infectious disease

Pediatric infectious diseases
Hasanein Ghali, MD
Department of Pediatrics
College of Medicine – University of Baghdad
December, 22nd, 2015
June 26, 20171

 Highly contagious, was once an inevitable experience
during childhood.
 Due to wide spread vaccination, endemic transmission
has been interrupted
 Single stranded, Lipid enveloped RNA virus
 Family paramyxoviridae, Genus morbillivirus.
June 26, 20173
Introduction

June 26, 20174
 Mode of transmission: Respiratory droplets, 2 days
before symptoms to 4 days after rash.
 Immunocompromised patients may shed virus for
longer period and should be isolated for the duration
of their disease.
 Approximately 90% of exposed susceptible individuals
experience measles.
 Face-to-face contact is not necessary.
Transmission

June 26, 20175
 Incubation period: 8 -12 days.
 Fever and malaise.
 Coryza, Conjunctivitis (photophobia) and Cough follow
within 24 hours.
 Kopliks spot: (50%-70%) Appears 1 – 4 days prior to
rash on the buccal mucosa adjacent to the molars
within 48 hours and increase in no. during 3-4 days.
 They are 1 -3 mm, Red spots with blue-white centers.
Clinical course

Clinical course
 They are infrequently identified, but pathognomonic
for measles, emphasizing the need for careful
inspection of the oropharynx in any child with fever.
 They disappear on the second day of the measles
rash.
June 26, 20176

 Rash: In the 4th day of illness, Red to purple papules
appears on the forehead, gradually spread downward
reaching the feet by the 3rd day. Coalescence of
lesions is common on the face and upper body.
 After it reaches its peak, it begins fading from the
top downward as it had appeared within 1 week or less.
 Of the major symptoms of measles, the cough lasts
the longest, often up to 10 days.
June 26, 20177
Clinical course

Other forms
 Mild form is seen in infants having maternal
antibodies, children recently received gamma
globulins and individuals immunized previously and
posses some levels of antibodies insufficient to
prevent infection but adequate to modify its course.
 An atypical measles syndrome: High fever, pulmonary
infiltrates and no or unusual rash has been reported
in immunocompromised individual.
June 26, 20178

Complications
 Otitis media, pneumonia (primary or secondary),
persistent bronchitis, and diarrhea especially among
poorly nourished children. Encephalitis is rare with
poor prognosis.
 A delayed degenerative disorder, (SSPE) Sub acute
Sclerosing PanEncephalitis: Personality changes,
seizures, coma, and death, may occur in about 9 -11
years following measles.
June 26, 20179

Diagnosis
 Clinical and epidemiological findings.
 Virus isolation from specimens obtained in the first
few days.
 Other findings in the acute phase include reduction
in the total WBC, with lymphocytes decrease more
than neutrophils.
June 26, 201710

 No specific antiviral therapy, only supportive.
 Vitamin A administered to all children diagnosed
with measles in communities where the vitamin A
deficiency is a recognized problem.
 Vitamin A deficiency in children is associated with
increased mortality from a variety of infectious
diseases, including measles.
June 26, 201711
Management

 Control of outbreaks: administration to vaccine
within 72 hours of exposure.
 Infants younger than 12 months of age and those who
are immunocompromised or pregnant should receive
appropriate dose of immune globulin.
June 26, 201712
Management

 In Iraq, the immunization schedule includes giving
measles vaccine at the age of 9 months, followed by
MMR at the age of 15 months.
June 26, 201713
Measles vaccine

Introduction
 German measles or 3-day measles.
 Mild disease of children but more severe in adults.
 Major significance is the transplacental infection and
fetal damage (congenital rubella syndrome).
 Single stranded RNA virus with a lipid envelope.
 Family Togaviridae, genus Rubivirus.
 Infectivity: 10 d after infection – 14 d after rash
June 26, 201728

Clinical course
 The incubation period: 14 -21 days.
 Mild illness, clinical features are neither distinctive
nor diagnostic.
 Many infections are subclinical.
 One – five days prodrome of low grade fever,
 In children, the prodrome may be absent or
unnoticed.
June 26, 201729

Clinical course
 Forchheimer spots, pinpoint red macules on the soft
palate early in illness, are helpful but not pathognomonic.
 The characteristic occipital and post auricular LAP is
highly variable and not specific for rubella.
 The exanthem which last about three days appears on
the face first as numerous discrete rose pink
maculopapules which rapidly spread downward to involve
the trunk and extremities.
June 26, 201730

Clinical course
 Second day, the facial eruption fades while the
lesions of the trunk coalesce. The rash disappears
usually on the third day without scaling or peeling.
 In adolescent and young adults, occipital tenderness
when combing the hair, bleeding gums after
brushing he teeth, transient polyarthralgia and
arthritis.
June 26, 201731

