Viral Infections Comprehensive Review
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Lecturer: Dr. Banez...
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HERPES SIMPLEX VIRUS Viral infections comprehensive review DR. MA. ANNA BANEZ PEDIATRIC INFECTIOUS DISEASES
2 SEROTYPES HSV 1 – mouth and skin above the waist HSV 2 – genital organs
2 TYPES of INFECTION 1. Primary Infection • mostly subclinical • otherwise,local superficial lesions w/ varying degrees of systemic reaction • w/ serious systemic reaction w/o lesions in NB and severely malnourished • circulating antibodies and CMI response in non‐fatal cases
2 TYPES of INFECTION 2. RECURRENT INFECTION • reactivation of latent infection in an immune host w/ circulating antibodies • follows non‐specific stimuli: cold, uv light, menstruation, fever, emotional stress • asymptomatic or localized lesions w/o systemic reactions
3 Distinct Times of Acquisition
Epidemiology • risk of transmission from pregnant women to fetus/newborn 44% after primary infection 3% after recurrence • neonatal disease more commonly acquired from maternal GUT during parturition • HSV2 account >/ 75% neonatal infections • majority of women w/ HSV infection are asymptomatic • genital lesions present at parturition /=12y : 1000‐1200mg/day q8 x3‐5 days
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PREVENTION Stat CS delivery for a woman with ruptured membranes and active genital lesions at term For exposed asymptomatic infants who were born vaginally to mothers with active genital lesions (10, recurrent or unknown status)
• •
– – –
•
CYTOMEGALOVIRUS
Obtain cultures:eyes,mouth,urine,stool Empiric acyclovir therapy after cultures are done Acyclovir therapy after culture is POSITIVE
Since infection rate for infants whose mothers have active recurrent genital herpes infection is /1 yr old
•
Alternative drugs: – Foscarnet – Cidofovir – Fomivirsen
• 90% with congenital infection demonstrate CNS & hearing defects in later years 30% - death rate of symptomatic congenital cytomegalovirus infection • infants with subclinical infection 5-10% - sensorineural hearing loss 3-5% - chorioretinitis less frequent:developmental abnormalities, microcephaly,neurologic defects
Epstein Barr Virus
Care of exposed persons • Hand hygiene, especially after changing diapers • Pregnant personnel must be educated about the risk of acquisition and practice standard precautions.
• Causes 80 to 95% of mononucleosis syndrome • Epidemiology: Source: Man – sole source Mode of transmission: 1. oral- salivary spread 2. close intimate contact - kissing 3. blood transfusion
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Epstein Barr Virus
Clinical Manifestations
• Incidence: predominantly in children and young adults • Period of communicability: Indeterminate; may be months after infection • Incubation Period: 30 to 50 day • Majority of primary infections in infants and young children are silent
Clinical Manifestations
Infectious Mononucleosis: – Prodromal period: 2‐5 days malaise, fatigue with or without fever – Triad: lymphadenopathy splenomegaly exudative pharyngitis
Occasional Signs and Symptoms Erythematous and maculopapular rash; 80% w/
– Signs and symptoms: Fever – usually rises to 39?C Adenopathy‐90%;usually in the anterior , posterior cervical , & submandibular nodes;suggestive if epitrochlear Splenomegaly – 50% Hepatomegaly – 10% Tonsillopharyngitis‐ Palatal petechiae
‘ampicillin rash’ if treated w/ ampicillin or amoxicillin Enanthem Edema of eyelids Jaundice Guillain‐ Barre syndrome Myelitis Bell’s palsy Acute cerebellar ataxia
Diagnosis • Other distinct disorders associated to EBV: – Lymphoproliferative disorders – Burkitt’s lymphoma – Nasopharyngeal carcinoma – Undifferentiated B‐cell lymphoma of the CNS
Absolute lymphocytosis : total leukocytes > 5,000/mm3 ‐ atypical lymphocytes >10% of total leukocytes Serologic Tests: 1. Paul‐Bunnel heterophil test and slide agglutination reaction (Monospot test) ‐ negative in children 90% of cases 2. Respiratory – common colds, pharyngitis, herpangina, stomatitis, pneumonia, pleurodynia 3. GIT – vomiting, diarrhea, abdominal pain, hepatitis 4. Skin – macular, maculopapular, vesicular, petechial rashes 5. CNS – encephalitis and paralysis
