Infections with Infections with exanthemsexanthems

Mészner Zsófia dr.Mészner Zsófia dr.

National Institute of Child National Institute of Child HealthHealth

Szent László HospitalSzent László Hospital

BudapestBudapest

Which clinical syndromes??

„„the classics”the classics” scarlet feverscarlet fever morbilli- measelsmorbilli- measels rubella-german measelsrubella-german measels varicellavaricella megalerythaemamegalerythaema herpesherpes exanthema subitumexanthema subitum variola, vaccina, variola, vaccina,

anthrax…anthrax…

Where is/what is this building?

What else?

impetigo, SSS, STSS..impetigo, SSS, STSS..

erythaema migrans erythaema migrans (lyme)(lyme)

erythaema nodosumerythaema nodosum Hand-mouth-foot Hand-mouth-foot

diseasedisease erysipelaserysipelas mucocutane candidiasismucocutane candidiasis etc…etc…

Which syndromes are not typically of infectious origin?

urticaria, atopic dermatitisurticaria, atopic dermatitis Drug induced exanthems (EBV + aminopenicillin)??Drug induced exanthems (EBV + aminopenicillin)??

„„Fix” exanthemFix” exanthem

Kawasaki disease??Kawasaki disease?? ITP, other vasculitis syITP, other vasculitis sy IRA, SLEIRA, SLE Stevens-Johnson sy Stevens-Johnson sy

„Emergency”

Meningococcus (Hib) Meningococcus (Hib) sepsis – early signssepsis – early signs Petechiae, fever, Petechiae, fever,

hyperacute start, hyperacute start, NO meningeal NO meningeal

signs!!!signs!!!

Typhus abdominalis Typhus abdominalis fever, roseola, fever, roseola,

splenomegalysplenomegaly

„Emergency”

STSS – toxin mediaeted STSS – toxin mediaeted sy, ICU!sy, ICU!

Cellulitis, deep Cellulitis, deep necrotizing fasciitisnecrotizing fasciitis varicella, surgical varicella, surgical

wounds, insect bites -wounds, insect bites -superinfections superinfections

Fever, neutropenia and Fever, neutropenia and cuteneous signs:cuteneous signs: Pseudomonas Pseudomonas

aeruginosa, fungiaeruginosa, fungi

What activity is done here?

                                          

Epidemiology

Vaccine preventible infectionsVaccine preventible infections Measels, rubella (MMR): extremly rare, Measels, rubella (MMR): extremly rare,

imported casesimported cases varicella (Varilrix) marked morbidityvaricella (Varilrix) marked morbidity

Other viral infectionsOther viral infections megalerythaema, megalerythaema, HHV-6,7,HHV-6,7, hand-mouth-foot hand-mouth-foot

diseasedisease

Vaccine preventible infectionsVaccine preventible infections

morbilli, rubellamorbilli, rubella, , (mumpsz) (MMR): (mumpsz) (MMR): extremly rare, imported extremly rare, imported casescases 1/500 exitus!!1/500 exitus!! no antiviral drug!no antiviral drug!

varicellavaricella (Varilrix) (Varilrix) marked morbiditymarked morbidity 40-50 thousand 40-50 thousand

cases/year (reported)cases/year (reported)

Other exanthemes MegalerythaemaMegalerythaema – –

exanthema exanthema infectiosuminfectiosum HPV B19HPV B19

HHV-6,7,8HHV-6,7,8 Hand-mouth-foot Hand-mouth-foot

diseasedisease enterovírusokenterovírusok

Which building?

Epidemiology again

„„purulent” infectionspurulent” infections Streptococcus pyogenes –Streptococcus pyogenes – angina, scarlat angina, scarlat

fever, STSS, AOM, mastoiditis, pneumonia, fever, STSS, AOM, mastoiditis, pneumonia, meningitis, rheumatic fever, poststreptococcal meningitis, rheumatic fever, poststreptococcal glomerulonephritisglomerulonephritis

Staphylococcus aureus – Staphylococcus aureus – impetigo, scarlatoid, impetigo, scarlatoid, pneumonia, sepsis sypneumonia, sepsis sy

antropozoonozesantropozoonozes Lyme (Lyme (EMEM), hand-mouth-foot…), hand-mouth-foot…

Morbilli - measels

Characteristic signs and symptomsCharacteristic signs and symptoms highly contagious 96-98% (herd immunity!)highly contagious 96-98% (herd immunity!) 14-d incubation, wheezing prodrom14-d incubation, wheezing prodrom 4.-day - exanthems4.-day - exanthems peelingpeeling self-limiting immunsuppression (cellularis)self-limiting immunsuppression (cellularis)

ComplicationsComplications viral pneumonia (Hoechts), encephalitis, SSPE?viral pneumonia (Hoechts), encephalitis, SSPE?

No antiviral!No antiviral!

Kanyaró (morbilli)*

23 cases (1998), 2/3 in nurseries23 cases (1998), 2/3 in nurseries Imported cases from Romania, Ukrajna Imported cases from Romania, Ukrajna no SSPE no SSPE Several epidemics all over EuropeSeveral epidemics all over Europe

MMR-autism – FALSE!MMR-autism – FALSE! doctors don’t recognize itdoctors don’t recognize it

No antiviralNo antiviral WHO:eradication to 2010? (inf. Morbidity 8.)WHO:eradication to 2010? (inf. Morbidity 8.)

*EPINFO, Magyarország 1998. Évi járványügyi *EPINFO, Magyarország 1998. Évi járványügyi helyzete, 1999.november 23.helyzete, 1999.november 23.

Where are we now?