Complications
1- Encephalitis, more in children.
2- Thrombocytopenia .
3- Arthritis or arthralgia involving the knees, ankle or
hands, especially young women, remains the most
serious complication of rubella in non pregnant women.
Joint manifestation, if occur in children, are usually
benign and transient.
June 26, 201732

Complications
4- Congenital rubella syndrome (1941): Due to
Maternal infection in the first 8 wks. This syndrome is
characterized by Nerve deafness (the single most
common finding), IUGR, Retinal findings (salt and
pepper retinopathy), Cardiac abnormalities (patent
ductus arteriosus and valvular diseases), Interstitial
pneumonitis, Meningoencephalitis and Interstitial
nephritis.
June 26, 201733

 Clinical and epidemiological.
 Antibody titers.
 Leukopenia and thrombocytopenia
June 26, 201734
Diagnosis

 No care beyond antipyretics and analgesics.
 The treatment is mainly supportive.
 Patients should be isolated from susceptible
individuals for 7 days after the onset of rash.
 Management of CRS is more complex and requires
pediatric, cardiac, audiologic, ophthalmologic, and
neurologic evaluation and follow up.
June 26, 201735
Treatment

 In Iraq, the immunization scheduled includes
giving rubella vaccine at the age of 15 months and
for females, at the child bearing age.
 Exposure to pregnant women is of concern.
June 26, 201736
Prevention

Introduction
 An acute self-limited infection.
 Family paramyxoviridae, genus rubulavirus.
 It is a single stranded pleomorphic RNA virus.
 Endemic in developing world, warranting continued
vaccine protection.
 Transmission: Respiratory droplets
 Virus appears in the saliva from up to 7 days before
to as long as 7 days after the onset of swelling.
 Incubation period: 12-25 days.
June 26, 201746

June 26, 201747
Target organs
1- Salivary glands, CNS, pancreas and testes.
2- Thyroid, ovaries, heart, kidneys, liver and joint.

Clinical course
 The presentation ranges from asymptomatic or
nonspecific to the typical illness associated with
Parotitis with or without complications.
 A prodrome of fever, headache, vomiting and
achiness lasts for 1–2 days.
 Parotitis then appears, unilateral initially but
become bilateral in 70% of cases.
 Ingestion of acidic food enhance pain in the parotid
area.
June 26, 201748

Clinical course
 The angle of the jaw is obscured and the ear lobe
may be lifted upward and outward.
 The opening of the stensen duct may be red and
edematous.
 The swelling peaks in 3 days, subsided in 7 days.
Fever resolves in 3-5 days. Submandibular salivary
glands may also be involved and swollen without
parotid involvement.
June 26, 201749

Complications
1- CNS complications: Meningitis or
meningoencephalitis is most common complication
along with gonadal involvement.
 Before, along with, or following Parotitis.
 fever, malaise and lethargy in infants, while in older;
headache, vomiting, and meningeal signs.
 10%-30% clinical, 40%-60% lab
June 26, 201750

 CSF examination: White blood cell pleocytosis with
a predominance of lymphocytes. The glucose is
normal in most of the cases and low
(hypoglycorrhachia) in 10 – 20%, while the protein is
normal or mildly elevated.
 Other CNS complications include transverse
myelitis, aqueduct stenosis and facial palsy.
Complications
June 26, 201751

Complications
2- Gonadal involvement: in young adolescent males,
epidymo-orchitis is 2nd only to Parotitis as common.
 Involvement in prepubescent male is extremely rare,
but following puberty it occurs in 30-40 % of male.
 Atrophy may occur but sterility is rare.
 Oophoritis is uncommon in post pubertal females,
June 26, 201752

Complications
3- Endocrine: Pancreatitis and Thyroiditis.
4- Cardiac: Myocarditis.
5- Joints: Arthralgia, monoarthritis, and polyarthritis.
6- Pulmonary: pneumonitis.
7- Renal: Nephritis.
8- Hematological: Thrombocytopenia.
9- Ophthalmic: Optic neuritis and conjunctivitis.
June 26, 201753

Diagnosis
 History of exposure, incubation period and clinical
findings.
 Raised serum amylase, leukopenia and relative
lymphocytosis
 Viral isolation.
 Antibody titer.
June 26, 201754

 Pain
 Antipyretics
 Adequate hydration
 the outcome of mumps is excellent even when
complicated by meningitis or encephalitis, although
fatal cases of CNS involvement have been reported.
June 26, 201755
Treatment

June 26, 201756
 MMR: two-dose vaccine schedule, at 15 months and
4-6 yrs.
 If the second dose was not given at 4-6 yr, it should
be given before puberty
 64% vs. 88% protection, long lasting.
Prevention

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