Viral infection in a child (Mumps, Measles, Rubella, Erythema infectiosum, Parvovirus B19, Roseola infantum (HHV6), Chickenpox, Hand, foot and mouth disease) Flashcards

Question

What is the most common illness associated with parvovirus B19 infection?

Answer 1

Erythema infectiosum aka Fifth disease aka 'Slapped-cheek' syndrome

Answer 2

Slapped cheek disease caused by parvovirus B19 ## Footnote *Howevver, in adults and women it can look like a lace-like rash as shown below.*

Answer 3

Haemoglobinopathies - parvovirus replicates in red blood cell precursors expressing the P antigen. Can lead to aplastic crises. Immunosuppressed patients - e.g. HIV, bone marrow transplant recipients. *Uncommon in elderly because seropositivity increases with age.*

Answer 4

Fifth disease - because it was the 5th of a group of illnesses with similar rashes to be named. Parvovirus B19 - a DNA virus

Answer 5

Viraemic phase of * mild fever - hardly noticeable * malaise * headache * myalgia Followed by * characteritic rash on the face ('slapped-cheek') a week later - *child starts to feel better when the rash appears* * 'lace'-like rash on trunk and limbs * arthralgia or arthritis are common in adults *Unlike other rashes it rarely affects the palms and soles.*

Answer 6

1. **Asymptomatic infection** - 5-10% of pre-schoolers and 65% of adults have antibodies 2. **Erythema infectiosum** - most common 3. **Aplastic crisis** - most serious consequence 4. **Fetal disease** - mother-to-fetus trasmission may lead to featl hydrops and death from anaemia although most fetuses recover

Answer 7

Children with chronic haemolytic anaemia where there is an increased rate of cell turnover (e.g. sickle cell disease or thalassaemia) and in immunocompromised children (e.g. malignancy) who do not have an antibody response to neutralise the infectious agent.

Answer 8

**No specific treatment required** **School exclusion not required** - child not infectious once rash appears _Prognosis_: * Child feels better as the rash appears * Rash peaks after a week then fades * For a few months afterwards, a warm bath, sunlight, heat or fever will trigger a recurrence of bright red cheeks and the rash itself. * Adults may get acute arthritis

Answer 9

Can affect unborn baby in first 20 weeks and if exposed should seek advice as maternal IgM and IgG will need to be checked.

Answer 10

Fetal bone marrow aplasia, especially anaemia causing **hydrops fetalis**.

Answer 11

3-5 days before the appearance of the rash No specific treatment

Answer 12

Exanthema subitum (bc rash apears so suddenly after fever) or sixth disease (lasts ~6 days) = roseola infantum HHV6 (and sometimes HHV7)

Answer 13

5-15 days Most affected are children aged 6months-2 years

Answer 14

* **High fever with malaise** lasting a few days * Followed by **generalised maculopapular rash** which appears after fever wanes * **Nagayama spots** which are papular exanthen on the uvula and soft palate * Febrile convulsions in 10-15% * Diarrhoea and cough are common * Many have a subclinical infection No school exclusion

Answer 15

Usually by the rash and symptoms Sometimes by antibodies to HHV-6/7

Answer 16

Measles or rubella Doctors frequently prescribe antibiotics to a febrile child with HHV-6 and then when the rash appears, it is attributed to an allergic reaction.

Answer 17

Roseola infanum shown Roseola starts on the torso and spreads outwards

Answer 18

Rash is not itchy nor infectious Spread by oral secretions

Answer 19

Aseptic meningitis Encephalitis Hepatitis Mononucleosis like syndrome *But usually good prognosis and no long-term side effects. Usually lifelong immunity to HHV6 develops.*

Answer 20

Nagayama spots on the uvula and soft palate Occurs in roseola infantum

Answer 21

Chickenpox increases risk of bacterial superinfections with staphylococci and streptococci in the short term --\>sepsis, toxic shock syndrome, or necrotising fasciitis

Answer 22

Chickenpox is caused by primary infection with varicella zoster virus. Shingles is a reactivation of the dormant virus in dorsal root ganglion

Answer 23

spread via the respiratory route (can be caught from someone with shingles) incubation period = 10-21 days

Answer 24

**Infectivity** = 4 days before rash, until 5 days after the rash first appeared\* **_School exclusion:_** NICE advise that the **most infectious period is 1–2 days before the rash** appears, bu**t infectivity continues until all the lesions are dry and have crusted over** (usually about 5 days after the onset of the rash).

