Board review viral infections
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Board review - Viral infections. Rubeola (nine-day or red measles). Prodromal symptoms - fever, malaise, dry (occasional croupy) cough, coryza, conjunctivitis c clear d/c, marked photophobia 1-2 days p prodromal symptoms - Koplik spots on the buccal mucosa

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Rubeola nine day or red measles
Rubeola (nine-day or red measles)

  • Prodromal symptoms - fever, malaise, dry (occasional croupy) cough, coryza, conjunctivitis c clear d/c, marked photophobia

  • 1-2 days p prodromal symptoms - Koplik spots on the buccal mucosa

  • Koplik spots - tiny, bluish-white dots surrounded by red halos

Rubeola nine day or red measles1
rubeola (nine-day or red measles)

  • Day 3 or 4 - blotchy, erythematous, blanching, maculopapular exanthem appears

  • Rash begins at the hairline and spreads cephalocaudally and involves palms and soles

  • Rash typically lasts 5 - 6 days

  • Can see desquimation in severe cases

Rubeola nine day or red measles2
rubeola (nine-day or red measles)

  • Patients can be systemically ill

  • Incubation period 9-10 days

  • Patients contagious from 4 days prior to the rash until 4 days after the resolution of the rash

  • Highly contagious - 90% for susceptible people

Rubeola nine day or red measles3
rubeola (nine-day or red measles)

  • High morbidity and mortality common in children in underdeveloped countries

  • Peak season is late winter to early spring

  • Potential complications - OM, PNA, obstructive laryngotracheitis, acute encephalitis

  • Vaccination is highly effective in preventing disease

Rubella german measles
Rubella (german measles)

  • Little or no prodrome in children

  • In adolescents - 1-5 days of low-grade fever, malaise, headache, adenopathy, sore throat, coryza

  • Exanthem - discrete, pinkish red, fine maculopapular eruption - begins on the face and spreads cephalocaudally

  • Rash becomes generalized in 24 hours and clears by 72 hours

Rubella german measles1
rubella (german measles)

  • Forchheimer spots - small reddish spots on the soft palate - can sometimes be seen on day 1 of the rash

  • Arthritis and arthralgias - frequent in adolescents and young women - beginning on day 2 or 3 lasting 5-10 days

  • Up to 25% of patients are asymptomatic - serology testing may be necessary to establish the diagnosis

Rubella german measles2
rubella (german Measles)

  • Important in establishing the diagnosis if the patient is pregnant or has been in contact c a pregnant woman

  • Peaks in late winter to early spring

  • Contagious from a few days before the rash to a few days after the rash

  • Incubation period 14-21 days

  • Complications - rare in childhood - arthritis, purpura c or s thrombocytopenia, mild encephalitis

Varicella chickenpox
Varicella (chickenpox)

  • Caused by varicella-zoster virus

  • Highly contagious

  • Brief prodrome of low-grade fever, URI symptoms, and mild malaise may occur

  • Rapid appearance of puritic exanthem

Varicella chickenpox1
varicella (chickenpox)

  • Lesions appear in crops - typically have 3 crops

  • Crops begin in trunk and scalp, then spread peripherally

  • Lesions begin as tiny erythematous papules, then become vesicles surrounded by red halos

  • Lesions began to dry - umbilicated appearance, then surrounding erythema fades and a scab forms

Varicella chickenpox2
varicella (chickenpox)

  • Hallmark - lesions in all stages of evolution

  • All scabs slough off 10-14 days

  • Scarring not typical unless superinfected

  • Cluster in areas of previous skin irritation

  • Puritic lesions on the skin

  • Painful lesions along the oral, rectal, and vaginal mucosa, external auditory canal, tympanic membrane

Varicella chickenpox3
varicella (chickenpox)