Hand, foot and mouth disease Acute hemorrhagic conjunctivitis Encephalitis and poliolike paralysis Aseptic meningitis with petechial exanthem Myopericarditis
Coxsackievirus A16 Enterovirus 71 Coxsackievirus A24 Enterovirus 70 Enterovirus 71 Echovirus 9 Coxsackievirus B1- B5
Clinical Syndromes
Clinical Syndromes
– Noteworthy virus/ disease associations Non specific febrile illness with rash Herpangina Pleurodynia or Bornholm’s disease
Echovirus 9
Coxsackieviruses B3 and B5
Orchitis and epidydimitis
Coxsackievirus B5, B2 and B4
Myositis Polymyositis
Coxsackievirus A2 Coxsackievirus A & Echovirus 18
Neonatal infections
Coxsackievirus B1- B5
Herpangina ‐ anorexia, dysphagia, salivation, sore throat, vesicles and ulcers on anterior pillars (most common site), soft palate, uvula, tonsils, pharyngeal wall, posterior buccal surfaces
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Clinical Syndromes
Hand, Foot and Mouth Syndrome
– Pleurodynia or Bornholm’s Disease ‐ sudden onset of fever and muscular pain (chest or abdomen), spasmodic and excruciatingly severe with profuse sweating ‐ usually lasts 1‐2 days ‐ may be biphasic
Clinical Syndromes
Clinical Syndromes
Non‐specific febrile illness with rash Echovirus 9 rubelliform or petechial rash rash & fever usually at the same time mimics meningoccocemia
Neonatal infections • asymptomatic to sepsis‐like illness,fatal encephalitis & myocarditis w/in 2 wks of life • transplacental transmission immediately prior to delivery
Diagnosis
Treatment
– Viral isolation: stool,throat,csf,blood,biopsy; less specific in stool alone since viral shedding x6‐ 12 wks in asypmtomatic patients – PCR – for enterovirus RNA in CSF – Rise in neutralizing antibody titer from an acute and convalescent specimen
– No specific therapy – Immune Globulin Intravenous (IgIV) ‐ may be beneficial for chronic enteroviral meningoencephalitis
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Poliovirus Infections
Poliovirus Infections (Poliomyelitis)
• Epidemiology WHO Polio Global Eradication Program ‐ launched in 1988 with the following strategies: 1. Routine immunization 2. National Immunization Days (NID) 3. Active Acute Flaccid Paralysis (AFP) Surveillance 4. “Mopping Up”: extra immunization rounds when a wild virus is found
Poliovirus Infections
Poliovirus Infections • Epidemiology Based on active WHO AFP Surveillance ‐ last case of wild poliovirus in America: in Peru (1991), and by 1994‐ declared polio‐ free ‐ In Philippines‐ last case of wild poliovirus: in Cebu (1993);last case in WPR 1997 ‐ Philippines and the rest of the Western Pacific Region were certified polio‐ free by 2000
• Epidemiology Remaining Polio‐ endemic countries : 1. India 2. Pakistan 3. Afghanistan 4. Nigeria
Poliovirus Infections • Epidemiology 2001 – type 1 circulating vaccine‐ derived poliovirus ( c VDPV) was isolated from 3 children in 3 places: Cagayan de Oro Cavite Laguna
Poliovirus Infections • Circulating vaccine‐ derived poliovirus ( c VDPV)
‐ dependent of sabin virus ‐ accumulation of small spot mutations over a period of >/= 6 months resulting in virologically different strain ‐ recovers properties of wild virus like neurovirulence, recombination and transmissibility ‐ ocurs only where there is no wild virus ‐ with accumulation of susceptibles
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Poliovirus Infections
Poliovirus Infections
• Source ‐ feces and possibly, oropharyngeal secretions of man • Mode of Transmission: ‐ fecal to oral ‐ possibly oral to oral (respiratory) routes
• Period of Communicability ‐ Patients are potentially contagious for as long as fecal excretion persists ‐ OPV recipient: virus persists in throat for 1‐2 weeks and excreted in feces for several weeks • Incubation period: 3‐6 days – abortive poliomyelitis 7‐21 days – paralysis in paralytic poliomyelitis
Clinical Forms
Clinical Forms
Inapparent illness – account for 90- 95% of cases Abortive Cases (4‐8%) Non specific febrile illness Malaise Nausea/ vomiting Headache Sorethroat Constipation Diffuse abdominal pain
Non paralytic or aseptic Paralytic (0.1‐ 2%) meningitis (1‐5%) Signs & symptoms of Signs & symptoms of minor illness non‐ paralytic illness + + Nuchal/ spinal skeletal Weakness of >1 muscle rigidity Or cranial (spinal, + bulbar, bulbospinal or encephalitic) Increase/ decrease in superficial/ or deep tendon reflexes Flacid paralysis w/o sensory loss (hallmark) + Absent DTRs
