We are going to stay on the pediatric infectious disease kick…….
What are the six (6) classic infectious exanthems of childhood and what organism causes each?
Diagnosis: Acute rheumatic fever
Criteria: Jones criteria
Acute rheumatic fever (ARF) is a sequella of symptoms that typically occur 2-4 weeks after an untreated bout of group A Streptoccocal (GAS) pharyngitis. Symptoms include arthritis, carditis, erythema marginatum, CNS symptoms, and subcutaneous nodules.
Jones criteria is constellation of symptoms of ARF and are subdivided into major and minor manifestations.
Elevated acute phase reactants
Prolonged PR interval
The diagnosis of ARF is made using the Jones criteria and is positive if the patient has evidence of a preceding GAS infection and:
You are participating in a medical mission in South America and are seeing a 11yo boy who is brought in by his mother. He has been complaining of joint pain and fever for the past 2 weeks. She tells you that it seems to “move” from joint to joint over this time and nothing seems to help. She does report that he has seemed to be sick for 4-6 weeks with various “cold” symptoms, but they didn’t seem too severe. On examination, he has temperature of 101.2oF and the below rash.
What should be your concern and what criteria can help make the diagnosis?
As with any educational or academic en devour, as soon as you finish a paper/poster/presentation, a new publication comes out that would have been awesome to include. I finished and published the Pneumonia podcast on July 12th and on July 14th, the IDSA/ATS released their updated guidelines on managing healthcare-associated (HAP) and ventilator-associated (VAP) pneumonia. Luckily, they didn’t change anything earth-shattering, just tightened them up a bit. Antibiotic regimens are below and they recommend 7-days total of therapy.
4 phases of development
Physical Exam Findings
The Zika virus is a flavivirus that is related to yellow fever, dengue fever, West Nile, and Japanese encephalitis. It was first discovered in 1947 in a rhesus monkey and is called “Zika” because it originated in the Zika forest in Uganda. It is transmitted by the Aedes species of mosquitoes (which also carries dengue, chikungunya, and yellow fever).
In May 2015, the Pan American Health Organization (PAHO) issued an alert regarding the first confirmed Zika virus infection in Brazil. Since then, there have documented cases of Zika virus infections in 20 countries in North and South America. Due to the threat and concern of transmission, the Center for Disease Control (CDC) issued a travel alert (Level 2-Practice Enhanced Precautions) for anyone traveling to these regions (see current list here).
Only 1 in 5 people who become infected by the Zika virus develop symptoms, which are usually a mild viral prodromal syndrome (fever, rash, arthralgias, myalgias, conjunctivitis). Serious manifestations can include Guillaine-Barre syndrome and congenital microcephaly. Brazil has seen a 20-fold increase in number of cases of microcephaly from 2010 to 2014. Since October 2015, there have been 4,180 suspected cases (average of ~150/yr) of microcephaly in Brazil, but only 700 mothers were tested for the virus with only 270 positive results. The first case of microcephaly associated by the Zika virus on US soil was in Hawaii on January 15th, 2016 to a mother who lived in Brazil.
Because of the surge of microcephaly cases in an endemic region of Zika, the CDC is recommending that women who are pregnant, or are trying to become pregnant, should post-pone any travel to these regions.
Signs and symptoms of the acute Zika infection are very non-specific and the list of differential diagnoses is broad. If a patient has any suspicious symptoms within one week of travel to any of the at-risk regions, testing should occur as the Zika virus has become a nationally notifiable condition by the CDC. Testing includes reverse transcriptase-polymerase chain reaction (RT-PCR), virus-specific IgM and neutralizing antibodies and are only performed at the CDC Arbovirus Diagnostic Laboratory. Clinicians should contact local health departments to facilitate obtaining the correct testing sample and expediting transfer to the lab.
There is no specific treatment for the Zika virus. Treatment plans should be directed towards symptom relief and includes rest, oral rehydration, and acetaminophen for fever and pain relief. Aspirin and other NSAIDs should be avoided until dengue fever can be ruled out to decrease the risk of hemorrhage.
If travel must occur to endemic regions, patients should be advised to follow strict mosquito precautions to try to limit the exposure from the Aedes vector. N,N-Diethyl-meta-toluamide (DEET), Picaridin, oil of lemon eucalyptus, and IR3535 are all recommended by the CDC and are safe in pregnancy. There is no vaccine to the Zika virus yet, but preliminary works seem to be promising and early reports are pointing to the end of 2016 as a reasonable estimate for human trials to start.
For a PA practicing in the United States, this just adds to the list of traveler’s disease that you have to be hypervigilant about in patients with general complaints and recent travel to endemic regions. By no means do we need to start screening every patient with viral symptoms for Zika. But…if your patient has traveled to these regions, is pregnant, or may come into contact with patients who are pregnant, you should contact your local health department and screen them appropriately now that it is a nationally reportable disease. You should also take appropriate quarantine precautions if your clinic/department also has pregnant patients to limit disease contact to the most at risk patients. To date, there are no direct transmission cases of the virus (only the Aedes vector), but viruses can shift fast and it is better to be safer than sorry.