  • Occurs year-round, peaks in late autumn and late winter through early spring

  • Incubation period ranges from 10-20 days

  • Contagious 1-2 days prior to rash until all lesions are crusted over

  • Complications - secondary bacterial skin infections (GAS), pneumonia, hepatitis, encephalitis, Reye syndrome

Varicella chickenpox4
varicella (chickenpox)

  • Severe in the immunocompromised host - can be fatal

  • Can have severe CNS, pulmonary, generalized visceral involvement (often hemorrhagic)

  • Need to get varicella-zoster immunogloblin 96 hours post-exposure to possible varicella


  • 30 distinct types

  • Variety of infections including conjunctivitis, URIs, pharyngitis, croup, bronchitis, bronchiolitis, pneumonia (occ fulminant), gastroenteritis, myocarditis, cystitis, encephalitis

  • Can be accompanied by a rash - variable in nature

  • Typically can see - conjunctivitis, rhinitis, pharyngitis c or s exudate, discrete, blanching, maculopapular rash


  • Can see anterior cervical and preauricular LAD, low-grade fever, malaise

  • Peak season is late winter through early summer

  • Contagious during first few days

  • Incubation period 6-9 days

Coxsackie hand foot and mouth disease
Coxsackie hand-foot-and-mouth disease

  • Brief prodome - low-grade fever, malaise, sore mouth, anorexia

  • 1-2 days later, rash appears

    • Oral lesions - shallow, yellow ulcers surrounded by red halos

    • Cutaneous lesions - begin as erythematous macules then evolve to small, thick-walled, grey vesicles on an erythematous base

Coxsackie hand foot and mouth disease1
Coxsackie hand-foot-and-mouth disease

  • Highly contagious

  • Incubation period 2-6 days

  • Lasts 2-7 days

  • Peak season summer through early fall

  • If no cutaneous lesions - herpangina

    • less painful and less intense than herpes gingivostomatitis

Erythema infectiosum fifth disease
erythema infectiosum (fifth disease)

  • Caused by Parvovirus B19

  • Affects preschool and young school aged children

  • Peak incidence in late winter and early spring, but it is seen year round

  • Characterized by rash - large, bright red, erythematous patches over both cheeks - warm, but non-tender

Erythema infectiosum fifth disease1
erythema infectiosum (fifth disease)

  • Facial rash fades, then see a symmetrical, macular, lacy, erythematous rash on the extremities

  • Resolution occurs within 3-7 days of onset

  • Transmitted by respiratory secretions, replicates in the RBC precursors in the bone marrow

  • Can cause aplastic crisis in patients with sickle cell disease, other hemogloblinopathies, and other forms in hemolytic anemia

Roseola infantum exanthem subitum
roseola infantum (exanthem subitum)

  • Febrile illness affecting children 6-36 months

  • Human herpesvirus 6 is causative agent

  • Symptoms include:

    • fever, usually >39

    • anorexia

    • irritability

    • these symptoms subside in 72 hours

Roseola infantum exanthem subitum1
roseola infantum (exanthem subitum)

  • As fever defervenscences, usually an erythematous, maculopapular rash that appear on the trunk and then spread to the extremities, face, scalp, and neck

  • Occurs year-round

  • More common in late fall and early spring

  • Incubation period thought to be 10-15 days

Infectious mononucleosis
Infectious mononucleosis

  • Acute self-limiting illness of children and young adults

  • Caused by EBV

  • Transmission by oral contact, sharing eating utensils, transfusion, or transplantation

  • Incubation period 30-50 days (shorter, 14-20 days, in transfusion-acquired infection)

  • Don’t usually see “classic mono” in young children

Infectious mononucleosis1
Infectious mononucleosis

  • Prodrome - fatigue, malaise, anorexia, HA, sweats, chills lasting 3-5 days

  • Symptoms

    • fever - can have wide daily fluctuations

    • pharyngitis c tonsillar and adenoidal enlargement c or s exudate, halitosis, palatal petechiae

