leukocytosis; ESR/CRP elevated early

Differential diagnosis – any cause of lymphadenopathy

Management

Most resolve spontaneously

Antibiotics only if concern for systemic CSD

Treatment for immunocompromised patients – oral agents and parenteral gentamycin

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Cat-Scratch Disease

Complications

Small percentage have systemic illness with high fever, malaise, fatigue, anorexia, other

Enlarged mediastinal nodes – pleurisy, obstruction

Splenic/hepatic abscesses

Patient and family education

Wash cat scratches with soap and water

Immunocompromised individuals should avoid cats

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Kingella Kingae Infection

An important invasive disease in children >6 months and <4 years

Normal flora in pharynx in children

Most common cause of septic arthritis in children

Susceptible to many antibiotics, but resistant to clindamycin/vancomycin

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Meningococcal Disease

Caused by many organisms, but N. meningitidis discussed here

Respiratory tract secretions; epidemics in semi-closed communities (day care)

Clinical findings

Occult bacteremia – febrile URI or GI infection; may resolve without intervention

Meningococcemia – rapid progression over several hours: fever, septic shock, petechiae to purpura fulminans, hypotension, DIC, adrenal hemorrhage, organ failure, coma; death in 12 hours

Meningococcal meningitis – fever, headache, stiff neck

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Meningococcal Disease

Diagnostic studies

Positive culture/Gram stain from CSF, blood, synovial fluid

PCR assays useful if antibiotics given

Differential diagnosis

Septicemia by other invasive bacteria

Viral meningitis

Other diseases causing rash, fever

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Meningococcal Disease

Management

Hospitalization mandatory

IV antibiotics pending cultures

Control measures

Chemoprophylaxis – within 24 hours of index case regardless of immunization status

Prophylaxis during outbreak – vaccination and chemoprophylaxis

Complications – caused by inflammation, intravascular hemorrhage, organ necrosis, shock; skeletal deformities/amputations common; ataxia, seizures, deafness, developmental delays, hydrocephalus

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Group A Streptococcus (GAS)

Respiratory tract, skin, soft tissues, blood

Upper respiratory tract secretions

Streptococcal pharyngitis common in winter and early spring; rare among children <3 years

Incubation period 2-5 days for pharyngitis; 7-10 days for skin infections

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Group A Streptococcus (GAS)

Clinical findings

Respiratory tract infection – peritonsillar abscess, cervical lymphadenitis, GABHS

Scarlet fever – erythrogenic toxin; abrupt illness with sore throat, fever, vomiting, headache, chills, malaise, erythematous tonsils/exudate; strawberry tongue, sandpaper rash

Bacteremia – meningitis, septic arthritis, pneumonia

Vaginitis and TSS

Perianal streptococcal cellulitis

Skin infections

Rheumatic fever

Necrotizing fasciitis

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Group A Streptococcus (GAS)

Management and complications

Antimicrobial therapy to decrease risk of complications

Pediatric autoimmune neuropsychiatric disorders (PANDAS); OCD, tic disorders, Tourette

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Tuberculosis

Mycobacterium tuberculosis – slow-growing

Moderately infectious in most situations

Infection – converting from negative to positive skin test or positive IGRA

Progression to disease highest in infants, 15-25 years, and older adults

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Tuberculosis

Clinical findings

Primary pulmonary TB – Table 24-4; low-grade fever, nonproductive cough, decreased appetite, weight loss or FTT, night sweats

25% to 30% will have extrapulmonary symptoms

Risk factors

Close contact with others with TB

Immigrants or have travelled to TB-prevalent areas

Clinical signs of TB

HIV positive/exposed to HIV or drug users

Hodgkin disease, lymphoma, DM, renal failure, malnutrition

Homeless shelters, nursing homes, correctional institutions

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Tuberculosis

Diagnostic studies

TB skin tests – positive if:

5 mm or greater in those in close contact with TB; have chest radiograph consistent with active TB; are immunocompromised

10 mm or greater if under 4 years with any high risk factors above

15 mm or greater if 4 years or older without risk factors

Onset of induration after 72 hours

IGRA assays

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Tuberculosis

Management

Consultation with TB specialist

Report to state/local health department

Antitubercular drug treatment with strict adherence to drug regimen

Isoniazid, rifampin, ethambutol most common

Monitoring response to treatment

Evaluate all individuals being treated

Routine labs not recommended in children

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Tuberculosis

Complications

Progressive primary pulmonary disease

Reactivation of pulmonary tuberculosis

Miliary disease

Lymph node disease

Pleural effusions

Tuberculous meningitis

Cutaneous meningitis

Hematogenous spread to other organs

Multiple drug-resistant tuberculosis

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Helminthic Zoonoses

Transmission by:

Direct infection by ingestion of eggs/penetration of larvae into body

Indirect infection by ingestion in food

Exposure to intermediate vector

Toxocariasis – found in dogs/cats

Visceral larva migrans, ocular larva migrans, covert disease

Consider in any child with nonspecific history of recurrent abdominal pain, reactive airway disease, allergies of unknown cause

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The Child Presenting with Fever

Fever – temperature 100.4°F (38°C) or higher

Two situations of particular challenge in neonates, infants, and children >36 months:

Fever without a focus

Fever of unknown origin

Infants <3 months; cause usually viral; must still work up for bacterial disease

Viruses have seasonal patterns

Bacteremia in 5% of infants <3 months

Bacteremia may be occult infection in young infants/children

Occult bacteremia in <0.5% of those vaccinated with Hib; streptococcus pneumoniae

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The Child Presenting with Fever

Fever without focus

Birth-24 months at greatest risk

Acute febrile illness without obvious etiology

Table 24-11 – most common pathogens

History and physical examination

Duration/degree of fever

Associated symptoms

Exposures

Vaccination

Neonatal history of complications

Chronic illness

Current medications

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The Child Presenting with Fever

Fever without focus (Cont.)

