163: Exanthematous Viral Diseases Flashcards
What is the incubation period for measles?
The incubation period for measles is 7 to 21 days.
What are the common clinical features of measles during the prodrome phase?
The common clinical features during the prodrome phase include fever, malaise, conjunctivitis, coryza, and cough (the 3 Cs), lasting for 4 days.
What is the pathognomonic enanthem associated with measles?
The pathognomonic enanthem associated with measles is Koplik spots, which are small, bright red macules with a 1- to 2-mm blue-white speck on the buccal mucosa, appearing 48 hours before the rash and lasting 12 to 72 hours.
What diagnostic tests are used for measles and when are they most effective?
The diagnostic tests for measles include real-time reverse transcription polymerase chain reaction (PCR) and ELISA. PCR is most successful when performed within 3 days of rash onset, while IgM from ELISA is positive on the first day of the rash and remains positive for at least 30 days.
What are the major complications associated with measles?
Major complications associated with measles include severe diarrhea, pneumonia, otitis media, transient immunosuppression, encephalitis, and a rare form of progressive neurodegenerative disease called subacute sclerosing panencephalitis.
What is the management approach for measles?
The management approach for measles is supportive care, which includes:
1. Antipyretics
2. Fluids
3. Management of complications
There are no specific antiviral therapies approved for measles.
What is the likely diagnosis and the pathognomonic sign to confirm it for a child presenting with fever, conjunctivitis, coryza, and cough followed by a rash?
The likely diagnosis is measles. The pathognomonic sign is Koplik spots, which are small, bright red macules with a blue-white speck on the buccal mucosa.
What is the typical duration of measles rash?
The rash peaks at 3 days and disappears in 4 to 5 days.
What is the most common method for diagnosing measles?
Real-time reverse transcription polymerase chain reaction (PCR).
When does the patient test positive for IgM in measles?
IgM is positive on the first day of the rash and remains positive for at least 30 days.
Who is at high risk for severe measles complications?
Infants, elderly, pregnant women, immunocompromised, and malnourished individuals.
What is the contagious period for measles?
5 days before and 4 days after the onset of the rash.
What are the key clinical features of measles that can help in its diagnosis?
The key clinical features of measles include:
1. Incubation period: 7-21 days
2. Prodrome: Fever, malaise, conjunctivitis, coryza, cough (the 3 Cs), lasting 4 days.
3. Pathognomonic enanthem: Koplik spots (small, bright red macules with blue-white specks on buccal mucosa), appearing 48 hours before the rash and lasting 12-72 hours.
4. Measles exanthem: Nonpruritic, erythematous macules and papules that begin on the forehead and behind the ears, spreading to the neck, trunk, extremities, hands, and feet; peak at 3 days and disappear in 4-5 days.
What are key considerations for ELISA test in the diagnosis of measles?
- It detects IgM antibodies, which are positive on the first day of the rash and remain positive for at least 30 days.
- It may be falsely negative within 72 hours of the rash onset, making timing crucial for accurate diagnosis.
- IgG documentation of a fourfold increase in titers can also support the diagnosis.
What management strategies are recommended for measles in a hospitalized setting?
Management strategies for measles include:
1. Supportive care: Antipyretics, fluids, and management of complications.
2. No specific antiviral therapies are approved for measles.
3. In a hospitalized setting, ensure standard and airborne transmission precautions are followed starting 4 days after rash onset.
What is the recommended dosage of Vitamin A for children with measles?
200,000 international units per day or 100,000 international units per day for infants, administered on 2 consecutive days.
What are the contraindications for the measles vaccine?
Moderate to severe illness, immediate anaphylactic reactions to previous measles vaccine, pregnant women, and immunocompromised individuals (e.g., HIV infection, immunosuppressive therapy).
What is the primary mode of transmission for rubella?
Direct or droplet contact from nasopharyngeal secretions.
What are the clinical findings associated with primary rubella?
Mild, subclinical disease, low-grade fever, myalgia, headache, conjunctivitis, rhinitis, cough, sore throat, lymphadenopathy, and a rash that appears after a prodrome.
What are the potential consequences of congenital rubella syndrome?
Microcephaly, congenital heart disease, sensorineural deafness, cataracts, glaucoma, low birth weight, and fetal death; 85% of infected fetuses may be affected.
What laboratory tests are used to diagnose rubella?
Rubella-specific IgM antibody test, viral culture (nose, throat, blood, urine, cerebrospinal fluid, synovial fluid), reverse transcription PCR, and CBC showing leukopenia and atypical lymphocytes.
What are the potential risks to the fetus for a pregnant woman exposed to rubella?
The fetus is at risk for congenital rubella syndrome, which can cause microcephaly, congenital heart disease, sensorineural deafness, cataracts, and fetal death. Diagnostic tests include rubella-specific IgM antibody and viral culture from throat, blood, or urine.
What prophylactic measures should be taken for a pregnant woman exposed to measles?
Measles immunoglobulin (IM or IV) should be administered to high-risk patients within 6 days of exposure.
What is the recommended treatment to reduce complications for a child with measles who develops severe diarrhea and pneumonia?
Vitamin A supplementation is recommended for all children with measles to reduce complications.
What demographic is most likely to experience arthritis due to rubella?
Arthritis due to rubella is most common in adult women.
What is the likely cause of a rash in a 4-year-old child who develops it 10 days after receiving the MMR vaccine?
The rash is likely a mild adverse reaction to the vaccine and is not a contraindication for future doses.
What is the maximum dose of measles immunoglobulin for high-risk patients?
15 mL for IM or 400 mg/kg for IV, within 6 days of exposure.
What is the schedule for the measles vaccine?
Live-attenuated, 2 doses with the first dose at or after 12 months of age, and 2nd dose no sooner than 28 days later. Confers lifelong immunity.
What is the primary host for rubella?
Humans are the only host.
What is the typical timing for rubella outbreaks?
Most frequently occurring in late winter and early spring months.
What type of virus causes rubella?
Enveloped positive-stranded RNA virus from the Togaviridae family.
What are the clinical findings of primary rubella?
Mild, subclinical disease, particularly in adults, with symptoms like low-grade fever, myalgia, and lymphadenopathy.
What is the significance of the rash in rubella?
The rash appears after a prodrome of symptoms and resolves within a few days; viremia is unlikely after the rash appears.
What are the recommended prevention strategies for measles in high-risk patients?
- Vitamin A: 200,000 international units per day for children and 100,000 for infants on 2 consecutive days.
- Ribavirin: For children with severe disease and immunocompromised status.
- Measles immunoglobulin: IM (0.5 mL/kg; max dose: 15 mL) or IV (400 mg/kg) within 6 days of exposure for high-risk patients.
- MMR vaccine: Administered within 72 hours of exposure for healthy patients.
What are the potential complications of congenital rubella syndrome?
- Microcephaly with mental retardation.
- Congenital heart disease: Includes ventricular septal defect, patent ductus arteriosus, and pulmonary artery stenosis.
- Sensorineural deafness.
- Ocular defects: Such as cataracts and glaucoma.
- Low birth weight and fetal death (85% of infected fetuses).
- Neonatal rubella: Growth retardation, interstitial pneumonitis, radiolucent bone disease, hepatosplenomegaly, thrombocytopenia, and dermal erythropoiesis (blueberry muffin lesions).
What are the contraindications for administering the MMR vaccine?
- Moderate to severe illness.
- Immediate anaphylactic reactions to previous measles vaccine.
- Pregnant women.
- Immunocompromised individuals: Including those with HIV infection or on immunosuppressive therapy.
- Hypersensitivity reactions: Due to components of the vaccine such as gelatin, neomycin, and egg white cross-reacting proteins.
What is the typical epidemiological pattern for rubella infections?
- Occurs most frequently in late winter and early spring months.
- Humans are the only host; primarily affects school-age children, adolescents, and young adults.
- Approximately 10% of the U.S. population older than 5 years is susceptible to rubella.
What is the primary method for diagnosing rubella virus infection?
The primary method for diagnosing rubella virus infection is isolating the virus in the throat, blood, cataracts, urine or CSF. Additionally, IgM antibodies can be detected from birth to 1 month of age, while IgG antibody titers may remain stable or increase over several months.
What are the rare complications associated with rubella infection?
Rare complications of rubella infection include peripheral neuritis, optic neuritis, encephalitis, myocarditis, pericarditis, hepatitis, orchitis, hemolytic anemia, thrombocytopenia, and hemophagocytic syndrome.
What is the recommended management for uncomplicated rubella?
The management for uncomplicated rubella is supportive care, along with standard and droplet precautions for 7 days after the rash appears. Nonpregnant individuals should receive the rubella vaccine within 3 days of exposure, and IM immunoglobulin (0.55 mL/kg) can be given as postexposure prophylaxis.
What is the incubation period for Erythema infectiosum caused by Parvovirus B19?
The incubation period for Erythema infectiosum caused by Parvovirus B19 is 4 to 14 days.
What are the common symptoms of Erythema infectiosum?
