Infectious diseases with maculopapular rash – measles, german measles, fifth disease and sixth disease.

Question 1

what is the epidemiology of measles ?

Answer 1

it is highly contagious
4 days before and 4 days after the onset of xanthem

peak incidence of less than 12 months

short contact over a distance of few meters

Question 2

what is the aetiology of measles ?

Answer 2

measles virus

Question 3

what are the characteristics of measles virus ?

Answer 3

morbilli genus

paramyxovirus family

Question 4

what is the incubation period of measles virus ?

Answer 4

2 weeks

Question 5

what are the clinical manifestations of measles virus ?

Answer 5

prodromal phase

lasts 4-7 days

• fever ,
  cold ,
  barking cough ,
  conjunctivitis , photosensitivity

KOLPIK SPOTS (enanthem) - white or bluish grey spots on irregular erythematous background in the buccal mucosa

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exanthema phase
develops 1-2 days after enanthem

lasts for 7 days

generalised lymphadenopathy

second fever PEAK - fever

usually on face and trunk
erythematous maculopapular , blanking partially confluent exanthema
- begins behind the ear
disseminates to the rest of the body towards the feet - palm and sole involvement is rare
fades after 5 days - leaving brown discolouration and disqualification

======

recovery
cough persists for another week

Question 6

what are the diagnostics of measles ?

Answer 6

lab
DECREASE in leukocytes and platelets

serology
GOLDEN STANDARD - measles specific IgM
IgG antibodies

RT PCR

biopsy - lymph nodes - warthin-finkeldey cells - multinucleated giant cells

Question 7

what is the treatment of measles ?

Answer 7

no antiviral therapy is there - only supportive therapy
antipyretics, antitussives, fluid substitution

SELF isolate

vit a - reduces morbidity and mortality (especially in malnourished children)

PEP- in patients

Question 8

what is the complication of measles ?

Answer 8

subacute sclerosing panencephalitis
- generalised lethal demyelinating inflammation of the brain caused by persistent measles virus infection

primarily affects male between 8-11 years of age

stage 1 - dementia
stage 2 - epilepsy
stage 3 - decerebration
stage 4 - veg state

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bacterial superinfection
otitis media
pneumonia

gastroenteritis

acute encephalitis

Giant cell pneumonia

Question 9

what is the prognosis of measles ?

Answer 9

good in uncomplicated cases

Fatal in newborns and immunocompromised patients

Question 10

what are the prevention of measles ?

Answer 10

Live vaccination with attenuated virus in combination with mumps and rubella (MMR) vaccine and possibly varicella (MMRV) vaccine

Infants: two vaccinations during childhood
First dose between 12 and 15 months; second dose between 4 and 6 years or at least 28 days after the first dose.

idividuals >18y
without vaccination or with unknown
immunization status

1 dose with MMR(V) -
vaccine

=========

Postexposure prophylaxis (PEP)
Indication: negative or indeterminate serology

Methods
Active immunization for immunocompetent individuals after direct exposure

Passive immunization for chronically ill and immunocompromised individuals

=========
immunoglobulins: administration max. until 6d after exposition
ind: immunodeficient patients, unvaccinated patients (infants <6m, pregnant
women)
after immunoglobulin therapy a vaccination is not safe for 8m

========

Measles is a notifiable disease.
Cases should be reported within 24 hours

Question 11

what are the differential diagnosis of measles ?

Answer 11

6 paediatric exanthema diseases:

1.
measles

2.
Scarlet fever

3.
rubella

4.
Morbus Dukes- Filatow

5.
Erythema
infectiosum

6.
Exanthema subitem

Question 12

what is german measles ?

Answer 12

rubella

Question 13

what are the characteristics of rubella ?

Answer 13

member of the Togaviridae family and

only member of the genus Rubivirus

single-strand RNA enveloped virus

humans are its only known reservoir

Question 14

what is the pathogenesis of rubella ?

Answer 14

they are MOST contagious while the rash is erupting

but virus can be shed from the throat 10 days before and 15 days after the onset of the rash
infants and those with congenital rubella can shed the virus for many months

someone with the vaccine do not spread rubella

rubella replicates in the nasopharynx and migrates into the lymph nodes - causing viremia

just like with measles the rubella rash appears as immunity develops and virus has dissapered from the blood

Question 15

what is the incubation period of rubella ?

