Pediatrics (week 7): viral exanthems & giving vaccines to peds

[liveonearth]

VIRAL EXANTHEMS
rash with systemic infx
five with names, a million and six that don't
measles, scarlett fever, rubella, Duck's dz (staph, enterococc/coxsack), fifth/pravo B19/erythema infectiosum
named ones scare parents more
we're hitting coxsackie season "my kid has sores on hands and feet, what's wrong with her?" sore in mouth too
herpangina is coxsackie in mouth only

MEASLES
9-day measles
morbilliform rash starts face goes down body, disappears in same pattern
maculopapular brown pink may congeal into red areas, rare petechiae
acute, extremely contagious, resp droplets
paramyxovirus, 7-14d incubation
communicable from 2-4 days before rash until after rash is gone
early sx: fever, hacking cough, conjunctivitis, *photophobia
later: coplick spots buccal mucosa, mb lips, white grain with red border
*not likely to be measles without coplick spots
after immunization 1-5% kids get high fever, rash after vaccine: not contagious
PE: look in mouth with light!!! really get in there
complic: rare, pneumo is most in infant, rare OM, thrombocytopenic purpura, encephalitis
can cause SSPE subactute sclerosing panencephalitis, mb fatal
tx: vit A works esp on malnourished kids

RUBELLA
3-day measles
RNA virus
incubates 7-14 days
contagious for 7 days before rash appears and 7 days after rash is gone
congenitally infected infants mb contagious for a year
1st trimester infx-->blind, deaf, heart defect, death
vaccine is live: none during preg but hospitals give to mom after birth
prodrome: 1-5 days of malaise
LAD post cervicals more in young
rash starts on face goes down gone in 3 days
fine rash gets sandpaper feel
DDX: milder, no coplic spots, no photophobia (measles has these)
no sore throat (scarlet fever has v sore throat)
tx: symptomatic, healthy kids recover completely s complications
vaccination is for a minimal risk

SCARLET FEVER
(not covered in class)
sx: very sore throat, fever, rash
dt exotoxin produced by strep pyogenes
rash: fine, red, rough, blanches c pressure, appears 12-48hrs after fever
starts on chest, armpits, behind ears, spared the face, worse in folds, pastia lines
in mouth: uvula
rash fades 3-4d after onset-->desquamation starts at face, a week late palms, fingers, also in axilla, groin, fingertips & toes
dx: clinical, incr leukocytes, incr neuts, same or incr eos, high ESR and CRP, +ASO
streptococci in throat culture
complic: septic and immune-mediated
septic complications rare today: ear, sinus infx, pneumonia, thoracis, meningitis, sepsis
immune: acute glomerulonephritis, rheumatic fever and erythema nodosum
secondary scarlatinous disease incl new fever, angina, septic infx and renal infx or rheumatic fever and occurs around day 18 of untxd scarlet fever

(back to class lecture)
ROSEOLA
very common and overdiagnosed
aka exanthem pseubitum
mc under 3-4 yoa, after that most kids are immune
very contagious, runs wild in daycare
incubates 5-15 days
most dt HHV6
SX: abrupt onset of high fever lasting 3-5 days, no other sx
SX: then fever drops suddenly and rash appears
this pattern is characteristic, otherwise it's not roseola
convulsions possible during high fevers in susceptible kids
rash starts on trunk, macular or maculopapular, some don't even notice it, mb brief
poss LAD, cough, corrhyza
no need for labs to confirm

FIFTHS DZ, PARVO B19
contagious from just before rash to just after it erupts
can occur for weeks, goes away, comes back
low fever, mild malaise, arthralgias
then classic slapped cheek look, mildly indurated
slapped cheek spreads, becomes more maculopapular mb lacy in appearance on chest and arms
dx by characteristic rash but mb confused with other exanthems
can do viral testing for IgM but she can't imagine why, nothing you'd do different knowing exactly what it is
during preg can cause fetal death but not teratogenic
aplastic crisis, joint pain may last for months
no vaccine available

VARICELLA
chicken pox is big
don't tell people it's a herpes virus they freak out
march-april-may is when it comes around
viruses do have a season, she can't explain
7-21 day incubation, usu 7-14, big peak in bell curve at 13-14 days
think droplets spread
pox party: parents work hard to find it, get their kids exposed
have kids take baths together, trade kazoo or lollypops back and forth
most contagious in prodrome or early in rash
parents think every rash is chicken pox
rash is vesicular, "dewdrop on rose petal", in crops, pop and crust, new crop in 6-8 hours
dx: new crops is confirmation it's chicken pox
some kids itch, others don't
most common on trunk, also face, rare on mucus membranes (painful)
if scratching watch for 2ndary infx, cellulitis
acute lasts 7-10 days, contagious until last crop of vesicles crusts
can do labs to verify but don't have to
complic: itises of organs, panc, enceph, neph, etc, congenital if preg gets it, death
tx: symptomatic, acyclovir 80mg/kg q6hr
vaccine: for those who get to puberty and haven't had chx pox, to prevent it in adulthood
recommended at 12-15 months but many parents pass this and try to get it naturally
adults get titer before being exposed to pox, consider vaccine
vaccine is live attenuated
20% get pox from vaccine, 20% get low grade fever, 20% get pain at injx site, etc etc etc
there is a vaccine offered to elders to prevent shingles
case: woman got shingles when child was vaccinated

