ENTEROVIRUS INFECTION
Aim: To know diagnostic criteria of Enterovirus infection in children, how to examine the child with Enterovirus infection and prove the diagnosis, differentiate, give the individual treatment and prophylaxis.
Professional motivation: ECHO and Coxsackie's viruses cause several acute infections, that have wide spectrum of clinical features: from low-grade fever and asymptomatic carrying up to severe meningoencephalitis, myocarditis and other. That's why, knowledge of Enterovirus infection diagnostic criteria, treatment and prophylaxis is very actual.
Basic Level:
1. To know how to ask complaints, disease history and life history in children (Propedeutic
Pediatrics).
2. To perform clinical examination of the child (Propedeutic Pediatrics).
3. To know microbiology, pathophysiology, and pathomorphology of Enterovirus infection (microbiology, pathophysiology, pathomorphology).
4. To diagnose Enterovirus infection after clinical and laboratory examination of the child (infectious diseases, Propedeutic Pediatrics, microbiology, pathophysiology).
5. To give etiologic, pathogenetic, and symptomatic treatment (pharmacology).
Students' Independent Study Program
Objectives for students' independent studies
You should prepare for the practical class using the existing textbook and lectures. Special attention should be paid to the following:
1. Etiology, epidemiology, pathogenesis, pathomorphology of Enterovirus infection.
2. Classification of Enterovirus infection.
3. Main diagnostic criteria of Enterovirus infection.
4. Differential diagnosis of Enterovirus infection.
5. Enterovirus infection treatment and prophylaxis.
Enterovirus infections (ECHO and Coxsackie's infections) a group of an acute diseases caused by ECHO and Coxsackie's enteroviruses, that are characterized by the variety of clinical displays from the mild fever and simple carrying of virus to protracted meningoencephalitis, myocarditis, myalgia and other.
Etiology: ECHO and Coxsackie's enteroviruses.
Epidemiology:
• The source of infection are patients and viral carriers.
• The mechanism of transmission is droplet, fecal-oral, transpacental.
• Receptivity is high, especially in the age of 3-10 years. Pathogenesis
1. Inoculation and replication of virus in an epithelium and lymphoid formations of the intestine and upper respiratory tract.
2. Viremia.
2. Damage of organs and systems. Classification
A form:
1. Typical forms: Isolated forms:
• serous meningitis;
• epidemic myalgia;
• herpangina;
• paralytic form;
• ECHO and Coxsackie's fever;
• ECHO and Coxsackie's exanthema;
• gastroenteritis;
• myocarditis;
• encephalomyocarditis in new-borns;
• enteroviral uveitis;
• orchitis, epididimitis;
• combined forms.
2. Atypical (effaced, subclinical). Severity:
• mild degree;
• moderate degree;
• severe degree. Course:
• smooth;
• nonsmooth.
Diagnostic criteria, common for all forms of Enterovirus infection
• Latent period lasts for 2-10 days.
• Acute beginning from toxic syndrome (high body temperature 39-40 °C, headache,
malaise, fatigue, repeated vomiting, decreased appetite), abdominal pain, catarrhal syndrome.
• Skin hyperemia of overhead half of the trunk, neck, and face.
• Injection of sclera vessels.
• Hyperemia, graininess of soft palate, and back pharyngeal wall.
• Neck catarrhal lymphadenitis, or polyadenitis, may be hepato-splenomegaly.
Serous meningitis - one of the most often forms
• It is often in children of 5-9 years.
• Sporadic forms or flashes in children collectives.
• High temperature (39-40 °C) for 1-10 days.
• intensive headache, nausea, vomiting, seizures and hallucinations.
• Loss of appetite, abdominal pain.
• Positive meningeal signs from the desease beginning (nuchal rigidity, Brudzinski's
and Kernig's signs, anterior fontanel bulging, decreased abdominal skin rephlexes).
• All this signs are instabile, disappear when temperature becomes normal.
• CSF: moderate polymorphonuclear-lymphocyte cytosis in the beginning, later -
lymphocyte cytosis, protein is normal (Pandy's test is negative), shugar is normal or slightly decreased.
• CSF normalization in 3-4 weeks.
• Possible relapses (on 15-3 0th days) - fever, headache, vomiting.
• In recovery period - asthenia, CSF hypertension. Epidemic myalgia
• Acute muscular pain in the chest, upper part of abdomen, back, limbs.
• Painful superficial breathing.
• Orthopnoe position of the patient (in case of pain attack).
• Duration is 3-14 days.
• May be relapses.