Common symptoms of Erythema infectiosum include a childhood illness with ‘slapped cheeks’ followed by an erythematous, lacy eruption on the trunk and extremities, symmetric polyarthritis, and a papular purpuric gloves-and-socks syndrome characterized by pruritic erythema, edema, and petechiae of the hands and feet.
What is the significance of the blood group P antigen in relation to Parvovirus B19 infection?
The blood group P antigen (globoside) serves as the receptor for Parvovirus B19; individuals who lack the P antigen are not susceptible to infection by the virus.
What are the contraindications for receiving the rubella vaccine?
Contraindications for receiving the rubella vaccine include being pregnant or breastfeeding, and individuals who are immunosuppressed or immunodeficient. Women receiving the rubella vaccine should also not become pregnant for 28 days following vaccination.
What is the likely diagnosis for a newborn with cataracts, sensorineural deafness, and a ‘blueberry muffin’ rash?
The likely diagnosis is Congenital Rubella Syndrome, acquired transplacentally from a non-immunized mother infected during pregnancy.
What is the primary method for diagnosing rubella virus infection?
Isolating rubella virus in the throat, urine, cataracts, or CSF; IgM antibody can be detected from birth to 1 month of age.
What are the common complications associated with congenital rubella?
Peripheral neuritis, optic neuritis, encephalitis, myocarditis, pericarditis, hepatitis, orchitis, hemolytic anemia, thrombocytopenia, and hemophagocytic syndrome.
What is the recommended management for uncomplicated rubella?
Supportive care and standard droplet precautions for 7 days after rash.
What is the vaccination schedule for rubella?
First dose at 12-15 months, second dose at 4-6 years old.
What is the incubation period for Erythema Infectiosum caused by Parvovirus B19?
4 to 14 days.
What is the transmission route for Parvovirus B19?
Respiratory route via aerosolized droplets, close contact, blood transfusion, and vertically from mother to fetus.
What are the symptoms of Erythema Infectiosum?
Childhood illness with ‘slapped cheeks’ followed by an erythematous, lacy eruption on the trunk and extremities.
What is a transient aplastic crisis in the context of Parvovirus B19?
It occurs in patients with increased red blood cell destruction or loss, leading to anemia and may trigger congestive heart failure and fetal hydrops.
What are the key management strategies for a patient diagnosed with uncomplicated rubella?
The key management strategies for uncomplicated rubella include:
1. Supportive care - primarily to alleviate symptoms.
2. Standard and droplet precautions - maintained for 7 days after the rash appears.
3. Rubella vaccine - administered to nonpregnant individuals within 3 days of exposure.
4. IM immunoglobulin - given at a dose of 0.55 mL/kg as postexposure prophylaxis.
5. Contact isolation - for patients with congenital rubella syndrome until they are at least 12 months old or negative cultures are confirmed after 3 months of age.
What are the clinical implications of transient aplastic crisis in patients with Parvovirus B19 infection?
Transient aplastic crisis in patients with Parvovirus B19 infection can lead to significant clinical implications, including:
- Increased red blood cell destruction or loss - which can exacerbate anemia.
- Potential triggers for congestive heart failure - particularly in patients with pre-existing heart conditions.
- Fetal hydrops - which may occur in pregnant women, leading to serious complications.
- Possibility of fetal death - due to severe anemia and associated complications.
How does the epidemiology of Erythema Infectiosum vary across different age groups?
The epidemiology of Erythema Infectiosum varies significantly across age groups:
- Children aged 5 to 19 years - 15% to 60% are affected, particularly during school outbreaks in late winter and early spring.
- Elderly individuals - more than 90% may show susceptibility due to waning immunity.
- All ages - can be affected throughout the year, indicating a broad epidemiological impact.
What are the common clinical features of Parvovirus B19 in children?
- Most are asymptomatic and unrecognized.
- Fifth disease is the most common clinical picture, beginning with nonspecific symptoms like headache, coryza, and low-grade fever, 2 days before rash.
- Arthralgia or arthritis occurs in 10% of patients, often affecting large joints.
- Exanthem presents as confluent, erythematous, edematous plaques on the malar eminence (‘slapped cheeks’), fading over 1-4 days to pink macules or papules on the trunk and extremities.
- Rash can be recurrent, triggered by sunlight, exercise, and emotional stress.
- Pruritus is a major feature in some outbreaks.
What are the diagnostic tests and results for Parvovirus B19 infection?
- Lab results are usually normal.
- Aplastic crisis may show reticulocytopenia and anemia.
- IgM antibodies are detected within a few days after onset and can be present for up to 6 months.
- IgG antibodies are identified by the seventh day of illness and last for years.
- PCR is the most sensitive test, especially in immunocompromised patients, and should be used along with IgM and IgG in pregnant patients.
What are the differential diagnoses to consider for Parvovirus B19 infection?
What is the likely diagnosis for a 35-year-old woman with symmetric polyarthritis and recent lacy rash?
The likely diagnosis is Parvovirus B19 infection, which can cause acute arthropathy, especially in adults.
What is the diagnosis for a teenager with painful edema and purpuric papules on hands and feet?
The diagnosis is Papular Pruritic Gloves-and-Socks Syndrome. It differs from erythema infectiosum as it involves purpuric papules with abrupt demarcation at the wrists and ankles and is contagious when the eruption is present.
What is the likely explanation for numbness and tingling in fingers of a patient with Parvovirus B19?
These symptoms are constitutional manifestations of Parvovirus B19 infection in adults.
T or F: A positive rheumatoid factor can occur in cases of parvovirus-associated arthritis.
True.
What joints are most commonly affected in a patient with Parvovirus B19 infection who develops symmetric polyarthritis?
The knees and small joints of the hands are most commonly affected. Occasionally may affect spine and costochondral joints.
What is the most common clinical picture of Parvovirus B19 in children?
Fifth disease. It begins with nonspecific symptoms such as headache, coryza, and low-grade fever, 2 days before rash (may also coincide with the rash).
What are the characteristic skin manifestations of Parvovirus B19 in children?
Confluent, erythematous, edematous plaques on the malar eminence, known as ‘slapped cheeks’, fading over 1-4 days.
What triggers recurrent symptoms of Parvovirus B19 in children?
Sunlight, exercise, temperature change, bathing, and emotional stress.
What are the common symptoms of Parvovirus B19 in adults?
- Acute arthropathy (primary manifestation; symmetric, sudden, self-limited)
- Constitutional symptoms (more severe in adults, more likely in women) of fever, adenopathy, mild arthritis without a rash, fatigue, malaise, and pruritus.
What is the typical rash appearance in adults with Parvovirus B19?
Usually macular and blotchy or lacy, often on the extremities, rarely demonstrating slapped-cheek appearance.
What is the significance of IgM antibodies in diagnosing Parvovirus B19?
They are detected within a few days after onset of illness and are present for up to 6 months, declining in titer in the second month after onset.
What laboratory findings are associated with aplastic crisis in Parvovirus B19?
Reticulocytopenia and anemia.
What is the typical duration for the rash associated with Papular pruritic gloves-and-socks syndrome?
Resolves spontaneously within 2 weeks.
What is the primary manifestation of Parvovirus B19 in adults?
Acute arthropathy, primarily affecting women.
What are the common clinical features of Parvovirus B19 in children, and how do they differ from those in adults?
Parvovirus B19 in Children:
- Most are asymptomatic and unrecognized.
- Fifth disease is the most common clinical picture, starting with nonspecific symptoms like headache, coryza, and low-grade fever 2 days before rash.
- Exanthem: confluent, erythematous plaques on malar eminence (‘slapped cheeks’), fading over 1-4 days.
- Arthralgia or arthritis in 10% of patients, primarily affecting large joints.
- Can be recurrent, triggered by sunlight, exercise, and emotional stress.
Parvovirus B19 in Adults:
- Acute arthropathy is the primary manifestation, often affecting knees and small joints.
- More severe constitutional symptoms, including fever and malaise.
- Rash is usually macular and blotchy, rarely showing ‘slapped-cheek’ appearance.
- Other skin manifestations include purpura and vesicles.
What laboratory findings are typically associated with Parvovirus B19 infection, and what do they indicate?
Laboratory Findings in Parvovirus B19 Infection:
- Aplastic Crisis: Reticulocytopenia and anemia may occur.
- ESR: Rarely elevated.
- Rheumatoid Factor: Positive in some cases of parvovirus-associated arthritis.
- IgM Antibodies: Detected within a few days after onset, present for up to 6 months; sensitivity of IgM is 62% to 70%.
- IgG Antibodies: Identified by the seventh day of illness and lasts for years.
- PCR: Most sensitive test, especially in immunocompromised patients; should be used along with IgM and IgG in pregnant patients. Specimen: serum or plasma, amniotic fluid, placental or fetal tissue or bone marrow.
What is the typical prognosis for transient aplastic crisis caused by Parvovirus B19?
Transient aplastic crisis usually resolves in 1 to 2 weeks, but can recur or persist for months. Most patients recover in 1 week.
What are the common complications associated with fetal B19 infection?