Post‐polio syndrome • Occurs 30‐40 years later as muscle pain, & exacerbation of weakness or new weakness or paralysis among 30‐40% of • Patients w/ childhood poliomyelitis
Difference between virus in VAPP & VDPV
Clinical Forms Vaccine‐Associated Paralytic Poliomyelitis • VAPP • a paralytic disease in OPV recipient /close contact • incidence: 1 case in >/3 million doses distributed
Features Structure
Virus circulation in a community Occurrence
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Virus in VAPP
VDPV
Identical to sabin vaccine virus
>3% different from sabin vaccine virus (mutant)
None
Circulates or is transmissible
Wherever OPV is used
Occurs only where there is no wild virus and there is an accumulation of susceptibles
Complications
Diagnosis
• GIT: gastric dilatation, hemorrhage, melena, paralytic ileus • Hypertension, occ pulmonary edema • Skeletal decalcification 2º to immobilization leading to hypercalcemia, hypercalciuria, nephrocalcinosis
Treatment: • No specific treatment;symptomatic & supportive Control Measures: • OPV:vaccine of choice for global eradication in areas w/ VDPV,developing countries where inadequate sanitation necessitates optimal mucosal barrier • IPV:areas not at risk to wild type, immunodeficient patients
• Clinical • Laboratory 1. viral isolation from 2 stool specimen taken 24‐ 48 hours apart within 14 days of onset of paralysis 2. serology: acute & convalescent sera 3. with CNS involvement: CSF examination ‐ pleocytosis with early PMN predominance followed by shift to mononuclears ‐ protein: normal or slightly elevated ‐ normal glucose 4. DNA sequence analysis – distinguish wild virus from vaccine virus
Influenza ‐Types A,B and C ‐Epidemic disease: Type A and B ‐ Influenza A subclassified by 2 surface antigens: Hemagglutinin (HA) & Neuraminidase (NA) ; examples: H1N1, H1N2, & H3N2 ‐Antigenic drift: minor variations in influenza B or A; seasonal epidemics ‐Antigenic shift: major variations in HA or NA; only w/ influenza A; pandemics
Influenza
Influenza Diagnosis:
‐predominantly respiratory ‐abrupt onset of coryza,conjunctivitis.pharyngitis, dry cough ‐localize as URI, croup, bronchiolitis or pneumonia ‐commonly associated w/ high fever(2‐4 days), myalgia, malaise & headache
viral culture, immunofluorescent, or rapid diagnostic tests for antigens, direct fluorescent antibody(DFA) and indirect immunofluorescent antibody(IFA) staining for Influenza A and B antigens in NP specimens
‐close contacts often have similar illness ‐indistinguishable from RSV, parainfluenza viruses & adenovirus
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Antiviral Drugs for Influenza Drug
Virus
Administration
Treatment Indications
Prophylaxis Indications
Prophylaxis Adverse Effects Central nervous system, anxiety, gastrointestinal
Amantadine
A
Oral
=1 y of age
=1 y of age
Rimantadine
A
Oral
=13 y of age
=1 y of age
Central nervous system, anxiety, gastrointestinal
A&B
Inhalation
=7 y of age
=5 y of age
Bronchospasm
A&B
Oral
=1 y of age
=1 y of age
Nausea, vomiting
Zanamivir Oseltamivir
Influenza Vaccine
* Influenza Vaccine Recommended in: • Children 6mos‐5 yo • High‐risk children:chronic heart /lung/metabolic diseases,renal disorders &hemoglobinopathies • Children on long term aspirin tx
* 2009 Flu pandemic
Children 6mos‐8yo: 2 doses, 4 weeks apart then yearly Preferably given Feb to June Healthy children>5 yo who want to be protected against influenza can be given the vaccine
• Global outbreak of a novel influenza AH1N1 identified April 2009 • Infects and transmissible between humans • A re‐assortment of 4 known strains of influenzae A virus subtype H1N1: 1 endemin in humans, 1 endemic in birds and 2 endemic in pigs • WHO data as of July 6,2009 : 94,512 cases, 429 deaths • Symptoms similar to other forms of influenzae: fever, cough, sorethroat, headache, myalgia, chills diarrhea , vomiting
Flu vaccine for 2009, Southern strain
Avian influenza (H5N1) ‐mainly in birds; deadly ‐doesn’t usually infect people but human infections have resulted from direct or close contact with H5N1 infected poultry