Answer 25

Fever initially Itchy rash starting on the head/trunk before spreading - macular then papular then vesicular. Mild systemic upset

Answer 26

**Macular** --\> **papular** --\> **vesicular --\>** **pustular** --\> **crusting** 50–500 lesions start on head and trunk, progress to peripheries *but may be just a few lesions* Appear as crops of papules, vesicles with surrounding erythema and pustules at different times for up to one week. Lesions may occur on the palate. **_Itchy_** and scratching; may result in permanent, depigmented scar formation or secondary infection. **New lesions appearing beyond 10 days suggest defective cellular immunity**

Answer 27

Keep cool, trim nails Calamine lotion School exclusion **Immunocompromised patients and newborns** **with peripartum exposure** should receive varicella zoster Ig (VZIG) - give **IV acyclovir** if chickenpox develops

Answer 28

* **Secondary bacterial infection of lesions**- * most common complication - staphylococcal, streptococcal * may lead to TSS or NF * **Central nervous system** * Encephalitis/cerebellitis (cerebellar involvement is characteristic of VZV) - generalised but not as severe as HSV and has a good prognosis; occurs around a week after onset of rash; child is ataxic * Aseptic meningitis * **In the immunocompromised -** * Pneumonia / pneumonitis * Disseminated haemorrhagic lesions * DIC * Arthritis, nephritis, pancreatitis are rarely seen

Answer 29

Suspect if high fever persists after first few days - usually indicated when fever initially settles then recurs **NSAIDs** increase risk May present as one infected lsion/small area of **cellulitis** but in some invasive GAS soft tissue infection may occur and cause **necrotising fasciitis and toxic shock syndrome**

Answer 30

Chest x-ray showing **miliary opacities secondary to healed varicella pneumonia**. Multiple tiny calcific miliary opacities noted throughout both lungs - these are of uniform size and dense suggesting calcification. There is no focal lung parenchymal mass or cavitating lesion seen. The appearances are characteristic for healed varicella pneumonia.

Answer 31

15% of pregnancies are susceptible to VZV * \<20 weeks gestation there is \<2% risk of skin scarring, ocular/neurological damage and digital dysplasia to fetus * 5days before or after delivery there is 25% risk of vesicular rash and 30% risk of mortality Exposed mothers can be protected with VZIG and treated with aciclovir. High risk infants should receive VZIG early and aciclovir if any signs of infection.

Answer 32

Cerebellar involvement is characteristic of VZV Generalised but not as severe as HSV and has a good prognosis Occurs around a week after onset of rash Child is ataxic Resolves within a month

Answer 33

Consequence of vasculitis in the skin and subcutaneous tissues. It is best known in relation to meningococcal disease and can lead to loss of large areas of skin by necrosis. May rarely occur after VZV infection **due to production of antiviral antibodies**, which **cross-react and inactivate the inhibitory coagulation factors protein C or protein S**. This results in an increased risk of clotting, which most often manifests as purpuric skin rash.

Answer 34

Severe disseminated disease with mortality up to 20% Vesicular eruptions persist and may become haeomorrhagic

Answer 35

Sensory nerves - most commonly in the thoracic area

Answer 36

Herpes zoster (shingles) in a child. Distribution is along the S1 dermatome. If recurrent or multidermatomal then suggests primary or secondary T cell immune defect

Answer 37

Vesicular rash along dermatomal distribution Rare to have neuralgic pain (unlike in adults) Shingles in childhood is more common in those who had chickenpox in the first year of life

Answer 38

Most commonly coxsackie A16 (CA16) and enterovirus 71 (E71) (members of the Picornaviridae family, Enterovirus genus). Faeco-oral and respiratory droplet route - infected individual can shed the virus for some weeks.

