4 yo female p/w 3 days of fever (tmax 102), 2 days of progressive non-pruritic rash on face/extremities, decreased PO/UOP, emesis x 1 (nonbloody,non-bilious), diarrhea x 2 (non-bloody), increasing fatigue x 5d, refusing to eat and walk       Meds: tylenol PRN Allergies: NKDA PMH: none FMH: neg Immunizations: received 4 yo shots several months ago Social: stays at home w/ mom, no travel history, older siblings with cold like symptoms, no rash Arthritis/Arthralgias  Desquamation  Lymphadenopathy  Meningitis  Enanthems (mucosal involvement)  Ulcerative vesicular lesions  Palm and Sole involvement  Predominantly on extremities  Respiratory Symptoms/Pulmonary infiltrates   Immunized 3 yo female with acute onset of fever, progressive vesicular rash on extremities with oral mucosal involvement, mild N/V/D, non-toxic appearing  Single-stranded RNA viruses** › Picornaviridae family  Polioviruses  Coxsackieviruses (Group A and B)  Echoviruses  Enteroviruses (serotypes 68-71)  “Summer viruses” ** › *Increased prevalence in summer months (May – October) › All year round in tropical climates (NOLA) Most cases involve children under age 5  Humans are only hosts  Fecal-oral is most common route  › Then replicates in lymph nodes of respiratory and GI systems › Initial viremia → heart, liver, skin › CNS infection usually the result of second major viremia    Most patients are mildly ill & recover completely Most common → febrile illness, viral exanthem, vomiting, diarrhea, and malaise Others: › › › › › › › › › › Hemorrhagic conjunctivitis Pharyngitis Herpangina Hand-foot-and-mouth disease Paralysis Hepatitis Myocarditis Pericarditis Encephalitis Aseptic meningitis A 6-day-old infant is brought to the ER in August with a 1-day history of decreased feeding, decreased activity, tactile fever, and rapid breathing. He was born at term. His mother reports that she had a nonspecific febrile illness 1 week before delivery for which she received no treatment. Her GBS screen was positive at 36 weeks' gestation, and she received two doses of ampicillin (>4 hours apart) during labor. The baby received no antibiotics and was discharged at 48 hours of age. Physical examination today reveals a toxic, lethargic infant who is grunting and has a temp of 39.4°C, HR of 180, and RR of 60. His lungs are clear, with subcostal retractions. He has a regular heart rhythm with gallop, his pulses are thready, his capillary refill is 4 seconds, and his extremities are cool. Of the following, the MOST likely cause of this baby's illness is A. early-onset group B Streptococcus infection B. echovirus 11 infection C. herpes simplex virus infection D. hypoplastic left heart syndrome E. respiratory syncytial virus infection High risk for developing disseminated infection  Severe manifestations:  › › › › › › › Fulminant Hepatitis Myocarditis Pneumonitis Meningitis Encephalitis DIC Multiorgan failure acquired from nurseries, or from symptomatic mothers (fever 1 week prior to delivery)  Symptoms develop at 3-7 days of life  Signs include  › mild listlessness, anorexia, transient respiratory distress, jaundice,  Viral culture** › Stool, throat, blood, CSF, or tissue › 8 to 10 days  PCR** › Only small sample needed › Results in 24 hours  Serology › Based on increase in antibody titers › Too many enterovirus serotypes to be practical  Testing by PCR has been associated with decreased IV abx use, ancillary testing, and hospital length of stay  Allows for patient isolation if necessary (ie, NICU)  Supportive care  Antivirals under investigation  IVIG may benefit immunodeficient patients › Also used in some with myocarditis or persistant meningoencephalitis  Contact precautions  HAND WASHING!!! 