Uncommon and Vaccine-Preventable Infections in Children

Educational Objectives

The goal of this program is to improve management of uncommon infections in children. After hearing and assimilating this program, the clinician will be better able to:

1. Differentiate primary varicella zoster virus (VZV) from secondary VZV.
2. Use diagnostic testing for detection of congenital syphilis.
3. Recognize signs and symptoms of epiglottitis and mumps.

Summary

Chicken pox: symptoms of primary varicella zoster virus (VZV) include low-grade fever, malaise, body aches, and a widespread vesicular rash which begins on the trunk and spreads to the extremities, face, and head; the rash is severely pruritic and appears as a small vesicle on an erythematous base; primary VZV is highly contagious and spread by airborne transmission; unvaccinated children are most susceptible; more severe disease occurs in older children, secondary household contacts, and persons who are immunocompromised; most children recover without sequelae, but severe complications include superinfection of the lesions, pneumonia, and involvement of the central nervous system

Shingles: secondary VZV infection; shingles occurs years after primary chicken pox infection or (more rarely) after vaccination; shingles is more localized than chicken pox; presents as a painful vesicular rash that follows a dermatomal distribution, which stems from the virus latently residing in the dorsal root ganglia after the primary infection; shingles is typically less contagious than chicken pox, but transmission may occur through contact with lesions; persons who are immunocompromised may acquire the infection through airborne transmission

Diagnosis of varicella: may be made with clinical findings; laboratory testing may be recommended for mild atypical chickenpox (eg, breakthrough infection after vaccination); polymerase chain reaction (PCR) performed on a lesion swab is the most accurate test; direct fluorescent antibody testing on lesion material and viral cultures are less sensitive than PCR; antibody titers are not preferred for diagnosis of acute disease because results may take 1 wk and false-negative results may be seen if testing is done too early

Treatment for varicella: chicken pox and shingles are self-limited in healthy patients; encourage acetaminophen (Tylenol) use and fluid intake; oral acyclovir is effective for tempering infection in a child with recent infection (≤3 days of illness); acyclovir is recommended for patients at higher risk for severe disease (eg, unvaccinated children, patients >12 yr of age, patients on long-term aspirin therapy, patients who are immunocompromised); may be used for prophylaxis in high-risk household contacts

Changing epidemiology of varicella: the one-dose vaccine was introduced into the pediatric immunization schedule in 1995; cases decreased by ≈71% and deaths decreased by ≈90%; the two-dose vaccine was introduced in 2007, which caused a reduction in cases of ≈90%; outbreaks of varicella were reduced by 80% after the two-dose vaccine was introduced; ≈72% of outbreaks in schools are in populations that are not vaccinated or are incompletely vaccinated

Varicella exposure: anticipatory guidance and reassurance should be provided to vaccinated persons after exposure; unvaccinated individuals exposed to a person with primary varicella, disseminated zoster, an person who is immunocompromised with zoster, or physical contact with “exhaust” or lesions is considered at high risk and the exposure is considered significant; disease may be much more serious if the exposed person is immunocompromised, a newborn, or pregnant

Prophylaxis: active vaccine is beneficial when administered to eligible candidates ≤3 to 5 days after exposure (eg, an unvaccinated child of 12 mo of age child exposed at daycare); reformed antibodies (varicella-specific immunoglobulin or intravenous immunoglobulin) may be administered to patients who are not eligible for active vaccine (eg, patients who are immunocompromised, pregnant women, newborn babies) at ≤10 days of exposure; preemptive acyclovir or valacyclovir may prevent severe complications in patients who are not eligible for antibody therapy

Congenital syphilis: symptoms include excessive rhinorrhea, peeling skin, swollen joints, and hepatomegaly; newborns may have transaminitis and thrombocytopenia; maternal and neonatal titers should be assessed and a physical examination done; maternal treatment during pregnancy is relevant; the treatment algorithm for syphilis provides risk stratification for newborns; the categories for congenital syphilis are unlikely, possible, probable, and likely; management is based on risk; recent trends — incidence of syphilis in the general population have increased since 2012, including in women of childbearing age; infants may not be symptomatic with a positive rapid plasma reagin (RPR); the cause of the current syphilis epidemic is multifactorial, but the opioid epidemic is believed to be one of the reasons; lack of timely prenatal care, lack of access to care, and lack of access to adequate treatment are major concerns; timely treatment with penicillin produces favorable outcomes

Herpetic whitlow: lesions are painful and may appear similar to cellulitis or bite marks with blisters; enlarged cells with enlarged nuclei may be seen on microscopy of lesion scrapings; that herpes simplex virus type 1 (HSV 1) affects the oral mucosa and HSV 2 affects the genitalia is a common misconception; most patients with HSV infection are asymptomatic; gingivostomatitis is the most common presentation of HSV 1 or 2 in children, followed by herpetic whitlow; a child with herpes labialis self-inoculates the virus when they chew on their finger; the diagnosis is mostly clinical with a relevant history; laboratory testing is usually not needed; PCR testing of lesions samples is the most sensitive; culture of the vesicle is less sensitive and results take longer than PCR; the Tzanck smear is a rapid test but does not distinguish between HSV and VZV and is not sensitive (false-negative results are possible)