Answer 15

7-28 days

Question 16

how is rubella transmitted ?

Answer 16

respiratory droplets

Question 17

what are the clinical manifestation of rubella ?

Answer 17

prodromal phase
lasting 1-5 days

post auricular and sub occipital , lymphadenopathy

ocasional splenomegaly

non specific symptoms - low grade fever , conujunctivitis , sore throat ,

arthralgia and arthritis are common in infected adults

forchiemer signs - enenthamen of the soft palate - but this enanthem is not
diagnostic for rubella (unlike Koplik’s spots in
measles)

=====

exanthema phase
lasts 2-3 days

In children, rash is usually the first sign of illness,
which lasts 3-5 days and disappears, that is why
it also called „3 -day Measles!!!!!

in older children and adults: prodrome often
precedes the rash

fine non confluent pink maculopapular rash
begins at HEAD , behind ears then to trunk extremities sparing plasma and soles

rash is pruritic in adults

polyarthritis

riad of fever, rash and swollen tender lymph nodes =Theodor’s sign

Question 18

what is the prognosis of rubella ?

Answer 18

age is the major determinant how severe rubella is !

acquired ( post natal) - subclinical

Question 19

what is the fatal complication of rubella ?

Answer 19

congenital rubella syndrome

Infection in first 2 months of pregnancy: 90% defect, 2-3 months:
some defects, 3-4 months: only 10% defect

Infant will be carrier after second year of age and becomes the main
reservoir

========

Chronic arthritis (especially women)

Thrombocytopenic purpura

Rubella during pregnancy
(TORCH infection): congenital rubella syndrome

Rare: rubella encephalitis,

Question 20

what is the clinical manifestation of german measles ?

Answer 20

physical defects, which most commonly relate to the
eyes, ears, and heart
=
triad of Gregg
(CCD = cardiac defect - paint ductus arteritis and pulmonary artery stenosis ,

conjunctivitis and cataracts - salt and pepper retinopathy , glaucoma

bilateral sensorineural hearing loss - cochlear defect )

====

early - hepatosplenomegaly
jaundice
haemolytic anemia
thrombocytpenia - blueberry muffin

====

late
cns defects - microcephaly , pan encephalitis
skeletal abnormalities

Question 21

diagnosis of rubella ?

Answer 21

Laboratory tests
CBC: leukocytopenia, increased plasma cells

CBC: leukocytopenia with relative lymphocytosis and increased plasma cells
Confirmatory test: serology
Detection of IgM antibodies
≥ 4-fold increase in IgG titer

======

prenatal diagnosis

newborn and mother
PCR for rubella RNA (throat swab, CSF)
Serology (abnormally high or persistent concentrations of IgM and/or IgG antibodies)
Viral culture (nasopharynx, blood)

Fetus
IgM antibody serology (chorionic villi, amniotic fluid)
PCR for rubella RNA

placental biopsy at 12 weeks is possible

Question 22

what is the treatment for rubella ?

Answer 22

Symptomatic treatment
Severe pruritis: antihistamines

Severe polyarthritis: rest and nonsteroidal anti-inflammatory drugs

=======

during pregnancy: serological tests must be made in first trimester ->
elevated IgG?-> second probe after 2 weeks!
-
-> still elevated? => abortion

Question 23

dd of diagnosis ?

Answer 23

scarlet fever, mild measles, infectious

mononucleosis, toxoplasmosis, roseola, erythema infectiosum

Question 24

prevention of rubella ?

Answer 24

vaccination -> lifelong immunity

Live attenuated virus
first dose of MMR vaccine at 12–15months of age
and a second dose at 4–6 years

pregnant women should not get vaccinated, due to transmission
of vaccine to fetus

======

Check vaccination status
ELISA (preferred method), latex agglutination, hemagglutination inhibition, or immunofluorescent antibody assay.

Question 25

what is fifth disease ? and what is the etiology?

Answer 25

Erythema infectiosum

Question 26

what is the epidemiology od erythema infectiousum?

Answer 26

Peak incidence: 5–15 years

Humans are the only reservoir for parvovirus B19

Only contagious before onset of rash!!!

Question 27

what is the route of transmission of erythema infectiousum?

Answer 27

aerosol

Other routes
Hematogenous transmission
Transplacental transmission: In seronegative pregnant women, transmission to the unborn fetus may occur

Question 28

incubation period of fifth disease ?