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Parainfluenza viruses ‐members of paramyxoviridae family ‐types 1‐4 ‐account for 50% of hospitalizations for croup, 15% of bronchiolitis and pneumonia ‐not associated with fever; systemic complaints rare ‐diagnosis is based only clinical and epidemiologic criteria ‐”Steeple sign” or progressive narrowing of the subglottic region on xray : characteristic of parainfluenza virus respiratory tract infection
Respiratory Syncitial Virus ‐association of RSV bronchiolitis early in life and reactive airway disease remains poorly understoood; underlying predisposition to reactive airway disease rather than a direct consequence of RSV infection ‐almost all children infected once by 2 yrs old ; reinfection common
Respiratory Syncitial Virus ‐major cause of bronchiolitis and pneumonia in children half of patients;with diarrhea. pharyngitis pneumonia: types 3,7,& 21 cause severe type w/ 10% mortality; residual airway damage: bronchiectasis; bronchiolitis obliterans, rarely pulmonary fibrosis pertussis‐like syndrome
Pharyngoconjunctival fever‐type 3; high fever x 4‐5 days, pharyngitis, non‐purulent conjunctivitis, preauricular & cervical lymphadenopathies & rhinitis + headache, malaise & weakness
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Adenovirus
Adenovirus
Other manifestations:
Infections in the Immunocompromised:
Follicular conjunctivitis Myocarditis GIT Infections‐ diarrhea, intussuception Hemorrhagic cystitis‐ suden onset bacteriologically sterile hematuria,dysuria, frequency & urgency x 1‐2 weeks; types 11 & 21 Reye Syndrome and Reye‐like Syndrome
Chronic meningoencephailtis in B‐cell deficiency Prolonged diarrhea in T‐cell deficiency
Diagnosis: immunohistology in biopsy ,viral culture or PCR, serology Treatment: posssible role of Cidofivir
Viral Gastroenteritis
DIARLEX ROTA-ADENO
Rotavirus ‐single most important cause of severe dehydration diarrhea in early childhood Astrovirus ‐2nd most important agent of viral diarrhea in young children Enteric adenovirus Caliciviruses ‐ most common cause of gastroenteritis outbreaks on older children & adults
• The latex reagent is composed of either anti‐ rotavirus antibodies(rabbit) or anti‐adenovirus antibodies (rabbit) bound to red latex particle • When a fecal extract containing rotavirus or adenovirus particles(antigen) is mixed with the test latex reagent, an antigen‐antibody reaction occurs resulting in visible agglutination (red color)of the latex particles.
Rotavirus Vaccine Monovalent human RV: 2‐dose series 1st dose: 6 wks old, 4 weeks apart 2nd dose: not later than 24 weeks Pentavalent human‐bovine reassortant RV: 1st dose:6‐12 weeks old, 4‐10 wk intervals final dose :not later than 32 weeks May be given with OPV or 2 weeks apart With a potentially higher risk of intussuception if 1st dose given beyond recommended age
THE END • "Lord, thank you for everything, I can’t name them all but it all comes from You, everyday I am very grateful for everything!"
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RABIES • Primarily a disease of animals • Dogs account for >90% of reported human cases • 6‐10% ‐ cats, cattle, horse, sheep, bats, exotic pets • Small rodents, birds & reptiles are NOT KNOWN to serve as reservoir of infections
RABIES & HIV
Rabies
• Variation:
• Transmission: bites of rabid animals or by licking of the mucosa or open wounds • Period of communicability: – Dogs & cats‐ 3‐5days before the onset of symptoms until the entire course of illness – Person to person‐ NOT DOCUMENTED
Rabies
– Severity of the bite – Site of bite in relation to nerve supply – Size of inoculum, protection offered by clothing & other factors – Age and immune status of host
• Incidence: WHO: 11th major killer diseases 60,000 deaths worldwide
• Incubation period: 1day to 5 years (8 WEEKS – average)
>30,000 die yearly in Asia about 10M exposed annually
DOH: 2006(219 cases) 2007(281 cases)
Rabies • Infected patients go through 4 stages – Incubation period • • • •
Usually 20‐90 days >95% will present with s/sx within 6 months Virus remains at the site of the bite The only time when vaccination is effective
– Prodrome • 2‐10 days • Virus reaches the spinal cord • 1st rabies specific sx‐pain or itching or paresthesia at bite site
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Rabies
Rabies
Acute neurologic phase‐2‐7days
• Diagnosis
2 TYPES: 1. Encephalitic or furious rabies ‐80% – – –
2.