Common complications of fetal B19 infection include:
- Fetal hydrops
- Extensive hemolysis leading to severe anemia, tissue anoxia, high-output heart failure, and generalized edema
- Increased risk of spontaneous abortion, especially in the first half of pregnancy.
What supportive treatments are recommended for patients with chronic anemia due to persistent B19 infection?
Supportive treatments for chronic anemia due to persistent B19 infection include:
- IV immunoglobulin
- Oxygen therapy and blood transfusion for patients with transient aplastic crisis.
What is the fetal death risk associated with fetal hydrops due to Parvovirus B19 infection?
The fetal death risk associated with fetal hydrops due to Parvovirus B19 infection is approximately 6.5%.
What are the recommended prevention strategies for Parvovirus B19 infection?
Currently, there is no vaccine available for Parvovirus B19 infection. Control measures are not likely to be effective, and no special precautions need to be taken. Respiratory and contact isolation is recommended if hospitalized patients have aplastic crisis or immunosuppression with chronic B19 anemia.
What is the likely cause and recommended treatment for a patient with chronic hemolytic anemia and hypoplasia of the erythroid series?
The likely cause is transient aplastic crisis due to Parvovirus B19. Treatment includes RBC transfusion, and most patients recover in one week.
What potential complications should be monitored for a pregnant woman diagnosed with Parvovirus B19 infection?
Potential complications include hydrops fetalis, severe anemia, and fetal death. Monitoring includes serologic testing for B19 IgG and IgM, frequent ultrasonograms, and umbilical cordocentesis to assess anemia, viral DNA, and IgG and IgM.
What underlying condition might explain persistent anemia in a patient with Parvovirus B19 infection despite treatment?
The patient may be immunocompromised, leading to chronic B19 infection and persistent anemia.
What is the underlying mechanism for aplastic crisis in Parvovirus B19 infection?
The underlying mechanism is lysis of erythroid progenitor cells by Parvovirus B19.
What is the typical prognosis for transient aplastic crisis caused by Parvovirus B19?
It can be fatal, but most patients recover in 1 week.
What is the most common complication of fetal B19 infection?
Fetal hydrops.
What is the fetal death risk associated with fetal hydrops due to Parvovirus B19 infection?
6.5%.
What treatment is typically used for chronic anemia due to persistent B19 infection?
IV immunoglobulin.
What are common symptoms of transient aplastic crisis?
Fever and constitutional complaints, then fatigue, pallor and worsening anemia after 1 week.
What is the common outcome for parvovirus B19-infected pregnant women regarding their fetuses?
33% to 50% of fetuses may be infected, with adverse outcomes in 10% of cases.
How does the prognosis of chronic B19 infection differ between immunocompromised patients and healthy individuals?
In immunocompromised patients, chronic B19 infection can lead to serious, prolonged anemia due to persistent lysis of RBC precursors and may require treatment with IV γ-globulin. In healthy individuals, transient aplastic crisis may occur but typically resolves without significant complications, often recovering within 1 week without the need for extensive treatment.
What is the fetal death risk associated with Parvovirus B19 infection during pregnancy, and what complications can arise from fetal parvovirus B19 infection?
The fetal death risk associated with Parvovirus B19 infection is approximately 6.5%.
Complications from fetal infection include:
- Spontaneous abortion (1st half of pregnancy)
- Hydrops fetalis (2nd half of pregnancy): Most common complication, leading to severe anemia and tissue anoxia. Extensive hemolysis results in high-output heart failure and generalized edema. Ultrasound findings: May show subcutaneous edema, ascites, pleural and pericardial effusion, and placental edema, polyhydramnios
- Congenital anemia
- Late fetal death
What preventive measures are recommended for managing Parvovirus B19 infection in hospitalized patients?
Preventive measures include:
- Respiratory and contact isolation: For hospitalized patients with aplastic crisis or immunosuppression due to chronic B19 anemia.
- No vaccine available: Currently, there is no vaccine for Parvovirus B19.
- Control measures: Not likely to be effective, and no special precautions are necessary for the general population.
What are the risk factors for early seropositivity to EBV?
Risk factors for early seropositivity to EBV include:
- Lower household income
- Parental education level
- Uninsured status
- Being Mexican American or Black
What is the incubation period for EBV infection?
The incubation period for EBV infection is typically between 4 to 8 weeks.
What are the common clinical features of infectious mononucleosis caused by EBV?
The common clinical features of infectious mononucleosis include:
- Triad of symptoms: fever, lymphadenopathy, pharyngitis (50% of cases)
- Fever lasts 1 to 3 weeks
- Lymphadenopathy is often tender, frequently found in the posterior cervical chain
- Pharyngitis can range from mild erythema to grossly enlarged tonsils with white exudate
- Other symptoms: fatigue, headache, mild transaminitis, cytopenias, atypical lymphocytosis
What complications can arise from EBV infection?
Complications from EBV infection can include:
- Airway obstruction
- Autoimmune hemolytic anemia or thrombocytopenia
- Neutropenia
- Myocarditis
- Hepatitis (20% of cases)
- Splenomegaly (50%), which resolves by 4-6 weeks
- Splenic rupture (0.1%), spontaneous in >50% of cases
- Neurologic complications: aseptic meningitis, transverse myelitis, peripheral neuritis, Guillain-Barré syndrome, cranial nerve palsies
What are Lipschütz ulcers and their characteristics?
Lipschütz ulcers are characterized by:
- Painful, multiple ulcers with red-purple ragged edges
- Located on the medial or outer surface of the labia minora, often deep with a necrotic or fibrinous base
- Symmetric ‘kissing’ pattern
- Frequently seen in prepubertal or adolescent females
- Associated with inguinal lymphadenopathy
- In males, may involve scrotal area
- Not recurrent and typically self-resolve in 2 to 6 weeks.
A 25-year-old presents with fever, lymphadenopathy, and pharyngitis. Blood tests show atypical lymphocytosis. What is the likely diagnosis, and what test confirms it?
The likely diagnosis is infectious mononucleosis caused by EBV. The Monospot test (heterophile antibody test) confirms the diagnosis.
A patient with infectious mononucleosis develops a rash after being treated with ampicillin. What is the cause of the rash, and does it indicate a permanent allergy?
The rash is caused by EBV-induced antibodies forming immune complexes. It does not indicate a permanent allergy to the medication.
A patient with EBV infection develops Guillain-Barré syndrome. What is the underlying mechanism?
Guillain-Barré syndrome is a neurologic complication of EBV infection, likely due to immune-mediated damage.
A patient with EBV infection develops atypical lymphocytosis. What is the reason behind this finding?
Atypical lymphocytosis indicates clonal expansion of cytotoxic T lymphocytes in response to EBV infection.
A patient with EBV infection develops a morbilliform rash after taking amoxicillin. What is the mechanism?
The rash is due to EBV-induced antibodies forming immune complexes, not a drug allergy.
A patient with EBV infection develops necrotic ulcers on the labia minora. What is the diagnosis?
The diagnosis is Lipschütz ulcers, a non-sexually related acute genital ulcer associated with EBV.
A patient with EBV infection develops a scarlatiniform rash. What is the likely cause?
The rash is a cutaneous eruption associated with EBV infection. Other types of rashes include morbilliform, urticarial, erythema-multiforme-like, or petechial (25% of cases).
What percentage of adults are latently infected with EBV?
More than 90%.
What are the two distinct types of EBV?
EBV-1 and EBV-2.
What is the primary mode of transmission for EBV?
Via saliva.
What is the most common manifestation of EBV in adolescents and adults?
Infectious mononucleosis, also known as ‘kissing disease’.
What are the common symptoms of infectious mononucleosis?
Fever, lymphadenopathy, and pharyngitis.
What are the hallmark features of nasal-type extranodal natural killer/T cell lymphoma (ENK/T)?
Strongly associated with EBV, characterized by a natural killer-cell phenotype, angioinvasion, and necrosis.
What is the clinical course of Hydroa vacciniforme-like lymphoproliferative (HVLL) disease?
Variable; can have prolonged periods of relapsing fevers and skin eruptions, and may progress to hematophagocytic syndrome and natural killer/T-cell lymphoma.
What are the common symptoms of lymphomatoid granulomatosis?
Cough, fever, and cavitary lung nodules, which can mimic Wegener granulomatosis.
What is the significance of lymphocytosis in the diagnosis of EBV-related conditions?
Lymphocytosis with a predominance of atypical lymphocytes is defined as more than 10% of total lymphocytes and is part of the diagnostic criteria.
What does a positive IgM VCA indicate in the context of EBV infection?
It indicates acute infection, while IgG EBNA positive argues against acute.
What does a positive IgM VCA indicate in the context of EBV infection?
It indicates acute infection, while IgG EBNA positive argues against acute infection.
What is the role of PCR-based assays in EBV-related diseases?
They are used to detect infection in immunocompromised patients, to monitor for posttransplantation lymphoproliferative disease, and to identify EBV-induced neoplasms.
What are the clinical features and potential complications of Nasal-type extranodal natural killer/T cell lymphoma (ENK/T)?
