EMERGING VECTOR-BORNE DISEASES IN CHILDREN DR SV PATIL PROF AND HEAD PAEDIATRICS BLDE-UNIVERSITY SRI BM.PATIL MEDICAL COLLEGE BIJAPUR

EMERGING VECTOR - BORNE DISEASES IN CHILDREN DR SV PATIL PROF AND HEAD PAEDIATRICS

Dengue fever Ricketsial fever Chickungunya fever Japanese encephalitis Malaria

Dengue fever

5 Case Rahul, 4 year male child presents with – Fever high grade, vomiting for 4 days – Treated with paracetamol but little response – Monsoon time and a case of dengue in neighborhood reported recently – How will you proceed in such a case? Ask Look Test

6 Ask for …… Localizing symptoms: – Cough, cold, ear ache: Tonsillitis, AOM, Sinusitis – Loose stools: Rotaviral, bloody diarrhea – Urinary symptoms: UTI – Boils: SSTI Without focus: – Pattern of fever, Well between fever spikes, history in contacts, coryza, systemic symptoms (myalgia) – Vaccination: Hib, typhoid, measles, MMR Danger symptoms: Lethargy, refusal of feeds, irritability, oliguria, convulsion, cold extremities (Serious infections)

7 Look for ….. Vitals: Pulse, CRT, BP/Pulse pressure, Tourniquete test, Skin rash Focus like: – Liver/spleen/LN, ascitis – Resp: Conj congestion, Coryza, Throat/Otoscopy, RR, Grunt, retractions, effusions – CNS: Alertness, FND, meningeal signs – Other systems

8 Test for ….. Test for (now or later?) – CBC, PS for MP (repeat if no response) – Urine analysis – culture SOS – Blood culture?? – X ray chest (If resp signs) – Repeat tests (CBC) SOS – Others: CRP, SGOT, SGPT, Widal, Dengue serology, RMT ????

9 Case continues …. Rahul’s tests done show: CBC: – Hb 13 gm%, HCT 40%, – WBC 3200, P 40, L 56 E 3, M1 – Platelets: 1.2 lakhs PS for MP: Negative Urine analysis: Albumin nil, Pus cells 2-3/hpf X ray chest: Normal DD: Malaria, Dengue, Viral fever, Enteric fever, Leptospirosis etc

10 Case continues ….. Rahul’s fever is persistent He now has some rash on his body He seems to have body ache and restlessness His mother repeats his investigations

11 Case continues …. Day 4Day 6 Hb1315 HCT4045 WBC DCP40, L56, E3, M1P34, L60, E5, M1 Platelets120,00070,000 PS for MP-ve Urine RoutineNormal Mother wants to know whether it is dengue and whether she should ask for dengue tests?

12 Which laboratory tests? Test for confirming dengue – NS1 Antigen, ELISA for IgG & IgM Need, timing, interpretation

13 Interpretation of dengue serology NS1 antigenIgMIgGInterpretation +ve-ve Early (< 4dys) -ve/+ve+ve-vePrimary -ve+ve+ve low titersCurrent/Recent -ve/+ve+ve+ve high titerSecondary -ve +ve High titersSecondary -ve +ve low titersPast infection Most important for preventing morbidity and mortality is serial clinical monitoring and CBC Do not withhold fluid therapy pending labs/-ve labs * * Exception being congenital dengue (in 1 st 3 months of life)

14 Case continues ….. Rahul is drinking and eating though less than before His fever is better with paracetamol He has passed urine 3-4 times since morning Mother wants to know whether she should admit Rahul in hospital?

15 Course of dengue illness Critical phase: Falling WBC & Platelets  Plasma leak & Rising HCT – 3 rd spacing  Shock, organ dysf., Acidosis, DIC  Severe bleeding with  HCT &  in WBC  Severe shock, organ damage & death.

16 WHO classification of dengue DF gradeClinical criteriaLaboratory criteria DFFever with 2 or more of following signs: Headache, retro-orbital pain, myalgia, arthralgia Leukopenia, occasionally thrombocytopenia with no plasma leakage DHF IAbove signs plus +ve tourniquete test HCT rise > 20% platelets < 100,000 DHF IIAbove signs plus spontaneous bleeding HCT rise > 20% platelets < 100,000 DHF III (DSS) Above signs plus circulatory failure HCT rise > 20% platelets < 100,000 DHF IV (DSS) Profound shock with undetectable BP and pulse HCT rise > 20% platelets < 100,000 Not suitable in all situation; severe dengue in absence of criteria

