1. PEDIATRIC INFECTIONS DISEASES Pediatric Exanthems Dr. JOHN SRAGOWICZ PA-C, MPAS 2008

5. Physical Examination Identify primary lesion and presence of secondary lesions Thorough physical examination essential to accurate diagnosis Etiology: Viral, Bacterial, Rickettsial, Fungal, Drug-induced

6. Laboratory Data Serologic tests not often helpful in acute setting Aspirates, scrapings and pustular fluid may be obtained

8. The exanthematous diseases of childhood were named according to the order in which they were reported: First disease: Measles (Rubeola) Second disease: Scarlet fever Third disease: German measles (rubella) Fourth disease: Duke’s Filatow disease (possible a scarlet fever variant) Fifth disease: Erythema infecciosum Sixth disease: Roseola, Erythema subitum

16. Rubeola (Measles-First Disease) Highly contagious disease characterized by enanthem and exanthem Etiology: Paramyxovirus virus, an RNA virus Rare in developing countries due to universal immunization Happens in Third world countries where can be fatal to malnourished children Transmission: Humans are the natural host and reservoir of the virus. Spread by respiratory droplets, primary replication of the virus occurs in the respiratory epithelial cells, where it replicates, later spreading to to the local lymphnodes, and then to the blood, resulting in a viremia Incubation period: 10-21 days with average of 14 days Late winter – early spring

22. Measles with Bronchopneumonia

26. Koplick spots

30. Clinical Features: Acute phase: Last 7-14 days. Presence of 4/5 of the following: Fever- 104F/39C averaging 5-10 days. Can persist up to 4 weeks Conjunctivitis- Dry eyes with dilated vessels (bulbar). Non purulent, non edema, non tearing, bilateral. Changes in oral mucosa: red strawberry tongue, pharyngeal erythema, dry red and cracked lip Extremity changes: edema hand/feet, erythema of palms/ sole precedes desquamation of fingers on palm and soles. The rash is erythematous, maculo-papular or morbiliform, scarlatiniform, non vesicular, affecting the groin and perineum . occurs on the trunk 3 days after fever. Also over buttocks Cervical lymphadenopathy: At least 1 node measuring 1.5 cms . The node is unilateral, nontender / nonsuppurative

32. LAB: WBC: elevated with left shift. Greater than 20.000 in 50% of cases ESR: Increased. Often greater than 40/50mm or more CRP: Elevated, above 3mg/dL Albumin 3g/dL or less Platelet count: Increase after the 1 st week of illness. U/A: 10 wbc/hpf, Pyuria, proteinuria Elevation of alanine aminotransferase ECG: acute phase- prolonged PR interval, Flat T waves, ST changes CX-Ray: May show dilated heart during acute phase ECHO: Detection of aneurysm. Strict ECHO follow-up. DD: Scarlet- Throat CX Positive, Increase ASO Titer Measles- Increase IgG, IgM Titer EBV, TOXO, CMV- Saliva, U/A, Titers

33. TX: Bed Rest until 72 hours without fever IVIG: Intravenous Immunoglobulin- 2g/kg one time over 10 hs Repeat to patients who fail to response the first shot. Aspirin: 80-100 mg/kg/d in divided dosis, for 10 days, or until child 48 hours afebrile 3-10 mg/kg/d for 6-8 weeks after fever resolves or until platelets count returns to normal Descontinue if patient has varicella or Influenza Steroids: controversial Complications: coronary artery dilatation and aneurysms

43. VARICELLA-ZOSTER (CHICKEN-POX) Highly contagious disease caused by Varicella-zoster virus: member of herpes virus family, a double-stranded DNA viruses causing varicella as a primary infection, or a recurrent infection (Shingles). Humans are the only source of infection Transmission: Contact with respiratory secretions, lesion fluid, airborne spread Primary infection occurs in the nasopharinx through droplet inoculation. Local replication starts in the nasopharinx, causing viremia and dissemination by circulating mononuclear cells Epidemiology: Varicella affects the preschool and school children (5-10 years) Seen more during late winter and early spring Transplacental transmission- newborn can develop varicella if mother contracted the disease 5 days before delivery Incubation period: 10-21 days, average 12-14 days