• May be combination with other forms. Paralytic form
• It is more often in children of 4-8 years.
• Normal temperature.
• Flaccid monoparesis of limbs (muscular weakness of buttocks, thighs, mimic muscles, impaired gait).
• Decresed muscular tonus and tendon rephlexes.
• Rapid normalization of impaired muscles function.
• CSF is normal.
Herpangina (vericulous pharyngitis)
• Exept common criteria - pharyngeal hyperemia with small papules (1-2 mm) on
palatal arch, tonsils, uvula, back pharyngeal wall which turn for vesicules very fast. Small vesicules disappear, larger - turns for aphthae with fibrinous center and red circumpherence.
• Submandibular lymphnodes enlargement.
• Recovery in 4-7 days.
Enteroviral fever ("small disease")
• It is the most often form, in preschoolers.
• "Three days" fever.
• Mild headache.
• Sometimes nausea, vomiting and abdominal pain.
• Conjunctives and pharynx are hyperemied.
• Lymphadenopathy, mild hepato-, splenomegaly.
• Duration is 2-3 weeks.
Epidemic exanthema
• Is often in schoolchildren.
• Typical common toxic and catarrhal signs.
• Rashes appear in 1-2 days simultaneously on the face, chest and limbs (pinkish
maculous-papulous or erythematous, descrйate).
• Maculous enanthema on the soft palate.
• Rashes disappear in 2-4 days, sometimes with pigmentation, without desquamation. Enteroviral diarrhea
• It is often in infants and toddlers.
• Moderate fever (39-40 °C). •Abdominal pain, vomiting.
• Stools are watery, sometimes with mucus, green admixtures.
• Metheorism may be present.
Respiratory-catarrhal form ("summer flu")
• Is characterized by common signs, typical for enteroviral infection
• Short (for 1-5 days) course, mild severity, without complications
• Dry cough and rhinitis
Encephalomyocarditis and myocarditis in newborns
• It is caused by Coxsackie B viruses.
• It is transmitted enterally or trasplacentary.
• Typical acute beginning from fever (39-40 °C).
• Dyspepsia (vomiting, diarrhea).
• Intoxication (malaise, decreased appetite, sleepiness).
• Dilation of cardiac borders, systolic murmur, tachycardia.
• Rapid development of cardiac insufficiency (dyspnea, hepatomegaly).
• Encephalitis with tonic-clonic seizures, consciousness violation.
• In CSF: lymphocyte pleocytosis, protein is elevated.
• On ECG - changes, typical for myocarditis (low voltage, negative T-vave, QRS-
dilation, ST-interval depression, hypoxic P-vave).
• Letal exit in 1-2 days.
Laboratory diagnostics
• Virological investigation of nasopharyngeal smears, feces, CSF.
• Serological investigations (CBR with paired sera), titre enlargement 4 times and more.
• CBC: leucopenia, with neutrophilia, lymphopenia, eosynophilia, elevated ESR.
• CSF: moderate neuthrophyl-lymphocyte, than lymphocyte pleocytosis, normal or
slight elevated protein, Pandy's test is negative, sugar and chlorides are normal or slight decreased.
Diagnosis example: Enterovirus infection, typical, isolatedform (epidemic myalgia), moderate degree, smooth course.
Differential diagnostics with: URT viral infections, typhoid, paratyphoid fever, tuberculous meningitis, acute appendicitis, cholecystitis, pancreatitis, rubella, yersiniosis, medicinal rashes, herpetic infection, acute intestinal infections.
Treatment:
• Bed rest in acute period.
• Etiologic therapy: specific therapy is absent.
• Control of fever.
• NSAIDs for pain relieve.
• Physiotherapy (in case of epidemic myalgia or paralytic form). Meningitis treatment
Base therapy:
• Bed regimen till body temperature normalization, disappearance of general cerebral
and considerable improvement of focal neurological signs, not less than 14-16 days;
• A diet (before stabilizing vital functions is due to adequate parenteral infusion
therapy);
• Brest feeding or bottle feeding by adopted formulas for infants, in the first day 1/2-
1/3 of average volume with a next increase to the complete volume during 2-3 days;
• A milk vegetable diet (№5) is appointed for preschoolers or school children, 5-6
times per day with the next diet №2 or №15 (depending the age) in the recovery period;
• Oral fluids intake corresponds to age norms (with including the IV fluids);
• Antibacterial therapy: for infants at presence of concomitant bacterial infection,
chronic infection, inflammatory changes in the CBC (by the broadspectrum antibiotic in average therapeutic doses, a short course).