Nasal-type ENK/T is characterized by aggressive non-Hodgkin lymphoma with a natural killer-cell phenotype. Common symptoms include ulcerated midfacial tumor leading to nasal obstruction, facial swelling, and sinusitis. Skin, soft tissue, GI tract, and testes involvement can occur in extranasal cases. Complications can include severe destruction of underlying tissues and potential progression to advanced stages requiring radiation and chemotherapy.
How does Hydroa vacciniforme-like lymphoproliferative (HVLL) disease present and what are its distinguishing features?
HVLL disease presents with symptoms similar to photoinduced hydroa vacciniforme, including development of vesicles, crusting, and varicelliform scarring. Distinguishing features include systemic symptoms such as fever, weight loss, hepatosplenomegaly, and lymphadenopathy, extensive facial edema, ulcerations, and scarring, and lesions located in photoprotected sites. Histopathology shows monoclonal proliferation of T cells with a CD8 phenotype.
What is lymphomatoid granulomatosis and what are the key diagnostic features?
Lymphomatoid granulomatosis is characterized by angioinvasive proliferation of EBV-infected B cells and a reactive, polyclonal T-cell population. Key features include symptoms such as cough, fever, and cavitary lung nodules, which can mimic Wegener granulomatosis, and cutaneous manifestations in 40% of cases, including stellate ulceration and subcutaneous nodules. Diagnosis should prompt a workup for underlying immunodeficiency and requires chemotherapy initiation.
What laboratory findings are indicative of EBV infection in immunocompromised patients?
Laboratory findings indicative of EBV infection include lymphocytosis with more than 10% atypical lymphocytes, heterophile antibody test (monospot test) confirming infectious mononucleosis, with 85% sensitivity, and EBV-specific antibodies: IgM VCA positive indicates acute infection, IgG EBNA positive argues against acute infection. PCR-based assays are used to detect infection in immunocompromised patients and monitor for posttransplantation lymphoproliferative disease.
What are the most likely conditions to consider in the differential diagnosis of EBV infection?
Cytomegalovirus mononucleosis, Group A streptococcal infection, Toxoplasmosis.
What is the typical recovery time for EBV infection without specific treatment?
Recovery typically takes 2-3 weeks without specific treatment, but may be more protracted in older adults.
What are the recommendations for managing fever or throat discomfort in EBV infection?
Use acetaminophen or NSAIDs for fever or throat discomfort. Avoid contact sports to prevent splenic rupture.
What is the significance of chronic active EBV infection?
Chronic active EBV infection occurs rarely, beginning as primary EBV infections and persisting for more than 6 months with severe illness and histologic evidence for organ disease; EBV antibody titers are significantly elevated.
What is the clinical benefit of systemic corticosteroids in EBV infection management?
Systemic corticosteroids may reduce the duration of fever or pharyngeal symptoms, but large meta-analysis has failed to show any clinical benefit.
Is there a vaccine available for EBV infection?
No vaccine is available for EBV infection.
A patient with EBV infection develops severe fatigue, fever, and splenomegaly lasting over six months. What is the condition, and how is it diagnosed?
The condition is Chronic Active EBV Infection. Diagnosis involves elevated EBV antibody titers and histologic evidence of organ disease.
A patient with EBV infection develops airway obstruction due to enlarged tonsils. What is the immediate management?
Immediate management includes systemic corticosteroids to reduce pharyngeal symptoms and airway obstruction.
A patient with EBV infection develops splenic rupture. What precaution could have prevented this complication?
Avoiding contact sports during the illness could have prevented splenic rupture.
What is a significant risk associated with contact sports during EBV infection?
Splenic rupture.
What is the management recommendation for fever or throat discomfort in EBV infection?
Acetaminophen or NSAIDs.
What two differential diagnoses to always rule out when considering EBV infection/infectious mononucleosis?
- Drug rash with eosinophilia and system syndrome (DRESS)
- Primary exanthem of HIV
This is the second-line therapy for EBV infection and is used for impending airway obstruction, thrombocytopenia and hemolytic anemia.
Systemic corticosteroids.
This type of EBV infection is aggressive and is endemic in Asia (Southern China) and among Central and South American natives.
Nasal-type extranodal natural killer T cell lymphoma (ENK/T)
What is the role of acyclovir in EBV infection management?
It has activity through inhibition of the EBV DNA polymerase but shows no clinical benefit and is not routinely used.
What smooth muscle tumor is EBV-associated? Enumerate the other EBV-associated lymphoproliferative diseases and malignancy.
Leiomyosarcoma
What genetic deficiency is associated with Hydroa vacciniforme-like lymphoproliferative disease?
GATA2 Deficiency
What ages do ENK-T, HVLL and lymphomatoid granulomatosis usually present?
- ENK-T: 50 years old (ulcerated midfacial tumor male, 2:1 ratio)
- HVLL: children (varicelliniform scarring in photoprotected sites)
- LG: 4th - 6th decade of life (stellate ulceration, cavitary lung nodules)
How many percent of cases of molluscum contagiosum are complicated by Gianotti-Crosti Syndrome?
5%
What is Gianotti-Crosti Syndrome (GCS) and its common characteristics?
Gianotti-Crosti Syndrome (GCS), also known as infantile papular acrodermatitis, is a common, self-limited exanthem that typically affects children between the ages of 3 months and 15 years, with a peak onset between 1 to 6 years. It is characterized by abrupt onset of symmetrically distributed, monomorphic papules or papulovesicles on the face, extensor surfaces of extremities, and buttocks.
What are the clinical features associated with Gianotti-Crosti Syndrome?
The clinical features of Gianotti-Crosti Syndrome include: 1. Abrupt onset of symmetrically distributed, monomorphic papules or papulovesicles. 2. Papules range from 1 to 5 mm in size, pink to red-brown in color, dome-shaped or flat-topped, and can coalesce to form large plaques. 3. Lesions may be hemorrhagic or scaly. 4. Pruritus is the most common accompanying symptom. 5. Patients are typically well appearing and may experience malaise, pharyngitis, low-grade fever, and lymphadenopathy.
What is the etiology and pathogenesis of Gianotti-Crosti Syndrome?
The etiology of Gianotti-Crosti Syndrome involves an immune reaction to a preceding virus, bacterium, or vaccine, and is not related to direct infection of the skin. Risk factors include young age and a history of atopic dermatitis. Common viral triggers include Hepatitis B and Epstein-Barr Virus (EBV).
How is Gianotti-Crosti Syndrome diagnosed?
Gianotti-Crosti Syndrome is diagnosed clinically, with no further workup needed in most cases. Skin biopsy is rarely required.
What is the clinical course and prognosis of Gianotti-Crosti Syndrome?
The clinical course of Gianotti-Crosti Syndrome is self-limited, typically lasting longer than most rashes associated with viruses, gradually fading over 10 to 60 days. It resolves without scarring but may lead to temporary post-inflammatory hyperpigmentation or hypopigmentation.
What management strategies are recommended for Gianotti-Crosti Syndrome?
Management of Gianotti-Crosti Syndrome generally does not require treatment in the majority of cases. However, medium-potency topical steroids may decrease the duration of lesions when applied once daily for 1 to 2 weeks, with close monitoring for worsening findings. Oral antihistamines or topical anti-itch lotions may help diminish severe pruritus.
What is Gianotti-Crosti Syndrome also known as?
Infantile papular acrodermatitis and papular acrodermatitis of childhood.
What age group is typically affected by Gianotti-Crosti Syndrome?
Children between the ages of 3 months and 15 years.
What is the peak onset age for Gianotti-Crosti Syndrome?
1 to 6 years.
What is the most common accompanying symptom of Gianotti-Crosti Syndrome?
Pruritus.
What is the typical clinical course of Gianotti-Crosti Syndrome?
Self-limited, gradually fading over 10 to 60 days without scarring.
What is the diagnosis process for Gianotti-Crosti Syndrome?
GCS is a clinical diagnosis; no further workup is needed.
What are some viral triggers associated with Gianotti-Crosti Syndrome?
Hepatitis B, EBV, and other viruses like CMV and mumps virus.
Noncutaneous findings may reflect the underlying infectious process triggering GCS. What are these findings and what infection are they pertaining to?
- hepatomegaly and lymphadenopathy: Hepatitis B
- splenomegaly: EBV
What are the 2 most likely differential diagnoses for Gianotti-Crosti Syndrome?
- Id reaction
- Papula urticaria
What is the prevalence of HCMV infection in children before reaching puberty?
10% to 20% of children are infected before reaching puberty.
What are the common cutaneous lesions associated with congenital HCMV infection?
Common cutaneous lesions include:
- Petechial rash (thrombocytopenia)
- Jaundice (hepatitis)
- Blueberry muffin lesions (dermal erythropoiesis)
What are the related physical findings in newborns with congenital HCMV infection?
Related physical findings include:
- Hepatosplenomegaly
- Microcephaly
- Periventricular calcifications
- Ventriculomegaly
- Encephalitis
- Chorioretinitis
- Hearing loss or neurodevelopmental sequelae
- Intrauterine growth retardation
- Postnatal failure to thrive
What is the typical presentation of primary HCMV infection in immunocompetent adults and children?