44. Clinical Features: Disease is preceded by fever, malaise, and URI symptoms. Skin Eruption: Centripetal distribution (lesions more on torso than face/extremities) Lesions can be seen on scalp and mucous membranes Lesions go through several stages: Papules, Vesicles, Pustules, Crust Classic Lesion: vesicle surrounded by erythema described as a “dew drop on a rose petal” Different types of lesions can be seen together in the same area. Eruption last 5-7 days Infectivity: Most contagious: 1-2 days before and 7 days after the onset of rash. Lesions are infected until they have turned into dried crust

45. Lab: Tzanc test: + presence of multinucleated giant cells, with epithelial cell degeneration. Viral culture from a new vesicle TX: Acyclovir 80mg/kg/d in 4/5 doses in immunocompromised patients . NEVER give ASPIRIN due to the association with REYE Syndrome. Active Immunization: Varivax: 1 dose between 1-13 y, 2 doses after 13 y with 1-2 months apart. Is contraindicated in persons with hypersensitivity to gelatin or neomycin. Passive Immunization: Varicella-Zoster Immune globulin (VZIG): Immunocompromised children Neonates whose mothers get varicella 5 days or less before delivery or within 48 hours after delivery Complications: 2ary Skin infection, Cellulitis, abscesses ( Staph, strept ), BCP fever, soreness on site of injection, varicella rash

59. 2Y girl with HZ on C-4/C-5 dermatome 8 months with HZ on C-5/C-6 dermatome

60. Neurocutaneous pathway on the trunk HZ in the T-1 dermatome

61. HERPES SIMPLEX Caused by the Herpes-virus hominis, which consists of 2 related viruses: Herpes simplex virus type 1 (HSV-1) / Herpes simplex virus type-2 (HSV-2) produce infections involving mucocutaneous surfaces, the CNS. Epidemiology: Seen in children/adolescents of all ages Spread through Direct Mucocutaneous contact ( potential exposure to HSV from sexual or other close contact (kissing, sharing of glasses, etc) Transmission result from: contact with persons with active ulcerative lesions persons without clinical manifestations of infection who are shedding HSV

64. Pathogenesis: Exposure to HSV at mucosal surfaces or abraded skin sites permits entry of the virus and initiation of its replication in cells of the epidermis and dermis. On entry into the neuronal cell, the virus is transported to the nerve cell bodies in ganglia, where the virus remains dormant in a sensory ganglion and dorsal root ganglia Latent virus may be reactivated and viral replication cycle occurs in ganglia and contiguous neural tissue. Virus then spreads to other mucosal skin surfaces through centrifugal migration of infectious virions via peripheral sensory nerves. Stimuli that have been observed to be associated with the reactivation of latent HSV have included stress, menstruation, and exposure to ultraviolet light.

67. Herpetic Vulvovaginitis: Caused by HSV-2 Genital herpes is characterized by fever, headache, malaise, and myalgias. Pain, itching, dysuria, vaginal and urethral discharge, and tender inguinal lymphadenopathy are the predominant local symptoms. Lesions may be present in varying stages, including vesicles, pustules, or painful erythematous ulcers. The cervix and urethra are involved in >80% of women with first-episode infections. May result from sexual abuse

68. LAB: Molecular techniques are the gold standard. Tzanck test (Giemsa): + test: presence of multinucleated giant cells, degeneration of epithelial cells HSV infection is best confirmed in the lab by isolation of the virus in tissue culture or by demonstration of HSV antigens or DNA in scrapings from lesions. Spin-amplified culture with subsequent staining for HSV antigen has shortened the time needed to identify HSV to <24 h. PCR is being used for the detection of HSV DNA TX: Supportive therapy: antipyretics, diet (cold drinks, soft diet, popsicles Acyclovir, Valacyclovir, Famciclovir (act on viral replication, causing chain termination of the viral DNA topical vidarabine, and cidofovir Idoxuridine ophtalmic drops when lesions are near the eye