Treatment: HSV infection is self-limited in immunocompetent patients; acyclovir is useful when administered early in the course of illness; patients who are immunocompromised may develop more severe disease and require antiviral therapy

Mumps: patients may have painless facial swelling and fever; mumps is a paramyxovirus; infection may cause systemic disease characterized by swelling of the salivary glands, primarily the parotid gland; ≈20% of patients may be asymptomatic; orchitis is the most frequent complication which occurs in ≈30% of unvaccinated patients and ≈6% of vaccinated patients; other complications include oophoritis, pancreatitis, hearing loss, and meningitis; a 99% reduction in US cases of mumps was seen after the introduction of the vaccine in 1967; breakthrough infections are possible in vaccinated persons; two doses of measles, mumps, and rubella (MMR) vaccine are recommended ≥4 wk apart; the first dose is usually given at 12 to 18 mo of age, and the second dose at school entry; a booster dose is recommended in outbreak situations; many outbreaks in the US have originated in other countries, but patients may have no history of travel; reduction in population immunity is expected to lead to a spike in mumps cases; masks protect against exposure; diagnosis — the preferred method is analysis of a buccal swab or oral secretions using PCR, which is more sensitive than antibody serology and not time-dependent); treatment is supportive

Epiglottitis: patients may have high fever and throat pain, but the throat appears normal; neck movement is extremely painful; patients may sit upright and lean forward for relief; later neck x-ray shows the characteristic “thumbprint” sign; rapid-onset airway obstruction and respiratory failure are major concerns; epiglottitis an acute infection or inflammation of the supraglottic soft tissues; diagnosis — characterized by drooling, dysphagia, dysphonia (muffled voice), and distress; most commonly caused by Haemophilus influenzae type b (Hib), but also may be caused by Streptococcus (eg, S. pneumoniae), and Staphylococcus

Treatment: airway should be addressed first; rapid response teams (eg, otolaryngology, anesthesiology) should be called; intubation or a surgical airway may be required; antibiotic therapy includes ampicillin sulbactam or ceftriaxone; vancomycin may be added for very ill patients; case rates and mortality rates have decreased since introduction of the Hib vaccine in 1985

Readings

Baird SM, Marsh PA, Padiglione A, et al. Review of epiglottitis in the post Haemophilus influenzae type-b vaccine era. ANZ J Surg. 2018;88(11):1135-1140. doi:10.1111/ans.14787; Cardemil CV, Dahl RM, James L, et al. Effectiveness of a third dose of MMR vaccine for mumps outbreak control. N Engl J Med. 2017 Sep 07;377(10):947-956; Hatsushika Y, Nii I, Taniguchi T. Varicella caused by airborne transmission of a localised herpes zoster infection in a family. BMJ Case Rep. 2021;14(9):e243217. Published 2021 Sep 3. doi:10.1136/bcr-2021-243217; Khorrami A, Khorrami MA, Gheriani H. Vaping-induced acute epiglottitis: a case report. Int J Emerg Med. 2023;16(1):56. Published 2023 Sep 5. doi:10.1186/s12245-023-00532-x; Krishnan R, Stuart PM. Developments in vaccination for herpes simplex virus. Front Microbiol. 2021;12:798927. Published 2021 Dec 7. doi:10.3389/fmicb.2021.798927; Lam E, Rosen JB, Zucker JR. Mumps: An update on outbreaks, vaccine efficacy, and genomic diversity. Clin Microbiol Rev. 2020;33(2):e00151-19. Published 2020 Feb 26. doi:10.1128/CMR.00151-19; Patil A, Goldust M, Wollina U. Herpes zoster: A review of clinical manifestations and management. Viruses. 2022;14(2):192. Published 2022 Jan 19. doi:10.3390/v14020192; Yang H, Zhang H, Wang C, Pang L. An analysis of the clinical features of children with early congenital Syphilis and Syphilitic Hepatitis. BMC Pediatr. 2021;21(1):498. Published 2021 Nov 9. doi:10.1186/s12887-021-02932-5.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Messina was recorded at the 46th Annual Florida Suncoast Pediatric Conference, held June 8-11, 2023, in Sarasota, FL, and presented by Johns Hopkins University School of Medicine, Baltimore, MD, and Johns Hopkins All Children's Hospital, St. Petersburg, FL. For information about upcoming CME activities from this presenter, please https://www.hopkinsallchildrens.org/Health-Professionals/Conferences-Classes/CME. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.00 CE contact hours.

Lecture ID:

PD694402

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.