Common Viral Infec - Part 2

2022 4.4b.
Viral Infections (Part 2)

DR. MARIBEL DOMINGO-PASAOA| 02/24/2021
PEDIATRICS II
OUTLINE COMPLICATIONS
I. Mumps VII. Respiratory Syncytial Virus • Meningitis w/ or w/o encephalitis
II. Enterovirus VIII. Rhinovirus → most common complication in childhood
A. Non-poliovirus IX. Adenovirus → symptomatic in 10-30%, but CSF pleocytosis in 40- 60% in
B. Poliovirus X. Human Metapneumovirus patients with mumps parotitis
III. Rabies XI. Coronavirus
→ may occur before, along with or after parotitis
IV. HIV XII. Viral Gastroenteritis
→ resolve in 7-10 days
V. Influenza
VI. Parainfluenza → less-common CNS complications: transverse myelitis,
aqueductal stenosis, facial palsy, sensorineural hearing
loss
LEGEND • Orchitis
Remember Lecturer Book Previous Trans Presentation → occur in 30-40% of post pubertal males
Hello → follow parotitis > 8 days after
→ may occur w/o parotitis
MUMPS ▪ fever, chills, exquisite pain & swelling of testes
• Epidemic parotitis ▪ bilateral in 30% or less
• Family Paromyxoviridae ▪ atrophy of testes may occur; sterility is rare
• Genus Rubulavirus • Oophoritis
• 1 serotype → uncommon in post pubertal females
→ may cause severe pain confused with appendicitis
EPIDEMIOLOGY: • Pancreatitis
→ may occur w/ or w/o parotid involvement
• Age incidence: → severe disease is rare
→ pre-vaccine era: 5-9 y/o → presents with fever, epigastric pain & vomiting
→ post-vaccine era: older children, adolescents, and young → maybe associated with diabetes mellitus, no causal link
adults • Myocarditis
• Route of transmission: droplet • Arthritis
• Period of infectiousness: 1-2 days before to 5 days after onset of • Thyroiditis
parotid swelling • Maternal infection during the 1st trimester of pregnancy
→ increased fetal wastage
CLINICAL MANIFESTATION → no fetal malformation
• Incubation period :12-25 days (16-18 days) → perinatal mumps disease in infants born to mother with mumps
• clinical spectrum: asymptomatic or nonspecific symptoms - late in gestation
parotitis w/ or w/o complications
• prodrome: 1-2 days w/ fever, headache, vomiting and achiness DIAGNOSIS
• parotitis: unilateral, but bilateral in 70 % of cases; (+) • clinical diagnosis: (+) exposure, incubation period, no MMR
tenderness, ipsilateral earache, enhanced pain with sour foods vaccine, (+) typical findings
→ Let the patient eat mango • elevated serum amylase
• definitive diagnosis:(seldom requested) cell culture, detection of
viral antigen by direct immunofluorescence, PCR, antibody
detection
DIFFERENTIAL DIAGNOSIS
• Parotitis due to parainfluenza 1 and 3 viruses, influenza A virus,
CMV, EBV, enterovirus, lymphocytic choriomeningitis virus,
HIV
• suppurative parotitis: Staphylococcus aureus
→ unilateral, (+) purulent discharge from Stensen’s duct
• Lymphadenitis: submandibular, cervical
• Obstruction of Stensen’s duct
• Collagen vascular disease: Sjogren’s syndrome, SLE
• Tumor
• It will support the diagnosis of mumps if the mass is anterior to the
sternocleidomastoid muscle TREATMENT
• with Parotitis: angle jaw obscured, ear lobe lifted upward and • Adequate hydration
outward • Relief of pain
• peak of swelling by D3, gradually subsides over 7 days • Antipyretics
• with red & edematous opening of Stensen’s duct • Diet adjusted according to patient’s ability to chew
→ you can ask the patient to open his/her mouth to check the → Soft/liquid diet
Stensen’s duct
• submandibular gland may be involved w/o parotitis PREVENTION
• fever & systemic S/Sx resolve in 3-5 days
• active immunization: 2 dose MMR at 12-15 months and 4-6 y/o
• outbreak: 2nd dose can be given after 4 weeks/1 month
Trans Group #5: Agbuya, Crisologo, Garcia, Guilang, Landingin, Pacio, Zamudio EDITOR: Garcia, Guilang 1 of 13
2022 4.4b. Viral Infections (Part 2)
PEDIATRICS II
ENTEROVIRUS (NONPOLIOVIRUS) INFECTION

GROUP A &B COXSACKIEVIRUSES, ECHOVIRUS AND
NUMBERED ENTEROVIRUS
EPIDEMIOLOGY
• Source: feces and oropharyngeal secretions
• Mode of transmission
→ person to person by fecal-oral route
→ possibly oral-oral (respiratory) route
• Incubation period: 3-6 days except for acute hemorrhagic CLINICAL MANIFESTATION
conjunctivitis (1-3 days)
• Respiratory manifestation
CLINICAL MANIFESTATION → may dominate like sore throat, coryza, tonsilitis, wheezing,
exacerbation of asthma, pneumonia, parotitis
• Asymptomatic infection: large percentage of infections are • Pleurodynia or Bornholm’s Disease
asymptomatic; majority of those shedding the virus are → Coxsackie B and Echovirus
asymptomatic → source for spread → epidemic or sporadic
• Nonspecific febrile illness → malaise, myalgia & headache are followed by sudden fever &
→ most common symptomatic manifestation (> 90 % of cases) spasmodic pleuritic chest or upper abdominal pain (myositis)
→ w/ abrupt fever (38.5 – 40c), malaise, irritability, lethargy, aggravated by cough, sneeze, deep breathing, movement
anorexia, diarrhea, nausea, vomiting, abdominal → if severe, mistaken for pneumonia or acute abdomen
discomfort, sore throat, respiratory symptoms, meningitis → last 3-6 days, frequently biphasic (will disappear and re-
→ difficult to differentiate clinically from serious bacterial appear)
infections • Myopericarditis & Pericarditis
→ with rashes (macular, maculopapular, urticarial, vesicular, → account for 25-35 % of proven cases
petechia eruption
→ usually Coxsackie B viruses
→ fever last 4-7 days (mean 3 days)
→ mild to severe
→ upper respiratory symptoms frequently precede fatigue,
HERPANGINA
dyspnea, chest pain, CHF, dysrhythmias
• ANOREXIA, DYSPHAGIA, SALIVATION, SORE THROAT
→ CXR: cardiomegaly
• vesicles and ulcers on anterior pillar (most common site) soft
→ ECG:ST segment, T wave, and/or rhythm abnormalities
palate, uvula, tonsils, pharyngeal wall, posterior buccal surfaces
→ Echocardiography: cardiac dilation, reduced contractility,
→ Coxsackie A virus
and / or pericardial effusion
NEUROLOGIC MANIFESTATION
• Viral Meningitis
→ the most common cause (>90 % of proven cases) in mumps-
immunized populations; affects infants < 3 months old
→ coxsackie B2-5, echo 4,6,7,9,11,16,30, entero 70 & 71
• Encephalitis
→ accounts for 10-20 % of proven encephalitis
• Poliomyelitis-like acute flaccid paralysis
→ entero 70 & 71 cox A7, cox B
• Chronic meningoencephalitis
→ in patients w/ antibody deficiencies and combined
HAND, FOOT AND MOUTH SYNDROME immunodeficiencies
• Coxsackie A16 (most common) → persistent CSF abnormalities, viral detection by culture or PCR
• Enterovirus 71 (more severe with neurologic and cardiopulmonary for year & recurrent encephalitis, progressive neurologic
involvement) deterioration
• Others: Coxsackie A5, 7, 9, 10, & B2 & 5
GIT MANIFESTATION
• vomiting, mild diarrhea, and abdominal pain are frequent but
not dominant
GUT MANIFESTATION
• orchitis, 2nd only to mumps as causes
• nephritis, IgA nephropathy
MYOSITIS AND ARTHRITIS

