Diseases of Absence - Disclosures I have no disclosures I do not intend to mention - njaap
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10/18/2018
Diseases of
Absence
Meg Fisher, MD
Medical Director,
The Unterberg
Children’s Hospital
Long Branch, NJ
Disclosures
• I have no disclosures
• I do not intend to mention
off label uses of drugs
• I have way too many slides so
we will be moving quickly
1
10/18/2018
Objectives
• Decide when a child should be sent
home from school and when that
child can return to school
• Decide which children can stay at
school
Reasons for Absence
• Child is a risk to others: contagious
• Child unable to participate
• Child is at risk: needs medical
attention
• Possible serious infection
• Dehydration
•Injury
2
10/18/2018
When to Return
• Child no longer contagious
• Child able to participate
• No need for acute medical attention
Case 1 - September
• A 10 year old who just returned from
a trip to Ireland develops fever
• He appears ill – you send him home
• The next day he has a runny nose
and he starts coughing
• He has bilateral conjunctivitis
What should you be worried about?
3
10/18/2018
Concerns
a) Pneumonia
b) Kawasaki disease
c) Adenovirus
d) Blarney stone fever
e) Measles
My Thoughts
a) Pneumonia – possible but why
conjunctivitis
b) Kawasaki disease – too old, cough
c) Adenovirus - possible
d) Blarney stone fever – I made that up
e) Measles – you bet, check for Koplik
spots today, rash tomorrow
4
10/18/2018
Measles
• RNA virus: family Paramyxoviridae,
genus Morbillivirus
• Transmitted by droplets and air
• Extremely contagious
• Incubation period 8 to 12 days
• Contagious 4 days prior to 4 days
after the rash appears
2018 Red Book. Measles
Measles in the US
• 1st Vaccine
licensed
1963
• About 95%
effective
• US measles
free since
2000
www.cdc.gov/measles/cases-outbreaks.html
5
10/18/2018
Measles in the US
• 2014: over 600 cases, 23 outbreaks
• 2018: 137 cases, 11 outbreaks so far*
• US travelers bring measles home
• Travelers to US bring measles along
• Secondary spread to unimmunized
contacts
*as of 9/8/18 www.cdc.gov/measles/index.html
Clinical Illness
• Fever, cough, conjunctivitis
• Day 2 to 3 of fever, Koplik spots appear
• One to 3 days later, rash appears on
the face, maculopapular to confluent
• Rash spreads and then fads over days
Photos from
6
10/18/2018
Fever, Cough, Conjunctivitis
Photos from
Koplik spots
Photos from
7
10/18/2018
Confluent Rash
Photos from
Complications
• Otitis media
• Respiratory: pneumonia (viral
and bacterial); laryngotracheitis
• Encephalitis
• Subacute sclerosing panencephalitis:
years later
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10/18/2018
Diagnosis
• Clinical
• Confirm with serology: IgG and IgM
• Virus isolation: nasopharyngeal swab,
urine
• Report all suspected cases:
local health department –
if not available, call the state
www.cdc.gov/measles/index.html 2018 Red Book. Measles
Treatment
• Isolate the patient: air and droplet
• Report the case
• Vitamin A: Once daily for two days
200,000 IU age > 12 mo; 100,000 IU
6-11 mo; 50,000 IU < 6 mo
• Ribavirin: in vitro, not approved
www.cdc.gov/measles/index.html 2018 Red Book. Measles
9
10/18/2018
Prevention
• Measles vaccines: MMR and MMRV
• Routine: 12-15 mo, 4-6 yr
• Post-exposure: within 72 hours
• Immunoglobulin 0.25 ml/kg (max 15)
• Travelers/outbreaks: MMR for ages 6 to
12 mo; child: give 2nd dose at age 12-15
months and 3rd dose at 4-6 years
www.cdc.gov/measles/index.html 2018 Red Book. Measles
Infection Control
• Staff: all should be immune
• Proof of immunity: 2 doses of vaccine or
seropositive
• NOTE: no need for serology if 2 doses given
• Born 1957 and later: 2 doses; seropositive
• Born before 1957: generally considered
immune but serology recommended if not
immunized; vaccine if negative
www.cdc.gov/measles/index.html 2018 Red Book. Measles
1010/18/2018
Infection Control
• Triage is essential
• When possible, make the diagnosis outside
of your office: car or hospital
• If the child is in your office, put into a room
• Mask on the child if possible
• The area is considered contaminated for 2
hours after the patient leaves
• Air in offices often re-circulated
Why Did He Get Measles?
