Pediatric Infectious Diseases cont’d...

1. Pediatric Infectious Diseases cont’d...

2. Case 1 • 15 month old Aboriginal male • rash, fever, irritability • 2 sibs with same rash, uncomplicated • PMHx: well • meds: none • NKDA • Imm: 2P, 4P, 6O, 12O

3. Case 1 • Physical exam: • febrile, unwell • rash

4. Case 1 • Management: • kept in negative pressure room • FSWU done - neg U/A and LP • covered with vancomycin • wound culture grew MRSA • stayed 4 days in hospital, discharged on Septra x 2 weeks

5. Case 2 • 12 month old Hutterite male • rash + fever 12 days ago, then sore right knee x 10 days • PMHx: well • meds: none • NKDA • Imm: 2P, 4P, 6P, 12O

6. Case 2 • Physical exam: • afebrile, well • MSK: R distal thigh swollen, warm, not red; decreased ROM of knee (-10o flexion, -10o extension); N ROM hip and ankle

7. Case 2 • Imaging: • Labs: • WBC: N • CK: N • ESR: 62 • CRP: 130.4 • BC drawn (grew Staph aureus)

8. Case 2 • Management: • covered with cloxacillin • admitted to hospital • further work-up: • bone scan + • U/S: thigh abscess • taken to OR for drainage • f/u X-ray abN

9. Case 2 • MRI: confirmed osteomyelitis, and revealed a distal femoral epiphyseal abscess • abscess drained in OR • discharged after 19 day hospital stay • iv cloxacillin recommended for 6 weeks

10. What was the underlying illness?

11. What was the underlying illness? Varicella Zoster Virus

12. Pathophysiology • human herpesvirus family • causes 2 diseases:

13. Pathophysiology • human herpesvirus family • causes 2 diseases: • varicella (chickenpox) zoster (shingles)

14. Pathophysiology

15. Pathophysiology • direct contact • infected respiratory tract secretions • airborne droplets

16. Pathophysiology • direct contact • infected respiratory tract secretions • airborne droplets • exposure to mucosa of upper respiratory tract or conjunctiva

17. Pathophysiology • incubation 10-23 days (avg, 14 days) • direct contact • infected respiratory tract secretions • airborne droplets • exposure to mucosa of upper respiratory tract or conjunctiva

18. Pathophysiology • incubation 10-23 days (avg, 14 days) • direct contact • infected respiratory tract secretions • airborne droplets • exposure to mucosa of upper respiratory tract or conjunctiva

19. Pathophysiology • incubation 10-23 days (avg, 14 days) • direct contact • infected respiratory tract secretions • airborne droplets • contagious 1-2 days before rash until all lesions crusted over • exposure to mucosa of upper respiratory tract or conjunctiva

20. Pathophysiology • incubation 10-23 days (avg, 14 days) • direct contact • infected respiratory tract secretions • airborne droplets • contagious 1-2 days before rash until all lesions crusted over • 90% risk of disease after exposure • exposure to mucosa of upper respiratory tract or conjunctiva

21. Clinical Manifestations • mild-moderate in children, more severe in adults • short or absent prodrome

22. Clinical Manifestations • macules g papules g vesicles g pustules g scabs • evolves as series of “crops” over 3-4 days • concentrated on trunk and head • 250-500 lesions • mild-moderate in children, more severe in adults • short or absent prodrome

23. Clinical Manifestations • variable severity

24. Clinical issues in pregnancy

25. Clinical issues in pregnancy • VZV in first 20 weeks: • fetal death, or • congenital varicella syndrome: • 1-2% risk if mum gets varicella • limb hypoplasia • cutaneous scarring • eye abnormalities • CNS damage T1 and T2

26. Clinical issues in pregnancy • VZV in second 20 weeks: • children can develop inapparent varicella and subsequent zoster earlier in life without extrauterine varicella T2 and T3