Primary HCMV infection in immunocompetent patients is usually asymptomatic, but some may present with HCMV mononucleosis, which has symptoms indistinguishable from EBV-induced mononucleosis.
What is the significance of HCMV in bone marrow and solid-organ transplant patients?
HCMV is a significant cause of morbidity in bone marrow transplant and solid-organ transplant patients, often leading to severe complications.
A newborn presents with petechial rash, jaundice, and blueberry muffin lesions. What is the most likely underlying condition?
The most likely condition is congenital human cytomegalovirus (HCMV) infection, as these are hallmark features including dermal erythropoiesis.
A 2-month-old infant presents with hepatosplenomegaly and periventricular calcifications. What is the most likely diagnosis?
The most likely diagnosis is congenital human cytomegalovirus (HCMV) infection.
What is the most common congenital viral infection in humans?
HCMV (Human Cytomegalovirus) is the most common congenital viral infection in humans.
How many percent of congenital HCMV infections exhibit sequelae?
10% to 15% of congenital infections exhibit sequelae.
What is the typical outcome for infants with symptomatic congenital HCMV infection?
Approximately 50% of symptomatic and 10% of asymptomatic children have hearing loss after congenital HCMV infection.
What is the typical presentation of primary HCMV infection in immunocompetent patients?
Primary HCMV infection in immunocompetent patients is usually asymptomatic.
What is HCMV mononucleosis and how does it present?
HCMV mononucleosis presents with symptoms indistinguishable from EBV-induced mononucleosis, such as fever, malaise, splenomegaly, hepatitis and peripheral and atypical lymphocytosis.
What are the cutaneous lesions associated with acute HCMV mononucleosis?
Rubelliform or morbilliform eruption, erythema nodosum, urticaria, and cutaneous ulcers (severe cases of drug hypersensitivity syndrome) are associated with acute HCMV mononucleosis.
What is the significance of congenital HCMV infection in newborns?
Congenital HCMV infection is a major cause of morbidity in newborns, particularly in children of primiparous women with primary infection during pregnancy.
How does the clinical presentation of HCMV infection differ between immunocompetent adults and children compared to congenital cases?
In immunocompetent adults and children, primary HCMV infection is usually asymptomatic. However, some may present with HCMV mononucleosis, which includes symptoms indistinguishable from EBV-induced mononucleosis. In contrast, congenital HCMV infection often leads to significant clinical manifestations in newborns, including thrombocytopenia, jaundice, and neurodevelopmental issues.
What are the manifestations of perinatal HCMV infection?
- Transmission via cervical secretions, breastmilk, or blood transfusions between 4 - 16 weeks of age.
- Usually asymptomatic, without diffuse visceral or CNS involvement
- May have self-limited lymphadenopathy, hepatosplenomegaly, or afebrile pneumonitis
- Usually have no cutaneous findings but may have cutaneous vasculitis and perineal ulcers
- In preterm infants: may have GCS, gray pallor, hepatosplenomegaly, with self-limited respiratory deterioration
Dermal erythropoiesis (thrombocytopenic purpura or blueberry muffin syndrome) is seen at birth and regresses during the 1st 6 weeks of life despite presence of the virus. Enumerate the conditions that exhibit this and describe its histology.
- Congenital HCMV
- Congenital Rubella
- Toxoplasmosis
- Blood dyscrasias
Histology: plaquelike aggregates of nucleated cells and nonnucleated erythrocytes in the reticular dermis
What are the significant cutaneous manifestations of congenital HCMV infection in newborns?
Petechial rash, jaundice, blueberry muffin lesions
T or F: Reactivation or secondary HCMV infection of a HCMV-immune woman during pregnancy usually results in symptomatic HCMV infection for the baby.
False. Reactivation or secondary HCMV infection of a HCMV-immune woman during pregnancy RARELY results in symptomatic HCMV infection for the baby.
How many percent of maternal primary HCMV infection result in intrauterine HCMV infection of the fetus and what fraction of these are symptomatic?
Intrauterine infection: 55%
Symptomatic: 1/3.
Which subset of solid-organ transplant recipients have the highest risk of developing HCMV disease?
Those who are not infected with HCMV but who receive an organ from an HCMV-positive individual.
It is the most reliable method to determine past HCMV infection and used as part of pretransplantation screening.
HCMV serology (IgG)
These tests may yield false-positive results in the setting of an HCMV infection.
RF and EBV IgM.
What is the gold standard for diagnosing HCMV infection?
Viral culture from blood using human fibroblasts.
What are the characteristic histologic features of CMV infection?
Cytomegalic cells with nuclear inclusions and ‘owl’s eye’ cells.
What are the differential diagnoses for congenital human cytomegalovirus infection?
What viral infection should be considered in a 3-year-old with a morbilliform rash and hepatosplenomegaly?
Human cytomegalovirus (HCMV) infection.
What is the most widely used test for diagnosing CMV and monitoring response to treatment in immunocompromised patients?
Quantitative nucleic acid amplification testing for CMV.
What are the symptoms of HCMV disease in immunocompromised patients?
Viral syndrome with fever, malaise, leukopenia, and thrombocytopenia; or tissue invasive disease (viral pneumonitis, enteritis, hepatitis, retinitis, CNS disease).
This HCMV symptom is seen in up to 25% of HIV-infected patients before the use of HAART.
HCMV retinitis.
What is the role of PCR in diagnosing HCMV infection?
PCR is used to detect active HCMV infection and can identify the virus in urine or saliva. It supplanted culture for diagnosis of active HCMV infection (it takes days to weeks to see the cytopathic effect in culture). It is also used to identify primary infection in children <12 months of age as they shed the virus for long periods of time.
delete
HCMV retinitis is seen in up to 25% of HIV-infected patients before the use of highly active antiretroviral therapy.
What are the common complications of postnatal HCMV infection?
Interstitial pneumonia, hemolytic anemia, splenic infarction, hepatitis, Guillain-Barré syndrome, meningoencephalitis, myocarditis, arthritis, and GI/genitourinary syndromes.
What antiviral drugs are approved for systemic treatment of HCMV disease?
Ganciclovir, valacyclovir, foscarnet, and cidofovir.
What is the primary infection age range for HHV-6?
Between 6 months and 2 years.
What are the two distinct species of HHV-6?
HHV-6a and HHV-6b.
What are the clinical features of HHV-6 primary infection in early childhood?
May be subclinical or present with high fever, irritability, rhinorrhea, and diarrhea.
What is exanthem subitum and its hallmark features?
Characterized by rose-colored macules and papules, lasting 3 to 5 days, with a unique rash appearance before or after fever resolution.
What is the diagnosis for a 6-month-old with a high fever followed by a rash?
Exanthem subitum (roseola), with the rash appearing around the time of fever resolution.
What is the diagnosis for a child with a rash and erythematous papules on the soft palate?
Exanthem subitum (roseola), with Nagayama spots.
What viral exanthems should be considered in a child with a rash and low-grade fever?
Unilateral laterothoracic exanthem (ULE) or exanthem subitum (roseola).
What is the typical prognosis for HCMV disease in immunocompetent individuals?
It is usually self-limited.
What is the average incubation period for HHV-6 infection?
5 to 15 days, with an average of 10 days.
What are the hallmark symptoms of exanthem subitum?
Development of rose-colored macules and papules surrounded by a white halo.
What is the significance of CD46 in HHV-6 infection?
CD46 is the cellular receptor for HHV-6 infection.
How does HHV-6 primarily infect human cells?
It preferentially infects activated CD4+ T lymphocytes.
What is a unique feature of the rash associated with exanthem subitum?
It presents 1 day before to 1 to 2 days after the fever resolves.
What is the common viral infection rate of HHV-6 in the population by age 2?
Up to 80% of the population acquires the infection by 2 years of age.
What are the common complications associated with primary HHV-6 infection?
Hepatitis, mononucleosis-like syndrome, meningoencephalitis, hemophagocytic syndrome, and pneumonitis.
What is the role of ganciclovir in the management of HHV-6 infection?
Ganciclovir is used for the treatment and prophylaxis of HHV-6 infection, especially in immunocompromised patients.
How does HHV-7 differ from HHV-6 in terms of epidemiology?
HHV-7 primary infection occurs during childhood but later and at a slower rate than HHV-6. Both viruses are ubiquitous in adulthood and have a worldwide distribution.
What is the significance of PCR in diagnosing HHV-7 infection?
PCR is used to diagnose active HHV-7 infection, but it can only be made from acellular material (CSF, serum, or plasma) because the virus is latent in peripheral blood mononuclear cells and tissue.
A child presents with a rash and febrile seizures. What viral infection should be considered?
Consider HHV-6 infection, as febrile seizures are the most common complication of primary HHV-6 infection.
What is the primary clinical diagnosis for HHV-6 infection in childhood?
Clinical diagnosis; laboratory testing is rarely needed.
What is the most common complication of primary HHV-6 infection?
Febrile seizures (8%).
What treatment is typically needed for immunocompetent patients with HHV-6 infection?
