Measles 11
Measles 11
Measles 11
Malnutrition
Underlying immunodeficiency
Pregnancy
Vitamin A deficiency
Clinical features
The disease is more common in preschool children,
infants are protected by transplacental antibodies,
which gradually decay by 9 m.
The prodromal phase is characterized by fever,
rhinorrhea, conjunctival congestion and dry hacking
cough.
Koplik spots considered as pathogonomic of measles
appear on the 2nd or 3rd day of the illness.
The rash usually appears on the fourth day with rise in
fever as faint reddish macules behind the ears, along
the hairline.
The rash rapidly becomes maculopapular and spreads
to the face, the neck, chest, arm, trunk thighs and
legs in that order over the next 2-3 days.
Measles Rash
Face
• Travels inferior over 2-3 days
Rubella Kawasaki
Maculopapular
Rash with Fever
Scarlet
Fever Echoviruses
Reoviruses
Mononucleosis
Roseola Infantum
25
Treatment
28
• Rubella is a mild disease in childhood occurring
in winter and spring
Infectivity
• 7 days pre-rash to 5 days post-rash
• It is spread by droplets
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Signs and Symptoms
Prodromal phase
• The incubation period is 14–21 days during
which time the child may have a mild illness with
low-grade fever.
Exanthematous phase
• Maculopapular rash starting on the face, then
spreading to cover the whole body, and lasting
up to 5 days.
Other features
• Suboccipital and post-auricular
lymphadenopathy
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Rubella Rash 31
Congenital rubella syndrome (CRS)
• Mother infected in first 4 months of pregnancy (highest risk).
• Infection in utero, failure of rubella vaccine is <5% and rarely results in CRS.
• Clinical features
▪ Cataracts/congenital glaucoma
▪ Congenital heart disease
▪ Hearing impairment (common)
▪ Purpura ("blueberry muffin baby")
▪ Hepatosplenomegaly
▪ Jaundice
▪ Microcephaly
▪ Developmental delay
▪ Radiolucent bone disease
• Prevention
▪ Routine childhood immunization
▪ Ensure immunity of women of childbearing age with vaccination
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A 4-year-old boy with congenital rubella syndrome with unilateral microphthalmos
and cataract formation in the left eye.
33
Diagnosis
Serology
• If there is a risk of a non-immune pregnant
woman has been exposed to the child, then the
diagnosis should be confirmed by serology.
34
Management
• Supportive
Prevention
• MMR (Measles, Mumps, Rubella) vaccine
Prognosis
▪ Excellent prognosis in patients with acquired
disease
▪ Irreversible defects in congenitally infected
patients
35
36
Complications
• Very rarely children may develop:
▪ Arthritis
▪ Myocarditis
▪ Encephalitis
▪ Thrombocytopenia
Note: When MMR vaccine uptake is reduced, remember
fetal rubella syndrome if a non-immune mother is
infected early in pregnancy
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Varicella (chicken
pox)
CP is a mild exanthematous illness in most
healthy children but can be a serious
disease in neonates,
immunocompromized, pregnant women,
and even healthy adults.
Chickenpox (Varicella)
• Chickenpox results from primary infection with
Varicella-zoster virus (VZV).
• Incubation Period
10–21 days
• Infectivity
1–2 days pre-rash until vesicles have crusted
over.
• Transmission rate is 86% in household contacts.
• Spreads via respiratory secretions (airborne) and
vesicular fluid. 40
Chickenpox (Varicella)
• Primary infection with virus usually results in life-long
immunity.
• >95% of young adults with varicella are immune.
• Maternal infection in 1st or early 2nd trimester (<2%
risk) can cause congenital varicella syndrome, which
manifests as:
▪ Low birth weight
▪ CNS abnormalities
▪ Digit/limb abnormalities
▪ Cutaneous scarring
▪ Eye defects
• Maternal infection 5 days before to 2 days after
delivery can lead to severe varicella of neonate.
41
Pathophysiology
• Infection is characterized by a generalized pruritic
vesicular rash.
• Children are contagious from 1–2 days prior to the
onset of the rash until the lesions have crusted.
• During primary infection, VZV establishes latency in
dorsal root ganglia.
• Reactivation of virus results in herpes zoster
(shingles).
• The most common complication of chickenpox is
bacterial superinfection with Strep. pyogenes or
Staph. aureus.