    • LAD - anterior cervical and posterior cervical - in classic cases, generalized LAD toward end of wk 1

Infectious mononucleosis2
Infectious mononucleosis

  • Symptoms cont:

    • splenomegaly - develops in 50% of patients in 2nd-3rd wk

    • hepatomegaly in 10% of patients

    • exanthem - erythematous, maculopapular, rubelliform rash in 5-10% of patients

Infectious mononucleosis3
Infectious mononucleosis

  • Complications:

    • pneumonia

    • hemolytic anemia and thrombocytopenia

    • icteric hepatitis

    • acute cerebellar ataxia, encephalitis, aseptic meningitis, myletis, Guillain-Barre

    • rarely myocarditis and pericarditis

Infectious mononucleosis4
Infectious mononucleosis

  • Complications cont:

    • upper airway obstruction from tonsillar and adenoidal enlargement

      • seen more often in younger patients

      • children < 5 yrs of age c obstruction are more likely to have secondary OM, recurrent bouts of OM, tonsillitis, and sinusitis

  • splenic rupture

Infectious mononucleosis5
Infectious mononucleosis

  • Diagnosis:

    • classic finding - lymphocytosis (50% or more) c 10% atypical lymphocytes

    • 80% or more of patients c elevated liver enzymes

    • Monospot - detects heterophil antibodies - specific, not as sensitive - 85% of adolescents + and fewer younger patients

    • specific EBV antibody titers and PCR

Infectious mononucleosis6
Infectious mononucleosis

  • DDx

    • If fever and exudative tonsillitis predominate

      • GAS, diphtheria, viral pharyngitis

  • If LAD and splenomegaly predominate

    • CMV, toxo, malignancy, drug-induced mono

  • If severe hepatic involvement

    • viral hepatitis, leptospirosis

  • Herpes simplex infections
    herpes simplex infections

    • Primarily involve the skin and mucous surfaces

    • Can be disseminated in neonates and immunocompromised hosts

    • Produces primary infection - enters a latent or dormant stage, residing in the sensory ganglia - can be reactivated at any time

    Herpes simplex infections1
    herpes simplex infections

    • HSV-1

      • >90% of primary infections caused by HSV-1 are subclinical

      • more common

  • HSV-2

    • usually the genital pathogen

    • usual pathogen of neonatal herpes

  • Herpes simplex infection
    herpes simplex infection

    • Diagnosis

      • usually made clinically

      • can scrap base of vesicle and a special stain - Giemsa-stained (Tzanck)

        • ballooned epithelial cells c intranuclear inclusions and multinucleated giant

    • viral cultures take 24-72 hours

    Primary herpes simplex infections
    Primary herpes simplex infections

    • Herpetic gingivostomatitis

      • high fever, irritability, anorexia, mouth pain, drooling in infants and toddlers

      • gingivae becomes intensely erythematous, edematous, friable and tends to bleed

      • small yellow ulcerations c red halos seen on buccal and labial mucosa, tongue, gingivae, palate, tonsils

    Primary herpes simplex infections1
    primary herpes simplex infections

    • Herpetic gingivostomatitis

      • yellowish white debris builds on the mucosal surfaces causing halitosis

      • vesiculopustular lesions on perioral surfaces

      • anterior cervical and tonsillar LAD

      • symptoms last 5-14 days, but virus can be shed for weeks following resolution

    Primary herpes simplex infections2
    primary herpes simplex infections

    • Skin infections

      • fever, malaise, localized lesions, regional LAD

      • direct inoculation (usually cold sores)

      • lesions are deep, thick-walled, painful vesicles on an erythematous base - usually grouped, but may be single

      • lesions evolve over several days - pustular, coalesce, ulcerate, then crust over

    Primary herpes simplex infections3
    primary herpes simplex infections

    • Skin infections

      • most common sites are lips and fingers or thumbs (herpes whitlow)