70. Roseola It is an acute infection of infants characterized by a rash that appears after 3-4 days of high fever AKA: exanthem subitum, roseola subitum, sixth Ds Etiology: Human herpes virus 6 or 7, double stranded DNA virus Self-limited benign disease Epidemiology: Affects 6 months to 36 months infants. Peak 6-7 months Incubation period 7-15 days Transmission: Saliva, airbone Lab: Serology: Anti-HHV-6 IgM, Anti-HHV-7 IgM Polymerase chain reaction of HHV-6 DNA Complication: Febrile seizures during the prodromal stage TX: Supportive

73. ROSEOLA

76. Clinical features: Incubation period: 4 - 18 days Primarily children between 3 to 15 years of age Mild prodrome: Fever, coryza, malaise are minimal for 3 days before rash Arthralgias, arthritis in about 10%. Three stages of Rash: 1- Slapped cheek appearance (1-4 days) 2- Erythematous papular eruption over upper and lower extremities spreading to trunk, assuming a lacy evanescent reticular appearance as it fades (lasts 4 days) 3- Evanescent stage: Rash typically resolves in 5-10 days although may wax & wane for weeks or months. Is precipitated by: Hot showers, vigorous exercise, sunlight 4-Papular Purpuric Gloves and Socks syndrome (only hands and feet affected) Parvovirus B-19, usually teenagers, lasts 7-14 days. Fever, rash and arthralgias. Rash is contagious at the time of eruption, presenting acral painful or pruritic palpable purpura mainly at ankle and wrists. Also presents symmetric swelling of digits,and oral petecchia and erosions, pharingeal erythema and edematous lips.

84. B19

86. Clinical Signs: Incubation of 16-21 days Contagiosity: 1-3 days before, to 7 days after the onset of parotid swelling Children return to school, 10 days after onset of parotid swelling Starts with fever, headache, malaise. Onset of mumps is pain and non-erythematous swelling in front and below the ear obscuring the mandibular ramus (ear displaced outward, upward) Swelling starts with one ear and then progresses to the other ear Often submaxillar and sublingual glands are also swollen Low grade fever and intense parotid pain when chewing Inflammation of the opening of Stensen duct in mouth

87. Complications: Meningitis: Most frequent. Asseptic meningitis Pancreatitis: mild inflammation is present Epididymoorchitis: Adolescents, young adults. Develops 4-10 days within the onset of the parotid swelling (testicular pain/swelling) LAB: Uncomplicated Parotitis: Leukopenia with lymphocytosis Suppurative parotitis/orchitis: leukocytosis Pancreas Involvement: Hyperamilasemia / Hyperlipasemia Meningitis: CSF pleocytosis (mainly mononuclear) Body fluid isolation of mumps virus in tissue culture TX: Rest, Bland diet, Buccal hygiene, Atb if suppurative parotitis, MMR, Tylenol/Motrin.

90. INFECTIOUS MONONUCLEOSIS Lymphoproliferative self-limited disease caused by the Epstein-Barr virus. Etiology: EBV, a DNA virus, belongs to the Herpes group virus Epidemiology: Occurs in all age groups, predominates in adolescents (intimacy period) and young adults. Mild cases can be seen in children Incubation: 30-50 days EBV spreads via respiratory droplets, coughing, kissing Pathophysiology: EBV replicates in oropharingeal epithelium Selective infection of B-lymphocytes occurs, resulting in proliferation of cells in tonsils, lymph nodes, spleen

91. Clinical Features: Incubation period of 30-50 days Low grade fever, sore throat, coryza, malaise, Exsudative pharyngitis (50%) with palatal petecchia Associated GABS pharingytis (25%) Cervical Lymphadenopathy- Enlarged, usually nontender Hepatomegaly Splenomegaly: moderate enlargement (50%) Skin rash: Seen in 10-15%. Increase to 40% if penicillin derivatives is used Morbiliform or scarlanitiform. CNS features: Encephalitis, asseptic meningitis, Guillain-Barre syndrome Classic illness is characterized by: fatigue, low grade fever, malaise, tonsillopharyngitis (often exsudative) adenopathy, HSplenomegaly (may persist for months)