• myalgia is a common complaint but direct muscle involvement
only occasionally
PEDIATRICS II
ACUTE HEMORRHAGIC CONJUNCTIVITIS POLIOVIRUS GLOBAL SITUATION

• children under five years of age are most vulnerable, Global Polio
• Enterovirus 70, Coxsackie A24
cases Polio cases worldwide decreased by over 99% since 1988
• from an estimated 350,000 cases to 356 reported cases in 2014.
NEONATAL INFECTIONS Of the three stain of wild poliovirus (type 1,2, and 3), poliovirus
• frequently w/ Coxsackie B2-B5, Echo 6,11,19 type 2 is first to be eradicated in 1999.
• transmitted before, during or after delivery or horizontally • Because of low vaccine coverage, Polio is re-emerging
• asymptomatic (majority) → benign febrile illness → severe • Polio (poliomyelitis) mainly affects children under 5 years of age
multisystem disease • 1 in 200 infections leads to irreversible paralysis. Among those
• affects healthy full term paralyzed, 5% to 10% die when their breathing muscles become
immobilized.
• (+) recent maternal viral illness: fever and abdominal pain
• Cases due to wild poliovirus have decreased by over 99% since
• severe disease usually w/ in 1st 2 weeks of life
1988, from an estimated 350,000 cases then, to 33 reported cases
• Frequent findings:
in 2018.
→ Fever, hypothermia, irritability, lethargy, anorexia, rash
(maculopapular, petechial, or papulovesicular), jaundice,
POLIO THIS WEEK AS OF 03 FEBRUARY 2020
respiratory symptoms, apnea, hepatomegaly, abdominal
• Summary of new WPV and cVDPV viruses this week (AFP/Acute
distention, emesis
Flaccid Paralysis cases and ES positive):
→ Minority w/sever disease: any combination of sepsis,
→ REMEMBER: All cases of weakness should be immediately
meningoencephalitis, myocarditis, hepatitis, coagulopathy
reported whatever the cause!
& pneumonitis
→ Afghanistan: one WPV1 and 14 cVDPV2 cases and two
• Transplant recipients and patients with malignancies
cVDPV2 positive environmental samples
→ illness may be severe and/ or prolonged, as progressive
→ Pakistan: three WPV1 and 18 cVDPV2 positive environmental
pneumonia, severe diarrhea, pericarditis, heart failure,
samples and eight cVDPV2 cases
meningoencephalitis, and disseminated disease
→ Benin: one cVDPV2 case and two positive environmental
→ with high fatality rates
samples
DIAGNOSIS CURRENT SITUATION (PHIL)
• VIRAL ISOLATION *based from the National Certification Committee Report
→ stool, throat, CSF, blood, biopsy • Polio Spread a Public Health Emergency of International Concern
→ gold standard for confirmation (WHO)
→ incubation period: 3-8 days • The Philippines is at high risk for wild poliovirus importation and
→ coxsackie A viruses unable to grow in culture outbreak because of:
→ less specific in stool alone since viral shedding x 6-12 wks in 1. Routine immunization coverage gaps
asymptomatic patients 2. No wide-scale supplementary immunization since 2002
3. Surveillance not sensitive enough
• DIRECT TESTING FOR NUCLEIC ACID 4. High population density
→ CSF, serum, urine, conjunctival, nasopharyngeal, throat, 5. Frequent international and domestic population movement
tracheal, rectal, stool and dried blood spot specimens and
tissues • Source:
→ overcomes the imperfect sensitivity and results of culture → feces and possibly, oropharyngeal secretion of man
▪ RT-PCR for enterovirus RNA in CSF • Mode of transmission:
→ fecal to oral
• ANTIBODY TITER → possibly oral to oral (respiratory) routes
→ rise in neutralizing antibodies from an acute and convalescent
specimen CLINICAL FORMS
• Inapparent illness: 90-95% of cases
TREATMENT • Abortive Poliomyelitis (minor illness)
• no specific therapy → 5% of cases
• IMMUNE GLOBULIN INTRAVENOUS (IGIV) → influenza-like syndrome (fever, malaise, anorexia, headache,
→ may be beneficial but lack proof of efficacy for: sore throat, abdominal/ muscular pain) x 2-3days
▪ chronic enteroviral meningoencephalitis in • Nonparalytic Poliomyelitis (aseptic meningitis)
immunodeficient patient → 1% of cases
▪ life-threatening neonatal infections → signs of abortive poliomyelitis + more intense headache,
▪ severe infections in patients w/ malignancies, hematopoietic nausea, vomiting, sorenes...symptoms-free interlude...
stem cell recipients, viral myocarditis, enterovirus 71 stiffness of posterior muscles of neck, trunk, limbs, fleeting
neurologic disease paralysis of bladder, constipation (CNS or major illness)
▪ PE: nuchal-spinal signs, abnormal superficial & deep
POLIOVIRUS INFECTIONS reflexes
EPIDEMIOLOGY → recovery in 3-10 days
• Paralytic Poliomyelitis: 0.1% of cases
• Based on active WHO Acute Flaccid Paralysis Surveillance • Spinal Paralytic Poliomyelitis
• It was previously eliminated but there was a recent outbreak due to → with apparent recovery after 1st phase for 2-5 days after w/c
the fear of vaccination exacerbation of previous headache and fever + severe
muscle pain → sensory & motor phenomena (paresthesia,
***Read more on Poliovirus hyperesthesia, fasciculations, spasms)
PEDIATRICS II
→ w/in 1-2 days → asymmetric flaccid paralysis or paresis, CONTROL MEASURES:

usually of one leg followed by one arm, absent deep tendon
• OPV:
reflexes, no sensory loss
→ vaccine of choice for global eradication in areas w/ VDPV,
• Bulbar Poliomyelitis
developing countries where inadequate sanitation
→ may occur w/o apparent spinal cord involvement
necessitates optimal mucosal barrier
→ a continuum: dominance of dysfunction of cranial nerves and
• IPV:
medullary center (paralysis of extraocular, facial, masticatory
→ areas not at risk to wild type, immunodeficient patients
muscles, nasal twang, inability to swallow, ineffective cough,
nasal regurgitation, deviation of palate, involvement of vital
centers, paralysis of vocal cords) RABIES
• Polioencephalitis: • Primarily a disease of animals
→ Rare; seizures, coma, spastic paralysis • Dogs account for >90% of reported human cases
• Vaccine-Associated Paralytic Poliomyelitis • 6-10% - cats, cattle, horse, sheep, bats, exotic pets
→ considered in any child with paralytic disease 7-14 days or • Small rodents, birds & reptiles are NOT KNOWN to serve as
later, after OPV reservoir of infections
→ may occur in the OPV recipient/ close contact
(immunocompromised or unvaccinated children) EPIDEMIOLOGY
→ incidence: 1 case in >/3 million doses distributed • Modes of Transmission
• Paralytic Poliomyelitis secondary to circulating vaccine- → Infected animal saliva
derived Poliovirus (c VDPV) ▪ Inoculated by a bite or scratch
→ Dependent of sabin virus ▪ Contact of infected saliva with human mucous membrane
→ Virologically different strain due to accumulation of small spot can also transmit infection
mutations → Human-to-human transmission:
→ Recovers properties of wild virus like neurovirulence, ▪ After transplantation of infected tissue
recombination and transmissibility → Human rabies due to aerosol transmission of virus after
→ Occurs only where there is no wild virus exposure in bat caves or laboratory accidents
→ With accumulation of susceptibles → Incubation period: 1 day to 5 years (average: 8 weeks)
→ Epidemiology
▪ In 2001: type 1 circulating vaccine-derived poliovirus (c
INFECTED PATIENTS GO THROUGH 4 STAGES
VDPV) was isolated from 3 children in 3 places:
- Cagayan de Oro
- Cavite Incubation period
- Laguna
• Usually 20-90 days
• >95% will present with s/sx within 6 months
FEATURES Virus in VAPP cVDPV
• Virus remains at the site of the bite
Structure Identical to sabin >3% different from sabin
• The only time when vaccination is effective
vaccine virus vaccine virus (mutant)
Virus circulation None Circulates or is transmissible
in a community Prodrome
Occurrence Wherever OPV is Occurs only where there is • 2-10 days
used no wild virus and there is an • Virus reaches the spinal cord
accumulation of susceptibles • 1st rabies specific sx - pain or itching or paresthesia at bite site
***susceptibles - high risk of being infected (immunocompromised or
unvaccinated) Acute neurologic phase
• 2-7 days
DIAGNOSIS
• 2 TYPES:
• Acute Flaccid Paralysis Surveillance 1. Encephalitic or furious rabies - 80%
→ Any child less than 15 years of age with Acute Flaccid - Hyperactive episodes (combative, bizarre
Paralysis should be considered a “suspect” behavior, apprehensive)
→ All AFP cases should be reported to disease surveillance - Hydrophobia (agitation, cringing, due to painful
coordinator/infection control nurse. Accomplish a case contractions of laryngeal muscles upon drinking)
investigation form - aerophobia
→ 2 stool specimens, taken 24-48 hours apart within 14 days of
onset of paralysis are collected 2. Paralytic or dumb rabies - 20%
→ 60-day follow-up by disease surveillance officer to check for - Paralysis of bitten area → respiratory paralysis
residual paralysis - Often missed, hydrophobia & aerophobia absent
→ Report a case even if either Guillain-Barre syndrome, - Rabies suspected if with paralysis or
transverse myelitis, or traumatic paralysis is being encephalitis
considered
Coma
TREATMENT: • 4-10 days
• No specific treatment; symptomatic & supportive • complications: myocarditis, diabetes insipidus, SIADH
• outcome: death due to respiratory paralysis
PEDIATRICS II
DIAGNOSIS ISOLATION OF HOSPITALIZED PATIENT:

• Usually made clinically • Standard precautions
• Presence of pathognomonic hydrophobia and aerophobia in a • If bitten by rabid patient or the patient's saliva has contaminated an
patient with history of exposure is enough to make the diagnosis open wound or mucous membrane → wash the involved area
thoroughly and post exposure prophylaxis should be
Laboratory work up administered
• RT-PCR of saliva (and oral swab) for genomic detection
• Corneal imprint for rabies virus direct fluorescent antibody test PREVENTION
(FAT)
• CSF examination - for those in whom the diagnosis is Post exposure prophylaxis (PEP)
questionable Objectives:
• CSF is examined by RT-PCR, IgG detection by ELISA or mouse • Minimize the virus at the site of inoculation
inoculation test (MIT) • To develop a high titer of neutralizing antibody early and maintain it
• Postmortem samples of brain tissue: RT-PCR, FAT and MIT, (+) for as long as possible
negri bodies
Local wound care
MANAGEMENT • Immediate vigorous washing and flushing with soap and water
preferably for 10 minutes
• Almost 100% mortality rate
→ Apply povidone iodine or alcohol
• Rabies is better prevented than treated
→ Avoid suturing of wounds since it may inoculate virus deeper
• There is no specific treatment
into the wound
• Very few survived, even with intensive supportive care
→ If suturing is unavoidable, it should be delayed for at least 2
hours after administration of RIG to allow diffusion of the
antibody to occur through the tissues
→ Avoid practices that may further contaminate the wound
MANAGEMENT ACCORDING TO RISK OF EXPOSURE
Category Rabies Vaccine Rabies Immunoglobulin