Treatment is NOT typically needed.
What is the role of ganciclovir in the management of HHV-6 infection?
It is used for treatment and prophylaxis of HHV-6 infection.
What percentage of exanthem subitum cases are caused by HHV-7?
10%.
How does primary infection with HHV-7 differ from HHV-6?
HHV-7 primary infection occurs later in life and at a slower rate than HHV-6.
What is a significant characteristic of HHV-7?
HHV-7 is known for its latency and is commonly found in the population.
What is a significant characteristic of HHV-7 in terms of its epidemiology?
Both HHV-6 and HHV-7 are ubiquitous in adulthood and have a worldwide distribution.
What is the significance of PCR in diagnosing HHV-6 infection?
PCR can only diagnose active infection from acellular material, as the virus is latent in peripheral blood mononuclear cells.
What is the relationship between HHV-6 and drug-induced hypersensitivity syndrome?
HHV-6 reactivation is well-described in drug hypersensitivity reactions, but its role in systemic inflammation is unclear.
What are the clinical implications of distinguishing between latent and active HHV-6 infection in patients older than 2 years of age?
Distinguishing between latent and active HHV-6 infection is crucial because:
- Treatment Decisions: Active infections may require antiviral treatment, while latent infections typically do not.
- Complication Management: Active infections can lead to complications such as febrile seizures, which occur in about 8% of cases.
- Prognosis: Understanding the infection state can help predict the clinical course and prognosis, especially in immunocompromised patients.
- Public Health: Identifying active infections can aid in controlling outbreaks and understanding transmission dynamics.
How does the management of HHV-6 infection differ in immunocompetent versus immunocompromised patients?
Management of HHV-6 infection varies significantly between immunocompetent and immunocompromised patients:
-
Immunocompetent Patients:
- Typically do not require treatment as infections are usually benign and self-limiting.
- Monitoring for complications.
What is the nature of HHV-6 infections?
HHV-6 infections are typically benign and self-limited.
Why is monitoring for complications essential in HHV-6 infections?
Monitoring for complications like febrile seizures is essential.
What may immunocompromised patients require for HHV-6?
Immunocompromised patients may require antiviral treatment such as Ganciclovir or Foscarnet to prevent reactivation and manage active infections.
What is often necessary to prevent HHV-6 reactivation in bone marrow transplant recipients?
Prophylaxis is often necessary to prevent HHV-6 reactivation, especially in bone marrow transplant recipients.
What are the potential complications of HHV-6 infection in bone marrow transplant recipients?
Potential complications of HHV-6 infection in bone marrow transplant recipients include:
- Subacute Encephalitis: Inflammation of the brain leading to neurological symptoms.
- Bone Marrow Suppression: Decreased production of blood cells, increasing infection risk.
- Pneumonitis: Inflammation of the lungs, causing respiratory issues.
- Thrombotic Microangiopathy: Small blood vessel damage leading to organ dysfunction.
- Thrombocytopenia: Low platelet count, increasing bleeding risk.
What role does HHV-7 play in the context of Exanthem Subitum compared to HHV-6?
HHV-7 plays a distinct role in Exanthem Subitum compared to HHV-6.
When does primary HHV-7 infection typically occur?
HHV-7 primary infection typically occurs later in life than HHV-6.
What are the rash characteristics associated with HHV-7?
The rash associated with HHV-7 is lighter in color and appears later in the disease course compared to HHV-6.
How do the clinical presentations of HHV-6 and HHV-7 compare?
While both viruses can cause similar symptoms, the specific clinical presentations may vary.
What is the frequency of HHV-7 confirmation in clinical studies related to Exanthem Subitum?
HHV-7 is less frequently confirmed in clinical studies related to Exanthem Subitum.
What are the common clinical features of Hand-Foot-Mouth Disease (HFMD)?
HFMD begins with a nonspecific prodrome:
- Low-grade fever (38°C to 39°C)
- Malaise
- Occasionally abdominal pain or upper respiratory tract symptoms.
What is the hallmark of HFMD?
Development of a vesicular eruption on the palms and soles:
- Starts as bright pink macules and papules
- Progresses to small vesicles with surrounding erythema
- Vesicles erode to form yellow to gray, oval or ‘football-shaped’ erosions surrounded by an erythematous halo.
Where are the vesicular eruptions found in HFMD?
Found on palms, soles, sides of hands and feet, buttocks, and occasionally external genitalia.
What is classic HFMD?
Nearly all patients develop oral erosions involving the tongue, buccal mucosa, hard palate, and less frequently, the oropharynx.
What is the typical clinical course and prognosis for HFMD?
Cutaneous vesicles crust over and fade in 7 to 10 days.
What complications can occur with HFMD?
Rare complications include:
- Aseptic meningitis (most common serious complication associated with HFMD):
- Rarely life-threatening
- Typically does NOT develop permanent sequelae.
What is associated with Enterovirus 71 in HFMD?
Enterovirus 71 is associated with severe illness and outbreaks in Asia.
What severe neurologic diseases can result from Enterovirus 71?
Severe neurologic disease can include encephalitis, encephalomyelitis, and polio-like syndromes.
What are the potential outcomes of severe Enterovirus 71 infections?
May also lead to myocarditis, pulmonary edema, pulmonary hemorrhage, and death.
What are the management strategies for Hand-Foot-Mouth Disease (HFMD)?
Supportive treatment to reduce discomfort and dehydration.
What is an active area of investigation for Hand-Foot-Mouth Disease (HFMD)?
Novel antiviral agents and vaccine development targeting enterovirus 71 due to:
- The strain’s virulence
- Geographic spread
- Rising prevalence
- Risk for devastating brainstem encephalitis.
What is the epidemiology of Hand-Foot-Mouth Disease (HFMD)?
Best recognized enteroviral exanthem with a worldwide distribution.
Most frequently affects children younger than 10 years. Infected adults rarely show signs of infection. In temperate climates, HFMD is most common in the summer and fall.
What are the common etiological agents of Hand-Foot-Mouth Disease (HFMD)?
Traditionally caused by coxsackievirus A16 and enterovirus 71.
Other causes include:
- Coxsackieviruses A5, A6, A7, A9, A10, A16, B1, B2, B3, and B5
- Echoviruses and other enteroviruses.
What is the diagnosis and hallmark feature of Hand-Foot-Mouth Disease (HFMD)?
The diagnosis is hand-foot-mouth disease (HFMD). The hallmark feature is vesicular eruptions on the palms and soles.
What differential diagnoses should be considered for a child with a rash presenting with petechiae and purpuric macules?
Consider enterovirus infections, Rocky Mountain spotted fever, or meningococcemia.
What is the likely diagnosis for a child developing a rash with erythematous macules and vesicles on the buttocks?
The likely diagnosis is hand-foot-mouth disease (HFMD).
What is the likely cause for a child developing a rash with petechiae and purpuric macules on the extremities?
The likely cause is hand-foot-mouth disease (HFMD).
What is the likely cause of a rash with vesicles on the palms and soles, accompanied by fever and sore throat?
The likely cause is an enterovirus infection.
What is the likely diagnosis for a child who develops a rash with vesicles on the palms and soles, accompanied by fever and sore throat?
The likely diagnosis is hand-foot-mouth disease (HFMD).
What is the typical clinical course of Hand-Foot-Mouth Disease (HFMD)?
HFMD is a self-limiting disease that typically resolves without specific antiviral treatment.
What are the common causes of aseptic meningitis associated with enteroviruses?
Nonpolio enteroviruses are the most common cause of aseptic meningitis, which can lead to life-threatening infections.
What are the hallmark clinical features of Hand-Foot-Mouth Disease?
The hallmark of HFMD is the development of a vesicular eruption on the palms and soles, starting as bright pink macules and papules that progress to vesicles.
What is the primary mode of transmission for enteroviruses?
Enteroviruses are primarily transmitted via the fecal-oral route and less commonly through respiratory inhalation.
What is the incubation period for enterovirus infections?
The incubation period for enterovirus infections is typically 3 to 6 days.
What supportive treatments are recommended for Hand-Foot-Mouth Disease?
Supportive treatment is recommended to reduce discomfort and dehydration.
What complications can arise from enterovirus infections in immunocompromised individuals?
Complications can include severe infections such as encephalitis, myocarditis, or sepsis.
What is the significance of enterovirus 71 in relation to Hand-Foot-Mouth Disease?
Enterovirus 71 is associated with severe illness and outbreaks of HFMD, particularly in Asia.
What can severe illness and outbreaks of HFM disease lead to?
Severe illness and outbreaks of HFM disease, particularly in Asia, can lead to serious neurological diseases.
What is the typical duration for cutaneous vesicles associated with HFM disease?
Cutaneous vesicles typically crust over and fade in 7 to 10 days.
What are the key clinical features of Hand-Foot-Mouth Disease (HFM disease)?
Key clinical features include:
- Begins with a nonspecific prodrome: low-grade fever (38°C to 39°C) lasting 1 to 2 days, malaise, and occasionally abdominal pain or URT symptoms.