                                                         

                                                                                                                                                       

Rubeola – rubella – german measels

Signs-symptomsSigns-symptoms Highly contagiousHighly contagious Incubation:17-21 dIncubation:17-21 d Mild courseMild course CRS – index of susceptibilityCRS – index of susceptibility

complicationscomplications encephalitisencephalitis CRSCRS

No antiviral!!No antiviral!!

Rubeola* Practically nonexistant?Practically nonexistant? 1998.: 125 confirmed cases (+25% 1998.: 125 confirmed cases (+25%

1997.)*1997.)*67,2% <15 mo67,2% <15 mo15,2% > older, unvaccinated15,2% > older, unvaccinated2 cases of CRS in 1998(!)2 cases of CRS in 1998(!)

*EPINFO, Magyarország 1998. Évi járványügyi *EPINFO, Magyarország 1998. Évi járványügyi helyzete, 1999.november 23.helyzete, 1999.november 23.

?

VZV infectionsVZV infections

chickenpoxchickenpoxvaricella - chickenpox varicella - chickenpox övsömör - herpes zoster – shinglesövsömör - herpes zoster – shingles

Smallpox??? – Vaccinia??Smallpox??? – Vaccinia??

No local treatment, please!!

?

The difference… VZVVZV

No,or short (1-2d) No,or short (1-2d) prodromprodrom

Polymorh Polymorh picture:3-4. day picture:3-4. day macules,-papules, macules,-papules, vezikules pustulesvezikules pustules

Crusts are not Crusts are not infectiousinfectious

1-2 week courses 1-2 week courses on averageon average

SmallpoxSmallpox 5-7 d prodrom5-7 d prodrom Deeply seated vesicles Deeply seated vesicles

on face and extremitieson face and extremities No polymorphismNo polymorphism Haemorrhagic laesionsHaemorrhagic laesions Crusts are infectiousCrusts are infectious Average course 3 weeksAverage course 3 weeks

Religions?

Megalerythaema

No good Hungarian nameNo good Hungarian name HPV B19HPV B19 Multiplicates in proerythrocytes – haemolyzisMultiplicates in proerythrocytes – haemolyzis No clear incubation - 14 from case to caseNo clear incubation - 14 from case to case Highly contagiosusHighly contagiosus Infants, school kidsInfants, school kids „„slapped face” only on day 14-17.!!slapped face” only on day 14-17.!! Arthritis in womenArthritis in women Heatlabil, spectacularexanthem – not Heatlabil, spectacularexanthem – not

contagious!!contagious!! SerodiagnosticsSerodiagnostics

Megalerythaema

Risk groupsRisk groups PregnancyPregnancy

Early sptaneous abortions (AB testingt!)Early sptaneous abortions (AB testingt!) Immunhydrops foetusImmunhydrops foetus

Hematology patientsHematology patients Aplastic crizis – ovalocytosis, spherocytosisAplastic crizis – ovalocytosis, spherocytosis

Immunocompromised patientsImmunocompromised patients Prolonged cytopenia (fvs, thr)Prolonged cytopenia (fvs, thr) IVIG IVIG

Where are – were - we now?

Kawasaki diseaseKawasaki disease(KD) Magyarországon(KD) Magyarországon

First recognised case in H.: 1977. prf. Nyerges First recognised case in H.: 1977. prf. Nyerges GáborGábor

Not registered – no dataNot registered – no data Significance: leading cause of acquired heart Significance: leading cause of acquired heart

disease in childhooddisease in childhood disease? syndrom?disease? syndrom? Kawasaki’s original articleKawasaki’s original article

A KD diagnostic criteriaA KD diagnostic criteria (by Kawasaki) (by Kawasaki)

Bilateral (dry) conjunctivitisBilateral (dry) conjunctivitis Mucosal signs (ips, tonque, oral cavity)Mucosal signs (ips, tonque, oral cavity) fever in spite of AB treatment (1-2 weeks)fever in spite of AB treatment (1-2 weeks) Skin signs: palmar-plantar redness, oedema, Skin signs: palmar-plantar redness, oedema,

peelingpeeling

polymorh (non vezikular) exanthempolymorh (non vezikular) exanthem Acute,non purulent cervical lymph node < 1,5 cmAcute,non purulent cervical lymph node < 1,5 cm

forrás: Pediatrics, 1974. 3; 271-6.forrás: Pediatrics, 1974. 3; 271-6.

KD AHA diagnostic criteria I.KD AHA diagnostic criteria I.

min. 5-day fevermin. 5-day fever min. 4:min. 4:

Extremities, polymorph exanthem, bilateral Extremities, polymorph exanthem, bilateral conjunctivitis, cheilitis, glossitis, cervical conjunctivitis, cheilitis, glossitis, cervical lymphnodelymphnode

Exclusion of other syndromes/diseasesExclusion of other syndromes/diseases

forrás: Circulation 1993, 87; 1776-80.forrás: Circulation 1993, 87; 1776-80.

KD AHA diagnostic criteriaI II. (atypical)KD AHA diagnostic criteriaI II. (atypical)

Less than 4 typical signsLess than 4 typical signs Echography: a. coronaria dilatation/aneurysmEchography: a. coronaria dilatation/aneurysm No other known etiologyNo other known etiology

forrás: Circulation 1993, 87; 1776-80.forrás: Circulation 1993, 87; 1776-80.

Anthrax?

Anthrax: antropozoonozisAnthrax: antropozoonozis Does not spread from person to person!!!Does not spread from person to person!!! Skin: „pokolvar”: necrotic, deep ulcerSkin: „pokolvar”: necrotic, deep ulcer Intestinal: haemorrhaegeIntestinal: haemorrhaege „„respiratory” – haemorrhagic mediastinitisrespiratory” – haemorrhagic mediastinitis

Thank you for your attention!