Hyperactive episodes(combative,bizarre behavior,apprehensive) Hydrophobia( agitation,cringing,due to painful contractions of laryngeal muscles upon drinking) aerophobia
Paralytic or dumb rabies‐20% – – –
Paralysis of bitten area respiratory paralysis Often missed;hydrophobia & aerophobia absent Rabies suspected if with paralysis or encephalitis
– CBC‐ wbc 20,000‐30,000/mm3 with polymorphonucleosis – CSF‐ mononuclear cells may increase 100/mm3, protein is slightly elevated – PREMORTEM DIAGNOSIS • Fluorescent microscopy of skin biopsies from nape • Isolation of virus • Detection of antibody‐serum & CSF in unvaccinated persons • Detection of viral nucleic acid (PCR) in infected tissues
Coma ‐ 4‐10 days ‐complications: myocarditis, diabetes insipidus,SIADH ‐outcome: death due to respiratory paralysis
Rabies
Rabies
• Diagnosis:
• PROGNOSIS: fatal • TREATMENT: intensive symptomatic or supportive care • ISOLATION: strict throughout the illness; caution against contamination of open wound or mucous membrane with patient’s saliva
– POSTMORTEM DIAGNOSIS‐ fluorescent microscopy of brain and salivary glands – ANIMAL BRAIN • Fluorescent antibody stain of brain tissue • Positive for negri bodies
Therapeutic Management of Patients Exposed to Rabies • General principles of post‐exposure treament ‐minimize amount of virus at the site of inoculation ‐develop a high titer of neutralizing antibody early
Local wound care • Immediate vigorous washing & flushing w/ soap & water • Apply alcohol or Povidone Iodine • Suturing avoided or delayed as it may inoculate virus deeper. If unavoidable, suturing done loosely. RIG must be instilled deep into the wound before suturing • Do not apply ointment, cream or occlusive dressing to the bite site • Anti‐tetanus prophylaxis should be initiated or boosted as indicated • Antibiotics for all category III cat bites, category III dog bites that are on the hand or deep,multiple & extensive ‐amoxycillin as propjylaxis ‐cloxacillin or amoxyclav if infected • Antibiotics for category I & II only if wound is infected
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Vaccination
Vaccination
CARE OF EXPOSED PERSONS: • ACTIVE IMMUNIZATION
• STANDARD INTRAMUSCULAR SCHEDULE
– Purified vero cell rabies vaccine 0.5ml/vial – Purified chick embryo cell vaccine 1ml/vial • PASSIVE IMMUNIZATION ‐ for all Category III exposures + anti‐rabies vaccine ‐RIG should be inflitrated around and into the wound as anatomicaly feasible even if lesion has begun to heal, the rest IM ‐may be given until 7days after the 1st dose – Human rabies immune globulin (PREFERRED) 20IU/K – Hyper immune equine rabies immune globulin(Fab2):
Day of immunization
PVRV
Day 0 Day 3 Day 7 Day 14 Day 28
0.5ml 0.5ml 0.5ml 0.5ml 0.5ml
PDEV/ PCECV 1ml 1ml 1ml 1ml 1ml
Site of injection One deltoid One deltoid One deltoid One deltoid One deltoid
40IU/K IM, needs skin testing
SUMMARY SCHEDULE OF ACTIVE IMMUNIZATION AGAINST RABIES
Postexposure Rabies Prophylaxis
Category I
Category I
• Feeding/touching an animal • Licking of intact skin (with reliable history and thorough physical examination) • Exposure to patient with S/Sx of rabies by sharing of eating or drinking utensils • Casual contact to patient with signs and symptoms of rabies
• Wash exposed skin immediately with soap and water • No vaccine or RIG needed • May opt to give pre‐exposure prophylaxis
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Category II
Category II
• Nibbling of uncovered skin • Minor scratches/abrasions without bleeding* • Licks on broken skin
• Start vaccine immediately • Complete vaccination regimen until day 28/30 if: – Animal is rabid, killed, had died or unavailable for 14‐day observation or examination – Animal under observation died within 14 days and was FAT‐positive or no FAT testing was done or had signs of rabies
* Includes wounds that are induced to bleed OLD: Complete vaccination regimen until day 90
Category II
Category III
• Complete vaccination regimen until day 7 if: – Animal is alive and remains healthy after 14‐day observation period – Animal under observation died within 14 days, was FAT‐ negative and without any signs of rabies