Answer 28

4-14 day

Question 29

what are the clinical manifestations of fifth disease ?

Answer 29

commences with high fever and malaise, when the virus
is most abundant in the bloodstream, and patients are usually no longer infectious

=========

Exanthem: 2–5 days following the onset of cold‑like symptoms - adults less likely to present with it

bright red rash of the cheeks with relative pallor around the
mouth gives it the nickname
“slapped cheek syndrome”.

Spread of exanthem to the extremities and trunk

Initially confluent and maculopapular; adopts a lace‑like, reticular appearance over time as it clears.

Associated with mild pruritus (in ∼ 50% of cases)

it is on trunk or extremities

Infection in adults usually only involves the reticular rash, with multiple joint pain
predominating.

Fades after ∼ 7–10 days; can be recurrent over several weeks (becoming more pronounced after exposure to sunlight or heat)

Question 30

what is the diagnosis of erythema infectiousum?

Answer 30

based on clinical presentation alone

Question 31

what is the diagnosis of erythema infectiousum?

Answer 31

IgM Appears within ∼ 10 days of initial exposure
IgG - approx. 2 weeks following infection
Enzyme-linked immunosorbent assay (ELISA), radioimmunoas
say (RIA)
-
Dot blot hybridization
-
Polymerase chain reaction (PCR) assay

Question 32

what is the treatment of fish disease ?

Answer 32

Antipyretics (i.e., fever reducers) are commonly used.

Short course of low‑dose prednisone for parvovirus B19‑associated arthritis

Question 33

what is the prevention of fish disease ?

Answer 33

Njama Vaccination

Question 34

what is sixth disease

and what is their etiology ?

Answer 34

Exanthema subitum
also called Roseola

caused by two human herpesviruses:

 human herpesvirus 6
(HHV-6) and
human herpesvirus 7 (HHV-
7), which are sometimes referred to collectively as
Roseolovirus
–> MAINLY HHV-6!!!!!

Question 35

what is the epidemiology of Exanthema subitum?

Answer 35

Most infections occur before the age of three.

Question 36

what is the incubation of roseola?

Answer 36

5–15 days

Question 37

how is the sixth disease transmitted ?

Answer 37

Transmission occurs via

saliva

Question 38

what are the clinical manifestations of roseola?

Answer 38

vary from absent to the
classic presentation of a fever of rapid onset 
fever generally
l
asts for three to five days

followed by a rash.
generally pink and las
ts for less than three days.

fever generally lasts for three to five days

Question 39

what are the clinical manifestations of roseola?

Answer 39

vary from absent to the
classic presentation of a fever

=========
Febrile phase
Duration: 3–5 days

of rapid onset high fever >40c
generally lasts for three to five days
rare cases, this can cause febrile convulsions

Cervical, postauricular, and/or occipital lymphadenopathy

Nagayama spots: papular enanthem on the uvula and soft palate

Inflamed tympanic membranes

===========
Exanthem phase
Duration: 1–3 days

Characteristic presentation: subsequent sudden decrease in temperature and development of a patchy, maculopapular exanthem
generally pink 
blanches upon pressure
usually begins on the trunk (
torso) and then spreads to the
arms, legs, and neck
 lasts for less than three days.

{In contrast, a child suffering from measles would usually appear sicker, with
symptoms of conjunctivitis, cold-like symptoms, and a cough, and their rash
wouldaffect the face and last for several days. }

fever generally lasts for three to five days

Question 40

what are the complication of Exanthema subitum?

Answer 40

febrile seizures - febrile seizures arenot harmful, do not require treatment, and have no long term negative effect

meningitis

Like other herpes viruses, HHV-
6 then remains latent
HV-6 is a major cause of morbidity and mortality in patients who are immunosuppressed, particularly in patients with AIDS and in those who are
transplant recipients

Question 41

how to diagnose Exanthema subitum?

Answer 41

clinical diagnosis

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Laboratory tests
Antibody testing: HHV-6 IgM detection is possible.
immunoblot analysis

Viral DNA testing: via PCR (possible detection using blood, urine, cerebrospinal fluid, or saliva samples

Question 42

what is the treatment for sixth disease ?

Answer 42

fluids and possibly acetaminophen to reduce fever)

If encephalitis occurs
ganciclovir or foscarnet may be useful