- Development of a vesicular eruption on the palms and soles, starting as bright pink macules and papules that progress to small vesicles with surrounding erythema.
- Vesicles erode to form yellow to gray, oval or ‘football-shaped’ erosions surrounded by an erythematous halo.
- Oral erosions involving the tongue, buccal mucosa, hard palate, and less frequently, the oropharynx.
What is the typical clinical course and prognosis for a patient with HFM disease?
The clinical course typically involves:
- Cutaneous vesicles crusting over and fading in 7 to 10 days.
- Onychomadesis can occur as a consequence of coxsackievirus A16 and enterovirus 71 infections.
- Aseptic meningitis is the most common serious complication associated with HFM disease, but it is rarely life-threatening and typically does not lead to permanent sequelae.
What complications can arise from enterovirus 71 infections?
Enterovirus 71 is associated with severe illness and can lead to complications such as encephalitis, myocarditis, pulmonary edema, and death.
What management strategies are recommended for Hand-Foot-Mouth Disease, particularly in severe cases?
Supportive treatment is essential to reduce discomfort and dehydration.
What is essential to reduce discomfort and dehydration?
Hydration is essential to reduce discomfort and dehydration.
What are areas of active investigation targeting enterovirus 71?
Novel antiviral agents and vaccine development targeting enterovirus 71 are areas of active investigation due to the strain’s virulence and associated risks.
How does the epidemiology of Hand-Foot-Mouth Disease (HFMD) inform public health strategies?
HFMD is best recognized as a viral exanthem with a worldwide distribution, predominantly affecting children younger than 10 years.
Do infected adults show signs of infection in HFMD?
Infected adults rarely show signs of infection, indicating a need for targeted public health messaging towards parents and caregivers.
When is HFMD most common?
The disease is most common in the summer and fall in temperate climates, suggesting seasonal public health monitoring and preventive measures during these times.
What are the potential complications associated with enterovirus infections, particularly in immunocompromised individuals?
Enterovirus infections can lead to severe complications such as aseptic meningitis, myocarditis, and encephalitis, particularly in immunocompromised individuals.
In which populations are severe infections more common?
Severe infections are more common in neonates and immunocompromised patients, highlighting the need for vigilant monitoring and management in these populations.
What is the emerging cause of atypical Hand-Foot-Mouth Disease (HFMD) identified in the US in 2011?
Coxsackievirus A6 (CVA6) was first isolated as the cause of clinically atypical HFMD and is now commonly identified in HFMD outbreaks.
What are the common clinical features associated with Coxsackievirus A6 infection?
Common clinical features include:
- Erythematous macules and vesicles on palmoplantar surfaces and buttocks.
- Papulovesicles, rounded vesicles, and erosions.
What are the characteristics of papulovesicles?
Papulovesicles are rounded vesicles and erosions on upper extremities, lower extremities, and perioral area.
What size of bullae is significant in children under 1 year of age?
Large bullae (>2 cm) in children under 1 year of age.
What type of lesions are seen in children over 5 years of age with coxsackievirus A6 infection?
Acrally distributed petechiae and purpura.
What differentiates eczema coxsackium from other conditions in coxsackievirus A6 infection?
Eczema coxsackium is characterized by:
- Concurrent oral aphthae.
- Palmoplantar macules and vesicles.
- Perioral involvement.
- Lack of herpetiform grouping of vesicles.
- Onset occurring in the context of family or community outbreak.
What is the likely diagnosis for a child with a history of atopic dermatitis who develops vesicles during a community outbreak?
The likely diagnosis is eczema coxsackium, which occurs during outbreaks of coxsackievirus and involves vesicles localized to areas of atopic dermatitis.
What is the likely diagnosis for a child presenting with a rash that blanches on pressure and resolves within 10 days?
The likely diagnosis is eruptive pseudoangiomatosis, which is associated with echovirus infections.
What is the likely cause of a rash with erythematous macules and vesicles on the palms and soles in a 5-year-old child?
The likely cause is coxsackievirus A6-associated atypical HFMD, which presents with these features.
What is the likely diagnosis for a child with a rash that includes large bullae (>2 cm) and acrally distributed petechiae?
The likely diagnosis is coxsackievirus A6-associated atypical HFMD.
What is the diagnosis for a child with a history of atopic dermatitis who develops vesicles without herpetiform grouping during a family outbreak?
The diagnosis is eczema coxsackium.
What is the diagnosis for a child who develops vesicles without herpetiform grouping during a family outbreak?
The diagnosis is eczema coxsackium, as it lacks herpetiform grouping and occurs in the context of a family outbreak.
What is the likely diagnosis for a child presenting with a rash that includes vesicles and erosions on the perioral area and extremities?
The likely diagnosis is coxsackievirus A6-associated atypical HFMD.
What is the likely cause for a child who develops a rash with vesicles on the palms and soles, but no oral lesions?
The likely cause is coxsackievirus A6-associated atypical HFMD, as oral lesions are less frequent in this variant.
What is the likely diagnosis for a child with a rash that resolves within 10 days and is associated with fever and diarrhea?
The likely diagnosis is eruptive pseudoangiomatosis.
What is the likely diagnosis for a child who develops a rash with vesicles and erosions on the extremities during a community outbreak?
The likely diagnosis is coxsackievirus A6-associated atypical HFMD.
What is the likely diagnosis for a child presenting with a rash that includes large bullae and acrally distributed petechiae?
The likely diagnosis is coxsackievirus A6-associated atypical HFMD.
What is the likely diagnosis for a child who develops a rash with vesicles and erosions on the perioral area and extremities?
The likely diagnosis is coxsackievirus A6-associated atypical HFMD.
What is the emerging cause of atypical Hand-Foot-Mouth Disease (HFMD)?
Coxsackievirus A6 (CVA6).
What are the common clinical features of CVA6-associated HFMD?
Erythematous macules, vesicles on palmo-plantar surfaces, and large bullae in infants.
What is the typical transmission route for Coxsackievirus A6?
Fecal-oral route and less often via respiratory secretions.
What are the two most common complications associated with CVA6 infection?
Desquamation of the hands and feet, and onychomadesis.
How long does the CVA6 exanthem generally take to resolve?
1 to 2 weeks.
What diagnostic method is confirmatory in complicated cases of CVA6 infection?
Enterovirus RT-PCR.
What is a defining feature of classic HFMD?
Oral ulcerations, which occur nearly 100% of the time.
What supportive treatment is recommended for CVA6-associated HFMD?
Managing pain and local wound care for larger vesicles and bullae.
What is the clinical course and prognosis of CVA6 infection?
Not generally associated with severe systemic illness and appears more in keeping with CVA16 than enterovirus 71.
What are the clinical features more suggestive of eczema coxsackium?
Concurrent oral aphthae, palmoplantar macules and vesicles, perioral involvement, and lack of herpetiform grouping of vesicles.
How does the clinical presentation of eczema coxsackium differ from typical eczema herpeticum?
Clinical features more suggestive of eczema coxsackium include:
- Concurrent oral aphthae.
- Palmoplantar macules and vesicles.
- Perioral involvement.
- Lack of herpetiform grouping of vesicles.
- Onset occurring in the context of family or community outbreak.
In contrast, eczema herpeticum typically presents with grouped vesicles and a more localized distribution.
What diagnostic methods are used to confirm Coxsackievirus A6 infection in complicated cases?
The diagnostic methods include:
What are the diagnostic methods for complicated cases?
The diagnostic methods include:
- Enterovirus RT-PCR: This is confirmatory in complicated cases and involves samples from swabs of stool, throat, or base of skin vesicles, or serum samples. It is more sensitive than enterovirus culture.
What are skin biopsies used for in complicated cases?
Skin biopsies show intraepidermal vesiculation with a predilection for the stratum granulosum and upper stratum spinosum, along with a neutrophil-rich infiltrate.
What is the clinical course and prognosis for Coxsackievirus A6-associated atypical HFM disease?
The clinical course and prognosis include:
- Not generally associated with severe systemic illness.
- Symptoms appear to be more in keeping with CVA16 than enterovirus 71.
- The CVA6 exanthem generally resolves in 1 to 2 weeks.
- Complications such as desquamation and onychomadesis may occur but are typically manageable with supportive care.
What is the typical age range for children affected by unilateral laterothoracic exanthem?
Typically occurs in children between 1 and 5 years of age, but may be seen from 8 months to 10 years of age.
What are the common clinical features of unilateral laterothoracic exanthem?
Common clinical features include:
- 1- to 2-mm, pinpoint, pruritic, pink papules with a surrounding pale halo.
- Localized to a large flexural region like the axillae or groin.
- Can become bilateral and more widespread within 5 to 15 days.
- Variety of morphologies: macules, papules, morbilliform, annular, scarlatiniform.
- Severe pruritus may occur.
What is the typical duration of the rash associated with unilateral laterothoracic exanthem?
The rash typically lasts from 2 weeks to 1 month.
What is unilateral laterothoracic exanthem?
Unilateral laterothoracic exanthem (ULE) is a rash that typically lasts from 2 to 6 weeks, but may last as long as 2 months.