Pathogenetic therapy:
• Glucocrticoids 3-5 mg/kg (by prednisolon), course not more than 10 days;
• Vascular medicine (penthoxyphyllin, nicergolin and others like that);
• In posthypoxia period - nootrops, vitamins group B;
• In case of CSF hypertension - dehydration by 25 % MgS04 IM, lasix 1-3 mg/kg
IV or IM, acetazolamide orally
• In case of seizures - Anticonvulsant therapy: benzodiasepines (seduxenum,
sibasonum) 0.3-0.5 mg/kg IV, if they are ineffective - 1 % hexenalum or thiopenthalum sodii in 3-5 mg/kg IV. Dehydration therapy: lasix 2-3 mg/kg IM or IV. encephalomyocarditis:
• dehydration (lasix 1-3 mg/kg, mannit, mannitol 1-1.5 g/kg); in case of seizures
(seduxen 0.3 mg/kg, droperidol 0.25 % 0.05-0.1 ml/kg);
• detoxication (rheosorbilact, albumen 5-15 ml/kg, 5 % glucose);
• glucocorticoids (prednisolone 1 -3 mg/kg);
• trental 0.2-0.5 ml/kg;
• noothrope facilities (noothropil 50 mg/kg, stugeron, cavinton, aminalon);
• cardiac glycosides (strophantin, corglicon up to 6 month 0.05 ml, 6-12 months 0.1
ml, farther 0.012 ml/kg);
• cardiotonic medicine (mildronat, ryboxin)
Bacterial complications: antibiotics (penicillins, cefalosporins). Prophylaxis:
1. Early exposure and isolation of patients up to 10 days, patients with serous meningitis are discharged from hospital not early than 21 days, clinicaly healthy and after normalization of CSF.
2. Interferon (in nostrils) 5 drops 3-4 times per day, for 10-15 days.
3. Human immune globulin 0.2 ml/kg IM.
4. Quaranteen for contacts for 14 days.
5. Current disinfection, hygienic regimen, respiratory mask wearing.
6. Ultraviolet insolation.
Test and assignment for self assessment
Multiple choices: Choose the correct answer / statement:
1. Enteroviral infections are caused:
A. By rheovirus
B. By herpes virus
C. By polio virus
D. By the respiratory syncitial virus
E. By ECHO and Coxsackie virus
2. Way of the agent transmission in Enteroviral infection is:
A. Contact-domestic and water
B. Water, domestic and transmissible
C. Orally-fecal and air-droplet
D. Transmissible and ascending
E. Air-droplet and domestic3. The most frequent atrium at Enteroviral infection is:
A. Wound surface
B. Mucus membranes of the pharynx and intestine
C. Mucus membranes of the upper respiratory tracts and stomach
D. Mucus membranes of the intestine
E. Lymphoid organs and cardio-vasculary system
4. What clinical signs from ennumerated are the most typical for Enteroviral infection and erentiate it from other diseases?
