Transcript Vector borne diseases in children
EMERGING VECTOR-BORNE DISEASES IN CHILDREN
DR SV PATIL PROF AND HEAD PAEDIATRICS BLDE-UNIVERSITY SRI BM.PATIL MEDICAL COLLEGE BIJAPUR
EMERGING VECTOR - BORNE DISEASES IN CHILDREN DR SV PATIL PROF AND HEAD PAEDIATRICS
• • Dengue fever Ricketsial fever • • • Chickungunya fever Japanese encephalitis Malaria
Dengue fever
Case
• Rahul, 4 year male child presents with – Fever high grade, vomiting for 4 days – Treated with paracetamol but little response – Monsoon time and a case of dengue in neighborhood reported recently – How will you proceed in such a case? • • •
Ask Look Test
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Ask for ……
• • • Localizing symptoms: – Cough, cold, ear ache: Tonsillitis, AOM, Sinusitis – Loose stools: Rotaviral, bloody diarrhea – Urinary symptoms: UTI – Boils: SSTI Without focus: – Pattern of fever, Well between fever spikes, history in contacts, coryza, systemic symptoms (myalgia) – Vaccination: Hib, typhoid, measles, MMR Danger symptoms: Lethargy, refusal of feeds, irritability, oliguria, convulsion, cold extremities (Serious infections) 6
Look for …..
• • Vitals: Pulse, CRT, BP/Pulse pressure , Tourniquete test, Skin rash Focus like: – Liver/spleen/LN, ascitis – Resp: Conj congestion, Coryza, Throat/Otoscopy, RR, Grunt, retractions, effusions – CNS: Alertness, FND, meningeal signs – Other systems 7
Test for …..
• Test for (now or later?) – CBC, PS for MP (repeat if no response) – Urine analysis – culture SOS – Blood culture?? – X ray chest (If resp signs) – Repeat tests (CBC) SOS – Others: CRP, SGOT, SGPT, Widal, Dengue serology, RMT ????
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Case continues ….
• • • • • Rahul’s tests done show: CBC: – Hb 13 gm%, HCT 40%, – WBC 3200, P 40, L 56 E 3, M1 – Platelets: 1.2 lakhs PS for MP: Negative Urine analysis: Albumin nil, Pus cells 2-3/hpf X ray chest: Normal DD: Malaria, Dengue, Viral fever, Enteric fever, Leptospirosis etc 9
Case continues …..
• • • • Rahul’s fever is persistent He now has some rash on his body He seems to have body ache and restlessness His mother repeats his investigations 10
Case continues ….
Hb HCT WBC DC Platelets PS for MP Urine Routine Day 4 13 40 3200 P40, L56, E3, M1 120,000 -ve Normal Day 6 15 45 2200 P34, L60, E5, M1 70,000 -ve Normal Mother wants to know whether it is dengue and whether she should ask for dengue tests? 11
Which laboratory tests?
• Test for confirming dengue – NS1 Antigen, ELISA for IgG & IgM • Need, timing, interpretation 12
Interpretation of dengue serology
NS1 antigen +ve -ve/+ve -ve -ve/+ve -ve -ve IgM -ve +ve +ve +ve -ve -ve IgG -ve -ve +ve low titers +ve high titer +ve High titers +ve low titers Interpretation Early (< 4dys) Primary
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Current/Recent Secondary Secondary Past infection
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Exception being congenital dengue (in 1 st 3 months of life)
• Most important for preventing morbidity and mortality is serial clinical monitoring and CBC • Do not withhold fluid therapy pending labs/-ve labs 13
Case continues …..
• • • • Rahul is drinking and eating though less than before His fever is better with paracetamol He has passed urine 3-4 times since morning Mother wants to know whether she should admit Rahul in hospital? 14
Course of dengue illness
Critical phase: Falling WBC & Platelets
Plasma leak & Rising HCT – 3 rd spacing
Shock, organ dysf., Acidosis, DIC
Severe bleeding with
HCT &
in WBC
Severe shock, organ damage & death.
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WHO classification of dengue
DF grade Clinical criteria Laboratory criteria DF DHF I DHF II DHF III (DSS) DHF IV (DSS) Fever with 2 or more of following signs: Headache, retro-orbital pain, myalgia, arthralgia Above signs plus +ve tourniquete test Above signs plus spontaneous bleeding Above signs plus circulatory failure Profound shock with undetectable BP and pulse Leukopenia, occasionally thrombocytopenia with no plasma leakage HCT rise > 20% platelets < 100,000 HCT rise > 20% platelets < 100,000 HCT rise > 20% platelets < 100,000 HCT rise > 20% platelets < 100,000 Not suitable in all situation; severe dengue in absence of criteria
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Suggested dengue classification
Severe Dengue Dengue +/- warning signs Without With warning signs 1) Severe plasma leakage 2) Severe hemorrhage 3) Severe organ impairment Criteria for dengue +/- warning signs Probable dengue Live in/travel to dengue endemic area. Fever and 2 of the following criteria
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Nausea, vomiting
• Rash • Aches and pains • +ve tourniquete test • Leukopenia • Any warning sign
Warning signs
•
Abd. Pain & tenderness
• Persistent vomiting • Clinical fluid accum. • Mucosal bleeds • Lethargy, restlessness • > 2 cm liver enlarged • Lab:
platelets HCT with rapid
in Criteria for severe dengue Severe plasma leakage
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Shock (DSS)
• Fluid accumulation with
respiratory distress Severe bleeding As evaluated by clinician Severe organ involvement
• Liver: AST/ALT > 1000 • CNS: Impaired consc. • Heart & other organs 17
Management principles
Step 1. Overall assessment: History, examination, labs Step 2. Diagnose & assess phase/severity of disease Step 3. Management: • Disease notification • Management decisions: • Group A (to be sent home) • Group B (in-hospital management) • Group C (emergency treatment & referral) 18
Case continues …..