COXSACKIE VIRUS
very common
dramatic but b9
enterovirus like polio
3-7 day incubat
more in kids under 5
hand foot and mouth (sounds too farmyard, freaks people out)
use term coxsackie virus, write it down because you know they will google it
write down that it is NOT HERPES
mc in late summer/fall
prodome: fever, malaise, sore throat, sore mouth
later: vesicular on buccal mucosa & pharynx, palms and soles, mb on dorsum, mb rash in diaper area in infants
oral lesions red papules-->vesicles-->ulcerate, usu only 4-6
herpangina (mouth only) same prodrome, may have neck ache
grayish spots also happen on tonsillar pillars, uvula, tongue
lots more oral coverage than with hand foot mouth
lesions usu heal in 1-5 days
dx on rash appearance and distribution, titer mb inaccurate dt range of coxsackie viruses
complic: siez c fever, usu self limiting, mb dehydrated dt oral lesions, aseptic meningitis
rare encephalitis
some kids shed virus for months
tx: symptomatic for oral lesions, mouthwashes
tx: swish clove oil mixed with olive oil but kids may not like it
tx: anbesol, anesthetic teething gels in water and swish, all smiles is clove oil based
tx: magic mouthwash, euqla parts liquid benadryl and maalox, pain onto lesions with qtip
no vaccine available

PERTUSSIS
whooping cough
in China known as the 100 day cough
bordatella pertussis spread by droplet
incubates 7-14 days, mb 21
rare to spread after infx x3wks
infx does not confer lifelong immunity but subsequent attacks are milder
sx: catarrhal stage is first, lots of mucus, no/little cough, have sneezing, corrhyza, uncommon fever
sx: paroxysmal cough with whooping inspirations very characteristic
sx: vomiting is common after paroxysm, infants may turn blue, rarely dxd in catarrhal stage
sx: convalescence stage, decr in paroxysms, everything fades x1-3 months
dx: pcr is better the culture, or pertussis specific culture requires special medium and swab expires quickly
check lab requirements before doing test, if don't have right medium sent pt somewhere
complic: 3mo of coughing, longer susceptibility to URIs, kids under 2 most likely to die from it, mortality is 1-2% under 1 yr, infants asphyxiate from secretions and have more convulsions, pneumonia common at all ages
tx: abx: oral erythromycin or azithromycin for index case and contacts, esp during catarrhal stage
tx: quarantine infected people from susceptible infants, immune compromised, lung pathology
tx: no point to abx in paroxysmal stage, "may stop spread" is doubtful
vaccine at 2, 4, 6 mo and boosters at 15 mo and 4-5 years
she uses TDaP vaccine, acellular pertussis
no rxns except idiosyncratic, most used for adults and teens
used to have DTP vaccine
that was whole cell pertussis with a lot of rxns, last done in 1996
this is why rumors of rxns are still so prevalent
capitalization in these vaccine abbreviations indicates size of dose
tetanus only is off label use and doesn't result in as good titers as with pertussis in vaccine
SE: fussy, drowsy, anorexia, unusual cry? less than with whole cell

DIPTHERIA
rare, 1-2 cases/yr in US
incubat 1-6 days then toxin causes localized tissue necrosis which become pseudomembrane
toxin can cause endocarditis and nerve damage, renal necrosis
rhinorrhea that become bloody and mucopurulent is typical in infants
mb a lot of cervical LAD and edema of mouth and pharynx
she has never seen it but it used to kill a lot of kids
dx: culture tissue under membrane or test for exotoxin (send to hospital)
complic: airway obstrx, frequency of complications more with more toxins
myocarditis in wks 5-6 of willness, usu transient
neuro: bl peripheral nn palsies, dysphagia, anorexia, dehydration
nasal regurge from bulbar paralysis
complications reverse slowly over months
tx: antitoxin early as possible, horse derived so ask re: allergy
vaccine: in DTAP

TETANUS
is at least out there
Clostridium tetani is endemic in soil
2-50 days incubation, 5-10mc
anaerobic bact introduced in anaerobic style: puncture, deep closed wound
sx: jaw stiffness, stiff mm
complications: fractures, cerebral hemorrhage, lots more
tx: hospital debridgement of wound, abx