• Single or multiple transdermal bites or scratches – Puncture wounds, lacerations, avulsions, deep abrasions
• Contamination of mucous membrane with saliva (i.e. licks) • Handling of infected carcass or ingestion of raw infected meat • All Category II exposures on head and neck area
OLD: Complete vaccination regimen until day 30
Category III
Category III
• Exposure to a rabies patient* through bites, contamination of mucous membranes with saliva/fluids through splattering, through mouth‐to mouth resuscitation, licks of eyes, lips, vulva, sexual activity, exchanging kisses on the mouth or other direct mucous membrane contact with saliva * does not include sharing of food/ drink/ utensils and casual contact with rabid patient
• Start vaccine and RIG immediately • Complete vaccination regimen until day 28/30 if: – Animal is rabid, killed, had died or unavailable for 14‐day observation or examination – Animal under observation died within 14 days and was FAT‐positive or no FAT testing was done or had signs of rabies
OLD: Complete vaccination regimen until day 90
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Category III
Passive Immunization
• Complete vaccination regimen until day 7 if: – Animal is alive and remains healthy after 14‐day observation period – Animal under observation died within 14 days, was FAT‐negative and without any signs of rabies
• Give anti‐tetanus prophylaxis
• to neutralize rapidly the virus locally in the wound before it reaches the local nerve endings • To provide the immediate availability of neutralizing Ab at the site of the exposure before it is physiologically possible for the patient to begin producing his or her own Ab after vaccination (usually 7 to 14 days later) • 3 kinds: HRIG, ERIG, Fab2
OLD: Complete vaccination regimen until day 30
Anti-Rabies Act of 2007 • Republic Act No. 9482 • An Act providing for the control and elimination of human and animal rabies • Signed into law on May 25,2007; IRR signed in March 2008 • Provisions: – – – – – –
National Rabies Prevention and Control Program, Philippines GOAL: To eliminate human rabies and declare the Philippines RABIES FREE by 2020
Mass dog registration/vaccination Dog population control Provision of PEP to bite victims Information‐education Responsible pet ownership Provision of free PreP to high risk individuals and children 5 – 14 yrs in high incidence areas (IR>2.5/M pop)
Pre-exposure Prophylaxis Day 0
Day 7
Regions with IR > 2.5/M pop
Day 21/28
IM dose = 0.5 ml PVRV or 1.0 ml PCECV ID dose = 0.1 ml PVRV, PCECV Into the deltoid muscle or anterolateral thigh in infants
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2007 N=281 5 (7.76/M) 2 (7.37/M) 8 (4.61/M) 3 (4.55/M) 9 (4.42/M) 7 (3.38/M) 12 (3.9/M) 4A (3.2/M) 1 (2.67/M)
2006 N=216 2 (8.65/M) 12 (5.2/M) 5 (4.16/M) 8 (4.16/M) 1 (3.11/M) 3 (2.36/M) 7 (2.92/M) 4A (1.01/M)
Guidelines for subsequent exposure following primary immunization(PreXP :D0,7,28 0r PEP:D0,3,7) ‐no RIG needed ‐any exposure,regardless of severity,after completion of the primary immunization should be given as follows: 6mos‐3 yrs 2 boosters on D0 & D3 > 3 years repeat full course of vaccine without RIG
Reported modes of Transmission HIV/AIDS registry Jan 1984-Aug 2008
Reported modes of transmission
N=3358
Heterosexual contact Homosexual contact Bisexual contact Blood/blood product Injecting drug use Needle prick injuries Perinatal No exposure reported
1,934 727 303 19 8 3 46 318
HIV • • • •
Broad spectrum of disease Varied clinical course AIDS‐most severe end of the clinical spectrum Target cells – T‐helper CD 4+ lymphocyte – Monocytes – Macrophages – CNS cells with CD4 + receptors
Mother to infant transmission (vertical) • Primary route of transmission • Rate: 12‐30% in US & Europe • Time of transmission – Before delivery • 30‐40%, (+) PCR within 1st week
– Intra‐partum transmission • 60‐70%, no detectable virus before 1 week of age
– Via breast feeding • WHO recommend breastfeeding in developing countries • 14% risk of transmission in women with HIV before pregnancy • 29% risk in women with HIV postnatally
