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Clin Med II Infectious Disease Lecture IIViral Diseases, part 3/3 Slide 2 Measles Slide 3 Acute systemic paramyxovirus Inhalation of infective droplets Major worldwide cause of morbidity and mortality 750,000 deaths in 2000 197,000 deaths in 2007 Rising rates of intentional undervaccinationsporadic outbreaks Highly contagious Slide 4 Measles Fever (40-40.6 C or 104-105 F) Malaise, coryza, cough, conjunctivitis Koplik spots Rash appears about 4 days after oonset Pinhead-sized papules brick-red, irregular, blochy maculopapular rash may become uniform erythema Face and behind ears trunk extremities Erythematous pharynx with yellowish tonsillar exudate Coated tongue Generalized lymphadenopathy Splenomegaly Slide 5 Measles Slide 6 Slide 7 LabsLeukopenia, thrombodytopenia, proteinuria Can culture virus from nasopharyngeal washings and blood IgM measles bodies or 4x rise in serum hemagglutination inhibition, fluorescent antibody staining of respiratory or urinary epithelial cells Complications CNSpostinfectious encephalomyelitismultiple forms read in text Bronchopneumonia, bronchiolitis, bronchiectasis Secondary bacterial infections Immune reactivity Gastroenteritis Conjunctivitis, keratitis, otosclerosis Slide 8 MeaslesTreatment Generalisolation until week following rash onset; bed rest until afebrile Antipyretics and fluids High dose vitamin Amaintains GI and respiratory mucosa Treatment of secondary bacterial infections Encephalitissymptomatic treatment only Slide 9 Measles Preventionimmunization (12-15 mo, 4-6 yrs) Do not give in pregnancy or immunosuppression Report all cases to public health. Refer in cases of HIV and pregnancy Admit: Meningitis, encephalitis, myelitis Severe pneumonia Diarrhea that compromises fluid balance Slide 10 Mumps Slide 11 Spread by respiratory droplets Children are most commonly affected Incidence highest in spring Incubation 14-21 days Up to 1/3 of infection-- asymptomatic Slide 12 Mumps Parotid tenderness, swelling Trismus Glands usually normal within 1 wk Fever and malaise Meningitis Orchitismost common extrasalivary site in adults Pancreatitismost common cause of pancreatitis in children Slide 13 Mumps Labsmild leukopenia, amylasemia (from salivary glands), mild kidney function abnormalities CSFpleiocytosis, hypoglorrhachia Diagnosisusually characteristic clinical picture Isolate of virus from swab of the duct of the parotid or other affected salivary gland Can isolate virus from CSF early in aseptic meningitis Nucleic acid amplificationmore sensitive than viral culture but limited availability Elevated IgM--diagnostic Slide 14 Mumps Treatmentisolate till swelling subsides, bed rest till afebrile; symptomatic relief Topical compresses IVIGcan try for complicated disease but no consensus Meningitissymptomatic; manage cerebral edema, airway, vital functions Epididymoorchitisscrotal support, ice bags, pain relief Pancreatitissymptomatic, hydration Usually lasts no longer than 2 weeks Preventionlive virus vaccine; routine immunization Often in combination with measles, rubella and VZV Slide 15 Rubella Slide 16 Systemic disase togavirus transmitted by inhalation of infective droplets One attack usually confers permanent immunity Difficult to distinguish from mono, measles, other viral illnesses arthritis is more prominent in rubella Principal importance devastating effects on fetus in utero Slide 17 Rubella Fetaldevastating Postnatally acquiredinnocuousup to 50% asymptomatic Fever, malaise, tender suboccipital adenitis, coryza Arthritisfingers, wrists, knees Early posterior cervical and postauricular lymphadenopathy Erythema of palate and throat Fine pink maculopapular rash on face, trunk and extremities in rapid progression (2-3 days) and fades quickly1 day in each area Slide 18 Rubella Slide 19 Labsleukopenia Diagnosiselevated IgM antibody, isolation of virus, 4x or greater rise in IgG False positive IgMEpstein-Barr, CMV, parvovirus, RF Exposure during pregnancyimmediate hemagglutination-binding rubella antibody level Infection during 1 st trimestercongenital rubella in 80% Evaluate immunizationtiters fall to seronegativity in 10% of patients after about 12 yrs Slide 20 Rubella Congenital rubellausually have wide variety of manifestationseye disease, microphthatlmia, hearing deficits, psychomotor retardation, heart defects, organomegaly, maculopapular rash Younger fetus at infectionmore severe illness Second trimesterdeafness Specific test for IgM rubella antibody Postinfectious encephalopathymortality rate 20% Slide 21 Rubella Treatmentsymptomatic (acetaminophen) Prognosismildrarely lasts more than 3-4 days Congenitalhigh mortality rate and permanent defects Preventionlive attenuated rubella virus vaccineoften in combination with measles, mumps, and