Infectious diseases with exanthema syndrome Lecturer: Gorishna Ivanna Lubomyrivna

Plan of the lecture Clinical, epidemiological peculiarities, differential diagnosis, treatment and prevention of Measles Clinical, epidemiological peculiarities, differential diagnosis, treatment and prevention of Rubella Clinical, epidemiological peculiarities, differential diagnosis, treatment and prevention of Scarlet fever Clinical, epidemiological peculiarities, differential diagnosis, treatment and prevention of Pseudotuberculosis Clinical, epidemiological peculiarities, differential diagnosis, treatment and prevention of Chickenpox

Measles Etiology: Measles virus - RNA virus, that belongs to the Paramyxoviridae family, Morbillivirus genus.

Transmission Source of infection – infected person during last 2 days of incubation period, catarrhal period, and 4 days period of eruption (in case of complications –10 days period of eruption). Infection is spread by inhalation of large and small airborne droplets. Susceptible organism - no immunized persons, older than 6 month, which never had measles.

Pathophysiology Local replication in the respiratory epithelium. Viremia - virus is spread by leukocytes to the reticuloendothelial system. necrosis of leukocytes, a secondary viremia occurs. specific antibody and cell-mediated responses - the illness resolves. Measles causes an immune suppression. It may predispose individuals to severe bacterial infection, particularly bronchopneumonia, a major cause of measles-related mortality among younger children.

Clinical presentation The incubation period 9 - 17 (21!) days. Prodromal period - 3 - 5 days. Temperature is usually high at first day. The classic three “C’s” (cough, coryza, conjunctivitis). the enanthema or Koplik’s spots. They usually disappear by the second day of the exanthema.

Measles conjunctivitis

Koplik’s spots

Measles enanthema

Exanthema period: 3-4 days Second increase of temperature. Initial lesions on the forehead and face. During 3-4 days they spread downward The rash is red maculopapular, initially discrete then confluent. Ctarrhal signs progress Koplick’s spots and enanthema remain for 1-2 days Pigmentation period (1-1.5 weeks) Pigmentation progresses in the same fashion as the rash, than desquamation (microscalling) Normalisation of the temperature Ctarrhal signs resolves

Measles, typical rashes, 1st day

Measles, typical rashes, 2nd day

Measles, hemorrhagic rashes

Measles, pigmentation period

Classification By the form: typical, by the severity: mild; moderate; severe (without hemorrhagic syndrome, with hemorrhagic syndrome); Atypical - abortive; mitigious; hyperreactive; subclinical; asymptomatic; measles in vaccinated; measles in person who receive antibiotics and hormones. By the course: smooth (uncomplicated); not smooth, uneven (complicated).

Complications By the time of development: By the localization: early (in prodromal and rashes period) late (in pigmentation period).  By the localization: respiratory system; digestive system; nervous system; eyes; ears; skin; urinary system.

Complications: primary (viral) laryngotracheitis (croup), bronchitis, encephalitis, Giant-cell pneumonia diarrhea keratoconjunctivitis Rare complications include hepatitis, encephalitis.

Complications: secondary bacterial otitis media, pneumonia, gingivostomatitis, pyelonephritis, diarrhea, dermatitis.

Peculiarities of measles in infants Atypical (mitigious) forms Shortened periods of the disease Mild clinical signs (catarrhal phenomena, fever, small rash with the shortened appearing and pigmentation) Complications are more frequent.

Laboratory work-up common laboratory tests are non-specific. leukopenia, lymphocytosis, eosynophylia, and thrombocytopenia (may be) serological test (DHAR, PHAR), Immune enzyme analysis virus isolation (nasopharyngeal smears) is technically difficult Cytoscopic examination presence of typical multinuclear giant cells

Differential diagnose scarlet fever, Epstain-Barr viral infection, meningococcal sepsis, pseudotuberculosis, Stevens-Johnson syndrome, adenovirus, enterovirus infection.

Scarlet fever, localisation of rashes

Allergic rashes

Meningococcemia

Stevens-Johnson syndrome

Adenovirus infection

Treatment Adequate hydration, bed rest; vitaminized food; Antipyretics for fever control: paracetamol 10-15 mg/kg not often than every 4 hours or ibuprophen 5-10 mg/kg per dose, not often than every 6 hours. Nasal decongestants not more than 3 days, in infants before 6 mo physiologic saline solution Mucosolvents and cough supressors; Vitamin A 200 000 Units orally daily Care for oral cavity, conjunctiva.

bacterial complications – antibacterial therapy severe episodes – corticosteroids (1-2 mg/kg for 2-3 days). croup: mist tent with 25-30 % oxygen inhalation, antianxiety medicines, steroids and mechanical ventilation in severe cases. meningitis: steroids, dehydrates, parenteral detoxication (albumin, plasma), anticonvulsants.