• Mother‐to‐Child Transmission(n=46) ‐25 M,21 F ‐1‐11 yo ‐30 asymptomatic ‐16 AIDS cases,7 deaths ‐last MTCT wasin FEB 2008 In 2007, 8 cases reported 4 –Region IV 3 –Region III 1 – Region I
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Clinical manifestations • • • •
Vary widely PE at birth may be normal Initial symptoms may be subtle/ non‐specific Symptoms more common in children than adults – – – –
Recurrent bacterial infections Chronic parotid swelling Lymphoproliferative interstitial pneumonitis Early onset of progressive neurologic disorder
Infections
20% of AIDS‐defining illnesses recurrent bacterial infections caused by encapsulated organisms(pneumococcus, salmonella) Most common serious infections: bacteremia, sepsis, pneumonia Opportunistic infections with severe depression of CD4 count PCP pneumonia: most common opportunistic infection children; peak: 3‐6 months;44‐47% mortality Tuberculosis‐higher prevalence of TB & HIV co‐infection in developing countries Oral candidiasis‐most common fungal infection in HIV infected patients Viral infections with Herpes viruses pose a significant problem
• GI • CNS – occurs in 50‐90 % of perinatally infected children in developing countries as progressive encephalopathy, loss of developmental milestone cognitive deterioration and impaired brain growth.
• RESPIRATORY TRACT – Recurrent otitis media and sinusitis are common – LIP – the most common chronic lower respiratory tract abnormality; affects 30‐40% of HIV infected children; maybe an exaggerated response to EBV & HIV, non‐productive cough, insidious hypoxia, bronchiectasis, pulmonary decompensation, clubbing
• CARDIOVASCULAR SYSTEM
– Oral candidiasis, gingivitis, parotitis – Most common symptoms: chronic or recurrent diarrhea with malabsorption, abdominal pain, dysphagia, failure to thrive, chronic hepatitis – Pathogens: salmonella, campylobacter,MAC, giardia, cryptosporidium, CMV, HSV, rotavirus, candida
• Renal – uncommon
• Skin – Severe & unresponsive seborrheic dermatitis or eczema
• Hematologic
– Rhythm disturbances; dilated cardiomyopathy & LVH
– Anemia, leukopenia, thrombocytopenia – Malignant diseases infrequent in children – Common reported neoplasms: NHL, primary CNS lymphoma, leiomyosarcoma
Diagnosis of HIV Infection
Steps to HIV Testing
• Initial clues to consider possibility of HIV infection: 1. Having multiple sex partners(MSP) 2. Unprotected sex w/a person who has MSP 3. Hx of STI 4. Hx of IV drug use 5. Unprotected sex w/ an HIV infected person 6. (+) clinical conditions suggestive of HIV infection not explaned by other causes 7. Children below 13 years born to HIV infected mothers
A.Pre‐test Counseling ‐important because of the profound psychosocial impact of an HIV(+) antibody test ‐assess person’s risk for HIV infection ‐provide adequate & correct info about HIV antibody test and HIV/AIDS ‐assess how the person would cope with a (+) test ‐promote behaviors that will prevent transmission
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Steps to HIV Testing
Steps to HIV Testing
B.Request for HIV Ab Test ‐informed CONSENT prior to test ‐request for HIV Ab testing must be written on the chart using a code name for the test ‐all hospital personnel with whom the patient may interact for the conduct of HIV testing should act professionally and responsibly to ensure CONFIDENTIALITY of the test
Diagnosis of HIV infection
C.Post‐test Counseling ‐provide intitial emotional support in case of a (+) HIV antibody test ‐provide adequate medical info about HIV/AIDS ‐identify other medical and social support system ‐re‐emphasize behaviors that will prevent HIV transmission to other people ‐if (‐), explain the meaning of a (‐) test and re‐ emphasize prevention
Case definition for HIV infection age 18months (CDC, 1999) • HIV antibody positive by repeatedly reactive EIA and confirmatory test (western blot or IFA) • Positive result on any HIV virologic test, HIV culture, HIV PCR, HIV p24 antigen • Any condition that meets criteria for AIDS