17 Suggested dengue classification Criteria for dengue +/- warning signs Without With warning signs 1) Severe plasma leakage 2) Severe hemorrhage 3) Severe organ impairment Dengue +/- warning signs Severe Dengue Criteria for severe dengue Probable dengue Live in/travel to dengue endemic area. Fever and 2 of the following criteria Nausea, vomiting Rash Aches and pains +ve tourniquete test Leukopenia Any warning sign Warning signs Abd. Pain & tenderness Persistent vomiting Clinical fluid accum. Mucosal bleeds Lethargy, restlessness > 2 cm liver enlarged Lab:  HCT with rapid  in platelets Severe plasma leakage Shock (DSS) Fluid accumulation with respiratory distress Severe bleeding As evaluated by clinician Severe organ involvement Liver: AST/ALT > 1000 CNS: Impaired consc. Heart & other organs

18 Management principles Step 1. Overall assessment: History, examination, labs Step 2. Diagnose & assess phase/severity of disease Step 3. Management: Disease notification Management decisions: Group A (to be sent home) Group B (in-hospital management) Group C (emergency treatment & referral)

19 Case continues ….. Rahul is drinking and eating though less than before His fever is better with paracetamol He has passed urine 3-4 times since morning Mother wants to know whether she should admit Rahul in hospital?

20 Group 1 (Home care) It includes those who: – Can tolerate adequate volume of oral fluids – Pass urine 4-5 times in 24 hours – No warning signs Rx: 5-6 glasses of ORS, Juices, other fluids, Paracetamol (NO NSAIDs/Mefenimic acid) FU: Daily FU till defervescence period is over at home by care taker and at clinic by medical professional for – Intake, output, repeat CBC, look for warning signs, response to therapy, deterioration or warning signs

21 Case continues ….. Rahul is now sick looking He has vomited several times and is not able to drink well He has developed cold hands and feet He is irritable and restless He has not passed urine for 8 hours Mother wants to know whether she should admit the child?

22 Group 2 (In-hospital Rx) Includes those with warning signs: Abd. Pain & tenderness Clinical fluid accum. Lethargy, restlessness Lab:  HCT/  in platelets High risk for complications like pregnancy, infancy, old age, obesity, diabetes mellitus, renal failure, chronic hemolytic diseases Difficult social situation (far away/living alone) Persistent vomiting Mucosal bleeds > 2 cm liver enlarged

ml/Kg/hr x 1-2 hr 3-5 ml/Kg/hr x 2-4 hr 2-3 ml/Kg/hr x 2-4 hr Clinical/CBC monitoring Taper over hr Response seen Worsening 5-10 ml/Kg/hr x 1-2 hr Clinical/CBC monitoring Response seenWorsening Severe shock Monitoring: Clinical q 1-4 hr; Urine output q 4-6 hr; CBC q 6-12 hr; Organ function tests sos Management of Group 2 with danger signs Refer to 3 0 care

24 Group 3 (Referral to tertiary care) Includes those with severe dengue (DSS): – severe plasma leakage leading to dengue shock and/or fluid accumulation with respiratory distress – severe hemorrhages – severe organ impairment (hepatic damage, renal impairment, cardiomyopathy, encephalopathy or encephalitis) Need access to intensive care, blood products and colloids

Dr. Nitin Shah25 Compensated shock (systolic pressure maintained but has signs of reduced perfusion) O2, Fluid resuscitation with isotonic crystalloid 5–10 ml/kg/hr over 1 hour Improvement IV crystalloid 5–7 ml/kg/hr for 1–2 hours, then:  to 3–5 ml/kg/hr for 2–4 hours;  to 2–3 ml/kg/hr for 2–4 hours. Improvement -  fluid further. Monitor HCT 6–8 hourly. Not stable, act according to HCT levels: if HCT , consider bolus or increase fluid administration; if HCT , consider fresh whole blood transfusion. Stop at 48 hours. No improvement HCT  or high HCT low Check HCT Significant Bleeding – consider Fresh whole blood transfusion 2 nd bolus ml/Kg for 1 hr Improvement No improvement  Fluids to 7–10 ml/kg/hr for 1–2 hours then  further

26 Hypotensive shock O2, Fluid resuscitation with isotonic crystalloid or 20 ml/kg over 15 min Improvement IV cryst./colloid 10 ml/Kg x 1 hr IV cryst. 5–7 ml/kg/hr x 1–2 hours 3–5 ml/kg/hr x 2–4 hours 2–3 ml/kg/hr x 2–4 hours. Improvement -  fluid further. Monitor HCT 6–8 hourly. Not stable, act according to HCT levels: if HCT , consider bolus or increase fluid administration; if HCT , consider fresh whole blood transfusion. Stop at 48 hours. No improvement HCT  or high HCT low Check 1st HCT Significant Bleeding – Fresh whole blood transfusion 2 nd bolus colloid ml/Kg for ½-1 hr ImprovementNo improvement Check 2 nd HCT HCT  or high HCT low 3 rd bolus colloid ml/Kg over 1 hr Improvement No improvement Check 3 rd HCT Fluid refractory shock

27 Case continues ….. Rahul was admitted in hospital and treated with IV fluids and he responded well His serial CBC showed platelets of only 30,000 He has some skin rash and mild epistaxis Mother insists on giving platelet transfusion to Rahul

28 Use of blood products At risk: – Profound shock, hypotension, NSAIds, Trauma (procedures), liver disease Recognition: – Falling HCT on fluid resuscitation with unstable hemodynamics, – Overt bleeding irrespective of HCT – Refractory/hypotensive shock, worsening metabolic acidosis Treatment: – Fresh PRBC or whole blood (Rarely platelets, FFP) – No role of prophylactic platelets!!!!