27. Clinical issues in pregnancy • VZV peripartum: • varicella infection can be fatal in the neonate if mother develops varicella 5 days before or 2 days after delivery • if mum develops varicella >5 days before and if infant >28 wks GA, severity of disease modified by transplacental maternal IgG antibody T3

28. Prevention once exposed • Postexposure immunization: • varicella vaccine, to people without evidence of immunity 12 months or older, within 72 hours of exposure (possibly up to 120 hours) • contraindicated in: • pregnant women • immunocompromised patients, including those on high dose daily systemic steroids

29. Prevention once exposed • Passive immunization: • VZIG/VariZIG, given IM, within 96 hours of exposure • decision to give depends on: • likelihood exposed person has no immunity • likelihood exposure will lead to infection • likelihood infection will lead to complications • at risk populations: • immunocompromised • pregnant women • certain neonates (mum develops rash -5 days to +2 days of delivery)

30. Diagnostic Tests

31. serology: • Ig M unreliable • significant increase in IgG from acute and convalescent serum for retrospective diagnosis Diagnostic Tests • PCR or DFA • virus culture less sensitive • sites: • vesicle base • saliva or buccal mucosa • CSF (PCR) • rarely from respiratory secretions

32. Treatment

33. Treatment • no treatment in otherwise healthy children • consider oral acyclovir in patients at risk of moderate to severe varicella: • > 12 years • chronic cutaneous or pulmonary disorders • on long-term salicylate therapy • on steroids (short, intermittent, or aerosolized courses) • pregnant, esp 2nd and 3rd trimesters

34. Treatment • intravenous acyclovir in immunocompromised patients: • on chronic corticosteroids • immunodeficient, eg. HIV • immune-suppressed, eg. leukemia on chemo

35. Complications

36. Complications • pneumonia • glomerulonephritis • hepatitis • thrombocytopenia • sepsis • etc. • bacterial superinfection of skin lesions • MSK infections (arthritis, osteomyelitis, necrotizing fasciitis) • CNS involvement (acute cerebellar ataxia, encephalitis, stroke)

37. Complications • “The burden of varicella complications before the introduction of routine varicella vaccination in Germany.” • JG Liese, V Grote, E Rosenfeld, R Fischer, BH Belohradsky, R vKries, ESPED Varicella Study Group • Pediatr Infect Dis J 2008;27: 119-124

38. Complications • prospective review of varicella-related hospital admissions in Germany (which has no universal vaccination)

39. Complications

40. Complications

41. Complications • Reasons for hospitalization:

42. Complications • Types of complications:

43. Complications

44. Complications

45. Complications • permanent sequelae in 15 (1.7%) • severe scarring (10) • ataxia (1) • mitral valve insufficiency from endocarditis (1) • visual restriction from retinal necrosis (1) • liver transplantation due to liver failure NYD (1) • hemiparesis from cerebral infarct (1)

46. Complications • possible permanent sequelae in 78 (8.7%) • severe scarring (19) • ataxia/coordination disorder (17) • epilepsy (4) • cerebral nerve paralysis (3) • other (35)

47. Complications • death in 10 (1.1%) • congenital varicella (2) • 4 immunocompromised patients (3 with ALL, 1 with IgG deficiency) • 4 immunocompetent patients (cardiocirculatory failure from myocarditis, severe bacterial superinfection and sepsis x 2, multiorgan system failure - pneumonia, meningoencephalitis, hemorrhagic complications)

48. Summary • VZV: • still out there • importance of immunization history • multiple complications, often in previously healthy children • preventable!

49. References • American Academy of Pediatrics. Varicella-Zoster Infections. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics;2009. (electronic access) • Gershon AA. Varicella-Zoster Virus Infections. Pediatr Rev 2008;29: 5-11. • Heininger U, Seward JF. Varicella. Lancet 2006;368: 1365-76. • Liese JG, Grote V, Rosenfeld E, Fischer R, Belohradsky BH, vKries R, ESPED Varicella Study Group. The burden of varicella complications before the introduction of routine varicella vaccination in Germany. Pediatr Infect Dis J 2008;27: 119-124.