1-4 yo  Incubation period 3 to 7 days  Prodromal phase of malaise, sore throat, mouth pain, anorexia and low grade fever  Coxsackie A16 virus  Oral lesions  Painful vesicles in mouth and on hands and feet › Surrounded by an erythematous margin  Nonvesicular lesions on buttocks, GU and extremities less commonly  Onychomadesis – proximal separation of the nail plate from the nail bed Most resolve spontaneously w/in 3d-1wk  Treatment is supportive  Hydration and analgesics  Magic Mouthwash  › Maalox › Benadryl › Viscous lidocaine Moderately contagious  Spread by direct contact with nasal discharge, saliva, blister fluid, or stool  Most contagious during the first week of the illness  › Can shed virus in stool for up to 8 weeks › No day care/school during the first few days of illness and in setting of open lesions Analgesia: Avoid aspirin (acetaminophen and ibuprofen are ok)  Diet: cold, soft foods, dairy, nothing spicy  Prevent spread: wash hands often, especially after using the bathroom  Avoid others during the first week of illness to prevent spread, avoid pregnant women  Coxsackie group A  Ages 3 -10 years  Incubation period 4-14 days  Prodromal phase  › Malaise, HA, N/V, myalgias, anorexia › sore throat and mouth pain 1-2 days prior to lesions › Fever (low grade > high) Erythematous ring surrounds  Puntate macules  vesiclulate, ulcerate  Anterior tonsillar pillars, soft palate, posterior pharynx  Self-limited  Resolve spontaneously within 1 week  Supportive care  › Young children are at risk of dehydration Ages 6 mo – 5 yo (peaks at 2yo)  Incubation 2 days – 2 weeks  Prodrome: fever, irritability, malaise, HA, PO, lymphadenopathy (cervical, submandibular)  Low to high grade fever   Red, edematous gingivae › bleed easily  Small vesicles ulcerate and coalesce › Large ulcerations with erythema surrounding  Buckle mucosa, tongue, gingiva, hard palate, pharynx, lips, perioral skin Diagnose with culture, PCR, or antigen testing  Resolve in 10 to 14 days  Treatment is supportive  › Hydration and analgesics  Acyclovir › If patients present in the first 72-96 hrs of disease, unable to drink or have significant pain  After resolution, reside in trigeminal ganglia Typically found in older children and adults  Not associated with infection  Can be associated with autoimmune disease (SLE, IBD)  Exquisitely painful ulcers  Large, yellow, pseudomembranous slough with erythematous border   Topical creams may help Usually not recommended  Benzocaine (orajel) › associated with methemoglobinemia  viscous lidocaine › may cause problems if absorbed systemically › may choke on secretions › may chew their buccal mucosa Herpangina ages Hand, Foot, Mouth Disease 1-4 yo Aphthous Stomatitis 3-10 yo Herpetic Gingivostomatitis 6mos – 5 yo Incubation 3-7 days 4-14 days 2 days – 2 weeks N/A prodrome Malaise, sore throat, mouth pain, anorexia Malaise, HA, N/V, sore throat, mouth pain, anorexia Usually none fever Usually low grade Usually low grade irritability, malaise, HA, anorexia, submandibular and cervical lymphadenitis Low-High grade fever Description of lesions Mildly painful Vesicles surrounding erythema (may ulcerate) Painful Vesicles/ulcers with surrounding erythema Vesicles that ulcerate and coalesce Beefy red gingiva Location of lesions Hands, feet, mouth (buccal mucosa and tongue), occasionally nonvesicular lesions on buttocks, genitals and extremities Anterior tonsillar pillars, Buccal mucosa, tongue, soft palate, posterior gingival, hard palate, pharynx pharynx, lips, perioral skin Exquisitely painful Large Ulcers , yellow pseudomembranous with erythematous border lips, tongue, buccal mucosa Most common virus, season Coxsackie A16 summer 1 week Symptomatic tx Group A Coxsackie summer 1 week symptomatic tx Duration and treatment HSV 1 Year round 10-14 days Acyclovir, symptomatic tx Older children , adults Usually none none Variable, can recur, symptomatic tx MEASLES Coxsackie A - HFM Rubella Parvovirus B19- Fifth’s Disease- Erythema Infectiosum Varicella RMSF HHV6- Roseola  Clue: This patient had a h/o 3 days of fever (that has since defervesced) before the appearance of the rash Scarlet Fever- Group A Strep Toxic Shock Syndrome  Clue: You might be more suspicious of this illness if this picture was a hypotensive woman Staph Scalded Skin Steven-Johnson-Syndrome Kawasaki Disease Meningococcemia EBV- mono  Clue: This patient was recently treated with Ampicillin  Who can name the original 6 childhood exanthems? (1st disease, etc) 1st disease: Rubeola, Measles  2nd disease: Scarlet Fever (s. pyogenes)  3rd disease: Rubella, German Measles  4th disease: Staph Scalded Skin Syndrome, Filatow-Duke’s Disease, Ritter’s Disease  5th disease: Erythema Infectiousum (parvo)  6th disease: exanthem subitum, roseola (HHV 6 or HHV 7) 