92. LAB: CBC: > 10% of atypical lymphocytes (greater than 50% lymphocytes), Leukocytosis Liver enzymes: Mild hepatitis is found, jaundice is rare EBV serology: Elisa (Monospot): rapid slide agglutinin test for heterophile antibodies: Often negative in children under 5 years old Detects 90% of cases in adolescents Anti-VCA IgG/IgM (viral capsid antigen) recent/past infection EBNA: Ebstein Barr Nuclear Antigen- positive means no latent infection 1 st antibody: IgM VCA- positive 2-3 week of infection. Wanes in 2-4 weeks 2 nd antibody: IgG VCA- positive in 2 nd to 4 th week of infection 3 rd antibody: EA- Present during EBV replication. 4 th antibody: EBNA- Presence coincides with recovery. Rises beyond 6 weeks

95. ROCKY MOUNTAIN SPOTTED FEVER (RMSF) Etiology: Is Rickettsia rickettsii, transmitted by those vectors: - Dog tick: Dermacentor variabilis (east) - Wood tick: Dermacentor andersoni (west) - Lone star tick: Amblyomma americanum (southwest) Epidemiology: Endemic in Southeastern, Central, Rocky mountain states. More common in children (5-9y), and in the summer Pathophysiology: Transmitted mainly by a tick bite, airborne droplets Incubation period; 2-14 days, average 7 days After exposure: - Rickettsia multiply in the endothelial lining and smooth muscle cells of blood vessels. - Disseminates via bloodstream, producing a generalized vasculitis associated with a centripetal petecchial rash and fever

96. Clinical features: Incubation period: 1 week Tick must attach and feed for 4-6 hours to transmit disease. Abrupt or gradual onset of fever, more than 40-C, not responding to meds Abrupt onset of Headache: intense, frontal, retrobulbar Myalgia (calf or thigh), abdominal pain, confusion, photophobia, vomiting Rash: Usually appears by 2 nd or 3 rd day after fever onset. Rash is small, irregular, erythematous macules that blanch, becoming maculopapular and petecchial ( rose to purpuric) spreading centrally Starts from wrists, ankles. (periphery) Whitin hours spreads centrally from extremities toward trunk, neck, face. Can appear in palms and soles and scrotum Can progress to necrosis of toes, ears, scrotum, nose, fingers. Also: CNS, Cardiac, Pulmonary, GI, Ocular symptoms

97. Prognosis: Improvement in 24-36 hours Defervescence in 2-3 days Majority improve in less than 1 week if treated early. TX: Supportive care ( avoid tick areas, pants inside boots, repellants, gloves hydration support, Platelets for thrombocytopenia Doxycycline: 2.2mg/kg BID PO 1 day. Then qd for 7-10days Tetracycline: 25-50mg/kg/d PO qd or 20-30mg/kg/d IV Chloramfenicol is an alternate drug

98. LAB: CBC: WBC normal or low first 4 days. Later, leukocytosis, ↑ band count anemia, thrombocytopenia ( consumptive coagulopathy) CMP, LFT: abnormal, DIC screen, CXR, ABG, EKG, Echo, Lytes: Hyponatremia CSF: Clear, with/ without ↑ protein. Pleiocytosis and ↑ protein in 1/3 of cases ELISA: sensitive and accurate, but it takes about 6 days (seroconversion) IFA: Indirect Fluorescent antibody- sensitivity 94-100%, specificity 100% IHA: Indirect Hemagglutination: sensitivity 91-100%, specificity 99% LA: latex agglutination-sensitivity 71-94%, specificity 99% PCR by DNA: takes 48 hours. Weil-Felix: 3-5 minutes. Poor specificity and insensitive. Titer 1:160 suspect