Category I Not recommended but Not recommended
a) touching/feeding an animal Preexposure prophylaxis may be
b) Licking of intact skin (with reliable history and thorough PE) considered
c) exposure via use of drinking/eating utensils of potentially rabid
pt
Category II Recommended Not recommended

a) Superficial scratch/abrasion without bleeding
b) Superficial scratch/abrasion that is induced to bleed
c) Nibbling of skin with bruising/hematoma
d) Licks on broken skin
Category III Recommended Recommended

a) Transdermal bites or scratches with spontaneous bleeding (to
include puncture wound, lacerations, avulsions)
b) Licking of mucous membrane
c) All Category Il exposure on head and neck area
d) Handling of infected carcass or ingestion of new infected meat
RABIES VACCINE
SCHEDULE OF ACTIVE IMMUNIZATION
Regimen Dose No. Of doses on specified days

PVRV PCECV Day 0 Day 3 Day 7 Day 14 Day 28/30*
(Verorab) (Rabipur)
Modified 2 site 0.1 ml 0.1 ml 2 2 2 0 2
Intradermal (ID)
regimen
Standard 0.5 ml 1.0 ml 1 1 1 1 1

Intramuscular
(IM) regimen
PEDIATRICS II
* For Category II and III

1) Complete vaccination regimen until day 28/30 if biting animal:
- laboratory proven to have rabies OR - have signs and symptoms of rabies OR
- is killed/died without laboratory testing OR
- cannot be observed for 14 days
2) May omit day 28/30 dose if biting animal:
- is alive AND remains healthy after 14 days observation
- is killed or died within 14 days observation but was FAT neg AND was confirmed without signs and symptoms of rabies
RABIES IMMUNOGLOBULIN
Generic Name Preparation Dose Skin Test

Purified Equine Rabies 200 iu/ml 40 iu/kg YES
Immune Globulin (ERIG) 5ml/vial
Human Rabies Immune 150 iu/ml 20 iu/kg NO

globulin (HRIG) 2ml/vial
• Skin test prior to ERIG administration

• Infiltration of all Category III wounds with RIG is mandatory
• A gauge 23 or 24 needle, 1 inch length should be used for infiltration. Multiple needle injections in the wound should be avoided
• If finger or toes need to be infiltrated, care not to impair blood circulation by injection of an excessive amount leading to cyanosis, swelling
and pain
POST EXPOSURE PROPHYLAXIS (PEP)

• It is necessary to give PEP even if the dog is vaccinated, because:
→ Animal vaccine failure may occur
→ Only 20-25% is the current dog vaccination rates, so rabies virus continue to circulate in the dog population
→ Some owners may claim that their dogs are vaccinated
• Bites by rodents (rats, mice, guinea pigs, hamsters and rabbits) do NOT require rabies PEP.
• Exposed persons who present for evaluation and treatment weeks or months after the bite, should be treated as if the exposure occur
recently
ANTI-TETANUS PROPHYLAXIS
Vaccination History Unknown or < 3 doses 3 or more doses

Td* TIG/ATS Td* TIG/ATS
Clean minor wounds YES NO NO** NO
All other wounds YES YES NO*** NO
*Tdap may be substituted for Td if the person has not received Tdap and is >10 years; DPT may be given for < 7 y/o; TT maybe given if Td or
Tdap not available
** YES if more than 10 years since last dose
*** YES if more than 5 years since last dose
RECOMMENDATIONS FOR ANTIBIOTIC TREATMENT
Description Recommended Alternatives

-All frankly infected wounds Cloxacillin or Coamoxiclav Clindamycin
- All Category III bites
Uninfected Category III wounds that are: Amoxicillin

• inflicted by cat
• inflicted by other animals that are either
deep, penetrating multiple or extensive or
located on the hand/face/genital area
PEDIATRICS II
Pre exposure prophylaxis (PrEP) INFECTIONS

• Rabies vaccination administered before an exposure to potentially • 20% of AIDS-defining illnesses recurrent bacterial infections
rabid animals/humans caused by encapsulated organisms (pneumococcus, salmonella)
• BENEFITS: • Most common serious infections: bacteremia, sepsis, pneumonia
→ The need for RIG is eliminated • Opportunistic infections with severe depression of CD4 count
→ PEP vaccine is reduced from 5 to 2 doses • PCP pneumonia
→ Protection against rabies is possible if PEP is delayed, → most common opportunistic infection children; peak: 3-6
especially in areas where access to vaccine or RIG is limited months;44-47% mortality
→ The cost of PEP is reduced • Tuberculosis
• The Anti-Rabies Act of 2007 recommends pre-exposure → higher prevalence of TB & HIV co infection in developing
prophylaxis for children aged 5-14 years who live in highly endemic countries
areas • Oral candidiasis
→ most common fungal infection in HIV infected patients
Day 0 Day 7 Day 21/28
• Viral infections with Herpes viruses pose a significant problem
IM dose = 0.5 ml PVRV or 1.0 ml PCECV
ID dose = 0.1 ml PVRV, PCECV
CNS
• Guidelines for subsequent exposure following primary • occurs in 50-90 % of perinatally infected children in developing
immunization (PreXP: D0, 7, 28 or PEP: D 0, 3, 7) countries as progressive encephalopathy, loss of developmental
→ any exposure, regardless of the interval between re-exposure milestone, cognitive deterioration, and impaired brain growth.
and last dose of the vaccine should receive a BOOSTER on DO
and D3 Respiratory Tract
→ NO RIG needed, booster doses will rapidly induce increased • Recurrent otitis media and sinusitis are common
antibody production • LIP - the most common chronic lower respiratory tract abnormality;
affects 30-40% of HIV infected children; maybe an exaggerated
HIV response to EBV & HIV, non-productive cough, insidious hypoxia,
• Broad spectrum of disease bronchiectasis, pulmonary decompensation, clubbing
• Varied clinical course
• AIDS - most severe end of the clinical spectrum Cardiovascular System
• Target cells
• Rhythm disturbances; dilated cardiomyopathy & LVH
→ T-helper CD 4+ lymphocyte
→ Monocytes
→ Macrophages
GI
→ CNS cells with CD4 + receptors • Oral candidiasis, gingivitis, parotitis
• Most common symptoms: chronic or recurrent diarrhea with
Mother to infant transmission (vertical) malabsorption, abdominal pain, dysphagia, failure to thrive,
chronic hepatitis
• Primary route of transmission
• Pathogens: salmonella, campylobacter, MAC, giardia,
• Rate of transmission:12-30% in US & Europe, 25-52% in Africa cryptosporidium, CMV, HSV, rotavirus, candida
• Time of transmission
→ Before delivery
Renal
▪ 30-40%, of infected NB
▪ (+) PCR within 1st week • uncommon
→ Intra-partum transmission
▪ 60-70%,of infected NB Skin
→ Via breast feeding • Severe & unresponsive seborrheic dermatitis or eczema
▪ risk of transmission
- in chronically infected women: 9-16%
Hematologic
- in women with HIV postnatally: 29-53%
• substitute milk formula to breastmilk if w/ maternal HIV or • Anemia, leukopenia, thrombocytopenia
ongoing sexual/parenteral exposure, but WHO recommends • Malignant diseases infrequent in children
breastfeeding in developing countries: benefits outweigh risk of • Common reported neoplasms: NHL, primary CNS lymphoma,
transmission leiomyosarcoma
CLINICAL MANIFESTATIONS SIGNS THAT MAY INDICATE HIV INFECTION

