Infectious Disease

1. A S H L E Y M A R A S S D N P , C P N P , S A N E - A
Pediatric Infectious Disease Overview

2. ID Assessment and Diagnosis
 Labs
 CBC- bacterial vs viral
 Platelet count
 CRP
 Procalcitonin
 ESR
 Cultures

3. Enterovirus
 More than 100 serotypes including A, B, coxsackievirus, and echo virus
 Transmitted via fecal oral route, respiratory, and vertical
 Most common in the summer and fall
 Include hand foot and mouth, herpangina, pleurodynia, conjunctivitis,
myocarditis, pericarditis, viral meningitis, pancreatitis, orchitis, and
neonatal sepsis

4. HSV 1
 Clinical manifestations are determined by the age, port of entry, and
immune status
 Gingivostomatitis:
 Pharyngitis with erythematous vesicles, halitosis, lymphadenopaty
 Herpes Labialis:
 Clusters of vesicles that progress to crustiness – classic cold sore
 Hand or Finger:
 Deep vesicles
 Traumatic herpetic infection

5. HSV1

6. HSV 2
 Clinical manifestations:
 Vesicopustules and ulceration with edema
 Primary lesions: vaginal mucosa, labia, perineum, and penile shaft
 Secondary lesions: generally less severe
 Neonatal Infection
 Always symptomatic
 Severe disease

7. HSV2

8. HSV
 Treatment is supportive unless the condition is life-threatening

9. Infectious Mononucleosis
 Epstein-Barr virus and Cytomegalovirus
 Most common in adolescents and young adults
 Mode of transmission- close personal contact, fomites, pharyngeal
secretions, blood transfusions
 Diagnostics:
 CBC- > 10% Lymphocytes
 Monospot- 80% accurate
 Viral culture
 EBV specific core

10. Infectious Mononucleosis
 Clinical manifestations:
 Fever- moderate to high for 3 days to weeks
 Sore throat- very painful for 7 -10 days
 Lymphadenopathy- anterior and posterior cervical nodes
 Splenomegaly
 Hepatomegaly
 Skin rash
 Periorbital edema

11. Infectious Mononucleosis
 Treatment:
 Supportive
 Fluids and calories
 Steroids and acyclovir are not recommended in uncomplicated disease
 Over the counter pain meds
 Contact sports and strenuous exercise should be avoided

12. Mononucleosis

13. Varicella
 Primary illness with reactivation leading to shingles
 Transmitted via direct contact with the lesions, droplets, and airborne
transmissions
 Victims infected with Shingles are infectious and can cause primary
infection
 Secondary infections are rare and are generally mild compared to the
primary infection.
 Diagnostics:
 Viral culture
 VZV PCR testing and ELISA

14. Varicella
 Clinical findings:
 Prodrome: low grade fever, headache, occasional URI, headache, and abdominal pain
lasting 1-2 days
 Rash: begins on the scalp, face or trunk, pruritic lesions that progress to vesicles, that
crust over after 24-48 hrs. The scabs last 5- 10 days , but are no longer contagious.
Severe fever accompanies the rash. Rash appears in all stages in all mucosal tissue.
 Treatment:
 Supportive with antihistamines for itching and acetaminophen for fever
 Immunocomprimised patients – IV Acyclovir
 Monitor for Reye’s Syndrome

15. Varicella

16. HIV: Human Immunodeficiency Virus
 35 million cases worldwide
 Africa carries 90% of the burden
 Rates increasing for 13-14 yr olds and 20-29 year olds
 50% of teen do not know they are infected
 Transmission to the infant
 In utero- 30%
 Intrapartum- 60%
 Postpartum- 15%

17. HIV
 Viral Load increases
 CD4 and T cell count decreases
 Symptoms:
 Lymphadenopathy
 Hepatosplenomegaly
 Failure to thrive
 Diarrhea
 Parotid swelling
 Bacterial infections (not as many in neonates)

18. HIV
 Testing
 Table 31-5
 Treatment
 Treatment goal- undetectable viral load
 Antiretrovirals x 3
 NNRTI and NRTI
 Newborn- Zidivudine prophylaxis protocol
 PrEP
 High risk for infection
 Daily two med regimen

19. Roseola (Exanthem Subitum)
 Also known as 6th disease
 Transmitted via oral, nasal, and conjunctival
 Occurs between 3 months and 3 years, but most commonly 6-18
months
 Diagnostics:
 CBC- decrease in WBC
 Follows a fever pattern
 Treatment:
 Supportive

20. Roseola (Exanthem Subitum)
 Clinical manifestations
 Sudden onset of fever (101-103)
 URI
 Lymphadenopathy
 Lethargy
 Injected conjunctiva
 GI complaints
 Reddened TM
 Fever breaks and rash appears
 Rash- diffuse, rose-colored maculopapular rash