Answer 39

Mild systemic upset (sore throat, fever, myalgia) Oral ulcers initially which are yellow surrounded by red haloes Painful vesicles on hands, feet, mouth, tongue, buttock then appear and last 7-10 days (start as 2-5 mm erythematous macules but rapidly progress to grey vesicles with an erythematous base) It is very contagious and typically occurs in outbreaks at nursery E71 sometimes causes vomiting

Answer 40

Usually clinical diagnosis but swabs can be taken from throat, vesicle or rectum. PCR is then used but only in specialist centres.

Answer 41

Incubation 3-7 days Infected person can shed the virus for some weeks

Answer 42

* **Hand foot and mouth disease** * **Herpangina** - *vesicular and ulcerated lesions on the soft palate and uvula (posterior oral cavity) causing anorexia, pain on swallowing, and fever. Severe cases may require intravenous fluids and appropriate analgesia.* * **Meningitis/encephalitis** - most make a full recovery * **Pleurodynia** (Bornholm disease) * **Myocarditis/pericarditis** * **Enteroviral neonatal sepsis syndrome** - first weeks of life from transplacental or intrapartum infection of the infant, mimics sepsis symptoms, no drugs are effective

Answer 43

In children younger than 10yrs and especially \<4yrs Most adults are immune following previous exposure

Answer 44

No but children who are unwell should be kept off school until they feel better Should contact HPA if you suspect that there may be a large outbreak.

Answer 45

Self-limiting within a few days **Symptomatic treatment only** - anagesia, hydration as dehydration is common due to poor fluid intake, suggest soup diet. If the mouth is very painful then **topical lidocaine oral gel**, **benzydamine spray or mouth wash** can be used. Mouth rinses with warm salty solution if relied upon not to swallow it. **Reassure** that no link to disease in cattle or animals

Answer 46

Herpangina - also caused by coxsackievirus and echoviruses ## Footnote *Also consider gingivitis, HSV, viral pharyngitis, Kawasaki disease.*

Answer 47

* **Secondary infection** of scratched lesions * **Dehydration** **Less common:** * Although mild can cause **fatalaties** e.g. epidemic occurred in China in 2009 and caused \>200 fatalities. * Usually this is due to enterovirus 71 which more commonly causes **neurological** complications (e.g. aseptic meningitis) and fatalities but CA16 can also cause deaths.

Answer 48

Good hand hygiene, covering nose and mouth when coughing or sneezing

Answer 49

Togavirus Rubella is also called German measles

Answer 50

Very rare with MMR vaccine (\<5 cases in UK per year) Outbreaks more common around winter and spring

Answer 51

* the incubation period is 14-21 days * individuals are infectious for ~11 days (7 days before symptoms appear to 4 days after the onset of the rash) * respiratory route spread

Answer 52

Clinical differentiation from other viral infections is unreliable Diagnosis needs to be confirmed serologically if there is any risk of exposure of a non-immune pregnancy woman

Answer 53

Prodrome, e.g. low-grade fever or none Rash: maculopapular, initially on the face/behind ears before spreading to the whole body, usually fades by the 3-5 day Lymphadenopathy: suboccipital and postauricular

Answer 54

Yes - 5 days from onset of rash

Answer 55

* **Ask about contact with pregant women** * School exclusion for 5 days after rash onset * Antipyretics for fever * No effective antiviral treatment ## Footnote *Prevention lies in immunisation*

Answer 56

* arthritis * thrombocytopaenia * encephalitis - usually ~6 days after rash * myocarditis Pregnant women - if contracted during weeks 8-10 of pregnancy there is a 90% risk of congenital rubella syndrome

Answer 57

* sensorineural deafness * congenital cataracts * congenital heart disease (e.g. patent ductus arteriosus) * growth retardation * hepatosplenomegaly * purpuric skin lesions * 'salt and pepper' chorioretinitis * microphthalmia * cerebral palsy