varicella Try to immunize girls prior to menarche Do not give immunization during pregnancy In US80% of 20-year-old women are immune to rubella Slide 22 Roseola Slide 23 Human herpesvirus 6principal cause of exanthema subitum Primary HHV6children under 2 years; major cause of infantile febrile seizures May also see encephalitis and acute liver failure HHV6 encephalitishippocampus, amygdala, limbus Symptomatic HHV6 is rare in immunocompetent adults mono-like illness (primary) or encephalitis (reactivated) Can see infection during pregnancy / congenital transmission Reactivated diseasemainly in immunocompromised adults associated with graft rejection, graft-versus-host disease May cause fulminant hepatic failure and acute decompensation of chronic liver disease in children Slide 24 Roseola Slide 25 Influenza Slide 26 Highly contagiousrespiratory droplets 3 types of virusesType A infects many mammals and birds, Types B and C infect humans almost exclusively Type Asubtypes from hemagglutinin (H) and neuraminidase (N) Annual epidemics in fall and winter10-20% of global population each year Pandemicslonger intervals (decades)major genetic reassortment of virus or mutation of animal virus Main current virusesH1N1 and H3N2 subtypes and type B. Slide 27 Influenza Types A and Bclinically indistinguishable infections Type Cminor Abrupt onsetFever, chills, malaise, myalgias, cough substernal soreness, headache, nasal stuffiness, nausea Elderlymay present with only lassitude, confusion Mild pharyngeal infection, flushed face, conjunctival redness, cervical lymphadenopathy Labsleukopenia, may see leukocytosis; proteinuria; isolate virus from throat swasbs, nasal washings, cell cultures Rapid assaysnasal or throat swabs60-80% sensitivity Slide 28 Influenza Complicationsnecrosis of respiratory epitheliumsecondary bacterial infections Bacterial enzymes activate influenza viruses Frequent complications sinusitis, otitis media, purulent bronchitis, pneumonia Young children, pregnant women, elderly, LTC facility patients, patients with comorbidities higher risk of complications ReadReye Syndrome Slide 29 Influenza Treatmentbed rest, analgesics, cough medicine Treat - suggestive clinical infection or laboratory confirmed influenza and high risk for complications No proven benefit of antivirals after 48 hrs, but should consider if patient is hospitalized Neuraminidase inhibitorsinhaled zanamivir or oral oseltamivirequally effective in treatment reduce duration of symptoms and secondary complications do not reduce hospitalizations or mortality Adamantanesamantadine and rimantadinehigh levels of resistance and not recommended for treatment Prognosisuncomplicated lasts 1-7 days; excellent prognosis in healthy, nonelderly adults Preventionannual administration of influenza vaccine Readinformation on flu vaccine including contraindications Slide 30 HPV Slide 31 Human Papilloma Virus Skin Wartsflat (superficial) or plantar (deep growths) typically regress over timeHPV 1-4 Benign Head and Neck Tumors single oral papillomaspedunculated with stalk and rough papillary appearance Laryngeal papillomasmost often caused by HPV-11most common benign epithelial tumors of larynx; can cause airway obstruction in children Condyloma Acuminataalmost exclusively on squamous epithelium of external genitalia and perianal areas 90% due to HPV 6 and HPV 11 Slide 32 Human Papilloma Virus Skin Warts Slide 33 Human Papilloma Virus Oral papilloma Slide 34 Human Papilloma Virus Condyloma Acuminata Slide 35 Slide 36 Human Papilloma Virus Cervical dysplasia koilocyotic cellsHPV 16-18 (70%) Dysplasia40-70% of lesions spontaneously regress Progressive changes from mild (CIN I) to moderate (CIN II) to severe (CIN III) dysplasia, carcinoma in situ, or both Slide 37 HPV Diagnosis wart can be confirmed microscopically by histologic appearancehyperplasia of prickle cells and excess keratin HPV infectionkoilocytoctic (vaculolated) squamous epithelia cells that are rounded and occur in clumps HPV virions on electron microscopy Molecular probes for HPV DNAestablish in cervical swab and tissue HPV does not gro in cell cultures HPV antibodiesrarely used Slide 38 Human Papilloma Virus Treatmentspontaneous disappearance of warts is the rule; may take months to years Cryotherapy, Electrocautery, Chemical Recurrences are common See guidelines for follow-up on cervical dysplasia PreventionHPV quadrivalent vaccine (Gardasil) Types 6,11,16,18 Slide 39 HIV Slide 40 Whole chapter of its ownI suggest you read! You should know: Major risk factors/Modes of transmission Presenting symptoms (Hallmark of symptomatic HIV?) and major complications Prevention measures HIV risk for health care professionals Major pathogens that need prophylaxis Indications for antiretroviral therapy Slide 41 Questions?