21. Roseola

22. Rubeola (Measles)
 Associated with high morbidity and mortality world wide
 Transmitted via droplet, fomites, blood, urine
 Peaks in the winter and spring
 THIS IS A SERIOUS ILLNESS IN CHILDREN!!
 Only a 5% chance of contracting the virus after first vaccine and a 2%
chance after the second vaccine
 Reportable disease
 Diagnostics: IgM antibody level, viral culture from urine, blood,
nasopharyngeal secretions

23. Rubeola (Measles)
 Clinical manifestations:
 Prodromal: last 4-5 days, URI symptoms, low to moderate fever, along with the 3 C’s
of measles- cough, coryza, conjunctivitis
 Koplik spots- blue/white patches in the oral mucosa last 12-15 days
 Rash stage: begins the 3rd to 4th day of the illness with a high fever (can be as high as
105)
 Rash begins on the head, behind the ears then gradually moving to the face and neck
 Rash progresses downward- 1st 24 hrs- face, neck and arms; 2nd 24hrs- back, abdomen, and
thighs

24. Rubeola (Measles)
 Treatment
 Supportive- fluids, bed rest, antipyretics, warm, dark room
 Antibiotic treatment for secondary bacterial infections
 Complications
 Bacterial superinfections
 Myocarditis
 Black Measles
 DIC
 Enchephalitis

25. Rubeola

26. Mumps
 Viral disease with enlargement of one or more salivary glands,
including the parotid glands
 Transmitted via saliva and urine
 Most common during late winter and spring, but can occur anytime
 Diagnostics: Viral culture and IgM and IgG antibody

27. Mumps
 Clinical Findings:
 Prodromal: fever, headache, anorexia, neck pain, and lethargy
 Swelling stage: swelling of the parotid glands, pain, mild to moderate fever, swelling
usually last between 3- 7 days
 “Pickle sign”- assessment of pain by eating something sour
 Stensen’s duct- red and swollen
 Treatment
 Supportive
 NSAIDS or steroids for arthritic involvement

28. Mumps

29. Erythema Infectiosum (Fifth disease)
 Parvovirus B19
 Transmitted via vertical from mother to baby, respiratory secretions,
and blood
 Childhood disease- peaking between 5-15 yrs
 Occurs mostly in late winter and early spring
 Diagnostics: lab test are not usually indicated

30. Erythema Infectiosum (Fifth disease)
 Clinical Manifestations
 Prodrome: mild fever, headache, and URI symptoms
 Rash:
 Slapped cheek- 1st appearance and last 1-4 days
 Lacy maculopapular rash on the body that spreads to the extremities- can last 1 month
 Exacerbation occurs with heat, exercise, stress, etc
 Treatment
 No antiviral recommended
 IV IG for the immunocompromised

31. Fifth Disease

32. Parainfluenza
 Major cause of Croup
 Also causes bronchoilitis, bronchitis, and pneumonia
 Spread through direct contact
 Types 1-4
 Type 1 associated with Croup
 Diagnostics: Routine testing is not needed

33. Parainfluenza
 Clinical Manifestations
 Affect the upper airway
 Sore throat
 Fever
 Rarely a rash
 Treatment:
 Supportive
 Oxygen and suctioning may be required
 Good hand hygiene is very important for parent education

34. Rubella (German or 3-day Measles)
 RNA virus that can be congenital or postnatal
 Transmitted through nasopharyngeal secretions, transplacentally, or
fomites
 Vaccines have significantly decreased the occurrence
 Lifelong immunity following the disease
 Diagnostics: antibody testing, clinical assessment

35. Rubella (German or 3-day Measles)
 Clinical Manifestations:
 Prodrome: Inflammation of the mucous membranes in the airways
 Lymphadenopathy: 24 hrs before the rash appears, postauricular, posterior cervical,
posterior occipital, rarely splenomegaly
 Rash: Begins on the face and spreads to the trunk lasting around 3 days, possible
itching and fever
 Treatment
 Supportive
 Steroids and platelet transfusions for purpura

36. Congenital Rubella

37. Lyme Disease
 Borrelia burgdorferi
 Carried and transmitted via ticks
 Ticks must feed on the host for at least 36 hours to have a significant
risk for infection of the host with Bb
 Three USA areas have the highest rate of infection- New England and
mid-atlantic states, upper midwest, and the west

38. Lyme Disease
 Diagnostics:
 Clinical assessment and history
 Sero- testing will not be positive until 1 week following the bite
 ELISA/IFA
 Western Blot
 Clinical Manifestations:
 Stage 1- 1-2 weeks following the bite, erythema migrans, last for a few weeks but fades
even without treatment, fever, malaise, headache, arthralgia, and stiff neck

39. Lyme Disease
 Clinical Manifestations:
 Stage 2- disseminated disease- multiple skin lesions, infections of the eyes, bone,
heart, synovium, muscle, liver, spleen, CNS (7TH nerve palsy), last from weeks to years
 Stage 3- begins with arthritis, joints are red and swollen, CNS encephalopathy (rare),
memory impairment
 Treatment
 If the clinical picture meets the criteria, do not wait on sero-testing results to begin
treatment
 Amoxicillin 50 mg/kg/day for 14-21 days- younger than 8 yrs
 Doxycycline 100 mg 2x day for 14-21 days- 8 yrs and older

