(BQ) Part 2 book Succinct pediatrics - Evaluation and management for infectious diseases and dermatologic disorders has contents: Epstein-Barr virus, respiratory viruses, varicella zoster virus, endemic mycoses, intestinal helminthic infections, diaper dermatitis,... and other contents.
PART Infectious Diseases Section Viral Infections Cytomegalovirus 275 Encephalitis 287 Enteroviruses and Parechoviruses 301 Epstein-Barr Virus 313 HIV 323 Influenza 353 Measles, Mumps, Rubella 367 Parvovirus 383 Rabies 387 Respiratory Viruses 397 Rotavirus 405 Varicella-Zoster Virus 413 26-Ch26-Succinct_273-286.indd 273 11/9/16 8:45 AM 26-Ch26-Succinct_273-286.indd 274 11/9/16 8:45 AM CHAPTER 26 Cytomegalovirus Amina Ahmed, MD Key Points ■■ ■■ ■■ Cytomegalovirus (CMV) is commonly acquired asymptomatically in the immunocompetent host Sensorineural hearing loss is associated with congenital CMV infection, with almost 50% of hearing loss developing after the newborn period While it is the most common congenital infection, symptomatic disease occurs in only 10% of those infected Lymphoproliferative disease associated with CMV is notable in immuno compromised hosts, now most commonly in stem cell and solid organ transplant recipients Overview Primary infection with cytomegalovirus (CMV) is common and usually asymptomatic but can cause a mononucleosis-type syndrome Recurrent infection occurs with reactivation of a latent virus or reinfection with a different strain in an individual who is seropositive for CMV infection Reactivation of viral infection is typically asymptomatic in the immunocompetent host, but it can result in horizontal or vertical transmission Cytomegaloviral disease is most problematic in neonates infected congenitally and in the immunocompromised host Causes and Differential Diagnosis Human CMV, as with other herpesviruses, establishes lifelong latency following primary infection The virus is intermittently shed in body fluids, including urine, saliva, cervicovaginal secretions, and human milk, for months to years Transmission of infection occurs by person-to-person contact, including sexual contact, with infectious virus in secretions Vertical transmission from a mother to her neonate can occur through of routes: transplacental, resulting in 26-Ch26-Succinct_273-286.indd 275 11/9/16 8:45 AM 276 Succinct Pediatrics congenital CMV infection; intrapartum, by exposure to infected cervical or vaginal secretions; or postnatally through breastfeeding The differential diagnosis of CMV mononucleosis includes mononucleosislike syndromes caused by other viruses such as Epstein-Barr virus (EBV), adenovirus, hepatitis A, hepatitis B, or HIV Most cases of infectious mononucleosis are caused by EBV, and CMV is responsible for most cases of heterophilenegative mononucleosis Illness caused by CMV is typically milder than EBV-associated mononucleosis Distinguishing features between the infections are described in the Evaluation section Serologic testing consistent with acute EBV confirms the disease Toxoplasmosis can also cause a heterophile-negative mononucleosis-like illness The syndrome is characterized predominantly by fever and lymphadenopathy It rarely causes pharyngitis or abnormal elevation of transaminase concentrations and is unassociated with characteristic hematologic abnormalities Adenoviral infections may manifest with symptoms that overlap those of mononucleosis, including pharyngitis with or without exudate Often conjunctivitis and other upper respiratory tract symptoms predominate in adenoviral infection Virus may be detected in throat or nasopharyngeal specimens by culture or molecular methods Early viral hepatitis, including that caused by hepatitis A or B virus, may resemble CMV-related illness The degree of hepatic involvement with hepatitis A or B virus quickly becomes more extensive than that seen with CMV, with transaminase values rapidly rising to above 1,000 IU/L Primary HIV should be considered in any adolescent presenting with febrile illness resembling mononucleosis Common findings include fever, sore throat, myalgia, and lymphadenopathy Rash unassociated with antibiotic use is uncommon in mononucleosis caused by CMV but frequently observed in primary HIV infection within the first 48 to 72 hours after onset of fever The