• Vary widely • Recurrent infection
• PE at birth may be normal → three or more severe episodes of a bacterial infection (such as
• Initial symptoms may be subtle/ non-specific pneumonia, meningitis, sepsis, cellulitis) in the past 12 months.
• Symptoms more common in children than adults • Oral thrush
→ Recurrent bacterial infections → erythema and white-beige pseudomembranous plaques on
→ Chronic parotid swelling the palate. gums and buccal mucosa. After the neonatal period,
→ Lymphoproliferative interstitial pneumonitis the presence of oral thrush is highly suggestive of HIV infection
→ Early onset of progressive neurologic disorder when it is: occurring when there has been no antibiotic
treatment, lasting over 30 days despite treatment, recurring,
extending beyond the tongue, or presenting as esophagus
candidiasis.
PEDIATRICS II
• Chronic parotitis • all hospital personnel with whom the patient may interact for the
→ unilateral or bilateral parotid swelling for 14 days, with or without conduct of HIV testing should act professionally and responsibly to
associated pain or fever. ensure CONFIDENTIALITY of the test
• Generalized lymphadenopathy
→ enlarged lymph nodes in two or more extra-inguinal regions DIAGNOSIS OF HIV INFECTION
without any apparent underlying cause.
• Hepatomegaly with no apparent cause: Serologic test
→ in the absence of concurrent viral infections such as • Maternal antibodies may persist until 18 months of age, so
cytomegalovirus (CMV). antibody tests are not reliable for diagnosing children less than 18
• Persistent and/or recurrent fever: months of age
→ fever (238°C) lasting 27 days or occurring more than once over • ELISA
a period of 7 days. • Western blot assay
• Neurological dysfunction
→ progressive neurological impairment, microcephaly, delay in Definitive virologic diagnosis
achieving developmental milestones, hypertonia, or mental
confusion. • HIV DNA PCR (preferred test)
• Herpes zoster (shingles) • performed at 6 weeks old
→ painful rash with blisters confined to one dermatome on one • a (+) virologic test should be confirmed by a repeat test
side.
• HIV dermatitis WHO PEDIATRIC CLINICAL STAGING
→ erythematous purpuric rash. Typical skin rashes include • For use in those 12 years or under with confirmed laboratory
extensive fungal infections of the skin, nails and scalp, and evidence of HIV infection
extensive molluscum contagiosum.
• Chronic suppurative lung disease. Clinical Stage HIV- Associated Clinical
Disease Classification
RISK FACTORS FOR HIV INFECTION I Asymptomatic
• Men who have unprotected sex with men II Mild
• Intravenous drug use III Advanced
• Blood transfusion before 1980 IV Severe
• Occupational exposure to an HIV-infected person (percutaneous
or mucocutaneous exposure) WHO CLINICAL STAGING OF HIV/AIDS FOR CHILDREN
• High-risk heterosexual contact (e.g., unprotected sex with a
commercial sex worker, unprotected sex with a person who has Clinical stage 1: ASYMPTOMATIC
risk factors for HIV infection or known HIV infection) • Persistent generalized lymphadenopathy
• Infants born to an HIV-infected mother
Clinical Stage 2: MILD
Principles for the conduct of HIV testing:
• Unexplained persistent hepatosplenomegaly
• 3C's • Papular pruritic eruptions
→ Confidential • Extensive warts
→ Counseling • Extensive molluscum contagiosum
→ Consent • Fungal nail infections
• Recurrent oral ulcerations
RA 8504 Philippine AIDS Prevention and Control Law • Unexplained persistent parotid enlargement
• Pre-HIV test counseling → Informed consent → HIV testing → • Linear gingival erythema
Post-HIV test counseling • Herpes zoster
• No one can read the results besides the patient him/herself • Recurrent or chronic upper respiratory tract infection
together with the counsellor/s
Clinical Stage 3: ADVANCED
STEPS TO HIV TESTING • unexplained moderate malnutrition not adequately responding to
standard treatment
A. Pre-test Counseling
• Unexplained persistent diarrhea (>14 days)
• important because of the profound psychosocial impact of an HIV • Unexplained persistent fever (>37.5 >1 month)
(+) antibody test • Persistent oral candidiasis
• assess person's risk for HIV infection • Oral hairy leukoplakia
• provide adequate & correct info about HIV antibody test and • Acute necrotizing ulcerative gingivits or periodontitis
HIV/AIDS • Pulmonary tuberculosis
• assess how the person would cope with a (+) test • Severe recurrent bacterial pneumonia
• promote behaviors that will prevent transmission • Symptomatic lymphoid interstitial pneumonitis
• Chronic HIV-associated disease including bronchiectasis -
B. Request for HIV Ab Test Unexplained anemia (<8g/dL), neutropenia (<500/cmm) and
• informed CONSENT prior to test thrombocytopenia (<50000/cmm)
• request for HIV Ab testing must be written on the chart using a
code name for the test
PEDIATRICS II
Clinical Stage 4 - SEVERE • Central nervous system toxoplasmosis (after neonatal period)
Extrapulmonary cryptococcosis, including meningitis
• Unexplained severe wasting or malnutrition not responding to
• HIV encephalopathy
• standard therapy
• Disseminated endemic mycosis (extrapulmonary histoplasmosis,
• Pneumocystis pneumonia Recurrent severe bacterial infections
• coccidioidomycosis)
(empyema, pyomyositis, bone or joint infections, meningitis,
excluding pneumonia) • Chronic cryptosporidiosis
• Chronic herpes simplex infection (orolabial or cutaneous of more • Chronis isosporiasis
than one month's duration or visceral at any site) • Disseminated non-tuberculous mycobacteria infection
• Extrapulmonary Tuberculosis • Cerebral or B cell non-Hodgkin lymphoma
• Kaposi Sarcoma • Progressive multifocal leukoencephalopathy
• Esophageal candidiasis (or candida of the trachea, bronchi or the • HIV-associated cardiomyopathy or nephropathy.
lungs)
• Cytomegalovirus infection: retinitis or cytomegalovirus infection
affecting another organ, with onset at age over one month
1994 Revised Human Immunodeficiency Virus Pediatric Classification System: Immune Categories Based on Age-
Specific CD4+ T Cell Count and Percentage
< 12 months 1-5 months 6-12 yrs