Prevention Specific active immunization by MMR vaccine (measles, mumps, rubella) at age 12 months. Revaccination at 6 years. Specific passive postexposure prophylaxis with serum immune globulin in a dose of 0.25 ml/kg, within 3 days of exposure. Nonspecific isolation of ill person until 5th day of the exanthema period, isolation of contact person from 8th to 21st day after exposure.

Rubella (German measles) It is caused by RNA rubella virus, which belongs to the Togaviridae family, Rubivirus genus.

Transmission the source of infection is a patient or carrier the mechanism of transmission is air-droplet, transplacental receptivity is common, especially high in children 2-9 years

Pathophysiology: Acquired Rubella: The primary cite of infection (atrium) - mucus membranes of nasopharynx, replication. hematogenous distribution (viremia). Damage of organs and systems. Immunological response, recovery. Congenital Rubella: Transplacental infection of the fetus. destruction of the cells by the virus (cytotoxic defect), violation of the organs’ development. Forming of the congenital defects.

CLINICAL PICTURE of the Acquired Rubella Incubation period is 14-21days Prodromal phase: 1-2 days before the onset of rash: Headache; Low-grade fever; Chills; Anorexia; Nausea; Eye pain, Conjunctivitis; Sore throat; Tender lymphadenopathy (particularly posterior auricular and suboccipital lymph nodes); Forchheimer sign - pinpoint or larger petechiae that usually occur on the soft palate

Exanthema phase (period): a discrete rose-pink maculopapular rash ranging from 1- 4 mm covers all the body through 1 day More intensive on external surfaces of the body Disappears in 2-3 days without pigmentation and scalling Temperature: Fever usually is not higher than 38.5°C. Lymph nodes: Enlarged posterior auricular and suboccipital lymph nodes. Mouth: The Forchheimer sign may still be present.

Rubella

Diagnostic criteria of the congenital Rubella Classical Triad: Cataract Congenital heart disease (patent ductus arteriosus, aortic valves defect, aortic stenosis, coarctation of the aorta, ventricular septal defect, pulmonary stenosis, atrial septal defect, transposition of the main arteries) Deafness

Classification of the acquired Rubella By the type: typical forms atypical forms (effaced, asymptomatic) By the severity: Mild Moderate Severe By the course: smooth (uncomplicated) uneven (complicated) Specific complications: meningitis, encephalitis, synovitis

Treatment Basic therapy: Hygienic regime, often room ventilation Control of fever – as in measles

Prevention: Isolation: for 4 days after the onset of rash in patients with acquired rubella. Contact isolation for children with congenital rubella infection until 1 year unless nasopharyngeal swab and urine cultures after age 3 months are repeatedly negative. Specific active –– MMR vaccine. The first dose of MMR at 12-15 months. The second dose of MMR at 6 years. Girls of 15 years if were not vaccinated before – Rubella monovaccine. Specific Passive prophylaxis for seronegative pregnant.

Chickenpox (Varicella) Etiology: Varicella–zoster virus from Herpesvirus family Transmission: Source of infection - ill person Chickenpox or Herpes zoster Is transmitted by respiratory route or by the direct contact. Susceptible organism - everyone, who didn’t ill before. Lifetime immunity.

Pathogenesis Inoculation of virus and it’s replication in epithelial cells of upper respiratory tract. Regional lymphadenitis. Viremia. Damage of the skin epithelium and mucosa epithelium. Generalization of the infection in immunecompromised persons. Damage of the nervous system (cerebellum).

Clinical presentation incubation period 11 to 21 days contagious period 1 to 2 days before the rashes erupt until all of the lesions have crusted (5 days after the last rashes have appeared) Prodrome 1 to 2 days fever, headache, malaise, and anorexia.

rashes, often pruritic, maculae  papule  vesicle  crusted lesion. first appear on the face or trunk are more numerous centrally than distally. erupt in crops for 3 to 4 days Polymorphism Lesions on the mucous membranes do not crust but form a shallow ulcer.

