The Communicable Disease Roseola Biology Essay

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Roseola infantum, also known as exanthema sibitum or sixth disease, is caused by human herpesvirus 6 (HHV-6) and, less commonly human herpesvirus 7 (HHV-7), which usually causes infection later in life. (Burns et al., 2013). "Human herpesvirus (HHV)-6 and HHV-7 are ubiquitous T-lymphotropic viruses that infect most humans" (Ansari, 2004, p.1450). The disease is most commonly acquired by children between 6 and 24 months old (peaks at 15 months), after protective maternal antibodies have dissipated, therefore, making the child vulnerable to infections (Burns, 2013). Acquisition of HHV-6 occurs early in life with 50% to 60% of children becoming HHV-6 seropositive by age 12 months and essentially all children infected 4 years of age. HHV-7 infection typically occurs slightly later than HHV-6, with prevalence greater than 90% reached by age 6 to 10 years (Leach, 2000). According to Burns et al., roseola infantum is rare in children younger than 3 months old or older than 3 years, but has been seen in infants as young as 8 weeks old. "Roseola occurs worldwide, year-round, and shows no gender preference" (Burns, 2013, p. 453).

Pathophysiology

The pathophysiologic processes of HHV-6 infection remain unclear. In vitro, the virus has a predisposition for T lymphocytes, especially activated CD4+ cells, but it is not known that CD4 is the cellular receptor. The virus can also infect B cells, natural killer cells, astrocytes, and macrophages; the latter may be a site for virus persistence and reactivation. After primary infection the virus becomes latent and can reactivate later in life. The mechanisms that control latency are poorly understood, and it is possible that the HHV-6 genome may integrate into the human chromosome. There are two subgroups of HHV-6 - A and B - have distinctive and important biologic and pathogenic profile, which may explain some of the differing clinical presentations. Primary infection in infants is associated almost exclusively with B strains. A strains have been isolated primarily from adults, usually as reactivation in immunocompromised patients (Koch, 2001).

Most people harbor HHV-6 and HHV-7 in their saliva, and infants and children acquire these infections at a relatively young age, so it is assumed that saliva (oral route) is the major source of transmission. However, the method of transmission is not completely understood and is probably also spread through nasal and conjunctival routes by other family members, caregivers, or other close contacts (Burns et al., 2013). An infected child is most likely to spread the infection during the febrile and viremic phase of illness. Most HHV-6 and HHV-7 infections in normal children represent primary infections, but immunocompromised patients and adults may develop systematic disease due to reactivation of latent virus. Despite the frequent presence of HHV-6 and HHV-7 in blood, no documented cases of transmission-associated infections have been reported (Leach, 2000).

Differential Diagnosis

Roseola-"Primary infection either HHV-6 or HHV-7 usually causes an undifferentiated febrile illness that may be very difficult to distinguish from other common viral infections of childhood" (Kliegman et al., 2011, p. 1120).

Fever without focus-"Fever without focus is an acute febrile illness in which the etiology of the fever is not apparent after careful history and physical exam. Children between birth and 24 months are at greatest risk, with 1-3 months old at the highest risk. (Burns et al., 2013, p. 485).

Measles-The prodromal stage of measles consists of URI symptoms, low to moderate fever (greater than 101°F, and cough, coryza, and conjunctivitis" (Burns et al., 2013, p. 462)

Rubella-"There are mild catarrhal symptoms (fever, GI upset, sore throat, eye pain, arthralgia)" (Burns et al., 2013, p. 465).

Meningitis- "Children 2 years or younger have the greatest incidence (of meningitis) with a peak occurring in children less than 1 year old" (Kliegman et al., 2011, p. 476). Symptoms may include fever, seizures, and maculopapular or petechial rash. "If febrile seizures occur (in roseola infantum), meningitis is usually added to the differential diagnosis" (Kliegman et al., 2011, p. 454).

Relevant Subjective Data

Case Study:

A 15-month-old female presents to the office accompanied by her mother with a CC of fever x 3 days. Today she also noticed a rash on the patients' trunk. States the patient has been "fussier than usual, but doesn't necessarily seem sick."