• He had a religious exemption from
immunizations
• Measles is still endemic in most of
Europe as well as most everywhere
other than the Western Hemisphere
• There are rare vaccine failures: that
is the reason for the second dose
1110/18/2018
Take Home Messages
• Think measles: fever, cough, conjunctivitis
and then rash
• Notify local health department stat
• Get the proper specimens: serology and
viral culture (NP preferred)
• Get everyone protected and immunized:
staff and patients
Case 2
• A 15 year old boy comes to the office
with fever, headache, and sore throat
• He says he was fine earlier in the day
• You examine him: T 101, throat OK
• You debate and decide to give an
antipyretic
• 20 minutes later you notice a rash
1210/18/2018
Rashes
• Petechiae: think bad things –
meningococcemia, low platelets
• Hives: think allergic reaction
• Maculopapular: think virus or allergy
• Erythema: think burn, infection
• Vesicles: think herpes viruses
• Photos help
Petechiae
1310/18/2018
Purpura fulminans
Hives
1410/18/2018
Maculopapular
Erythema
1510/18/2018
Vesicles
Case 2
• The rash is petechial – oh dear!
• Where do you send him? – ideally to
the hospital
• What does he need? – fluids and an
antibiotic
1610/18/2018
Meningococcemia
• Gram negative bacteria: Neiserria
meningiditis, types A, B, C, W135, Y
• Spread person to person by
respiratory and saliva
• Fever, headache, vomiting, rash
• Asymptomatic carriage to rapid
progression
Meningococcemia
• Sepsis with purpura fulminans
• Meningococcal meningitis
• Diagnosis: culture, spinal fluid
• Treatment: fluids and antibiotics
• Outcomes: full recovery, deafness,
loss of limbs, organ damage, death
1710/18/2018
1810/18/2018
Prevention
• Chemoprophylaxis: close contacts,
follow health department advice
• Vaccines:
• MCV4: universal, age 11-12, age 16
• MenB: at risk >10 yr, no risk age 16-23
Case 3
• A 17 year old comes to the office
complaining of jaw swelling and fever
• His temperature is 100.5. He has a
tender swelling at the angle of the jaw
What are you worried about?
1910/18/2018
Concerns
• Tonsillitis
• Mumps
• Dental abscess
• External otitis
• TMJ disease
Concerns
• Tonsillitis – anterior cervical node
• Mumps – parotitis, angle of jaw
• Dental abscess – submandibular node
• External otitis – preauricular node
• TMJ disease – pain preauricular area
2010/18/2018
Lymph Nodes of the Neck
Mumps
• RNA virus, Paramyxoviridae family, genus
Rubulavirus
• Transmitted by saliva and respiratory
secretions
• Incubation 16 to 18 days (range 12-25 d)
• Contagious before and during parotitis;
(virus recovered 7 d pre to 8 d post)
2018 Red Book. Mumps
2110/18/2018
Mumps
• Vaccine efficacy 88% with 2 doses but…
• Midwest outbreak 2006, college students
• NY, NJ 2009-10 outbreak: Orthodox
• Belmar, NJ Bar outbreak: young adults
• NHL outbreak 2014: NJ Devils and more
• Many infected patients had 2 doses
Graph from Red Book Online
Mumps: Clinical Illness
• Salivary glands infected: Parotitis
• Often asymptomatic
• CNS pleocytosis common
• Orchitis after puberty; sterility rare
• Diagnosis: virus detection by culture or
RT-PCR; buccal swab, saliva, CSF;
serology – IgM tricky, increasing IgG
CDC photo
2210/18/2018
Mumps
• Differential diagnosis of parotitis:
other viruses (cytomegalovirus, EBV,
influenza, parainfluenza, LCM,
enteroviruses, HIV) and less commonly,
bacteria (atypical mycobacteria, gram
positive and gram negatives)
• Treatment: supportive, report the case
• Prevention: 2 doses of vaccine; consider
third dose during outbreaks
2018 Red Book. Mumps
Some Others
• Influenza: contagious a day before
symptoms, easily transmitted, stay
home until afebrile without meds
• Norovirus: vomiting and diarrhea,
spreads easily, stay home until better
• Streptococcal pharyngitis: sore
throat, pus, nodes, ok to return after
a dose of penicillin
2310/18/2018
Diseases of Presence
• Lice: short legs, no jump
• Infectious mononucleosis: shed for life
• MRSA carrier: 25-40% of us
• Strep carrier: 10-15% school age
• Noninfectious colitis: if able
• Poison Ivy: allergic reaction
Smiling is a contagious condition!
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