MUMPS
she has seen 4-5 cases
parotitis acute infx may hit ov and testicles
paramyxovirus, resp droplet spread
1-14 day incubation
contagious while glands are swollen
peaks in spring
uncommon before 2yoa
part of MMR vaccination
dz confers lifetime immunity
prodrome uncommon in children, same as all others
12-24 hours later glands swell up
dx: hard to miss ginormous swollen glands, painful, won't chew, pretty good fever
swelling lasts 1-3 days, edema of surrounding tissues, around ears, mb tender
usu BL, other salivary glands mb involved
no labs needed
hx: ask if more pain with sour foods
swollen glands not erythematous, blockage usu unilateral
complic most in post pubertal pts: orchitis in 20% of males post puberty, unilat swelling, rare sterility, oophorotis rare, meningoencephalitis is rare but more before 2 yrs, pancreatitis at end of 1st week (nausea, vomiting)
prost, lacrimal, etc any gland may be infected
tx: symptomatic, soft diet, avoid incr salivation, popular: mashed potatoes
complications: usu tx symptomatically as well
stay out of school until 9 days after onset of swelling
vaccine rec as infant and booster age 5ish

MONO
EBV
incubation 30-50 days
can occur before 5yoa but much mc in adolescents
young: abd pain, rash
sx: fever, prolonged fatigue, pharyngitis, symmetrical and prominent LAD anywhere, cx or occip
sx: splenomeg in 50%
dx: cbc with differential, see atypical lymphocytes
dx: monospot for ab's not wildly reliable: if neg when clinical picture is convincing, repeat
less reliable in younger, 90% reliable in adolescents
ab titer remains high for a year
complic: strep pharyngitis in 25%, splenic rupture 1/1000, airway obstrx, etc
tx: resolves in 1-4 wks, supportive care is adequate, vit A, D, antiviral herbs
whatever you can get in, drops of vit A & D easy to get in
steroids if and only if LAD threatens airway obstrx
no vaccine


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VACCINES
CDC makes recommended and catchup schedules
regulations by public health depts and schools
pertussis most severe in 1st year of life
may need fewer shots if giving vaccines later in life: better response
caution re: confrontations with other physicians
"people want vaccine info that is neither hype nor terror"
"vaccination is somewhat akin to religion" with some medical professionals
families get kicked out of pediatrics practices for not wanting to vaccinate
doc's role is to advise but not to make the decision: give facts not opinions
many rxns attributed to vaccines are coincidence or idiosyncratic rxns
vaccine scheduling should be individually customized and OK with family
discuss with partners, involved grandparents etc
support parents in whatever decision they choose: vaccinate, partial, none
discuss and chart refusals at length

she gives a lot of shots, vaccines
must have parent buy in, then give them even if kids freak, don't let kids run show
"4 year olds are 100% drama", drama is beforehand, drama after shots is minimal
clean the area "this is cold and wet"
need distractors, toys, prize bin full of cheap stuff, stickers, silly bands
*go fast, don't worry so much about hitting a vessel-don't draw back, "in-shot-done"
never lie to kids, don't tell them it won't hurt, they'll never trust you again
"this is going to hurt a little bit, like a pinch"
tell them what it will hurt less than (burn, falling down)
lets kids choose their bandaids
ask teenager: do you want to watch me give somebody give a shot (B12 shots with long needle, volume, great demo)
needle can come off syringe, just smile, say enough got in, go on with smile
unless it didn't go in, then reinject right away
don't act scared, just do it, give kid a prize

HEP B
vaccine given at birth with heel stick
hospitals are OK with hep B negative parents who refuse the birth shot, no hassle
hep B in infants either from vertical transmission or sexual abuse
chronic more likely if exposed when young
SE's of vaccine: 3% pain @ injx site, 1% fevr
vaccine is conjugate: outer prot linked to toxin to be immunogenic, grown in yeast
Vaccine options: Recombivax (recombinant, inexpensive), Engerix B (GSK), Comvax (Hib too), Pediarix (DTaP, IPPV Hep B--GSK)
some pts don't seroconvert to hep b vaccine, EVAR

HIB
titers don't show proper immune response before 6 months of age
85% of all invasive HIB occurs in kids under age of 5
no point in vaccine after 5, causes URI
used to be mc cause of meningitis in kids under 2, mort rate was 5%
5% of survivors had neuro sequellae
no rxns to vaccine in her experience

POLIO
paralytic sequellae
recommended course is given young, she says give before travel, after 1 year
no recorded cases in US for long time
except for a closed community outbreak dt missionary brought it home
outbreaks elsewhere in the world about 1500 cases/year
oral vaccine was contagious bug-->complete immunity
current injx is attenuated

PNEUMOCOCCAL
also given young
strep pneumo now mc cause of meningitis in kids under 2
has replaced HIB
conjugated vaccine has 7/9 strains
expensive: 134.97/dose physician cost

HEP A
vaccine now required by PDX public schools
more people want to do it these days
acquired fecal/oral
get vaccine before travel to areas with less than pristine conditions