• • • • Rahul is drinking and eating though less than before His fever is better with paracetamol He has passed urine 3-4 times since morning Mother wants to know whether she should admit Rahul in hospital? 19
Group 1 (Home care)
• • • It includes those who: – Can tolerate adequate volume of oral fluids – Pass urine 4-5 times in 24 hours – No warning signs Rx: 5-6 glasses of ORS, Juices, other fluids, Paracetamol (NO NSAIDs/Mefenimic acid) FU: Daily FU till defervescence period is over at home by care taker and at clinic by medical professional for – Intake, output, repeat CBC, look for warning signs, response to therapy, deterioration or warning signs 20
Case continues …..
• • • • • • Rahul is now sick looking He has vomited several times and is not able to drink well He has developed cold hands and feet He is irritable and restless He has not passed urine for 8 hours Mother wants to know whether she should admit the child?
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Group 2 (In-hospital Rx)
• • • Includes those with warning signs: • Abd. Pain & tenderness • Persistent vomiting • Clinical fluid accum. • Mucosal bleeds • • Lethargy, restlessness Lab: HCT/ in platelets • > 2 cm liver enlarged High risk for complications like pregnancy, infancy, old age, obesity, diabetes mellitus, renal failure, chronic hemolytic diseases Difficult social situation (far away/living alone) 22
Management of Group 2 with danger signs 5-7 ml/Kg/hr x 1-2 hr 3-5 ml/Kg/hr x 2-4 hr
Clinical/CBC monitoring
Response seen 2-3 ml/Kg/hr x 2-4 hr Worsening 5-10 ml/Kg/hr x 1-2 hr
Clinical/CBC monitoring
Response seen Worsening Taper over 24-48 hr Severe shock Monitoring: Clinical q 1-4 hr; Urine output q 4-6 hr; CBC q 6-12 hr; Organ function tests sos Refer to 3 0 care 23
Group 3 (Referral to tertiary care)
• Includes those with severe dengue (DSS): – severe plasma leakage leading to dengue shock and/or fluid accumulation with respiratory distress – severe hemorrhages – severe organ impairment (hepatic damage, renal impairment, cardiomyopathy, encephalopathy or encephalitis) Need access to intensive care, blood products and colloids 24
Compensated shock (systolic pressure maintained but has signs of reduced perfusion) O2, Fluid resuscitation with isotonic crystalloid 5–10 ml/kg/hr over 1 hour Improvement
IV crystalloid 5–7 ml/kg/hr for 1–2 hours, then: to 3–5 ml/kg/hr for 2–4 hours; to 2–3 ml/kg/hr for 2–4 hours.
Improvement fluid further.
Monitor HCT 6–8 hourly.
Not stable, act according to HCT levels: if HCT , consider bolus or increase fluid administration; if HCT , consider fresh whole blood transfusion.
Stop at 48 hours.
HCT 2 nd
or high bolus 10-20 ml/Kg for 1 hr Improvement
Fluids to 7–10 ml/kg/hr for 1–2 hours then
Dr. Nitin Shah
further No improvement Check HCT HCT low Significant Bleeding – consider Fresh whole blood transfusion No improvement
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Hypotensive shock O2, Fluid resuscitation with isotonic crystalloid or colloid @ 20 ml/kg over 15 min Improvement
IV cryst./colloid 10 ml/Kg x 1 hr IV cryst. 5–7 ml/kg/hr x 1–2 hours 3–5 ml/kg/hr x 2–4 hours 2–3 ml/kg/hr x 2–4 hours.
Improvement fluid further.
Monitor HCT 6–8 hourly.
Not stable, act according to HCT levels: if HCT , consider bolus or increase fluid administration; if HCT , consider fresh whole blood transfusion.
Stop at 48 hours.
HCT
or high No improvement Check 1st HCT HCT low 2 nd bolus colloid 10-20 ml/Kg for ½-1 hr Significant Bleeding – Fresh whole blood transfusion Improvement HCT
or high Check 2 nd No improvement HCT HCT low 3 rd bolus colloid 10-20 ml/Kg over 1 hr Check 3 rd HCT Improvement No improvement Fluid refractory shock
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Case continues …..