40. Lyme Disease

41. MRSA
 Must know the prevalence in your community as a Practitioner
 Most commonly found in the skin and soft tissue
 Has moved from only hospital-based to community-based, as well.
 Clues to MRSA: furuncle or boils with no drainage, redness, pain,
warmth, others in the family with skin infection, fails beta-lactam,
recent history of infection, pus, involved in contact sports, CF,
respiratory infection, and multiple lesions

42. MRSA
 Treatment (based on severity)
 Culture if lesion contains purulent drainage or I and D if larger than 5 cm- send for
culture and gram stain, sensitivity and D-test
 See page 492 Burns- Algorithm for treatment
 Some outpatient recommendations (Table 31.6):
 Clindamycin
 Doxycycline
 Minocycline
 Bactrim
 Linezolid

43. MRSA

44. Cat Scratch Disease (CSD)
 Bartonella henselae
 Chronic (> 3 weeks) lymphadenopathy
 90% caused by actual cat scratches
 Clinical Manifestations:
 Vesicular or pustule lesions
 Ulceration of the mucous membranes
 Axillary, cervical, submandibular, preauricular, epitrochlear, inguinal, and femoral
lymphadenopathy last 1-2 months normally
 Fever and overall illness

45. Cat Scratch Disease (CSD)
 Treatment
 Spontaneous recovery in 2-4 months
 Supportive treatment- antipyretics and analgesics
 Antibiotics used for systemic CSD
 Azithromycin
 Ciproflaxin
 Gentamycin
 Bactrim
 Clarithromycin

46. Cat Scratch Disease- Axillary Node

47. Meningococcal Disease
 N. meningitidis
 Transmitted via respiratory secretions via colonization
 Most common in the winter and the spring
 Risk increases in day cares, dorms, and military housing
 Teens have the highest mortality

48. Meningococcal Disease
 Clinical Manifestations:
 Occult bacteremia: febrile, URI or digestive tract symptoms, maculopapular rash
 Meningococcemia: fever, pharygitis, headache, conjunctivitis, photophobia,
weakness, myocarditis, seizures, maculopapular or petechial rash- may quickly
progress to septic shock- very scary!!!!
 Meningococcal Meningitis
 Treatment:
 IV antibiotics are started while waiting for the results of cultures! Do not wait!
 Penicillin, cefotaxime, ceftriaxone, dexamethasone

49. Meningococcal Disease

50. GABHS
 Not just Strep throat
 Only transmission is the respiratory tract
 Pharyngitis is most common between 5-15 yrs
 Skin infection is more common in children 12m to 4 yrs
 Diagnostics:
 Culture
 Rapid Strep- poor sensitivity- must follow with a culture

51. GABHS
 Clinical Manifestations- can present as any of the following illnesses:
 Pharyngitis
 Pneumonia
 Scarlet fever
 Skin infection
 Bacteremia
 Vaginitis
 Perianal cellulitis
 Necrotizing fasciitis
 Toxic shock

52. GABHS
 Treatment
 Penicillin V po and Penicillin G IM are the drugs of choice
 Bactrim and Tetracyclines should not be used
 Other acceptable modes of treatment include:
 Oral cephalosporins
 Macrolides
 Topical Mupirocin can be used for uncomplicated impetigo
 If multiple or traveling lesions occur- systemic antibiotics should be used
 Return to school when afebrile and 24 hrs following start of antibiotics
 More aggressive therapy is required for systemic disease

54. Tuberculosis
 M. tuberculosis
 Transmitted via droplet contamination
 Most common:
 Low-socioeconomic
 Poor nutrition
 Lack of access to care
 Crowded living arrangements
 Ethnic minority
 Foreign-born

55. Tuberculosis
 Clinical Manifestations
 Primary Pulmonary TB:
 Most children are asymptomatic when first tested
 Low-grade fever
 Cough
 Lethargy
 Night-sweats
 Erythematous nodules under the skin
 Enlarged lymph nodes
 Miliary TB
 Children under the age of 3
 Necrosis and multiple organ failure can occur

56. Tuberculosis
 Diagnostics:
 Culture
 Chest x-ray
 Tuberculin skin test
 Treatment:
 Isonozid (INH)
 Rifampin (RIF)
 Pyrazinamide (PZA)
 Corticosteriods for complicated percardial or pleural effusions

57. Fever without a Focus
 Excellent algorithm on page 505 in Burns
 This a very important topic in the primary care setting. Babies with
fever demand immediate attention!

58. Reference
 Blosser, C. G., Brady, M. A., & Muller, W. K. (2009). Infectious diseases
and immunizations. In C. E. Burns, A. M. Dunn, M. A. Brady, N. B.
Starr & C. G. Blosser (Eds.), Pediatric Primary Care (pp. 477-552). St.
Louis, MO: Saunders Elsevier.