42
Pathophysiology (cont.)
• Parents of children who suffer from this complication
often report that children were improving and afebrile
with crusting lesions when they developed a new fever
late in the course of illness.
• Secondary Bacterial Infections (SBIs) include pyogenic
arthritis, osteomyelitis, pneumonia, bacteremia, and
necrotizing fasciitis.
• Nonbacterial complications of chickenpox include
pneumonia, cerebellar ataxia, encephalitis, hepatitis,
hemorrhagic varicella, and arthritis.
• Disseminated VZV infection may cause death in
immunocompromised patients as well as in healthy
patients with a history of recent steroid therapy. 43
44
45
Clinical Presentation
• Prodrome is 1–3 days, with fever and respiratory
symptoms
• Characteristic polymorphous rash
▪ Very pruritic
▪ Crops of red macules, which quickly become vesicles
surrounded by erythema
▪ “Dewdrop on erythematous base"
▪ Vesicles burst and lesions crust over
▪ On trunk, face, scalp, conjunctivae, oral mucosa,
palms and soles
▪ New crops usually stop forming after 5–7 days
46
Clinical Features
History
• Children with chickenpox have a history of contact
with another infected person within the previous
10 to 21 days.
• Although mild cases of varicella may occur in
children who have been vaccinated against the
disease, children usually have no history of
varicella immunization.
• Prodromal symptoms include fever and malaise.
47
Clinical Features (cont.)
Physical Examination
• Fever is often present.
• The child appears mildly to moderately ill.
• In cases of disseminated chickenpox or bacterial
superinfection, the child may appear very ill.
• The rash begins on the neck, face, or upper trunk and
spreads outward over the next 3 to 5 days.
• Mucous membranes may be involved.
• Lesions initially appear as small papules on an
erythematous base.
48
Clinical Features (cont.)
Physical Examination (cont.)
• The papules evolve into vesicles that eventually form
crusts.
• The rash is often intensely pruritic.
• It is important to inspect the rash for signs of hemorrhage
or infection.
• Lung examination may reveal signs of pneumonia, caused
by VZV or bacteria.
• Careful examination of the bones and joints may indicate
infection caused by Staph. aureus or Strep. pyogenes.
• Neurologic examination may reveal cerebellar ataxia.
49
Laboratory Evaluation
• Diagnosis of varicella is based on clinical findings.
• If the diagnosis is uncertain, it may be necessary to
send scrapings of the bases of vesicular lesions for
direct fluorescent antibody testing specific for VZV.
• A Tzanck smear reveals multinucleated giant cells
▪ It is not specific for VZV and is less sensitive and accurate
than direct fluorescent antibody.
• It is also possible to culture virus from lesions, but
results are not immediately available.
• Blood culture is warranted if bacterial super-infection
is suspected.
• Chest radiograph, CBC, coagulation screen, and liver
enzymes may be appropriate in ill-appearing
children. 50
51
52
Complications
• Secondary bacterial infection (most common)
▪ Infection with staphylococci, GAS
▪ Presents as impetigo, abscesses, cellulitis, necrotizing fasciitis,
sepsis
• Cerebellar ataxia, pneumonia, hepatitis, encephalitis
• Immunocompromised patients: varicella may be life-
threatening
• Neonates born to mothers who develop varicella from 5
days before to 2 days after delivery are considered high risk
▪ Must administer varicella-zoster immune globulin (VZIG), follow
for signs of infection/sepsis, and consider starting acyclovir
• Virus latent in sensory ganglia and reappears as herpes
zoster in 68/100,000 individuals
▪ Incidence is increased in immunocompromised patients 53
Treatment
• Supportive (hydration, acetaminophen, anti-pruritics).
▪ AVOID salicylates due to risk of Reye syndrome.
• Proper hygiene, discourage scratching.
• Acyclovir (20 mg/kg/dose QID for 5 days) should be used
for:
▪ Severe disease
▪ Immunocompromised patients
▪ Neonates
• Avoid contact with others until lesions are dry and crusted
and no new ones are appearing.
54
Prophylaxis and Prevention
• Immunization important to prevent complications
(Varicella vaccine subcutaneous at the age of 15
months)
• VZIG (Varicella zoster immunoglobulin) for post-
exposure in high risk susceptible patient (within 4
days of exposure)
• School exclusion: 5 days from start of skin eruption
55
Etiopathogenesis
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