• • • • Rahul was admitted in hospital and treated with IV fluids and he responded well His serial CBC showed platelets of only 30,000 He has some skin rash and mild epistaxis Mother insists on giving platelet transfusion to Rahul 27
Use of blood products
• • • At risk: – Profound shock, hypotension, NSAIds, Trauma (procedures), liver disease Recognition: – Falling HCT on fluid resuscitation with unstable hemodynamics, – Overt bleeding irrespective of HCT – Refractory/hypotensive shock, worsening metabolic acidosis Treatment: – Fresh PRBC or whole blood (Rarely platelets, FFP) – No role of prophylactic platelets!!!!
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Case continues …..
• • • • • • Rahul is now well He is eating and drinking well He is passing urine well It is 8 days and he is afebrile for 2 days His CBC shows Hb of 11 gm%, WBC 4200, P40,L56, E4, Platelets of 90,000 Mother wants to know when can Rahul go home?
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Criteria for discharge
• • • All of the following must be present Clinical: – No fever for 48 hours – Improvement in clinical status (general well-being, appetite, haemodynamic status, urine output, no respiratory distress) – Time frame for critical phase over Laboratory: – – Increasing trend of platelet count Stable hematocrit without intravenous fluids 30
RICKETTSIAL INFECTIONS
Rickettsial Infections
• Symptoms--
FEVER
headache myalgia rash and eschar
generalized lymphnodes,and hepatosplenomegaly
RASH-PALMS AND SOLES
• • • • GI- symptoms-Nausea,Vomiting Abd pain, Diarrhoea RS-Cough, Distress, CNS-Dizziness,Disorientation, Photphobia and Visual disturbances Others include-periorbital edema,conjunct congestion Epistaxis,hearing loss and arthralgia
SEVERE SYMPTOMS
• • • • Interstitial Pneumonia, Pulmonary edema CNS-Meningoencephalitis syndrome Renal-ARF Disseminated Intravascular Coagulation,Hepatic failure and Myocarditis.
Laboratory findings
• • • • • • Hematology-TLC-is low and leucocytosis Platelets less in 60% ESR is high Hyponatremia,,Hypoalbunemia,Thrombocytop enia SGOT- elevated Weil Felix test (5-7) days PCR- Immunoflorescence(gold standard)
Diagnosis
• • • • • • Fever-PUO- Fever with rash(palms and soles) Tick bite and exposure Epidemiological data Lab findings Defervescence with antibiotics DD-Measles,Dengue,Inf mono,Malaria Typhoid TSS and CVD
Treatment
• • • Tetracyclin,Doxycyclin Chloromycetin, Macrolides and Quinolines 5mg/kg in 2 doses min 5-7 days, and Supportive therapy.
JAPANESE ENCEPHALITIS
JAPANESE ENCEPHALITIS
• • • • • •
Case Definition of Suspected case:
- Acute onset of fever, not more than 5-7 days duration.
- Change in mental status with/ without New onset of seizures (excluding febrile seizures) (Other early clinical findings . may include irritability, somnolence or abnormal behavior greater than that seen with usual febrile illness)
JE
JE- CONTD
• • • • • • • • •
Laboratory-Confirmed case : A suspected case with any one of the following markers:
Presence of lgM antibody in serum and/ or CSF to a specific virus including JE/Entero Virus or others Four fold difference in lgG antibody titre in paired sera Virus isolation from brain tissue Antigen detection by immunofluroscence Nucleic acid detection by PCR In the sentinel surveillance network, AES/JE will be diagnosed by lgM Capture ELISA, and virus isolation will be done in National Reference Laboratory.
CHICKUNGUNYA FEVER
• • • • Triad of fever, rash and joint manifestations Clinically-fever>38.5,severe arthralgia(possible) Epidemiological-visit epidemic area 15 days prior to symptoms.(probable) Lab-isolation virus, PCR IgM AND IgG (confirmed)
• Caused by-chik virus, aedes aegypti vector • • • (human-mosq-human)-post mansoon Monkeys rodents birds and others.
Symptoms-fever(92%),arthralgia(87%),back ache(67%) and head ache(62%) Differs from adults-
Common
Fever Arthralgia Backache Headache
Infrequent Rare in adults but seen sometimes in children
Rash Stomatitis Photophobia Retro-orbital pain Oral ulcers Vomiting HyperpigmentationExfo liative dermatitis Diarrea Meningeal syndrome Acute encephalopathy
SEQUELAE
• • • Arthralgia resolves in 87%,3.7% episodic stiffness and 2.8% persistent stiff Lab diagnosis–virus isolation PCR IgM antibody and rising IgG titres Differential diagnosis –Leptospirosis,dengue fever,malaria,meningitis and rheumatic fever
Management
• • • • • First contact-Differential diagnosis should be thought Assess dehydration(severe,mild to moderate) Total leucocyte count->10,000-leptospira, and <50,000 –dengue fever peripheral smear-MP Paracetamol -50-60mg/kg/day Exercise and physiotherapy
Thank you all!
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