Measles, chickenpox, and mumps

Measles and chicken pox. Mumps in children

Measles

Definition and Pathogenesis

•    This is an acute and highly contagious infection caused by measles virus
•    The measles virus is a RNA virus
•     Transmission occurs through airborne, respiratory secretions or close contact with respiratory droplets from infected individuals
•    The virus enters the body through the mucous membranes of the nasopharynx and conjunctiva
•     They may multiply, giving local reactions
•     The viruses are then carried around in the bloodstream, finally reaching the skin (rash)
•     Decreased immunity leads to increased susceptibility to complications from viruses damaging the epithelial layer of the skin, digestive tract, respiratory tract, ears, eyes and even the brain
•    Secondary bacterial infections can occur

Clinical Presentation
•      Incubation period takes 8-12 days from exposure to the onset of symptoms and 14 days from exposure to the onset of rash
•        The illness starts as a severe cold with high fever, cough, watery red eyes and nasal discharge
•        Prodromal phase takes 3 days, and it is characterised by cough, coryza, conjunctivitis
•      Koplik spots are white spots, sand grain dot-sized in a red back ground on the mucous membrane of the mouth, especially the inside the lips and cheeks opposite the lower molars.
o These are pathognomonic for measles
• Rash phase
o Maculopapular rash appears on the 4th day
      It dark red, slightly raised and irregular starts from the face, neck, and then spreads all over the body
o The rash is difficult to see on a dark skin
     Desquamation and depigmentation of the skin usually follows
o The rash phase is accompanied by high fever

Complications of Measles
•       Complications are common and often cause death, especially in malnourished children
•       Complications are also more common in immunosuppressed children (HIV, leukaemia)
•        The common complications of measles are:
o Otitis media (common in infants)
o Bronchopneumonia
o Gastrointestinal symptoms/ viral gastroenteritis
o Myocarditis
o Activation of latent tuberculosis
o Keratitis
o Malnutrition
o Xerophthalmia
o Croup (laryngotracheobronchitis)
o Mouth ulcers
o Deep or extensive mouth ulcer (concrum oris)
o Encephalitis/ Encephalopathy (rare)
o Subacute sclerosing pan encephalitis is late neurologic complication of slow measles infection, occurring years after the acute illness

Diagnosis of Measles
•    History of fever, nasal discharge and red eyes
•    Examination- koplik spots usually pathognomonic but are not always present at the time of the most pronounced rash
•       Chest X-ray in bronchopneumonia, if there is failure of treatment suspect TB
•       In case of complicated measles the following can be seen:
o Diarrhoea (including dysentery and persistent diarrhoea)
o Pneumonia
o Stridor
o Mouth ulcers
o Ear infection and severe eye infection (which may lead to corneal ulceration and blindness)
o Encephalitis

Management of Measles

•      Admit to hospital for proper treatment if the child has:

o General danger signs such as lethargy, inability to drink, convulsions
o Malnutrition
o Bronchopneumonia, severe or very severe
o Laryngotracheobronchitis
o Dehydration, vomiting for more than 24 hours
o Xerophthalmia (dry eyes)
o Other factors, such as anaemia
o Neutropenia below 1000/mm3
is a sign of serious condition

Supportive care
o For fever give antipyretics if temperature >38.5oC give paracetamol 10-15gm/kg, don't give aspirin it cause bleeding
• Nutrition
o The most important part, especially in malnourished children
o Nasogastric tube may be needed
o Vitamin A should be given to all children with measles
    Vitamin A improves outcome in malnourished children
Dose: 100,000 I.U < 6 months, up to 200,000 I.U for children > 1 year
o Breastfeeding should be encouraged especially during illness
•     Fluid
o Rehydrate dehydrated children
o Check daily for signs of dehydration in case of high fever and hyperventilation
o Increase the amount of maintenance fluid
•      Antibiotics
o Treat all bacterial complications with antibiotics

