Herpangina/Hand-foot-mouth/Pertussis/Rheumatic Fever

Rheumatic Fever

12 year old male presents with fatigability, large joint pain, muscle weakness and chorea. An erythematous, non-painful, serpiginous rash is observed of the trunk and extremities. Your primary differential is:

Pertussis (Bordetella pertussis, a.k.a. whooping cough)

18 month old presents with a 2-day history of paroxysmal cough ending in a high-pitched inspiratory "whoop". Your primary differential is:

Herpangina

4 y.o. presents with acute onset of high fever, HA, hypersalivation, and N&V. On PE, small blisters and vesicular lesions are seen on the soft palate, anterior tonsillar pillars, and uvula that are ulcerative. Your primary differential is:

hand-foot-mouth

A 9 y.o. patient presents with a 2-day history of sore throat, cough, decreased appetite, fever, malaise, and myalgia. Also reports sores in the mouth that developed today, appear ulcerative and confluent and are spread all throughout the oral cavity. Your primary differential is:

Supportive measures: rest, hydration, analgesic. Antibiotics not indicated in convalescent phase of infection. OTC decong., antihistamines, antitussives are of no help with pertussis symptoms.

A mother presents with 18 m.o. child with complaint of paroxysmal cough that is 'high-pitched' and has lasted for nearly 2 months. Positive diagnosis of Bordetella pertussis infection is made. What treatment do you offer?

Pertussis (Bordetella pertussis/whooping cough/100-day cough)

A mother presents with 18 m.o. child with complaint of paroxysmal cough that is 'high-pitched' and has lasted for nearly 2 months. Your primary differential is:

Review commonality of the clinical manifestations of rheumatoid arthritis. (picture)

Review commonality of the clinical manifestations of rheumatic fever. (picture) CPSES

palms, soles of feet, interdigital area, and buttocks can be confluent flat or raised red spots (macules or papules), usually progress to blistering ulcerations (yellow-gray blisters)

As seen with Hand-foot-mouth, skin rash develops 1-2 days after mouth lesions and located:

2 weeks of symptom onset chance of false negative increases thereafter

Bacterial culture is most useful in diagnosis of Pertussis if obtained within what time period from symptom onset?

21 days --> all household contacts --> any high-risk individuals (infants < 12 mo, pregnant women in 3rd trimester, immunocompromised, sever asthmatics) --> People who work in NICU or childcare settings

CDC recommendation for pertussis post-exposure prophylaxis are for individuals to be treated if contact within how many days of exposure?

1. Macrolides 2. Vaccination (if less that 10 years old or for those who have not been dosed within the last 5 years)

CDC recommendation for pertussis post-exposure prophylaxis is with what two agents?

-->Respiratory distress: tachypnea, retractions, nasal flaring, grunting, accessory muscle use. Cyanosis and Apnea. -->Dx'd pneumonia -->Inability to feed -->Seizures (seen with fever or sequelae to CNS infection) -->Dehydration

Indications for hospitalization of the infant may include:

pericardial friction rub new onset heart murmur

In cases of rheumatic fever, auscultation of the heart may demonstrate what abnormalities? (2)

None Clinical Diagnosis *could r/o strep with rapid screen

Diagnostic to consider with concern for Herpangina (Coxsackie-Virus)?

None Clinical Diagnosis Only

Diagnostics for Hand-foot-mouth includes what?

1. Throat Culture or Anti-Streptolysin O titer 2. ESR and CRP (inflammatory markers) 3. EKG (prolonged PR interval) 4. Echocardiogram (cardiomegaly, pericardial effusion, valve dysfunction)

Diagnostics for to be considered with suspicion of rheumatic fever include: (4)

1. CBC - markedly increased WBCs (lymphocytosis) 2. Bacterial Culture (nasopharyngeal specimen; Gold Standard) 3. PCR (rapid) 4. Serology (assay for antibody titers) 5. Chest Xray these are not one-size

Diagnostics indicated with concern for Bordetella pertussis include: (5)

•10 years after last episode or age 40 years for patients with ARF including carditis and persistent valvular disease • 10 years after last episode or age 21 years for patients with ARF including carditis without residual heart disease • 5 years after last episode or age 21 years for patients with ARF without carditis

Duration of secondary prophylaxis is:

Positive GABHS Culture or Elevated Anti-Streptolysin O titer --PLUS-- 2 'Major' criteria or 1 'Major' criteria and 2 'minor' criteria

Explain the requirements for diagnosis of rheumatic fever.