101. SCARLET FEVER Etiology: Group A Beta-hemolytic streptococcus strain (Streptococcus pyogenes ) that produces erythrotoxigenic toxins Epidemiology: Occur in children between 2-10 years old Most cases seen in winter and early spring Pathogenesis: Oropharinx is the portal of entry to airborne droplets where it replicates. Complications: Acute glomerulonephritis, Rheumatic fever LAB: CBC, Rapid strept antigen test, Throath Cx, Dick test not in use Treatment: Supportive, rest Oral or IM Penicillin or derivatives Erythromycin / Clindamycin if allergic to Penicillin

102. Clinical Features: Incubation period: 2- 4 days. Average 1- 7 days Prodomal symptoms: fever, sore throat, malaise, myalgia, HA, abd. Pain Mouth: Pharinx, tonsils are beefy red, and may have exsudate Hemorrhagic spots on anterior pillar of tonsils and palate (petecchia) Large, tender anterior cervical nodes Tongue: white coat with edematous red papilla. The coat desquamate and reveals a swollen, red and a strawberry aspect of tongue Face: Malar flush with Circumoral pallor present Pastia line’s: Deep red non blanching lesions in the antecubital area RASH: Starts 12-48 hours after onset of fever. fine maculopapular, sandpaper texture, on erythematous background. Affect neck, axilla, shoulders, most prominent in trunk, groin Blanches when pressure is applied. Skin desquamates within 7-21 days from onset of illness, starting with hands.

108. PERTUSSIS- WHOOPING COUGH Is a life threatening infection in very young infants Etiology: Bordetella pertussis , a gram negative Epidemiology: Disease of young infants, children, and adolescents Infection via respiratory droplets, direct contact with nasal secretions Pathophysiology: Replicates only in association with ciliated epithelium, causing congestion, inflammation of the bronchi LAB: Culture of Bordetella by nasopharyngeal culture is the standard test. Direct immunofluorescent assay of nasopharyngeal secretions TX: Isolation, Supportive (hydration, sucction secretions, humidified oxygen) Erythromycin for 14 days. 50mg/kg/d divided 4 doses , Zythromax Corticoids is questionable. Prevention: Immunization DTaP (fade after 5-10 y), Boostrix/Adacel (10-18 y)

109. Clinical features: Incubation period of 7-14 days (4-21 days) 3 stages: Catarrhal: Last 1-2 weeks URI symptoms, low grade or absent fever, mild cough, coryza Highly communicable during this stage and the first 3 weeks after cough Paroxysmal: Last 2- 6 weeks Salvo of paroxysmal cough ending with an inspiratory whoop through narrowed glottis during the forceful inspiratory phase with accumulation of a thick airway secretion Presence: petecchia, subconjuntival hemorrhage, cyanosis, eyelid edema Convalescent : Last 1-3 weeks Cough lessens and disappears or cough can persist for several weeks Lung auscultation is normal, unless atelectasis or pneumonia occurred Complications: Pneumonia (90%), atelectasis, subcutaneous emphysema

111. LYME DISEASE Etiology: spirochete Borrelia burgdorferi transmitted by a deer tick, Ixodes dammini. Deer tick is flat, small, 8 legs, male is black, female is red/black. According to a specialized California laboratory, 20% of patients with Lyme are co-infected with Anaplasma, Babesia or Erlichia Epidemiology: Affect people from all ages, 1/3 are children, adolescent. late spring/early summer months in Northeast, North Central, Pacific states Pathophysiology: Borrelia is injected into the skin with the saliva of the deer tick. Then migrate within the skin, forming a rash (erythema chronicum migrans). Rash starts as red macule or papule and expands to an annular lesion up to 30 cm in diameter with partial central clearing. Then the spirochete is spread hematogeneously to heart, joints and CNS. Complications: Chronic arthritis in 10% (pauciarticular)

113. LAB: Lyme Titer: ELISA- develops 3-4 weeks after infection begins Western blot Test: More specific test, confirmatory test. Negative western blot and a positive Elisa: no Lyme Ds. Western Blot positive test: confirms a positive Elisa result Skin biopsy: positive direct immunofluorescence provides a rapid test IgG/IgM Titers will remain elevated for months/years, after the treatment. TX: Amoxicillin 250mg tid for 30 days for under 8/9 years old Amoxicillin 500mg tid for 30 days if over 9 years old Doxycycline 100mg bid for 30 days if over 9 years old Eythromycin 30mg/kg/day for 30 days Patients with only a rash: treat for 14 days Severe arthritis or carditis: Ceftriaxone or PCN IV 14-21 days

