Diseases of Absence. Disclosures

Transcription

1 Diseases of Absence Meg Fisher, MD Medical Director, The Unterberg Children s Hospital Long Branch, NJ Disclosures I have no disclosures I do not intend to mention off label uses of drugs I have way too many slides so we will be moving quickly 1

2 Objectives Decide when a child should be sent home from school and when that child can return to school Decide which children can stay at school Reasons for Absence Child is a risk to others: contagious Child unable to participate Child is at risk: needs medical attention Possible serious infection Dehydration Injury 2

3 When to Return Child no longer contagious Child able to participate No need for acute medical attention Case 1 - September A 10 year old who just returned from a trip to Ireland develops fever He appears ill you send him home The next day he has a runny nose and he starts coughing He has bilateral conjunctivitis What should you be worried about? 3

4 Concerns a) Pneumonia b) Kawasaki disease c) Adenovirus d) Blarney stone fever e) Measles My Thoughts a) Pneumonia possible but why conjunctivitis b) Kawasaki disease too old, cough c) Adenovirus - possible d) Blarney stone fever I made that up e) Measles you bet, check for Koplik spots today, rash tomorrow 4

5 Measles RNA virus: family Paramyxoviridae, genus Morbillivirus Transmitted by droplets and air Extremely contagious Incubation period 8 to 12 days Contagious 4 days prior to 4 days after the rash appears 2018 Red Book. Measles Measles in the US 1 st Vaccine licensed 1963 About 95% effective US measles free since

6 Measles in the US 2014: over 600 cases, 23 outbreaks 2018: 137 cases, 11 outbreaks so far* US travelers bring measles home Travelers to US bring measles along Secondary spread to unimmunized contacts *as of 9/8/18 Clinical Illness Fever, cough, conjunctivitis Day 2 to 3 of fever, Koplik spots appear One to 3 days later, rash appears on the face, maculopapular to confluent Rash spreads and then fads over days Photos from 6

7 Fever, Cough, Conjunctivitis Photos from Koplik spots Photos from 7

8 Confluent Rash Photos from Otitis media Complications Respiratory: pneumonia (viral and bacterial); laryngotracheitis Encephalitis Subacute sclerosing panencephalitis: years later 8

9 Clinical Diagnosis Confirm with serology: IgG and IgM Virus isolation: nasopharyngeal swab, urine Report all suspected cases: local health department if not available, call the state Red Book. Measles Treatment Isolate the patient: air and droplet Report the case Vitamin A: Once daily for two days 200,000 IU age > 12 mo; 100,000 IU 6-11 mo; 50,000 IU < 6 mo Ribavirin: in vitro, not approved Red Book. Measles 9

10 Prevention Measles vaccines: MMR and MMRV Routine: mo, 4-6 yr Post-exposure: within 72 hours Immunoglobulin 0.25 ml/kg (max 15) Travelers/outbreaks: MMR for ages 6 to 12 mo; child: give 2 nd dose at age months and 3 rd dose at 4-6 years Red Book. Measles Infection Control Staff: all should be immune Proof of immunity: 2 doses of vaccine or seropositive NOTE: no need for serology if 2 doses given Born 1957 and later: 2 doses; seropositive Born before 1957: generally considered immune but serology recommended if not immunized; vaccine if negative Red Book. Measles 10

11 Infection Control Triage is essential When possible, make the diagnosis outside of your office: car or hospital If the child is in your office, put into a room Mask on the child if possible The area is considered contaminated for 2 hours after the patient leaves Air in offices often re-circulated Why Did He Get Measles? He had a religious exemption from immunizations Measles is still endemic in most of Europe as well as most everywhere other than the Western Hemisphere There are rare vaccine failures: that is the reason for the second dose 11

12 Take Home Messages Think measles: fever, cough, conjunctivitis and then rash Notify local health department stat Get the proper specimens: serology and viral culture (NP preferred) Get everyone protected and immunized: staff and patients Case 2 A 15 year old boy comes to the office with fever, headache, and sore throat He says he was fine earlier in the day You examine him: T 101, throat OK You debate and decide to give an antipyretic 20 minutes later you notice a rash 12

13 Rashes Petechiae: think bad things meningococcemia, low platelets Hives: think allergic reaction Maculopapular: think virus or allergy Erythema: think burn, infection Vesicles: think herpes viruses Photos help Petechiae 13

14 Purpura fulminans Hives 14

15 Maculopapular Erythema 15

16 Vesicles Case 2 The rash is petechial oh dear! Where do you send him? ideally to the hospital What does he need? fluids and an antibiotic 16

17 Meningococcemia Gram negative bacteria: Neiserria meningiditis, types A, B, C, W135, Y Spread person to person by respiratory and saliva Fever, headache, vomiting, rash Asymptomatic carriage to rapid progression Meningococcemia Sepsis with purpura fulminans Meningococcal meningitis Diagnosis: culture, spinal fluid Treatment: fluids and antibiotics Outcomes: full recovery, deafness, loss of limbs, organ damage, death 17

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19 Prevention Chemoprophylaxis: close contacts, follow health department advice Vaccines: MCV4: universal, age 11-12, age 16 MenB: at risk >10 yr, no risk age Case 3 A 17 year old comes to the office complaining of jaw swelling and fever His temperature is He has a tender swelling at the angle of the jaw What are you worried about? 19

20 Concerns Tonsillitis Mumps Dental abscess External otitis TMJ disease Concerns Tonsillitis anterior cervical node Mumps parotitis, angle of jaw Dental abscess submandibular node External otitis preauricular node TMJ disease pain preauricular area 20

21 Lymph Nodes of the Neck Mumps RNA virus, Paramyxoviridae family, genus Rubulavirus Transmitted by saliva and respiratory secretions Incubation 16 to 18 days (range d) Contagious before and during parotitis; (virus recovered 7 d pre to 8 d post) 2018 Red Book. Mumps 21

22 Mumps Vaccine efficacy 88% with 2 doses but Midwest outbreak 2006, college students NY, NJ outbreak: Orthodox Belmar, NJ Bar outbreak: young adults NHL outbreak 2014: NJ Devils and more Many infected patients had 2 doses Graph from Red Book Online Mumps: Clinical Illness Salivary glands infected: Parotitis Often asymptomatic CNS pleocytosis common Orchitis after puberty; sterility rare Diagnosis: virus detection by culture or RT-PCR; buccal swab, saliva, CSF; serology IgM tricky, increasing IgG CDC photo 22

23 Mumps Differential diagnosis of parotitis: other viruses (cytomegalovirus, EBV, influenza, parainfluenza, LCM, enteroviruses, HIV) and less commonly, bacteria (atypical mycobacteria, gram positive and gram negatives) Treatment: supportive, report the case Prevention: 2 doses of vaccine; consider third dose during outbreaks 2018 Red Book. Mumps Some Others Influenza: contagious a day before symptoms, easily transmitted, stay home until afebrile without meds Norovirus: vomiting and diarrhea, spreads easily, stay home until better Streptococcal pharyngitis: sore throat, pus, nodes, ok to return after a dose of penicillin 23

24 Diseases of Presence Lice: short legs, no jump Infectious mononucleosis: shed for life MRSA carrier: 25-40% of us Strep carrier: 10-15% school age Noninfectious colitis: if able Poison Ivy: allergic reaction Smiling is a contagious condition! 24