Chickenpox

Chickenpox, typical localization of rashes

Chickenpox, rashes on mucus membranes

Classification By the type: typical forms atypical forms (subclinical, bullous, hemorrhagic, gangrenous, generalized) By the severity: Mild Moderate Severe By the course: smooth (uncomplicated) uneven (complicated)

Hemorrhagic form

Complications secondary bacterial - Staphylo- or streptodermia otitis, pneumonia Viral: pneumonia croup Encephalitis (involvement of the cerebellum, or cerebrum) less common – Guillain-Barre syndrome, transverse myelitis, optic neuritis, and facial nerve palsy.

Phlegmona

Rare complications idiopathic thrombocytopenic purpura, nephritis, myocarditis, arthritis.

Laboratory investigations In CBC: leucopenia, lymphocytosis, normal ESR. Vesicle scrapings contain multinucleated giant cells, and vesicle fluid contains virus Immune enzyme method Serological reactions: CBR, IHAR CSF investigation – in case of meningoencephalitis.

Treatment antiseptic fluids for skin lesions; antihistamines for itching; Gurgling with oral antiseptic fluids after the food intake paracethamol or ibuprophen for fever control. Acyclovir for immune compromised children, generalized forms, thrombocytopenia, neonatal varicella – (IV 10 mg/kg 3 t.d. for 7 days or up to 48 hours after the last elements) Severe forms - orally 80 mg/kg/day 4 t.d. for children elder than 2 years and teenagers. Also for severe cases in neonates – varicella-Zoster immune globulin (0.2 ml/kg).

Prevention Nonspecific To isolate ill person until the 5 day after the last vesicles has appeared. To isolate contact persons from 9 till 21 day after exposure. Specific passive - VZ immune globulin in immunecompromised children within 72 hours of exposure. Specific active - VZ-vaccine

Scarlet fever Scarlet fever is an acute infectious disease, that is caused by group A β-hemolytic streptococcus

Epidemiology: a source of infection – ill person not only with scarlet fever, but another forms of GABHS-infections (sore throat, tonsillitis, erysipelas, streptodermia). – Infection is spread by inhalation of infected airborne droplets. – Susceptible organism – children 2-9 years old.

Pathogenesis Incubation period is short, not more than 7 days has three lines: 1. Toxic (toxic damage of cardiovascular, central nervous, endocrine systems). 2. Septic (tonsillitis, secondary bacterial complications). 3. Allergic (depression of immunity leads to allergic complications). Incubation period is short, not more than 7 days

Clinical presentation: acute onset fever (often above 39C), sore throat (often with dysphagia), Erythema and enanthema on the soft palate. purulent tonsilar exudates. Anterior cervical lymph nodes are tender and enlarged. Coated than swollen, red tongue (strawberry tongue). Other features are nausea and vomiting, headache, abdominal discomfort.

Scarlet fever, pharyngitis, enanthema

Scarlet fever, pharyngi-tis, tonsillitis

Strawberry tongue

a rash appears 1-2 days after the onset. first on the neck and then on the trunk and extremities through 24 hours. dusky red, blanching tiny papules that have a rough texture ("sand paper" sign). flushing face with circumoral pallor (Filatov’s sign). the rash is intensified in skin folds and at sites of pressure. Pastia’s lines: In the antecubital and axillary fosses linear petechiae with accentuation of the erythema. Papules are usually absent at palms, and soles

Scarlet fever, localisation of rashes

Scarlet fever, morphology of rashes

Scarlet fever, intensive rashes in the sites of pressure

Filatov’s sign

Pastia’s lines

The exanthema lasts 4 - 5 days then desquamate, first on the face last on the palms and soles. Pharyngitis usually resolves in 5 to 7 days.

Desquamation of the skin

Classification 1. Form: typical; atypical: subclinical; extra pharyngeal (burns, wounds, post-natal, after operations, delivery); with aggravated symptoms (hypertoxic, hemorrhagic). 2. Severity: mild; moderate; severe: toxic, septic, toxic-septic. 3. Course: smooth; uneven (relapses, complications).

Purulent Complications: otitis media, lymphadenitis, perytonsilar abscess, necrotizing tonsillitis, sepsis, Pneumonia, Sinusitis, Meningitis, Bone or joint problems (osteomyelitis or arthritis)

Necrotizing tonsillitis

Perytonsillitis

Perytonsillar absces

Streptodermia, strawberry tongue

Allergic Complications rheumatic fever, myocarditis, arthritis, nephritis.