Immune category No mm3 CD4 (%) No mm3 CD4 (%) No mm3 CD4 (%)
(CD4)
Category 1: No ≥1, 500 (≥25%) ≥1, 000 (≥25%) ≥500 (≥25%)
Clinical
suppression
Category 2: 750-1499 (15%-24%) 500-999 (15%-24%) 200-499 (15%-24%)
Moderate
suppression
Category 3: < 750 (<15%) <500 (<15%) <200 (<15%)
Severe
suppression
• Consider AGE as variable when interpreting CD4 count
• CD4 absolute count changes with age while the CD4% does not
CD4% is a better marker of disease progression up to the 6 years of age
• Early diagnosis/aggressive treatment of opportunistic infection

MANAGEMENT
• Prophylaxis
• Antiretroviral therapy
• Prevention of infection Tuberculosis
→ Prophylaxis against specific infections • TB screening is strongly recommended for all w/ HIV infection
→ Vaccination • INH preventive therapy (6 mos) to all HIV infected children with a
→ IVlg (+) TST or after exposure to PTB, after disease has been excluded
• Provision of psychosocial support
Pneumocystis jiroveci pneumonia
ART in Children • Trimethoprim sulfa, aerosolized pentamidine, dapsone
• at 4-6wks-1 yo unless HIV infection excluded
• Backbone of management
• older children: if CD4% <15%
• 2 NRTI + 1 NNRTI (or 1PI)
→ ZIDOVUDINE (AZT)
MAC prophylaxis
▪ syrup:10 mg/ml 8-15 mg/kdose BID
• Clarithromycin or azithromycin
▪ Or (180-300 mg/m2) BID
• given to children with advanced immunosuppression
→ LAMIVUDINE (3TC)
▪ Syrup: 10 mg/ml
<1 yo CD4 <750 cells/mm3
• EFAVIRENZ (EFV)
→ Capsule: 200 mg Tablet: 600 mg 2-5 yo CD4 <75 cells/mm3
→ ~15 (10-20) mg/kg/day OD 1-2 yo CD4 <500 cells/mm3
2 6 yo CD4 < 50 cells/mm3
PREVENTION
A. Abstinence
B. Be faithful (mutual monogamy)
C. Careful sex/correct and consistent condom use
D. Do not take prohibited drugs/do not share contaminated
needles
E. Education/Early detection and treatment of STI
PEDIATRICS II
PROPHYLAXIS • respiratory manifestations: isolated URTI, croup, or bronchiolitis

or pneumonia.
• IVIG:400mg/kg every 4 weeks
• children may have abdominal pain, vomiting and diarrhea
• Hypogammaglobulinemia
• febrile x 2-4 days, cough may persist longer
• To prevent serious bacterial infection for HIV infected children with:
• high transmissibility, family members/close contacts with similar
at 2 lab documented serious bacterial infections
illness
• Lab-documented inability to make antigen-specific antibodies
COMPLICATIONS
Suggested Immunization for children with suspected or
• Acute otitis media
confirmed HIV infection → 25% of cases of documented influenza.
• Pneumonia
Vaccines → primary viral process or a secondary bacterial infection (usually
OPV No Staphylococcus aureus) facilitated through damaged respiratory
IPV Yes epithelium
DTaP/Tdap Yes • Unusual clinical manifestations
HAV Yes → acute myositis (influenza type B); muscle weakness and pain
HBV Yes on calf muscles, and myoglobinuria
Hib Yes → myocarditis
Pneumococcal Yes → toxic shock syndrome
Influenza Yes → encephalitis, myelitis, and Guillain-Barré syndrome
Meningococcal Yes
→ Reye syndrome (use of salicylates during influenza type B
Rotavirus Yes
infection
MMR and Varicella Should be given to asymptomatic
***live viruses infected children w/ CD4+ count >15%
RISK FACTORS FOR SEVERE INFLUENZA
• congenital and acquired valvular disease
BCG recommended by WHO in TB endemic • cardiomyopathy
countries if asymptomatic • bronchopulmonary dysplasia
• asthma
• cystic fibrosis
PREVENTION OF PERINATAL TRANSMISSION • neuromuscular diseases affecting the accessory
• muscles of breathing
• Pediatric Clinical Trials 076: ZDV at 4 weeks AOG, during labor • pregnancy
and delivery and to the newborn for 1st 6 weeks-> 75% decrease • chemotherapy
transmission
• immunodeficiency
• CDC and WHO recommend CART regimen during pregnancy
irrespective of viral load/CD4 countles
Table 258-2 Children and Adolescents Who Are at Higher Risk for
→ Combination of elective C-section and maternal ZDV treatment Influenza Complications
reduced transmission by 87%.
• Children younger than 2 yr of age
• The most effective way to prevent postpartum transmission is to
• Persons with chronic pulmonary (including asthma),
stop breastfeeding
cardiovascular (except hypertension alone), renal, hepatic,
• HIV (+) mothers may not breastfeed as long as there is (AFASS)
hematologic (including sickle cell disease), metabolic disorders
replacement feeding option:
(including diabetes mellitus), or neurologic and
→ Acceptable neurodevelopmental conditions (including disorders of the brain,
→ Feasible spinal cord, peripheral nerve, and muscle such as cerebral palsy,
→ Affordable epilepsy (seizure disorders, stroke, intellectual disability (mental
→ Sustainable retardation), moderate to severe developmental delay, muscular
→ Safe dystrophy, or spinal cord injury)
• Baby should be given oral Nevirapine OD or Zidovudine BID soon • Persons with immunosuppression, including that caused by
after birth X 6 weeks. Do DNA HIV PCR at 6 weeks old. medications or by HIV infection
• Adolescents who are pregnant or postpartum (within 2 wk after
INFLUENZA delivery)
• Types A, B and C • Persons younger than 19 yr of age who are receiving long-term
• Epidemic disease: Type A and B aspirin therapy
• Influenza A subclassified by 2 surface antigens: • American Indians/Alaska Natives
→ Hemagglutinin (HA) • Persons who are morbidly obese
→ Neuraminidase (NA) • Residents of long-term care facilities
→ examples: H1N1, H1N2, & H3N2
• Antigenic drift Current for 2014-2015 influenza ceason
→ minor variations in influenza B or A; seasonal epidemics *Antiviral treatment is recommended for high-risk children with
• Antigenic shift confirmed or suspected influenza; antivirals are also recommended
→ major variations in HA or NA; only w/ influenza A; pandemics for children who are hospitalized Þr have severe or progressive
• abrupt onset, with a predominance of systemic symptoms disease.
including high fever, myalgias, chills, headache, malaise, and *Although all children younger than 5 yr of age are considered at
anorexia (more than any other respiratory virus) higher risk for complications from influenza, the highest risk is for
• with coryza, pharyngitis, and dry cough at the onset, but may be those younger than 2 yr of age, with the highest hospitalization and
less prominent than systemic symptoms death rates among infants younger than 6 mo of age.
PEDIATRICS II
MANAGEMENT reactive airway disease rather than a direct consequence of RSV