114. GONOCOCCAL INFECTION Etiology: Neisseria gonorrhea, G- diplococcus Epidemiology: Seen in the following groups of children: Newborn infants: acquired from the infected maternal vaginal canal Prepubertal children: as a result of sexual abuse Adolescents: as a result of sexual abuse or voluntary sexual activity Males: 15/19 20/24 years Female: 15/19 years Incubation period is 2-7 days LAB: Gram stain: G – intracellular paired organisms Culture in Thayer-Martin medium or chocolate agar of specimens taken from the eyes, vagina, cervix, penis, anus, throat STD panel: HIV, Chlamydia, Syphilis, Trichomonas Synovial fluid culture is positive in 50% with Gonococcal Bacteremia

115. Clinical features: Newborn: Ophtalmia neonatorum. Appear 2-5 days after delivery. Bilateral discharge that becomes muco-purulent with/without streaks of blood. Conjunctiva and Lid is edematous. Corneal ulcer, blindness if not treated early Sexually abused children: copious purulent discharge from vagina/penis. other sites: Rectum, throat Disseminated gonococcal infection: Is a gonococcal bacteremia. Cervical motion tenderness: Characteristic on pelvic examination in patients with ascending cervical infection Urethritis: Copious mucoid purulent discharge after exposure, often bloodstained Micturition is painful, associated with urine retention. The persistent inflammation predisposes to a urethral stricture. Proctitis may be present in homosexuals

116. Complications: Blindness, meningitis, Inf. endocarditis, osteomyelitis, PID Arthritis-Dermatitis syndrome: Seen in > 90% of cases May be migratory Associated pain/ swelling of big joints (knees, ankles, wrists, elbows), Tenosynovitis Rash: In Disseminated Gonococcal Infection cases: 50-75% of cases. petecchial or pustural lesions appear on distal extremity, 3-21 days after exposure, together with arthralgias, septic arthritis, fever, chills, malaise

117. Tx: Neonate: Hospitalize after cultures: blood, spinal fluid, eye, urine. Ophtalmia neonatorum Ceftriaxone single dose 25/50mg/kg IV-IM up to 125mg given once Eye care: sterile saline irrigation at frequent intervals Prophylaxis: 1% silver nitrate or 0,5% erythromycin ointment Non-disseminated: Ceftriaxone single dose of 125mg IM and Erythromycin or Zythromax for prepubertal children. Doxycyclin or Zythromax for children older than 8 years old (presumption of having Chlamydia ) Disseminated gonococcal infection: Hospitalize Ceftriaxone 25/50mg/kg IV-IM daily/7 days Cefotaxime 50-100 mg IV-IM in two doses for 7 days. Continue for 14 days if meningitis is present Erythromycin, Zythromax, Doxycyclin, PO (presumption of having Chlamydia )

119. Intracellular diplococci Urethritis

120. Gonococcal rash

121. SYPHILIS Etiology: Treponema pallidum , a spirochete Epidemiology: Occurs in sexually active adolescents and adults May result from sexual abuse in children Spread: sexual contact with ulcerative lesions of skin/ mucous membrane from one infected individual to another non infected individual LAB: Non treponemal antibody test: VDRL, RPR: rapid plasma reagin Treponemal antibody test: Confirmatory test of diagnosis of syphilis infection. Once infected, stays + FTA-ABS (fluorescent treponemal antibody)+ MHA-TP (microagglutination assay for antibody to treponema pallidum CSF: neurosyphilis- mononuclear pleocytosis, ↑ protein, normal glucose Dark-Field microscopy of smears from skin/ mucous membranes lesions X-R: Long Bones- metaphyseal osteochondritis and/or diaphyseal periostitis Chest: fluffy difuse infiltration in pneumonia alba