diagnosis of HIV can be confirmed by serologic testing or polymerase chain reaction (PCR) testing Clinical Features The clinical presentation of CMV infection depends on host factors Primary CMV infection in the immunocompetent child or adult typically results in minimal or no clinical disease Adolescents and adults are more likely to exhibit symptoms of the mononucleosis syndrome, which is characterized by protracted fevers and malaise with limited localizing symptoms or signs Severe or life-threatening disease occurs rarely with CMV infection in immunocompetent persons but may include pneumonitis, enterocolitis, myocarditis, pericarditis, and hemolytic anemia Icteric or granulomatous hepatitis can occur Cytomegaloviral meningoencephalitis has been reported and may occur as a complication of CMV mononucleosis or an isolated manifestation of primary CMV infection The expected course of CMV mononucleosis in healthy hosts is recovery without sequelae Typical duration of illness is to weeks, but symptoms may occasionally persist longer Prolonged fatigue, as occasionally 26-Ch26-Succinct_273-286.indd 276 11/9/16 8:45 AM Chapter 26 • Cytomegalovirus 277 observed with EBV infection, is uncommon With reactivation of infection or reinfection with new strains, individuals usually remain asymptomatic Among immunocompromised hosts, including those infected with HIV and solid organ and hematopoietic stem cell transplant recipients, primary or reactivation CMV infection can result in severe or life-threatening disease Cytomegaloviral retinitis is by far the most common manifestation of CMV disease among HIV-infected individuals In those with AIDS, acquisition of CMV infection increases with age; thus, adults are more likely to be coinfected with HIV and CMV Cytomegalovirus retinitis is typically unilateral at presentation but, in the absence of antiviral therapy or immune recovery, can progress to bilateral involvement Patients present with blurred vision, decreased visual acuity, or visual field defects Young children may exhibit strabismus as a result of visual compromise Before the availability of combination antiretroviral therapy (cART), CMV retinitis was the leading cause of vision loss and blindness in this population Additional clinical manifestations of CMV disease in AIDS include gastrointestinal diseases such as enterocolitis and esophagitis Pneumonitis is less common than observed in other immunocompromised hosts Central nervous system (CNS) disease attributable to CMV is uncommon but may present as encephalitis or polyradiculopathy Cytomegaloviral infection and disease classically present between and months after transplantation Clinical manifestations range from asymptomatic viremia to a mononucleosis-like illness (CMV syndrome) to tissue invasive disease associated with significant morbidity and mortality Cytomegaloviral syndrome is defined as clinical illness without evidence of end-organ involvement and is characterized by fever, malaise, leukopenia, thrombocytopenia, and transaminitis End-organ disease is distinguished by detection of the virus from tissue from the involved organ The manifestations of disease in solid organ transplant (SOT) recipients vary by transplanted organ type but can include pneumonitis, hepatitis, enterocolitis, and encephalitis Major indirect effects of CMV infection include both acute and chronic graft rejection, especially among renal and liver transplant recipients Cytomegaloviral infection further depresses cell-mediated immunity, promoting opportunistic bacterial and fungal infections, development of EBV-associated posttransplant lymphoproliferative disease, and decreased patient survival In neonates, CMV is the most common cause of congenitally acquired infection Although the infection is asymptomatic in most infected neonates, a substantial proportion of them develop permanent neurologic sequelae Both primary and recurrent maternal infection during pregnancy can result in intrauterine transmission The risk of transmission is substantially higher for mothers with primary infection (approximately 40%) versus mothers with recurrent infection (approximately 1%), but most cases of congenital CMV are a consequence of maternal CMV reactivation or reinfection Infants born infected as a result of primary