      • eyelids and periorbital tissue infection can lead to keratoconjunctivitis - dx by dendritic ulcerations on slit lamp exam

        • can lead to visual impairment - consult ophtho

    Eczema herpeticum kaposi varicelliform eruption
    Eczema herpeticum (kaposi varicelliform eruption)

    • Onset of high fever, irritability, and discomfort

    • Lesions appear in crops in areas of currently or recently affected skin (for those with atopic eczema or chronic dermatitis)

    • Lesions begin as pustules, then rupture and crust over the course of a couple of days

    • Lesions can become hemorrhagic

    Eczema herpeticum kaposi varicelliform eruption1
    Eczema herpeticum (kaposi varicelliform eruption)

    • Multiple crops can appear over 7-10 days (like varicella)

    • Can be mild or fulminant, depending (in part) on the underlying dermatitis

    • If area of involvement is large, can be lots of fluid loss and potentially fatal

    • Treat promptly c acyclovir

    • Risk of secondary bacterial infections

    Recurrent herpes simplex infection
    Recurrent herpes simplex infection

    • Triggers include fever, sunlight, local trauma, menses, emotional stress

    • Seen most commonly as cold sores

    • Prodrome of localized burning, itching or stinging before eruption of grouped vesicles

    Recurrent herpes simplex infection1
    recurrent herpes simplex infection

    • Vesicles contain yellow, serous fluid and are often smaller and less thick-walled than the primary lesions

    • Vesicular fluid becomes cloudy after 2-3 days, then crusts over

    • Regional, tender LAD

    Herpes zoster shingles
    herpes zoster (shingles)

    • Caused by varicella-zoster virus

    • After primary infection, virus lies dormant in genome of sensory nerve root cell

    • Postulated triggers include mechanical and thermal trauma, infection, debilitation as well as immunosuppression

    • Lesions are grouped, thin-walled vesicles on an erythematous base distributed along the course of a spinal or cranial nerve root (dermatome)

    Herpes zoster shingles1
    herpes zoster (shingles)

    • Lesions evolve from macule to papule to vesicle then crusted over a few days

    • May have associated nerve root pain - not common in pediatrics - usually short-lived unless it involves a cranial nerve root dermatome

    • +/- fever or constitutional symptoms

    • Regional LAD common

    Herpes zoster shingles2
    herpes zoster (shingles)

    • Thoracic, cervical, trigeminal, lumbar, facial nerve dermatomes (order of frequency)

    • If cranial nerve involvement - prodrome of severe HA, facial pain, or auricular pain prior to the eruption

    • Affected patients can transmit varicella, but less of a problem b/c lesions are often covered by clothing and the o/p is not involved in most cases

    Gianotti crosti syndrome
    gianotti-crosti syndrome

    • Papular acrodermatitis

    • Associated c amicteric hepatitis B, EBV, echovirus, coxasckievirus, parainfluenza virus, CMV, and RSV

    • Most patients between 1-6 years old (range 3 months to 15 years)

    • Prodrome of low-grade fever and malaise

    • May be associated c generalized LAD, hepatomegaly, URI symptoms, and diarrhea

    Gianotti crosti syndrome1
    gianotti-crosti syndrome

    • Lesions appear within a few days - discrete, firm, lichenois papules c flat tops ranging from 1-10 mm (larger in infants and smaller in older children)

    • Papules can be flesh colored, pink, red, dusky, coppery, or purpuric

    • Distributed symmetrically over extremities (including palms and soles), buttocks, and face - relative sparing of the trunk and scalp

    • No mucosal involvement and non-purtitic

    Gianotti crosti syndrome2
    gianotti-crosti syndrome

    • Usually clears in 2-3 weeks, but can last for 8 weeks or more

    • Lab studies are generally non-specific, but liver enzymes should be obtained and if abnormal - hepatitis B or EBV serology should be done

    • Treatment is supportive

    • Steroid creams contraindicated b/c they can make the rash worse