122. Clinical Feature: Incubation period: 3 weeks (range 10-90 days) Primary Stage: Chancre-Primary Syphilis Last 1-6 weeks. Solitary, painless, indurated, ulcerated lesion on genitalia This lesion represents the site of inoculation Painless inguinal adenopathy Secondary Stage: Secondary Syphilis Last 2-10 weeks Flu-like illness: fever, malaise, myalgia, HA, Arthralgias, adenopathy Moth eaten Alopecia in beard, scalp, eyelashes mucous patches: on tongue, mouth, look superficial erosions, but papules can be seen. Are round, oval, serpiginous in outline and red color or covered with a greyish membrane. Serpiginous lesions are called snail track ulcers. Rash: Erythematous maculopapular squamous lesions on torso, palms, soles Condyloma Lata: whitish, moist, anal condyloma lata lesions are highly infectious wart like lesions distributed mainly in the anogenital area

123. Subclinical latent stage: Diagnosed by presence of reactive sorologic test. Lasts 1-40 years Late stage (Tertiary Syphilis): seen in 1/3 of patients many years after the 1ary/2ary stage. Gummas or granulomatous lesions develop subcutaneously, expand and ulcerate in the skin. They can also appear in the liver, bones, brain, etc… cutaneous, visceral, CV, CNS (neurosyphilis, gummatous lesions)  death

124. TX: Syphilis less than 1 year duration: Benzathine penicillin G: 50,000 U/kg IM in a single dose. Up to 2,400.000 U Erythromycin 50mg/kg PO QID, 2 weeks Tetracycline 500mg PO QID, 2 weeks in patients over 9 years old Doxycycline 100mg PO BID for 2 weeks in patients over 9 years old Syphilis greater than 1 year duration: Benzathine Penicillin G 50,000 U/kg IM weekly, for 3 consecutives weeks Tetracycline 500mg PO QID, 4 weeks in patients over 9 years old Doxycycline 100mg PO BID, 4 weeks in patients over 9 years old NeuroSyphilis: Aqueous Penicillin G 200,000/300,000 U/kg/d. Not exceed 24 million units day divided in q4 or q6 for 10-14 days All cases should be reported to the health department

131. CONGENITAL SYPHILIS Intrauterine infection by fetus from a mother infected with Treponema Pallidum Etiology: Treponema pallidum, a spirochete Epidemiology: Associated with lack of prenatal care, and illicit drug use Lab: Non-treponemal test on cord blood: VDRL, RPR Confirmatory test: treponemal test FTA-ABS Darkfield microscopy of skin/membranes lesion X-ray of long bones CSF fluid exam: Pleocytosis, ↑ protein, VDRL + Complications: Stillbirth, Blindness, Deformities (saber shin, saddle nose) TX: Aqueous crystalline penicillin G: 100,000/150.000 U/kg/d IV 2/3X, 14d Procaine penicillin G: 50,000 U/kg IM daily, 10-14 days 3 weeks tx, if CNS is involved

132. Clinical features: Early congenital Syphilis < 2 years of age Clinical signs absent or minimal Rhinitis (snuffles): mucopurulent , profuse discharge May result in rhagades or fissures around mouth Cutaneous eruptions: Erythematous macules or papules, or papulosquamous lesions, round or oval in shape. Lesions fade to coppery brown color. Vesicobullous hemorrhagic lesions, palmo-plantar scaling Late congenital Syphilis > 2 years of age Interstitial keratitis: appears between 6-14 years, corneal opacity, pain, photophobia, lacrimation Hutchinson teeth: notching of biting surface of upper central incisors 8 th nerve deafness Saber shins Higoumenaki sign (unilateral tickening of inner clavicle) Syphilitic arthritis (8-15 years) Gummas in bones

136. JUAN SRAGOWICZ PA-C, MPAS

138. Dx: CSF analysis and culture (blood cx often positive) WBC Protein Glucose Normal Age dependent 20-45 >50% of serum Acute bacterial Elevated Increased Decreased Partially treated Nl or increased Increased Nl or decreased Viral Increased, rarely >1000 Mild elevation