infection
• increase fluid intake
• almost all children infected once by 2 yrs old; reinfection common
• control of fever with paracetamol or ibuprofen; not aspirin
• antibiotics for bacterial superinfection: suspected if w/
recrudescence of fever, prolonged fever, clinical deterioration (if
DIAGNOSIS
uncomplicated, child should be well after 48-72 hours) • Bronchiolitis is a clinical diagnosis
• RSV can be suspected with varying certainty on the
PARAINFLUENZA VIRUSES • season of the year (+) virus in the community, the presence of
• members of paramyxoviridae family colds in older household contacts and the age of the child
• Types 1-4 • Definitive Diagnosis: viral culture, viral RNA RT-PCR, viral
• affects primarily upper respiratory tract as low-grade fever, antigen
rhinorrhea, cough, pharyngitis x 1-3 days → hoarseness, • The most important diagnostic concern is to identify bacterial or
barking cough, inspiratory stridor chlamydial involvement
• particularly associated with croup (laryngotracheitis/ • In infants 1-4 mo old with cxr of interstitial pneumonitis Chlamydia
laryngotracheobronchitis) accounting for ~50% of hospitalizations, trachomatis should be considered if
15% of bronchiolitis and pneumonia → history of conjunctivitis
• 2nd to RSV as a cause of lower RTI → subacute onset
→ prominent cough &inspiratory crackles, Not wheezing
DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS → absent fever
• signs suggesting bacterial pneumonia:
• Diagnosis often based only on clinical and epidemiologic criteria
→ Lobar consolidation, pleural effusion
• Croup is a clinical diagnosis
→ neutrophilia, neutropenia in the presence of severe disease,
• Differential Diagnosis:
→ ileus or other abdominal signs
→ foreign body aspiration
→ high temperature, and circulatory collapse
→ epiglottitis
→ pharyngeal abscess
TREATMENT:
→ subglottic hemangioma
• “Steeple sign," or progressive narrowing of the subglottic region • Supportive
on x-ray is characteristic of croup • there is disagreement about aerosolized saline or hypertonic saline,
→ differential considerations: acute epiglottitis, thermal injury, epinephrine, or B2-agonists
angioedema, and bacterial tracheitis • Ribavirin aerosol treatment not routine; small studies show
• Laboratory Diagnosis: tissue culture, direct immunofluorescent increase O2 saturation, consistent decrease for mechanical
staining of virus antigen, PCR assays ventilation, decrease length of PICU stay, decrease hospitalization
days among recipients
MANAGEMENT • Antibiotics rarely indicated
• No specific antiviral drug
PREVENTION:
• preferred management: single dose of oral dexamethasone (0.6
mg/kg) • Palivizumab,humanized mouse monoclonal antibody given IM,
• alternative management: single dose of IM dexamethasone or reduces risk of RSV hospitalization in high-risk children (chronic
budesonide (2 mg (2 ml solution] via nebulizer) lung disease of prematurity,preterm, CHD): q 30 days starting early
• dose may be repeated, but not on a routine basis november x 5 doses
• For moderate to severe croup: nebulized epinephrine (either
racemic epinephrine 2.25%, 0.5 mL in 2.5 mL of saline, or l- HUMAN RHINOVIRUS(HRV)
epinephrine, 1: 1,000 dilution in 5 mL of saline) • most frequent cause of the common colds in adults and children
• observe for at least 2 hr after epinephrine treatment for recurrence • 100 serotypes: Picornaviridae family
of obstructive symptoms. Repeat if necessary • multiple serotypes may circulate simultaneously
• Oxygen for hypoxia • present in high concentrations on nasal secretions; persists for
• antibiotics only for secondary bacterial infections of the middle hours in secretions in hands, other surfaces (phones, doorknobs,
ear(s) or lower respiratory tract. stethoscopes) which can lead to infection if transferred to nose,
eyes, or mouth
RESPIRATORY SYNCITIAL VIRUS • Incubation period: 1- 4 days
• major cause of bronchiolitis and pneumonia in children <1 yr old • common colds: sneezing, nasal congestion, rhinorrhea &sore
• RSV accounts for ~40-75% of cases of hospitalized bronchiolitis, throat
• 15-40% of cases of childhood pneumonia, and 6-15% of croup • fever less common
• the most important respiratory pathogen of early childhood • symptoms more severe, lasts longer in children(D10)
• initially, with rhinorrhea; cough appear simultaneously or 1-3 days • major infectious trigger for asthma among young children
after with sneezing, low grade fever → audible wheezing • Complications: sinusitis, asthma exacerbations, bronchitis,
• if progressive: cough and wheezing increase, (+) air hunger, • pneumonia
• tachypnea, retractions, hyperexpansion of chest, restlessness, • HRV-associated wheezing during infancy considered a significant
cyanosis • risk factor for childhood asthma
• CXR: normal (30%); 70% with hyperexpansion, peribronchial • Diagnosis: RT-PCR
thickening, & interstitial infiltrates; segmental or lobar consolidation • Prevention:
is unusual, pleural effusion is rare. → hand hygiene
• association of RSV bronchiolitis early in life and reactive airway → avoid touching eyes, nose and mouth
disease remains poorly understoood; underlying predisposition to
PEDIATRICS II
ADENOVIRUS TREATMENT:
• 50 species grouped into 7 species w/ different tissue tropism & • supportive
target organs • Nucleoside analogue Cidofivir w/ in vitro activity; used topically for
Acute Respiratory Disease epidemic keratoconjunctivitis, intravenously for AdV infections in
• common manifestations in children (5-10% of all childhood immunocompromised
respiratory disease) & adults
• primary infections in infants as: HUMAN METAPNEUMOVIRUS (HMPV)
→ bronchiolitis • Respiratory virus identified in 2001
→ pneumonia - may manifest as bacterial disease w/ lobar • One of the most common causes of serious lower respiratory
infiltrates, high fever, parapneumonic effusion tract illness in children worldwide
→ pharyngitis - coryza, sore throat and fever; as isolated disease • Incubation period: 3-5 days
in 15-20% of pre-schoolers & infants • Associated w/ common cold (w/ otitis media in 30%) and lower
→ pertussis-like syndrome respiratory tract illnesses like bronchiolitis, pneumonia, croup, &
exacerbation of reactive airway disease
• Signs and symptoms indistinguishable to RSV, clinicallly
OTHER MANIFESTATIONS
• Diagnosis: RT-PCR, difficult to isolate in cell culture
Ocular Manifestations • Treatment: supportive
• follicular conjunctivitis (self-limiting)
• epidemic keratoconjunctivitis CORONAVIRUSES
→ involves the cornea and conjunctiva • Cause up to 15% of common colds and also implicated in croup,
→ more severe form asthma exacerbations, bronchiolitis, & pneumonia
• May cause enteritis and colitis in neonates and infants,
Pharyngoconjunctival fever underappreciated as cause of meningitis or encephalitis
• (+) four coronaviruses endemic in humans: Human coronaviruses
• as sporadic or community outbreaks from public swimming (HCOVs) 229E, OC43, NL63 & HKU1
facilities • 2 epidemics of previously unknown coronaviruses
• high fever x 4-5 days, non-purulent bulbar & palpebral (granular) → SAR-associated coronavirus (SARS-CoV) in 2003
conjunctivitis, pharyngitis (maybe follicular), preauricular & cervical → Middle East respiratory syndrome coronovirus (MERS CoV) in
lymphadenopathies & rhinitis + headache, malaise & weakness 2012
Gastrointestinal Infections MERS-COV