Laboratory tests 1. The diagnose is confirmed by throat culture 2. Serology (antistreptolizin O, antideoxyribonuclease B) may be useful for documenting recent GABHS infection. 3. The CBC: WBC is higher 12.5 * 109/L with left shift, eosynophilia, elevated ESR

Treatment: Bed rest during an acute period. Etiological treatment : In the mild case: The course of treatment is 10 days. penicillin orally 50,000-100,000 EU/kg/day divided in 3-4 doses or: Erythromycin (or another macrolides) is alternative antibiotic (30 –50 mg/kg/day). In the moderate case: The course of treatment is 10-14 days. penicillin intramuscularly, the same dose In the severe case: intravenously for 10-14 days cefalosporins of the 1st-2nd generation, or klindamycin, or vancomycin.

Treatment: Detoxication therapy: Antihistamines (in average doses) Medicine which strengthens vascular wall (vit. C and PP: ascorutin, galascorbin) Control of fever Local treatment with antiseptic fluids (gurgling), UV-insolation. Patient may go home from infection department not earlier the 10th day of the illness, in 10 days blood analysis, urinalyses, ECG must be repeated.

Prevention: isolation of the patient for 10 days, but he mustn’t visit school until 22 day of the disease. Contract persons (children before 8 years) should be isolated for 7 days (period of incubation).

Pseudotuberculosis (mesenteric adenitis) Etiology: Yersinia pseudotuberculosis belongs to the family Enterobacteriaceae, genus Yersinia

Epidemiology: source of infection - wild and home animals (rats, dogs, foxes, cats and other); Way of transmitting – alimentary; Susceptible organism – children (not infants), adults. Incubation period is 3-18 days

Pathogenesis: Entering the bacilli to gastrointestinal tract. Inocculation of them in enterocytes. Regional lymphadenitis (regional infection). Generalization (bacteriemia, toxemia). Parenhymatous phase (fixation of pathogen by liver and spleen). Immunological response, recovering from disease. May be secondary bacteriemia (exacerbations and relapses).

Clinical criteria Complaints: malaise, fatigue, headache, sleepless, anorexia, arthralgias, muscle pain, sore throat, nausea, abdominal pain, dyspepsia. Rash: maculopapulous (like in scarlet fever), may be erythematous. The eruption is characterized by dusky red, tiny papules. The rash is present on face, intensified periorbitally, on the neck (“glasses” symptom, “hood” symptom); on the body the rash is intensified in skin folds, at the sites of pressure, on the hands, feet, (“gloves”, “socks” symptom), round the joints. The exanthema usually lasts 4 to 5 days and then begins to desquamate, first on the face and last on the palms and soles.

“hood” symptom

“socks” symptom

Erythema nodosum

Desquamation on buttocks

Desquamation on palms

catharral syndrome - pharyngeal and tonsilar erythema conjunctivitis, rhinitis “strawberry” tongue Abdominal syndrome; tenderness during the palpation of abdomen, may be acute appendicitis. Dyspepsia: nausea, vomiting, liquid feces. Hepatomegaly, rare – splenomegaly, lymphadenopathy. Hepatitis with or without the jaundice. Arthritis of knees, elbows, foot and hand joints or arthralgia. Toxic myocarditis. Toxic nephritis, pyelonephritis. Bronchitis or pneumonia may also develop.

“strawberry” tongue

Complications: Appendicitis, Bacteriemia, Diffuse ulceration and inflammation of the small intestine and colon, Intussusception, Meningitis, Osteomyelitis, Peritonitis.

Laboratory findings CBC: Bacteriological – Serological – leucocytosis, neutrophilia with left shift, eosynophilia, ESR is enlarged. Bacteriological – Yersinia Pseudotuberculosis may be found in feces, urine, blood and throat mucus. Serological – (AR, IHAR with diagnostic tires 1:200 and more). Immune-enzyme analysis Specific antibodies Ig M are positive in an acute phase of the disease.

Treatment Regime and diet Etiologic: -by chloramphenicol 10-15 mg/kg 3 or 4 times per day during all period of pyrexia and plus 3 days (no less then 14 days). Alternative antibiotics: cefalosporins of the 3rd-4th generation. In severe case combination together with aminoglycosides of the 3rd generation (IM, IV). Pathogenetic: detoxication oral or parenteral; corticosteroids 1-3 mg/kg with a short course (in severe cases, in case of carditis) Antipyretics NSAIDs in case of arthritis, carditis, nodular erythema (ibuprophen, aspirin, voltaren, indomethacin in average doses)

Prevention: Eliminate reservoirs and minimize the contamination of food products. Always institute enteric precautions in the care of patients hospitalized with infection. Avoid unpasteurized milk and raw pork, particularly chitterlings, which often are consumed during the holiday season. Supervision for persons from the epidemic focus for 18 days with fecal bacteriological test.