What is the suspected etiology of unilateral laterothoracic exanthem?
The etiology is unknown, but a viral trigger is suspected due to its seasonality and associated viral symptoms, along with a lack of response to antibiotics.
What is the diagnosis and typical duration of the rash in a 1-year-old child with pinpoint pruritic pink papules in the axillae that spread centrifugally?
The diagnosis is unilateral laterothoracic exanthem (ULE). The rash typically lasts 2 to 6 weeks but may persist for up to 2 months.
What viral exanthem could resolve with postinflammatory pigment changes?
This could be unilateral laterothoracic exanthem (ULE), which resolves with postinflammatory pigment changes.
What is the diagnosis for a child who develops a rash with pink papules and a surrounding pale halo in the groin?
The diagnosis is unilateral laterothoracic exanthem (ULE).
What is the diagnosis for a child who develops a rash with pinpoint pink papules that spread centrifugally?
The diagnosis is unilateral laterothoracic exanthem (ULE).
What is another name for unilateral laterothoracic exanthem?
Asymmetric periflexural exanthem of childhood.
In which season does unilateral laterothoracic exanthem typically occur?
The text does not specify the season.
In which season does unilateral laterothoracic exanthem most frequently occur?
Late winter and early spring.
What age group is typically affected by unilateral laterothoracic exanthem?
Children between 1 and 5 years of age.
What is the typical duration of the rash associated with unilateral laterothoracic exanthem?
2 to 6 weeks, but may last as long as 2 months.
What is the clinical diagnosis for unilateral laterothoracic exanthem?
Clinical diagnosis with no laboratory tests indicated.
What is a common symptom preceding unilateral laterothoracic exanthem?
Mild upper respiratory tract symptoms or low-grade fever.
What type of papules are characteristic of unilateral laterothoracic exanthem?
Pinpoint, pruritic, pink papules with a surrounding pale halo.
What is the management focus for unilateral laterothoracic exanthem?
Controlling pruritus with topical corticosteroids, anti-itch lotions, and/or oral antihistamines.
What is the typical distribution pattern of the rash in unilateral laterothoracic exanthem?
It can be unilateral and asymmetric, but may become bilateral and more widespread.
What is the etiology of unilateral laterothoracic exanthem?
Etiology is unknown, but a viral trigger is suspected due to its seasonality.
What is the typical age range for children affected by unilateral laterothoracic exanthem, and what is its common presentation?
Unilateral laterothoracic exanthem typically affects children between 1 and 5 years of age, presenting as pink papules with a surrounding pale halo localized to a large flexural region, which may spread centrifugally.
What are the common clinical features of unilateral laterothoracic exanthem?
Common clinical features include pink papules localized to a large flexural region.
What are the common clinical features of unilateral laterothoracic exanthem?
Common clinical features include: 1. 1 to 2 mm, pinpoint, pruritic, pink papules. 2. Surrounding pale halo localized to a large flexural region. 3. Can become bilateral and more widespread within 5 to 15 days. 4. Variety of morphologies: macules, papules, morbilliform, annular, scarlatiniform. 5. Severe pruritus. 6. Preceding viral syndrome with mild upper respiratory tract symptoms, low-grade fever, or GI tract symptoms.
What is the typical duration of the rash associated with unilateral laterothoracic exanthem?
The rash typically lasts from 2 to 6 weeks, but may last as long as 2 months. It usually resolves spontaneously without scarring, although desquamation and postinflammatory pigment change may be present as the exanthem resolves.
What is the management approach for unilateral laterothoracic exanthem?
Management focuses on controlling pruritus and may include: - Topical corticosteroids. - Anti-itch lotions. - Oral antihistamines.
What is the suspected etiology of unilateral laterothoracic exanthem?
The etiology of unilateral laterothoracic exanthem is unknown, but a viral trigger is suspected due to its seasonality and associated viral symptoms, along with a lack of response to antibiotics.
What are the characteristic exanthems associated with Measles (Rubeola)?
Nonpruritic, erythematous macules and papules with cranio-caudal spread.
What is the characteristic exanthem of Rubella (3-day measles)?
Pruritic pink to red macules and papules on the face, progressing to neck, trunk.
What are the clinical manifestations associated with Erythema Infectiosum (fifth disease)?
Confluent, erythematous, edematous plaques on malar eminence; lesions may recur for weeks or months.
What is the characteristic exanthem of Papular purpuric gloves-and-socks syndrome?
Itchy, painful, symmetric edema and erythema of the distal hands and feet with abrupt demarcation at the wrists and ankles.
What are the characteristic exanthems associated with Human Cytomegalovirus (HCMV)?
Symmetrical monomorphic papules or papulovesicles on the face, extensor surfaces, and buttocks.
What is the characteristic exanthem of Exanthem subitum (roseola infantum, sixth disease)?
Rose-colored macules and papules surrounded by a white halo over the neck and trunk.
What are the clinical features of Hand-foot-mouth disease?
Vesicular eruption of the palms and soles, with ‘football-shaped’ erosions surrounded by an erythematous halo.
What are the clinical manifestations of Atypical hand-foot-mouth disease?
Papulovesicles, vesicles, and erosions of the palms, soles, extremities, and perioral; oral mucosa less frequently involved.
What is the characteristic exanthem of Erupive pseudoangiomatosis?
Small papules resembling angiomas on the face and extremities.
What are the clinical features of Unilateral thoracic exanthema (symmetric periflexural exanthema of childhood)?
Pinpoint pink papules with pale halo localized to large flexural region; unilateral and asymmetrical distribution; pruritus.
What is the etiology of Measles (Rubeola)?
Rubeolavirus from the Paramyxoviridae family.
What are the characteristic exanthems associated with Rubella (3-day measles)?
Pruritic pink to red macules and papules on the face, progressing to neck, trunk, and extremities.
What is the etiological agent of Erythema Infectiosum (fifth disease)?
Parvovirus B19.
What are the symptoms associated with Papular purpuric gloves-and-socks syndrome?
Itchy, painful, symmetric edema and erythema of the distal hands and feet with abrupt demarcation at the wrists and ankles.
What is the characteristic rash associated with Epstein-Barr virus infection?
Ampicillin rash in individuals treated with antibiotics, characterized by erythema multiforme and urticarial.
What are the exanthems associated with Gianotti-Crosti syndrome?
Symmetrical monomorphic papules or papulovesicles on the face, extensor surfaces, and buttocks.
What is the characteristic rash of Exanthem subitum (roseola infantum)?
Rose-colored macules and papules surrounded by a white halo over the neck and trunk.
What are the symptoms of Hand-foot-mouth disease?
Vesicular eruption of the palms and soles, with ‘football-shaped’ erosions surrounded by an erythematous halo.
What is the etiological agent of atypical hand-foot-mouth disease?
Coxsackievirus A6.
What are the symptoms associated with eruptive pseudoangiomatosis?
Small papules resembling angiomas on the face and extremities.
What is the characteristic rash of Unilateral thoracic exanthem?
Pinpoint pink papules with pale halo localized to large flexural region.
What are the characteristic exanthems associated with Measles and their clinical manifestations?
Characteristic Exanthem: Nonpruritic, erythematous.
What are the characteristics of the exanthem associated with Rubella (3-day measles)?
Pruritic pink to red macules and papules on the face, progressing to neck, trunk, and extremities.
What are the clinical manifestations of Rubella?
Low-grade fever, myalgia, headache, conjunctivitis, rhinitis, cough, sore throat, lymphadenopathy.
What are the characteristics of the exanthem associated with Erythema Infectiosum (fifth disease)?
Confluent, erythematous, edematous plaques on malar eminence (slapped cheek); lesions may recur for weeks or months.
What are the clinical manifestations of Erythema Infectiosum?
Fever, malaise, conjunctivitis, and arthralgia.
What are the key clinical features of Hand-Foot-Mouth Disease?
Vesicular eruption of the palms and soles, with ‘football-shaped’ erosions surrounded by an erythematous halo.
What are the clinical manifestations of Hand-Foot-Mouth Disease?
Low-grade fever, malaise, abdominal pain or upper respiratory tract symptoms, sore throat or sore mouth, oral erosions of the tongue, buccal mucosa, hard palate, and oropharynx.
What are the characteristics of the exanthem associated with Atypical Hand-Foot-Mouth Disease?
Papulovesicles, vesicles, and erosions of the palms, soles, extremities, and perioral; oral mucosa less frequently involved.
What are the clinical manifestations of Atypical Hand-Foot-Mouth Disease?
Fever, sore throat, headache, cough, and diarrhea.
It is also called as the heterophile-negative mononucleosis.
HCMV Mononucleosis.
T or F: HCMV mononucleosis usually has pharyngitis and lymphadenopathy.
False. It does NOT typically have pharyngitis and lymphadenopathy.
These two antivirals are used for HCMV prophylaxis.
Ganciclovir and valacyclovir.
This is known to improve hearing and neurodevelopmental outcomes in patients with symptomatic congenital HCMV infection.
Oral valacyclovir for 6 months.
Enumerate the differential diagnosis of HCMV mononucleosis.