• detected in the stools of 5-10% of children with acute diarrhea • Incubation period: 10 days
• self-limiting, although can be severe • Less transmissible than SARS-CoV
• may also cause mesenteric adenitis • Presents as acute respiratory infection with fever, cough and
pulmonary parenchymal disease (pneumonia or ARDS)
Hemorrhagic Cystitis • Case fatality rate: >65%
• sudden onset of hematuria, dysuria, frequency, and urgency with • ~65% have severe disease requiring hospitalization, ~5% mild
negative urine bacterial culture results. disease, the rest asymptomatic
• resolves spontaneously in 1-2 wk. • Diagnosis: RT-PCR
• Treatment: supportive
Other Complications
• Rarely cause myocarditis, hepatitis, or meningoencephalitis in VIRAL GASTROENTERITIS
immunocompetent individuals. ROTAVIRUS
• single most important cause of severe dehydration diarrhea in
Reye Syndrome and Reye-like Syndrome early childhood
• also associated w/ influenza B & varicella • most severe in 3- 24 mos old; 25% of severe disease in > 2 yo,
• acute encephalopathy & fatty degeneration of liver all infected by 4-5 yo
• occurs 4-12 years old -prodromal URI (90%) or chicken pox → • incubation period: <48 hrs (1-7 days)
apparent recovery → w/in 5-7days, protracted vomiting, delirium, • mild to moderate fever and vomiting followed by frequent watery
combative behavior, stupor, come, death. (+) slight to moderate stools. vomiting & fever stop by D2, diarrhea for 5- 7 days
hepatomegaly & hepatic dysfunction, no jaundice, normal CSF
• generalized loss of mitochondrial fxn ASTROVIRUS
• (+) etiologic link between aspirin and viral infections • 2nd most important agent of viral diarrhea in young children
Immunocompromised patients • milder, less significant dehydration
• at high risk for severe disease particularly recipients of
hematopoietic stem cell transplants and solid organ ENTERIC ADENOVIRUS
transplants • longer duration 10 - 14 days
• organ failure due to pneumonia, hepatitis, gastroenteritis, and
disseminated disease CALICIVIRUSES
• most common cause of gastroenteritis outbreaks on older
LABORATORY DIAGNOSIS:
children & adults
• viral culture or PCR, serology
PEDIATRICS II
DIARLEX ROTA-ADENO
• stool latex for rotavirus & adenovirus
• When a fecal extract containing rotavirus or adenovirus particles
(antigen) is mixed with the test latex reagent, an antigen-antibody
reaction occurs --> visible agglutination (red color) of the latex
particles.

Common Viral Infec - Part 2

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2022 4.4b.

Viral Infections (Part 2)

ENTEROVIRUS (NONPOLIOVIRUS) INFECTION

MYOSITIS AND ARTHRITIS

ACUTE HEMORRHAGIC CONJUNCTIVITIS POLIOVIRUS GLOBAL SITUATION

→ w/in 1-2 days → asymmetric flaccid paralysis or paresis, CONTROL MEASURES:

DIAGNOSIS ISOLATION OF HOSPITALIZED PATIENT:

MANAGEMENT ACCORDING TO RISK OF EXPOSURE

Category Rabies Vaccine Rabies Immunoglobulin

Category II Recommended Not recommended

Category III Recommended Recommended

Regimen Dose No. Of doses on specified days

Standard 0.5 ml 1.0 ml 1 1 1 1 1

* For Category II and III

Generic Name Preparation Dose Skin Test

Human Rabies Immune 150 iu/ml 20 iu/kg NO

• Skin test prior to ERIG administration

POST EXPOSURE PROPHYLAXIS (PEP)

Vaccination History Unknown or < 3 doses 3 or more doses

RECOMMENDATIONS FOR ANTIBIOTIC TREATMENT

Description Recommended Alternatives

Uninfected Category III wounds that are: Amoxicillin

Pre exposure prophylaxis (PrEP) INFECTIONS

CLINICAL MANIFESTATIONS SIGNS THAT MAY INDICATE HIV INFECTION

< 12 months 1-5 months 6-12 yrs

• Early diagnosis/aggressive treatment of opportunistic infection

PROPHYLAXIS • respiratory manifestations: isolated URTI, croup, or bronchiolitis

MANAGEMENT reactive airway disease rather than a direct consequence of RSV

Gastrointestinal Infections MERS-COV

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