Next is toxic shock syndrome

Next is toxic shock syndrome and this is also a staphylococcal toxin and sometimes a streptococcal toxin. This is similar to the erythrogenic toxin of scarlet fever and very different from exfoliative toxin from phage group II staph. Here the classic disease of course was the epidemic relating to the staphylococcal infections with tampons, which the primary source went unrecognized and the manifestations were the toxic shock. It was actually described first in young children by Jim Todd relating to localized infections with disseminated toxin, usually skin infections. The manifestations; hypotension, clinical or laboratory abnormalities in greater than or equal to three organ systems, and reasonable evidence of ruling out other etiologies. This is desquamation in an adult with toxic shock. This is the sunburn-like rash and this is showing some generalized erythema and conjunctivitis. Just to go back to toxic shock; we occasionally see cases in, for example, group A streptococcal infections with pneumonia. You need to be aware of this. There is evidence now that treating these patients with IVIG benefits, decreases their degree of fever and their morbidity.
Okay, the last of the diseases that have some similarity with scarlet fever is erythema infectiosum and this is caused by parvovirus B19. It has a case-to-case interval of 6-14 days. The important thing is that after exposure about a week later you are contagious, but generally asymptomatic or have a mild fever. Then a week after that the rash occurs and at that time the patient is no longer contagious. The rash starts on the face with a “slapped cheek” appearance. The original rash starts centrally, spreads peripherally, is not very diagnostic, but takes on a lace-like pattern. The rash is more prominent on extensive surfaces and adults have arthralgias and arthritis. This is a classic picture from almost 100 years ago, showing the slapped cheek appearance with circumoral pallor. This is a little boy with a real disease. Not too unhappy. This is a picture of a lace-like rash and here is a photograph of what it looks like. The big issue of parvovirus B19 we’ve already mentioned as far as infection in pregnant women.

Now I want to switch over and talk a bit about enteroviruses, and I’m going to say more at the end about enteroviruses. But a lot of clinical manifestations can occur with enterovirus infections. This is … almost 40 years ago I occupied my time studying these things so everybody yawns when I try to make a big deal out of this. So I’m just going to go through and give you some major manifestations of what you should be aware of. Then we’ll come back and talk specifically about enterovirus epidemiology. I’m going to talk about EcHO-9 coxsackie A-9 and coxsackie A-16 as examples. EcHO virus 9 was the first of the enteroviruses to be well characterized with exanthems, with exanthem and aseptic meningitis. That you have fever, headache, nuchal rigidity, nausea, vomiting, various findings relating to aseptic meningitis. Rash occurs in about one-third of the cases but it’s adversely related to age. The older you are, the less likely you are to have rash. Other findings are typical enterovirus manifestations. The rash is rubelliform, erythematous, maculopapular, discreet. Generally starts centrally. It looks like this, and there are also some petechiae here. This is another child with petechial lesions. So the important thing here is that you have an illness with fever, some evidence of meningitis and on LP they have aseptic meningitis. The cell count usually in the meningitis has a predominance of polys early and you have petechiae popping out right in front of you as well as a rash. So the big thing is differential from meningococcemia. And this you can’t do. You are not able to do this clinically so when you have that scenario with fever you need to treat these patients as if they have meningococcemia. Now this is not only due to EcHO-9. You see this with multiple other enteroviruses. Just to show you some pictures. These almost ulcerative purpuric lesions look like meningococcemia. This is a child with a coxsackie A-9 infection. This by comparison is a child with meningococcemia. So the message is that you can have these enterovirus exanthems even without meningitis and they look like meningococcemia, and you need to treat them as if they were. You can’t differentiate them and sometimes, for example at Ft. Leonard Wood, actually both were circulating at the same time and there were cases that had meningococcemia during the outbreak of EcHO type 9 disease.
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