•    Treat pneumonia
o In early stages the cause is virus, later bacteria super infection
o Pneumonia is sometimes very severe
o Penicillin plus Gentamycin may then be tried
o Oxygen may be needed

     Treat otitis media
• Care of the mouth
o Clean the child's mouth with clean water 4 times a day
o Apply gentian violet (GV) 0.25% (½ strength GV paint) to sores

•     Treatment of Laryngotracheobronchitis
o Maintain airway
o Steam, a bed sheet of an infant bed makes a perfect steam tent
o Nebulized adrenaline provides transient improvement by constricting local vessels and reducing swelling and oedema
o Humidified oxygen
o Make sure the child drinks enough if can’t take small feedings by mouth or
nasogastric tube, IV fluids are indicated
o Decrease of mucosal swelling
       Prednisolone 2mg/kg/day or hydrocortisone 100 mg IM (might be advantageous)
o Antibiotics (if bacterial infection is suspected) Amoxyllin 15mg/kg/dose 8 hourly or chloramphenicol

•      Care of eyes and skin
o Daily washing and inspection
o Secondary bacterial infection may require antibiotic eye ointment
•     Treatment of encephalopathy
o Refer to hospital

Prevention of Measles
•      Measles vaccine is highly effective, providing protection for roughly 95% of children after a single dose
•      Immunize against measles at 9 months, give simultaneously Vitamin A 100,000 IU
•      Do not postpone immunization because of moderate intercurrent illness
•      In case of measles contact immunize non-immunized children above 6 months on admission (if 6-9 months on admission: make sure revaccination takes place at 9 months)
•     Attend reproductive and child health (RCH) clinic for growth monitoring
•     Ensure good nutrition, including vitamin A rich food
•     Five days before and after the rash the child is still infectious
•     Because respiratory transmission is very efficient, active cases of measles should be isolated where possible, especially from immunocompromised individuals

Chickenpox in children

Overview of Chickenpox
Chickenpox: A viral childhood disease caused by varicella zoster
•     The virus infects susceptible individuals by the conjunctivae or respiratory tract and replicates in the nasopharynx and upper respiratory tract
•      It disseminates by a primary viremia and infects regional lymph nodes, the liver, the spleen and other organs
•      A secondary viremia follows, resulting in a cutaneous infection with the typical vesicular rash
•      Chickenpox almost never occurs twice in the same individual
o After primary infection chickenpox remains dormant in host nerve cells and may reactivate in the form of ‘shingles’ or ‘zoster’ with age or immunocompromised state

Epidemiology
•   Varicella is a highly contagious infection of childhood
•    The peak age is 5-10 years, but the disease can occur at any age
•      Transmission is by direct contact, droplet and air
•       The incubation period is 14 to 16 days (11 to 20 days)

•       Prodromal symptoms
o Fever, malaise and anorexia may proceed the rash by 1 day
•        Rash
o Small red papules that rapidly progress to non umbilicated oval vesicles or an
erythematous base
o The fluid progresses from clear to cloudy, and the vesicles ulcerate, crust and heal
o A new crop appears for 3-4 days beginning on the trunk, the head, the face, and less commonly, the extremities
o There may be 100-300 lesions, with all forms of lesions being present at the same time
o Pruritus is almost universal
o Lesions may be present on all mucus membranes including mouth

o Systemic signs and fever
•          Reactivation
o After primary infection, varicella zoster virus remains dormant in the dorsal root
ganglion and can reactivate with stress, old age, or immunocompromised state
o Reactivation zoster or ‘shingles’ occurs in specific a dermatomal distribution

•        Congenital varicella
o Varicella in pregnant woman may lead into foetal varicella infection, characterized by
√low birth weight,
√cortical atrophy,
√seizures,
√mental retardation,
√chorioretinitis,
√cataracts,
√microcephaly,
√intracranial calcifications, and
√diagnostic cicatricial
√scarring of the body or extremities