29 Case continues ….. Rahul is now well He is eating and drinking well He is passing urine well It is 8 days and he is afebrile for 2 days His CBC shows Hb of 11 gm%, WBC 4200, P40,L56, E4, Platelets of 90,000 Mother wants to know when can Rahul go home?

30 Criteria for discharge All of the following must be present Clinical: – No fever for 48 hours – Improvement in clinical status (general well-being, appetite, haemodynamic status, urine output, no respiratory distress) – Time frame for critical phase over Laboratory: – Increasing trend of platelet count – Stable hematocrit without intravenous fluids

RICKETTSIAL INFECTIONS

Rickettsial Infections Symptoms-- FEVER headache myalgia rash and eschar generalized lymphnodes,and hepatosplenomegaly RASH-PALMS AND SOLES

GI- symptoms-Nausea,Vomiting Abd pain, Diarrhoea RS-Cough, Distress, CNS-Dizziness,Disorientation, Photphobia and Visual disturbances Others include-periorbital edema,conjunct congestion Epistaxis,hearing loss and arthralgia

SEVERE SYMPTOMS Interstitial Pneumonia, Pulmonary edema CNS-Meningoencephalitis syndrome Renal-ARF Disseminated Intravascular Coagulation,Hepatic failure and Myocarditis.

Laboratory findings Hematology-TLC-is low and leucocytosis Platelets less in 60% ESR is high Hyponatremia,,Hypoalbunemia,Thrombocytop enia SGOT- elevated Weil Felix test (5-7) days PCR- Immunoflorescence(gold standard)

Diagnosis Fever-PUO- Fever with rash(palms and soles) Tick bite and exposure Epidemiological data Lab findings- Defervescence with antibiotics DD-Measles,Dengue,Inf mono,Malaria Typhoid TSS and CVD

Treatment Tetracyclin,Doxycyclin Chloromycetin, Macrolides and Quinolines 5mg/kg in 2 doses min 5-7 days, and Supportive therapy.

JAPANESE ENCEPHALITIS

Case Definition of Suspected case: - Acute onset of fever, not more than 5-7 days duration. - Change in mental status with/ without  New onset of seizures (excluding febrile seizures)  (Other early clinical findings. may include irritability, somnolence or abnormal behavior greater than that seen with usual febrile illness)

JE

JE- CONTD Laboratory-Confirmed case : A suspected case with any one of the following markers:  Presence of lgM antibody in serum and/ or CSF to a specific virus including JE/Entero Virus or others  Four fold difference in lgG antibody titre in paired sera  Virus isolation from brain tissue  Antigen detection by immunofluroscence  Nucleic acid detection by PCR In the sentinel surveillance network, AES/JE will be diagnosed by lgM Capture ELISA, and virus isolation will be done in National Reference Laboratory.

CHICKUNGUNYA FEVER

Triad of fever, rash and joint manifestations Clinically-fever>38.5,severe arthralgia(possible) Epidemiological-visit epidemic area 15 days prior to symptoms.(probable) Lab-isolation virus, PCR IgM AND IgG (confirmed)

Caused by-chik virus, aedes aegypti vector (human-mosq-human)-post mansoon Monkeys rodents birds and others. Symptoms-fever(92%),arthralgia(87%),back ache(67%) and head ache(62%) Differs from adults-

CommonInfrequentRare in adults but seen sometimes in children FeverRashPhotophobia ArthralgiaStomatitisRetro-orbital pain BackacheOral ulcersVomiting HeadacheHyperpigmentationExfo liative dermatitis Diarrea Meningeal syndrome Acute encephalopathy

SEQUELAE Arthralgia resolves in 87%,3.7% episodic stiffness and 2.8% persistent stiff Lab diagnosis–virus isolation PCR IgM antibody and rising IgG titres Differential diagnosis –Leptospirosis,dengue fever,malaria,meningitis and rheumatic fever

Management First contact-Differential diagnosis should be thought Assess dehydration(severe,mild to moderate) Total leucocyte count->10,000-leptospira, and <50,000 –dengue fever peripheral smear-MP Paracetamol mg/kg/day Exercise and physiotherapy

48 Thank you all!