|
Chapter 2 Index
A. Evaluation by system:
1. General
2. HEENT
3. Cardiopulmonary
4. GI
5. GU
6. Orthopedics
7. Neurological
8. Skin
--The Evaluation of a
Rash: Is it Allergic?
--Common Viral Rashes of Childhood |
|
Parvovirus B19
(Journal of Pediatrics 1996;128:579-585)
Case Report: 37 week gestation: 2 normal US. Sudden
enlargement of abdomen in 37th week; spontaneous ROM with meconium
staining. Emergency C Section: Apgars 4/6; PE: BW 2.91 kg, AGA, Pale skin,
raised, reddish blue rash described as blueberry muffin rash particularly on
face and forehead: petechiae and purpura. There was generalized edema, but
child not grossly hydropic. RDS; liver markedly enlarged and firm, bleeding
seen around catheter. Baby was extremely hypotonic with decreased level of
consciousness. Labs: hct 18%, WBC 89000, plts 82000; ph:6.86, pCO2 62, pO23,
increased creatinine PT/PTT: 28/103; elevated BR and conjugated br;
transaminases high; high NH4
Chest X-ray: Cardiomegaly with pleural effusions.
Abdominal US: No focal abnormalities in the liver, but did
have ascites.
Cranial US: Normal; ECHO: persistent pulmonary hypertension
- heart normal. Death occurred at 60 hours of age.
Sum of Case: Polyhydramniotic, meconium staining, low
Apgars, anemia, thrombocytopenia, liver function test abnormalities, DIC,
purpura and petechiae, RDS with persis pulm hypertension, renal failure –
prerenal.
What is Your Differential Diagnosis?
- Disseminated HSV: No dermal erythropoeisis described, no vesicles, no
eye abnorm.
- CMV: No microcephaly, intracranial calcification or splenomegaly.
- Enteroviruses: ECHO in particular may give sepsis like picture; no
fever, GI, myocarditis, or pulmonary disease.
- Toxoplasmosis: No CNS involvement, skin manifestations atypical.
- Listeria: Absence of papular rash and pneumonia not characteristic.
- Parvovirus: Dermal erythropoiesis not previously described.
- Rubella: Mother known to be immune to rubella; infant not SGA, no
heart or eye disease.
- Treponema pallidum: Infant not premature, absence of rhinitis and
pneumonitis against
| |
HSV |
CMV |
ECHO |
Toxo |
Listeria |
Parvo |
Rubella |
T.Pallid |
| Anemia |
x |
x |
x |
x |
X |
x |
x |
x |
| Liver disease |
x |
x |
x |
x |
X |
x |
x |
x |
| Rash |
x |
x |
|
+/- |
|
|
x |
|
| Hydrops |
|
x |
|
x |
|
x |
|
x |
| PPH |
x |
x |
|
x |
|
x |
x |
|
| Hypotonia |
x |
|
x |
x |
|
|
x |
x |
Pathology: Liver biopsy: Enterovirus grew from culture -
turned out to be polio? Now have PCR for Parvovirus B19. Thus not only can
cause the macerated fetus with hydrops syndrome, but also a congenital viral
infection syndrome in the newborn.
Parvovirus B19: New and Old Syndromes
(Contemporary Peds: April 1996 pg. 85-96)
Fetus:
- Previously reported red cell aplasia and hydrops: can be lethal -
estimated fetal death can be up to 3-5%. 40% of pregnant women do not have
immunity.
- Congenital Viral Infection Syndrome
Child:
- Erythema Infectiosum (Fifth Disease)
- Red Cell Hypoplasia syndrome
- Transient aplastic crisis (TAC) in children with underlying hemolytic
disorders
- Nonspecific febrile illness
- ITP: can even be associated with a positive ANA. Dx by PCR
Adult:
- Arthralgia and purpura with influenza like illness or subclinical
infection.
- Symmetrical peripheral polyarthropathy affecting hands, knees, wrists,
ankles (seen rarely in children as well).
Laboratory Diagnosis:
- 1980: First known symptomatic cases of human parvovirus. Diagnosed by
antibody tests
- IgM specific antibody during the acute phase of infection:
seroconverts to IgG a few weeks afterwards.
- Electron Microscopes, Immunoassays available on a limited basis.
- PCR test also now available - particularly helpful in ITP or illnesses
with no rash.
Prevention and Treatment:
- A Pilot study using recombinant viral antigens to immunize normal
volunteers is underway. A vaccine is a number of years away.
- For unprotected women in early pregnancy, for the immunocompromised
patient, some discussion of IVIG has occurred, but there is no data for
the normal patient yet. It seems to help in limited trials of
immunocompromised patients.
Specific Questions about Fifth’s Disease:
1. Can children with the rash be sent to school?
Answer: Yes, they are no longer contagious after the rash breaks out.
2. Should school teachers, daycare workers, etc. be screened for
parvovirus?
Answer: If a pregnant woman is exposed, an IgG test can be offered.
These patients should also have their alpha feto protein measured.
3. How is the infection passed?
Answer: Respiratory. Therefore handwashing and proper disposal of
tissues can be helpful in preventing spread.
4. Is a child with other forms of parvovirus (eg TAC) contagious?
Answer: Yes. These children, if hospitalized, should be on contact
isolation with gowns, gloves, etc.
Next Page |