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Clinical Categories for Children with Human Immunodeficiency Virus (HIV) Infection CATEGORY N: NOT SYMPTOMATIC • Children who have no signs or symptoms considered to be the result of HIV infection or who h we only one of the conditions listed in Category A. CATEGORY A: MILDLY SYMPTOMATIC • Children with two or more of the conditions listed bel )W but none of the conditions listed in Categories B and C. • Lymphadenopathy (>0.5 cm at more than two sites; bilateral= one site) • Hepatomegaly • Splenomegaly • Dermatitis • Parotitis • Recurrent or persistent upper respiratory infections, sinusitis, or otitis media
CATEGORY B: MODERATELY SYMPTOMATIC
• Children who have symptomatic conditions other than those listed for Category A or C that are attributed to HIV infection. Examples of conditions in clinical Category B include but are not limited to: • Anemia (6 months of age • Cardiomyopathy • Cytomegalovirus infection, with onset before 1 month of age • Diarrhea, recurrent or chronic • Hepatitis
CATEGORY B: MODERATELY SYMPTOMATIC • Herpes simplex virus (HSV) stomatitis, recurrent (more than two episodes within 1 year) • HSV bronchitis, pneumonitis, or esophagitis with onset before 1 month of age • Herpes zoster (shingles) involving at least two distinct episodes or more than one dermatome • Leiomyosarcoma • Lymphoid interstitial pneumonia (LIP) or pulmonary lymphoid hyperplasia complex • Nephropathy • Nocardiosis • Persistent fever (lasting >1 month) • Toxoplasmosis, onset before 1 month of age • Varicella, disseminated (complicated chickenpox)
CATEGORY C: SEVERELY SYMPTOMATIC
CATEGORY C: SEVERELY SYMPTOMATIC
Serious bacterial infections, multiple or recurrent (i.e., any combination of at least two cul‐ture‐ confirmed infections within a 2‐year period), of the following types: septicemia, pneumonia, meningitis, bone or joint infection, or abscess of an internal organ or body cavity (excluding otitis media, superficial skin or mucosal abscesses, and indwelling cathe‐ ter‐related infections) Candidiasis, esophageal or pulmonary (bronchi, trachea, lungs) Coccidioidomycosis, disseminated (at site other than or in addition to lungs or cervical or hilar lymph nodes) Cryptococcosis, extrapulmonary Cryptosporidiosis or isosporiasis with diarrhea persisting >1 month Cytomegalovirus disease with onset of symptoms at age >1 month (at a site other than liver, spleen, or lymph nodes) Encephalopathy (at least one of the following progressive findings present for at least 2 months in the absence of a concurrent illness other than HIV infection that could explain the findings): a) failure to attain or loss of developmental milestones or loss of intellectual ability, verified by standard developmental scale or neuropsychological tests; b) impaired brain growth or acquired microcephaly demonstrated by head circumference measure‐ments or brain atrophy demonstrated by computerized tomography or magnetic resonance imaging (serial imaging is required for children 1 month; or bronchitis, pneumonitis, or esophagitis for any duration affecting a child >1 month of age
Histoplasmosis, disseminated (at a site other than or in addition to lungs or cervical or hilar lymph nodes) Kaposi's sarcoma Lymphoma, primary, in brain Lymphoma, small, noncleaved cell (Burkitt’s), or immunobiastic or large cell lymphoma of B‐ceii or unknown immunologic phenotype Mycobacterium tuberculosis, disseminated or extrapulmonary Mycobacterium, other species or unidentified species, disseminated (at a site other than or in addition to lungs, skin, or cervical or hilar lymph nodes) Mycobacterium avium complex or Mycobacterium kansasii, disseminated (at site other than or in addition to lungs, skin, or cervical or hilar lymph nodes) Pneumocystis carinii pneumonia Progressive multifocal leukoencephalopathy Salmonella (nontyphoid) septicemia, recurrent Toxoplasmosis of the brain with onset at >1 month of age Wasting syndrome in the absence of a concurrent illness other than HIV infection that could explain the following findings: a) persistent weight loss >10% of baseline OR b) downward crossing of at least two of the following percentile lines on the weight‐for‐age chart (e.g., 95th, 75th, 50th, 25th, 5th) in a child 21 year of age OR c)
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