maternal infection are more likely to have symptomatic 26-Ch26-Succinct_273-286.indd 277 11/9/16 8:45 AM 278 Succinct Pediatrics disease and, consequently, are at higher risk of neurologic sequelae associated with congenital CMV infection Classic CMV disease is characterized by petechiae, hepatosplenomegaly, microcephaly, thrombocytopenia, jaundice, and intracranial (typically periventricular) calcifications Clinical and laboratory findings for neonates with symptomatic congenital CMV infection are summarized in Table 26-1 Hepatosplenomegaly, although nonspecific to congenital CMV disease, is one of the more common manifestations of symptomatic infection Petechiae and purpura are caused by thrombocytopenia, and may be present anywhere on the skin Violaceous infiltrative papules or “blueberry muffin spots,” more characteristic of congenital rubella syndrome, represent sites of extramedullary hematopoiesis Approximately 5% to 30% of symptomatic infants have chorioretinitis Other ocular abnormalities include microphthalmos, cataracts, and retinal necrosis and calcification Microcephaly may be present at birth or progressive in the first year of life Central nervous system involvement may also be exhibited by seizures, sensorineural hearing loss, and meningoencephalitis Transient signs and symptoms such as hepatosplenomegaly, jaundice, and abnormal laboratory results gradually resolve over the course of the first several weeks of life However, a significant proportion of both symptomatic and asymptomatic infants develop neurologic sequelae as a Table 26-1 Clinical and Laboratory Findings in Neonates With Symptomatic Congenital CMV Infection Finding Percent With Abnormality Clinical Findings Petechiae 76 Jaundice 67 Hepatosplenomegaly 60 Microcephaly 53 Intrauterine growth retardation 50 Chorioretinitis/optic atrophy 20 Purpura 13 Seizures Laboratory Findings Elevated AST (>80 U/L) 83 Conjugated hyperbilirubinemia (direct bilirubin >4 mg/dL) 81 Thrombocytopenia (120 mg/dL) 46 Abbreviations: AST, aspartate aminotransferase; CSF, cerebrospinal fluid From Ross SA, Boppana SB Congenital cytomegalovirus infection: outcome and diagnosis Semin Pediatr Infect Dis 2004;16(1):44–49, with permission from Elsevier 26-Ch26-Succinct_273-286.indd 278 11/9/16 8:45 AM Chapter 26 • Cytomegalovirus 279 consequence of congenital infection, including cognitive deficits, cerebral palsy, visual impairment, and, most frequently, sensorineural hearing loss It is estimated that 40% to 58% of symptomatic and 13.5% of asymptomatic infants develop permanent neurologic sequelae (Evidence Level II-2) Perinatal and postnatal infections of the newborn occur through contact with CMV-infected maternal cervicovaginal secretions during delivery or through human milk ingestion after delivery Transfusion-acquired CMV infection is now largely prevented by widespread use of CMV-negative and leukocyte-depleted blood products in neonatal intensive care units Human milk plays a significant role in perinatal transmission, with up to 90% of seropositive lactating women shedding CMV in milk Perinatal infection in term infants is most frequently asymptomatic Premature infants, especially those with very low birthweight ( 781610 020763 Leonard G Feld, MD, PhD, MMM, FAAP John D Mahan, MD, FAAP Topics include Succinct Pediatrics Evaluation and Management for Infectious Diseases and Dermatologic Disorders Evaluation and Management for Infectious Diseases and Dermatologic Disorders Succinct Pediatrics AAP Succinct Pediatrics Book Evaluation and Management for Infectious Diseases and Dermatologic Disorders Leonard G Feld, MD, PhD, MMM, FAAP John D Mahan, MD, FAAP ... patients, and varicella-zoster and West Nile viruses in patients each 27 -Ch27 -Succinct_ 28 7-3 00.indd 28 8 11/7/16 12: 18 PM Chapter 27 • Encephalitis 28 9 Box 2 7 -2 Nonviral Infectious and Noninfectious... Clin Infect Dis 20 08;47(3):303– 327 27 -Ch27 -Succinct_ 28 7-3 00.indd 29 9 11/7/16 12: 18 PM 27 -Ch27 -Succinct_ 28 7-3 00.indd 300 11/7/16 12: 18 PM CHAPTER 28 Enteroviruses and Parechoviruses José R Romero,... Clin Infect Dis 20 08;47(3):303– 327 , with permission from Oxford University Press 27 -Ch27 -Succinct_ 28 7-3 00.indd 29 1 11/7/16 12: 18 PM 29 2 Succinct Pediatrics Table 2 7 -2 Possible Etiologies of Encephalitis