Diagnostic workup – algorithm Fig. 24-8

Febrile toxic child <36 month – admit to hospital

Negative, low-risk workup results:

WBC <15,000/mm3; bands <1500/mm3; nonelevated ESR/CRP

Cath UA – <10 WBCs; negative leukocytes/nitrites

Fewer than five WBCs in stool

Negative chest X-ray if cough present

Cultures monitored every 24 hours until final results

Viral testing based on seasonality

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The Child Presenting with Fever

Fever without focus (Cont.)

Differential diagnosis

Upper/lower respiratory tract disease

Gastrointestinal disease

Musculoskeletal infections

Occult bacteremia

Management

Applying risk criteria – based on clinical assessment and laboratory findings

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The Child Presenting with Fever

Fever without focus (Cont.)

High risk

Febrile infant <1 month; any toxic-appearing newborn, infant, child

Infant 1-3 months with fever

Infant 1-3 months with chronic illness or unreliable caretakers

Infant <3 months even with focal sign

Infants/children 3-36 months with temp. >39°C and high-risk laboratory results

Child of any age with fever, petechiae, and who is ill-appearing

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The Child Presenting with Fever

Fever without focus (Cont.)

Low risk

1-3 months, nontoxic; low-risk diagnostic results

3-6 months; fever <39°C; not ill-appearing

3-36 months; fever >39°C; not ill-appearing; previously healthy, focal signs, positive influenza A

3-36 months; mildly ill; fever >39°C; low-risk diagnostic results; documented immunizations to Hib, S. pneumoniae

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The Child Presenting with Fever

Fever without focus (Cont.)

Follow-up for any child not hospitalized:

Reevaluation in 24 hours; access to ED

Daily follow-up on cultures

See immediately if cultures positive

Detailed instructions for parent

Symptoms of worsening

What to do

Careful follow-up

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The Child Presenting with Fever

Fever of unknown origin

Fever present most days for >3 weeks

No etiology despite workup

Recommend infectious disease consult

Many are presentations of common disorders

Infections

Rheumatological/connective tissue disease

Neoplastic diseases

Children – most common: UTI/pyelonephritis, respiratory illness, localized infections

Adolescents – most common: TB, IBD, autoimmune disorders, lymphoma

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The Child Presenting with Fever

Fever of unknown origin (Cont.)

Clinical findings – history

Symptoms, signs, ROS, history

Past medical history of infections, surgery

Medications

Family medical history

Family pets

Unusual dietary habits

PICA

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The Child Presenting with Fever

Fever of unknown origin (Cont.)

Clinical findings – physical examination

Rashes, lesions

Oropharynx for infections, exudate, erythema

Lymphadenopathy

Joints/bones for tenderness/swelling

Rectal exam/guaiac tests

Pelvic examination in adolescent females

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The Child Presenting with Fever

Fever of unknown origin (Cont.)

Clinical findings – laboratory studies

CBC with differential; ESR, CRP, procalcitonin

Blood cultures

UA/cultures

Mantoux skin test

Radiography if indicated

Liver chemistries

Heterophil antibody/ANA in older children

Bone marrow biopsy

Echocardiogram if indicated

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The Child Presenting with Fever

Fever of unknown origin (Cont.)

Differential diagnosis

Infectious disease

Collagen-vascular disease

Malignancies

Drug fever

Nosocomial infections

HV-associated illnesses

Endocrine disease

Munchausen syndrome by proxy

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The Child Presenting with Fever

Fever of unknown origin (Cont.)

Management

Consultation with infectious disease specialist

Frequent visits to monitor

Avoid empiric use of antibiotics

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Discussion Questions

A new immigrant, who is a healthy 5-year-old, comes for his health care maintenance visit. The family does not have any documentation of prior vaccines. How do you proceed? Are there any vaccines that he no longer needs? What resources are available within your community for patients to get vaccines at no cost?

A healthy 43-day-old infant comes in for a health care maintenance visit. What is the minimum age for vaccines? Would you give vaccines today? Why or why not? If the family planned on traveling to Pakistan in one week, would that change your decision? How do you respond to a family’s concerns about the variety of possible side effects/conditions that are attributed to vaccines?

Do all states require prenatal HIV screening? What are the issues about universal screening? How does HIV screening affect your practice?

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Discussion Questions (Cont.)

What can be the role of the primary care provider in preventing infections in day care centers?

Name the tick and mosquito vectors in your community. What protocols are in place in your clinic to screen for their associated illnesses?

What is the local plan for emergency preparedness within your community? Within your state?

Identify the resources for health and safety services within your community that directly affect the quality of care children receive in out-of-home child care facilities. Where are there gaps? Identify what you could do to improve the knowledge of child care personnel in these facilities regarding health and safety of the children they serve.

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