Direct contact, contact with contaminated surfaces/objects Respiratory droplets Fecal-oral

Hand-foot-mouth disease is transmissible via which routes?

children < 10 years old can infect adults

Hand-foot-mouth most commonly affects what age demographic?

Most commonly age <5 yo, but can infect adults.

Herpangina (Coxsackie-Virus) generally affects what age group?

Herpangina (Coxsackie-Virus A-22)

Highly contagious viral infection associated with sudden onset of high fever, HA, hypersalivation, and N&V. Sore throat is characterized by vesicular lesions on the soft palate that ulcerate in about 2-3 days.

Hand-foot-mouth disease

Highly contagious viral infection caused by enterovirus 71, Coxsackieviruses A6 & A16. Symptoms characterized by sore throat, cough, decreased appetite, fever, malaise, myalgia (prodromal symptoms) followed in 1-2 days with oral lesions that ulcerate.

Anti-Streptolysin O titer is best. Throat Cultures have higher false-negative findings later in course of illness (after 2 weeks)

In the diagnosis of rheumatic fever, confirmation of strep infection is best determined with what diagnostic test?

Most contagious during first week. Viral shed continues 4-8 weeks in stool.

Individuals with hand-foot-mouth are most infectious during what phase of illness? How long do they remain contagious?

Rheumatic Fever

Is a systemic immune process that is a sequela of a beta-hemolytic streptococcal infection of the pharynx. Caused by Streptococcus pyogenes.

Aspirin Naproxen Sodium

Joint symptoms inherent to rheumatic fever are best treated with what pharmacological agents?

Anywhere in the mouth Tongue, buccal mucosa, palate, & anterior tonsillar pillars

Lesions characteristic of Hand-foot-mouth disease are observed where in the oropharyngeal cavity?

cardiac dysrhythmias or heart blocks QT-prolongation is macrolide associated adverse effect

Macrolides are contraindicated in patients with what condition?

Sydenham Chorea (comes from the Greek word for "dance")

Medical Term: Is a movement irregularity characterized by rapid, irregular, and aimless involuntary movements of the arms and legs, trunk, and facial muscles. Has neurologic etiology.

tussive

Medical Term: Related to coughing.

paroxysmal

Medical Term: Symptoms that are worse at night.

catarrhal

Medical term defined as "copious discharge of mucus associated with inflammation of mucous membranes, especially of the nose and throat"

Rheumatic Fever

Mother presents with 6 y.o. son and complaints of new onset rash, small painless bumps on the top of his hands and fingers, and migratory pain of the large joints. She reports that the child had a sore throat about two weeks ago. Your primary differential is:

2-3 weeks common can be 1-5 weeks

Onset of rheumatic fever symptoms commonly occurs how long after initial infection?

Summer and Fall

Peak incidence of hand-foot-and mouth is what seasons?

Children < 2 years old adults can be reservoir of disease

Pertussis is common in what age demographic?

Macrolides: Azithromycin Clarithromycin Erythromycin other: trimethoprim/sulfamethoxazole (Bactrim DS)

Pharmacological therapy aimed at treating Pertussis is with what agents? (2)

Benzathine penicillin G IM every 28 days 600,000 units IM for patients ≤ 27 kg (60 lbs) 1,200,000 units IM for patients > 27 kg (60 lbs)

Prophylactic treatment of rheumatic fever patients is primarily with what pharmacological agent?