Diagnosis and Treatment of Chickenpox
Diagnosis
•     History of fever and typical rash
•     Examination of typical vesicular rash
Treatment
•     Symptomatic therapy including non-aspirin antipyretic,
-     cool bath and careful hygiene
•     Intravenous acyclovir in immunocompromised patients
•    Oral acyclovir (20 mg/kg/dose qid) for 5 days shorten the duration of illness in children who are not immunocompromised if given within 24 hours of the first cutaneous lesion
Or syrup
Antipurutus oilment; calamine lotion

Complications and Prevention of Chickenpox
  
Complications
•    Although chickenpox is generally a mild disease, complications can arise
•     Infection by varicella zoster virus is a more severe disease for neonates, adults, and immunocompromised individuals
•      HIV-infected children frequently have a prolonged course and may have recurrent episodes of varicella zoster infection or reactivation ‘shingles’
•     Secondary infection of skin lesions by streptococci or staphylococci /fresh eating disease is common
o Infection may be mild or life threatening (e.g. toxic shock or necrotizing fasciitis)
•     Thrombocytopeania and hemorrhagic lesions or bleeding
•      Pneumonia
•      Myocarditis
•      Pericarditis
•      Orchitis
•      Hepatitis
•      Ulcerative gastritis
•      Glomerulonephritis
•      Arthritis
•      Reyes syndrome may be preceded by varicella, therefore avoid aspirin (platelate deficiencies)

•      Neurologic complications:
√ post-infectious encephalitis,
√cerebellar ataxia,
√nystagmus and
√tremor,
√Guillain-Barré syndrome,
√transverse myelitis,
√cranial nerve palsies, optic neuritis, and √hypothalamic syndrome

Prevention
• A single dose of a live attenuated varicella vaccine recommended in healthy children ages 1-12 years
•     The vaccine is not part of the EPI in Tanzania
•     When available, human varicella zoster immunoglobulin should be given to immunocompromised patients, neonates and pregnant women who have had significant contact with chickenpox but have no antibodies to varicella zoster virus

Clinical Features of Mumps
•     Mumps: An infection caused by RNA virus of the family paramyxovirus
•    Transmission is by droplet spread and the incubation period is 2-3 weeks

Clinical Features
•    Fever,
.    malaise,
.    parotitis is an inflammation of parotid glad
•   Pain and swelling of the parotid gland may be unilateral at first and then bilateral
•    The swelling may be easier to see than to feel
•    The swelling is between the angle of the mandible and sternomastoid muscle, extending beneath the ear lobe which is pushed upwards and outwards
•    The swelling usually subsides within 7-10 days, but patients are infectious from a few days before the swelling is seen up to 3 days after the enlargement subsides
•     CNS manifestations are seen and are a possible causes of aseptic meningitis (no bacterial infection)
•    Orchitis can be seen, especially in older children and young adults (inflammation of testes) oophritis (ovary)

Diagnosis, Differential Diagnosis and Treatment of Mumps

•     Diagnosis is based on the presenting features (signs and symptoms) as stated above
•     Differential diagnosis
o Malnutrition can present with enlarged parotid and cervical lymph nodes, but there is no fever associated with it
o Extrapulmonary TB may also present with enlarged cervical lymph nodes
o HIV infected children may also present with enlarged parotid gland(s)

• Treatment
o No specific treatment is available except for supportive treatment
         Give supportive treatment

•     Prevention
o Live attenuated vaccine to children (when to give depends on country but ranges from 9-15 months), but is not part of Tanzania EPI

Complications of Mumps
•    Pancreatitis
•    Meningoencephalitis
•    Epididymo-orchitis or oophritis
o Can lead to infertility later in life though not common

    Rare Complications
•   Nephritis
•   Myocarditis
•   Mastitis
•   Deafness
•   Arthritis
•   Thrombocytopenia
•   Thyroiditis
•   Occular manifestations
.    Pancreatitis

Posted by
Welfare Jambo
Blog
Welfarejambo.blogspot.com