A. Meningeal signs
B. Sings of conjunctivitis and rhinitis
C. Presence of papulous rashes and itch
D. Hectic temperature and signs of intoxication
E. Hyperemia the face and neck, sometimes with appearance of the maculo-papulous rashes
5. For confirmation of enteroviral infection it is needed to do:
A. Virology of nasopharyngeal smears, urine, CSF and complement binding reaction with paired sera
B. Virology of nasopharyngeal smears, feces, CSF and indirect hemagglutination reaction
C. Virology of nasopharyngeal smears, feces, CSF and complement binding reaction with paired sera
D. Virology of urine, feces, CSF and bacteriological research of feces
E. Virology of nasopharyngeal smears, feces, urine and reaction of indirect fluorescence
6. What epidemiologic information confirm the diagnosis of enteroviral infection?
A. Presence of group diseases or flashes: the sick children have herpangina, myalgia, and meningitis
B. Presence of group diseases: the sick children have diarrhea, fever, meningitis
C. Presence of flashes: the sick children have herpangina, carditis, and diarrhea
D. Presence of group diseases or flashes: the sick children have severe toxic syndrome, meningitis
E. Presence of periodic flashes: the sick children have herpangina, arthritis, and diarrhea
7. What treatment of enteroviral infection is the most correct?
A. Diet. Only pathogenetic and symptomatic treatment
B. Specific treatment is not present. Antibiotics and symptomatic treatment
C. Diet. Purpose of antiviral and pathogenetic therapy
D. The changes on diet are not needed. Gamma-globulin and ribonuclease is specific treatment
E. A diet is not appointed. Antibiotics and dehydration treatment
8. What is the specific prophylaxis of enteroviral infection?
A. Vaccination by inactivated vaccine in age of 1 year
B. A specific prophylaxis is not developed
C. Vaccination by inactivated vaccine in age of 3 and 9 years
D. Infection of specific Ig in the age of 3 months
E. Infection of specific Ig in the age of 15 months
9. Indicate preventive measures in the focus of enteroviral infection:
A. Observation of patients and contacts, final disinfection
B. Hospitalization of sick and contacts for 10 days, current disinfection
C. Hospitalization of patients, isolation of contacts for 14 days, current disinfection
D. Observation of patients, isolation of contacts for 7 days, final disinfection
E. Observation of patients and contacts, giving them interferon
10. What preparations are given to the children in the focus of enteroviral infection?
A. Gamma-globulin and interferon 14-15 days
B. Anaferon for 10 days
C. Antibiotics for 5 days
D. Specific Ig 3 for days
E. Specific anatoxin is given for the first 2 days
Algorithm of practical students' work
Complaints and anamnesis taking in newborns and infants
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Tactful and calm conversation with the parents of sick child.
5. Explanation of future steps concerning the child (hospitalization, some methods of examination, etc.).
Complaints and anamnesis taking in toddlers and preschoolers (children aged from 1 to 6 years)
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. By means of game playing find a contact with a child.
5. Tactful and calm conversation with the parents of sick child.
6. Explanation of future steps concerning the child (hospitalization, some methods of examination, etc.).
Complaints and anamnesis taking in school age children
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Tactful and calm conversation with sick child his/her parents.
5. Explanation of further steps to child and his/her parents (hospitalization, some methods of examination, etc.).
1. To collect complaints:
• fever, malaise, poor appetite;
• rashes;
• head ache, vomiting, that does not bring relief, cramps, paresis and paralyses of extremities;
• pain in the chest, abdomen;
• tearing of eyes, worsening of the vision;
• secretion from a nose, sore throat, cough;
• pain in the heart area, palpitation;
• pain in the inflamed-half of the scrotum;
• diarrhea, constipation.
2. To collect anamnesis of disease, epidemiological anamnesis:
• an acute beginning from the fever, toxic signs, dyspepsia, respiratory syndrome, sore
throat, joining of rashes, paresis, paralysis, time of their appearance;
• contact with a person who had a similar disease 2-10 days before.
• Conversation accomplishment.
3. To inspect a patient:
Physical methods of examination of newborns and infants
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Explain to the parents what examination should be performed and obtain there informed consent.
5. Prepare for examination(clean and warm hands, warm phonendoscope, etc.).
Physical methods of examination of toddlers and preschoolers
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Explain to the parents what examination should be performed and obtain there informed consent.
5. Find a contact with a child; try to gain his/her confidence.
6. Prepare for examination(clean and warm hands, warm phonendoscope, etc.).
Physical methods of examination of school age children
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Explain to the parents what examination should be performed and obtain there informed consent.
5. Find a contact with a child; try to gain his/her confidence.
6. Prepare for examination (clean and warm hands, warm phonendoscope, use the screen if necessary etc.).
A. Examination:
• meningeal pose;
• hyperemia of the face, neck, trunk, maculo-papulous rash on the face;
• injection of sclera vessels, conjunctivitis, brown color of the iris;
• hyperemia, graininess of soft palate, back pharyngeal wall, "herpetic" rashes on the tonsils;
• limitation of thorax excursion;
• absence of active movements in the impaired extremities, their pallor;
• hyperemia, edema of one half of scrotum.
B. Palpation:
• enlarged, moderately tender neck lymph nodes;
• tender one side of thorax, upper part of abdomen, grumbling along the intestine;
• a sensitiveness and passive movements in the impaired extremities are stored;
• positive meningeal symptoms;
• enlarged, tender testicle and epididymis.
C. Percussion: widened cardiac dullness.
D. Auscultation: tachycardia, arrhythmia, deafness ofthe heart tones, systolicmurmur on the apex. Conversation accomplishment.
Informing about the results of examination
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Explain to a child and his/her parents what examinations should be performed and obtain their informed consent.
5. Involve adolescent and his/her relatives in to the conversation (compare present examination results with previous ones, clarify whether your expectations are clear for them or not).
6. Conversation accomplishment.
To estimate the results of additional researches
• Complete blood analysis: Moderate leucocytosis, neuthrophilia with late lymphocytosis, eosynophilia
• CSF: increased pressure, protein, lymphocytes, decreased glucose.