5-15 years old rare in those < 4 yo or > 40 yo

Rheumatic fever commonly affects individuals of what age demographic?

Catarrhal stage

Stage of Pertussis infection that is most infectious.

Convalescent Stage of Pertussis

Stage of Pertussis: 1-3 weeks in duration, symptoms begin to abate, cough can persist intermittently for months.

Paroxysmal Stage of Pertussis

Stage of Pertussis: 2-4 weeks, paroxysmal cough with inspiratory whooping, thick mucous and post tussive emesis.

Catarrhal Stage of Pertussis

Stage of Pertussis: lasts 1-2 weeks; low grade fever; congestion and rhinorrhea; irritating cough

inspiratory "whoop" https://www.youtube.com/watch?v=l5SHtdczSBc

The cough characteristic of Pertussis is a severe paroxysmal cough that ends in a high-pitched _______________ _____________.

Bordetella pertussis (whooping cough) "100-day cough"

This condition is a bacterial infection with characteristic catarrhal stage of malaise, cough, coryza, and anorexia.

Fecal-oral route Respiratory Direct Contact

Transmission of Herpangina (Coxsackie-virus) occurs how?

Airborne

Transmission of Pertussis is via what route?

Symptom Management interventions ibuprofen, Tylenol hydration

Treatment for hand-foot-mouth is focused on what interventions?

Supportive, symptom control ibuprofen and Tylenol hydration

Treatment of Herpangina (Coxsackie-Virus) is with what interventions?

Antibiotics: -->Macrolides (-mycins) -->Bactrim DS (TMP-SMX)

Treatment of Pertussis (whooping cough) is with what primary intervention?

Bedrest from 2-12 weeks

Treatment of Rheumatic fever patients who demonstrate severe illness with/without elevated ESR rates may include what nonpharmacologic intervention?

True

True or False: Bordetella pertussis is designated for mandatory state reporting?

False - not helpful

True or False: OTC agents (decongestants, antitussives, antihistamines) will assist in symptom management of the patient diagnosed with Pertussis.

True

True or False: Rheumatic Fever patients require ongoing prophylactic treatment to prevent recurrence of disease?

Soft palate, anterior tonsillar pillars, & uvula not on tonsils themselves

Ulcerations characteristic of Herpangina (Coxsackie-virus) originate where in the oropharyngeal cavity?

Older than 7 years old Routinely given at 11-12 years of age Bordatella pertussis immunity wanes over time. Immunization schedule in childhood is with DTaP at 2-4-6-15months; 4-6 years. Tdap can be given PRN at age 7, but routine vaccination begins at age 11-12, recommended q 10 years.

What age does the Tdap Vaccination become appropriate? Why do we continue to vaccinate against pertussis?

Upper case reflects full dose vaccination Lower case reflects booster dose of vaccination

What is important to know about the DTaP and Tdap vaccination abbreviation regarding upper and lower case use?

major criteria: JONES minor criteria: CAFE-PAL

What is the mnemonic for Rheumatic Fever?

Myocarditis cardiomegaly or new onset heart murmur (mitral or aortic valve dysfunction)

What is the only manifestation of Rheumatic Fever that has long term health implications?

Eradication of group A Strep. 1. Benzathine penicillin G single IM injection others 2. Penicillin V or Amoxicillin if allergy --> Cephalosporin or Macrolide

What is the primary objective in the treatment of rheumatic fever?

DTaP 2, 4, 6, 15 months fifth and final dose at 4-6 years

What is the recommended vaccine for prevention of whooping cough and what are the associated administration times?

Summer and Fall

What time of year does Herpangina (Coxsackie-Virus) incidence peak?

Shaggy Heart Border secondary to mediastinal infiltrate and exudate

XRay results concerning for Pertussis would demonstrate what characteristic abnormal finding?

Serology (assay for antibody titers) best to utilize from weeks 2-8 of illness (or longer)

You are suspicious for possible Pertussis infection in a patient who has had symptoms for 6 weeks. What is the best diagnostic test to order.