CC: Fever x 3 days

APQRST

Associated symptoms: Admits: Non-pruritic rash (1,3,4,5), lethargy (1,2,4), diarrhea (1), red eyes with discharge (1,3,4), periorbital edema (1), swollen lymph nodes (1,3,4,5,6), runny nose (1,3,4,5), sore throat (1,3,4,5)

Denies: cough (3), coryza (3), generalized pain (5), Koplik spots (3), headache (4,5), reddened oropharynx (1,3,4), anorexia (1,2,3,4,5), arthralgias (4,5), back pain (5), seizures (5), petichiae (5), sore throat (1,3,4,5), vomiting (5), eye pain (4)

Precipitative: Admits "sudden onset of high fever" (above 101°F) prior to lower grade fever and rash (1). Denies recent infection or illness (1,2,3,4,5).

Prodromal: Admits URI symptoms prior to or coinciding with fever

Provocative: N/A

Palliative: Admits taking Acetominophen with mild relief, cold cloths to cool patient

Quality: Admits patient feels warm

Quantity: High fever x 2days (above 101°), Low grade fever currently (day 3)

Region: Admits generalized

Radiation: N/A

Severity: N/A

Sequence: Admits: Onset of fever from 101°F to more than 103°F for 3 to 7 (commonly 3 to 4) days, but the child does not seem particularly ill. As the fever breaks a diffuse, nonpruritic, discrete, rose-colored maculopapular rash appears (Burns et al., 2013).

Timing: Admits: Abrupt onset of fever. No prior occurrence of high fever.

Past Medical History

Major Illnesses: Denies major illnesses.

Accidents/Injuries/Hospitalizations: Denies major accidents, injuries or hospitalizations.

Diagnostic Procedures/Tests: Denies diagnostic procedures or tests.

Immunizations: Admits UTD.

Allergies: Denies allergies.

Current Health History

Current/ongoing/Chronic conditions or diseases: Denies ongoing/chronic conditions or diseases.

Current Medications: Acetaminophen 10-15 mg/kg orally every 4-6 hours when required.

Current Treatments: Denies current treatments.

Elimination: Diarrhea x 2 days.

Nutrition: Decreased appetite x 2 days

Sleep: Sleep patterns interrupted x 2 days

Family Medical History:

Admits: Siblings with similar symptoms

Personal/Social History

Admits: Recent sick contact at day care, school, etc. Generally takes a week or two for signs and symptoms to appear (Burns et al., 2013).

HPDP

Health promotion and disease prevention at this age could include such issues as teeth brushing, bottle in bed usage, car safety, parental use of seat belts, poison, and fire safety (Bright futures).

Relevant Objective Data

Physical Exam

General Appearance: Lethargic, No AMS. VSS and WNL, febrile.

Head: Skull normocephalic, round and symmetrical, possible bulging of anterior fontanel with CNS involvement. No nuchal rigidity.

Ears: Auricles symmetrical in size and shape, reddened TM bilaterally, no bulging, drainage, or discharge.

Eyes: Symmetric in size and shape bilaterally, periorbital edema present bilaterally, reddened conjunctiva bilaterally with drainage or discharge, red reflux intact.

Nose: Possible rhinnorhea, congestion, erythematous nasopharynx.

Mouth/Throat: No Koplik spots, erythematous oropharynx.

Respiratory: Respirations even and unlabored. Lung fields clear to auscultation. Possible coarseness if URI symptoms are present.

Lymphatic: Cervical and posterior occipital lymphadenopathy. Non-tender, no streaking, or erythema.

Integumentary: Discrete, rose-colored maculopapular rash, 2-3 mm in diameter over trunk. No rash present on face, neck, or legs. No petechiae.

Diagnostic

A WBC count initially shows a decrease, and then drops further by the third or fourth day, and then returns to the normal range. The WBC count tends to follow the pattern of the fever. Serologic testing involves isolating HHV-6 for peripheral blood mononuclear cells and documenting a significant rise in antibody titer; however, test results can vary widely so diagnosing unequivocal acute infection is problematic. Serial titers 2 to 3 weeks apart are more reliable. Fourfold increases in HHV-6 or HHV-7 IgG antibodies suggest active infection. Virus cultures can also be useful. A rapid HHV-6 culture is available. A reverse transcriptase polymerase chain reaction (RT-PCR) assay can distinguish between the acute and latent infection (Burns et al., 2013).