• ECG: lowering of voltage, tachycardia, arrhythmia, violation of conduction, lowering ofthe ST segment, inversion of the T-vave.
• Virology, serology: less informative.
• Explaining the results of examination to child's parents.
• Conversation accomplishment.
5. To substantiate the diagnosis.
Planning and prediction of conservative treatment results
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Explain to child's parents the necessity of further treatment directions correctly and accessibly.
5. Discuss with parents and their child the peculiarities of drug intake, duration of usage, side effects and find out whether they understand your explanations.
6. Conversation accomplishment
6. To prescribe the treatment: regime, diet, detoxication, anticonvulsive, antipyretics, corticosteroids, cardiac glycosides, cardio tonic facilities (at severe course), noothrope preparations.
Informing about treatment prognosis
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Correct and clear explanation of expected results of treatment.
5. Discuss with the parents and their child the importance of continuous treatment, following the treatment scheme; make sure that your explanations are properly understood.
6. Conversation accomplishment.
Step
1. To the child of 10 years was put diagnosis of enteroviral infection. During objective examination his common state is satisfactory; a temperature is normal, present Haceid monoparesis of extremities, weakness of buttocks, thigh, and mimic muscles. Name the form ofthe disease.
A. Summer flu
B. Serous meningitis
C. Paralytic form
D. Epidemic myalgia
E. Herpangina
2. To the child of 6 years was put diagnosis of enteroviral infection. During objective examination he complains of acute, paroxysmal pain in his chest, which looks like the attacks, increases at a cough, motions. Name the form of the disease.
A. Pleurisy
B. Paralytic form
C. Myocarditis
D. Epidemic myalgia
E. Herpangina
3. The child of 7 years is ill for 2 days, complains of cold, dry cough, hyperemia of the face, pharynx, and conjunctivitis. His smaller sister a few days ago had signs of herpangina and diarrhea. Name the probable diagnosis in his case.
A. Enteroviral infection, herpangina
B. Enteroviral infection, respiratory-catarrhal form
C. Measles, prodromal period
D. Herpetic infection
E. Adenoviral infection, pharyngocojunctival fever
A real life situation to be solved
1. A boy, 5 years old became ill 3 days ago: body temperature 38.6 °C, vomiting, sore throat, headache. On the 3rd day maculopapulous rashes all over the body had appeared.
Conjunctives are hyperemied, hyperemia of the pharynx, tonsils; they are covered with small papules and vesicles that are filled with transparent exudate.
1. Name previous diagnose.
2. What laboratory investigations could prove it?
2. Agirl, 12 years old, complains of: high body temperature (39.2 °C), headache, severe paroxysmal pain in the neck, chest, upper part of abdominal wall. Pain increases with deep breathing. Objectively: conjunctives are hyperemied, hyperemia of the pharynx, tonsils. Heart tones are loud, heart rate -100 per minute. Breathing - vesicular. Breathing rate - 20 per minute. Abdomen is soft, slight tender epigastrium. Peritoneal signs are absent.
1. Name previous diagnose.
2. What diseases it must be differentiated from?
Answers for the self-control:
Tests: 1. E, 2. C; 3.B; 4. E; 5. C. 6.A; 7. D; 8. B; 9. C; 10. A. Step: l.C: 2.D; 3.B
Real - life situation 1:
1. Enterovirus infection, combined form: exanthema, herpangina, moderate severity.
2. Virologic investigation of nasopharyngeal mucus, paired serologic investigation.
Real - life situation 2:
1. Enterovirus infection, epidemic myalgia, moderate severity.
2. From influenza, pleurisy, pleuropneumonia, "acute abdomen".
Result Level
Students must know:
• Etiology, epidemiology, pathogenesis, pathomorphology of Enterovirus infection.
• Classification of Enterovirus infection.
• Main diagnostic criteria of Enterovirus infection.
• Differential diagnosis of Enterovirus infection.
• Enterovirus infection treatment and prophylaxis. Students should be able to do:
• To diagnose Enterovirus infection.
• Interpret results of the laboratory and instrumental examination of the child in case of Enterovirus infection.
• Perform differential diagnosis of Enterovirus infection.
• Prescribe treatment to children with this pathology and its prophylaxis.
Дата добавления: 2015-11-04; просмотров: 26 | Нарушение авторских прав
| <== предыдущая лекция | | | следующая лекция ==> |
| Ф. Энгельс. Маркс и «neue Rheinische Zeitung» | | |