Treatment

Supportive care is usually all that is needed for infants/children with roseola. "The infection is self-limited, and when the clinical diagnosis is made by recognition of the rash infection is generally resolved" (Koch, 2001). Specific antiviral therapy is not currently recommended for routine cases of primary HHV-6 and HHV-7 infection. Unusual or severe manifestations of primary or presumed reactivated HHV-6 infection such as encephalitis, especially in inmmunocompromised patients, may benefit from antiviral treatment (Kleigman et al., 2011).

Pharmacologic

Acetominophen 10-15 mg/kg orally every 4-6 hours as required for fever reduction, maximum 90 mg/kg/day (Epocrates).

Action: Antipyretic for reducing fever. Direct action on the hypothalamic heat-regulating center.

Adverse reactions: nausea, rash, headache, anaphylactic reactions, hepatotoxicity, acute renal tubular necrosis, anemia, thrombocytopenia.

Drug interactions: Barbituates, Carbamazepine, Ethanol, local anesthetics, epinephrine, phenobarbital, rifampins, monitor and or modify other medications that include Acetominophen.

Cost: OTC, no prescription necessary.

Parental/Patient Instructions: Medicate every 4-6 hours as needed for fever and/or mild discomfort. Max dose for infants/children 90 mg/kg/day.

Ibuprofen 5-10 mg/kg orally every 6-8 hours when required, for fever reduction, maximum 40 mg/kg/day (Epocrates).

Action: Antipyretic for reducing fever. Direct action on the hypothalamic heat-regulating center.

Adverse reactions: Dyspepsia, nausea, abdominal pain, constipations, headache, dizziness, drowsiness, rash, AST and ALT elevation, fluid retention, tinnitus, ecchymosis, photosensitivity

Drug interactions: Monitor and/or modify Acetominophen and aspirin. Over 150 contraindicated medicines.

Cost: OTC, no prescription necessary.

Parental Patient Instructions: Medicate every 6-8 hours as needed for fever and/or mild discomfort. Max dose 40 mg/kg/day.

Nonpharmacologic

Oral hydration, cool packs for fever, tepid baths, rest.

Patient/Parent Education

Parents should know that primary infections with HHV-6 and HHV-7 are widespread throughout the human population with no current way of interrupting transmission (Leach, 2000).

Parents should be advised to maintain hydration and may use antipyretics if the child is uncomfortable with the fever. Aspirin should be avoided because of risk of Reye syndrome (Kleigman et al., 2011).

Complications are rare, except in children with suppressed immune systems. Individuals with healthy immune systems generally develop lifelong immunity to HHV-6 (Kliegman et al., 2011).

The skin eruption lasts hours to 2 to 3 days, begins on the trunk, and spreads centrifugally. It gradually fades and resolves without scarring. (Burns et al., 2011)

Observe for fever, (>100.5°F) increasing temperature after the appearance of rash, which could indicate a more serious disease. Patient should be revaluated (Burns et al., 2011).

Febrile seizures are a common complication in roseola if fever remains too high. Be sure to monitor temperature closely (Kleigman, 2011).

Roseola is contagious even if no rash is present. That means that the disease can spread while an infected child only has a fever, even before its clear that the child has roseola. Watch for signs of roseola if your child has been in contact with another child who has the illness.

Infected child should not be overdressed, as this can cause the fever to increase.

Bathing in tepid water can help bring down the fever; do not bathe in alcohol.

Avoid sharing of utensils, cups, etc. with other children, especially at daycare, school, etc.

Follow up and Referral

Generally no follow up treatment for roseola is necessary, however in rare cases there can be complications.

Call healthcare provider anytime your child has a fever greater than 103°F to rule out a more serious cause of fever. Especially if fever persists after the appearance of rash, or if fever lasts more than 7 days. Or if rash doesn't improve after 3 days.

Call 911 if a seizure occurs.

If your immune system is compromised and you come in contact with someone who has roseola, contact your healthcare provider. You may need monitoring for a possible infection that could be more severe than it is for a child.

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