4
yo female p/w 3 days of fever
(tmax 102), 2 days of progressive
non-pruritic rash on face/extremities,
decreased PO/UOP, emesis x 1 (nonbloody,non-bilious), diarrhea x 2
(non-bloody), increasing fatigue x
5d, refusing to eat and walk
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Meds: tylenol PRN
Allergies: NKDA
PMH: none
FMH: neg
Immunizations: received 4 yo shots several months ago
Social: stays at home w/ mom, no travel history, older siblings
with cold like symptoms, no rash
Arthritis/Arthralgias
 Desquamation
 Lymphadenopathy
 Meningitis
 Enanthems (mucosal involvement)
 Ulcerative vesicular lesions
 Palm and Sole involvement
 Predominantly on extremities
 Respiratory Symptoms/Pulmonary infiltrates
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Immunized 3 yo female with acute onset
of fever, progressive vesicular rash on
extremities with oral mucosal
involvement, mild N/V/D, non-toxic
appearing

Single-stranded RNA viruses**
› Picornaviridae family
 Polioviruses
 Coxsackieviruses (Group A and B)
 Echoviruses
 Enteroviruses (serotypes 68-71)

“Summer viruses” **
› *Increased prevalence in summer months
(May – October)
› All year round in tropical climates (NOLA)
Most cases involve children under age 5
 Humans are only hosts
 Fecal-oral is most common route
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› Then replicates in lymph nodes of respiratory
and GI systems
› Initial viremia → heart, liver, skin
› CNS infection usually the result of second
major viremia
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Most patients are mildly ill & recover completely
Most common → febrile illness, viral exanthem,
vomiting, diarrhea, and malaise
Others:
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Hemorrhagic conjunctivitis
Pharyngitis
Herpangina
Hand-foot-and-mouth disease
Paralysis
Hepatitis
Myocarditis
Pericarditis
Encephalitis
Aseptic meningitis
A 6-day-old infant is brought to the ER in August with a 1-day history
of decreased feeding, decreased activity, tactile fever, and rapid
breathing. He was born at term. His mother reports that she had a
nonspecific febrile illness 1 week before delivery for which she
received no treatment. Her GBS screen was positive at 36 weeks'
gestation, and she received two doses of ampicillin (>4 hours apart)
during labor. The baby received no antibiotics and was discharged
at 48 hours of age. Physical examination today reveals a toxic,
lethargic infant who is grunting and has a temp of 39.4°C, HR of 180,
and RR of 60. His lungs are clear, with subcostal retractions. He has a
regular heart rhythm with gallop, his pulses are thready, his capillary
refill is 4 seconds, and his extremities are cool.
Of the following, the MOST likely cause of this baby's illness is
A.
early-onset group B Streptococcus infection
B.
echovirus 11 infection
C.
herpes simplex virus infection
D.
hypoplastic left heart syndrome
E.
respiratory syncytial virus infection
High risk for developing disseminated
infection
 Severe manifestations:
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Fulminant Hepatitis
Myocarditis
Pneumonitis
Meningitis
Encephalitis
DIC
Multiorgan failure
acquired from nurseries, or from
symptomatic mothers (fever 1 week
prior to delivery)
 Symptoms develop at 3-7 days of life
 Signs include
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› mild listlessness, anorexia, transient
respiratory distress, jaundice,

Viral culture**
› Stool, throat, blood, CSF, or tissue
› 8 to 10 days
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PCR**
› Only small sample needed
› Results in 24 hours
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Serology
› Based on increase in antibody titers
› Too many enterovirus serotypes to be
practical
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Testing by PCR has been associated with
decreased IV abx use, ancillary testing,
and hospital length of stay
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Allows for patient isolation if necessary
(ie, NICU)
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Supportive care
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Antivirals under investigation
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IVIG may benefit immunodeficient
patients
› Also used in some with myocarditis or
persistant meningoencephalitis
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Contact precautions
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HAND WASHING!!!
1-4 yo
 Incubation period 3 to 7 days
 Prodromal phase of malaise, sore throat,
mouth pain, anorexia and low grade
fever
 Coxsackie A16 virus
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Oral lesions

Painful vesicles in
mouth and on
hands and feet
› Surrounded by an
erythematous
margin
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Nonvesicular
lesions on buttocks,
GU and extremities
less commonly

Onychomadesis – proximal separation of
the nail plate from the nail bed
Most resolve spontaneously w/in 3d-1wk
 Treatment is supportive
 Hydration and analgesics
 Magic Mouthwash
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› Maalox
› Benadryl
› Viscous lidocaine
Moderately contagious
 Spread by direct contact with nasal
discharge, saliva, blister fluid, or stool
 Most contagious during the first week of
the illness
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› Can shed virus in stool for up to 8 weeks
› No day care/school during the first few days
of illness and in setting of open lesions
Analgesia: Avoid aspirin
(acetaminophen and ibuprofen are ok)
 Diet: cold, soft foods, dairy, nothing spicy
 Prevent spread: wash hands often,
especially after using the bathroom
 Avoid others during the first week of
illness to prevent spread, avoid pregnant
women
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Coxsackie group A
 Ages 3 -10 years
 Incubation period 4-14 days
 Prodromal phase
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› Malaise, HA, N/V, myalgias, anorexia
› sore throat and mouth pain 1-2 days prior to
lesions
› Fever (low grade > high)
Erythematous ring surrounds
 Puntate macules  vesiclulate, ulcerate
 Anterior tonsillar pillars, soft palate,
posterior pharynx
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Self-limited
 Resolve spontaneously within 1 week
 Supportive care
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› Young children are at risk of dehydration
Ages 6 mo – 5 yo (peaks at 2yo)
 Incubation 2 days – 2 weeks
 Prodrome: fever, irritability, malaise, HA, PO,
lymphadenopathy (cervical, submandibular)
 Low to high grade fever
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Red, edematous gingivae
› bleed easily
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Small vesicles ulcerate and coalesce
› Large ulcerations with erythema surrounding
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Buckle mucosa, tongue, gingiva, hard
palate, pharynx, lips, perioral skin
Diagnose with culture, PCR, or antigen
testing
 Resolve in 10 to 14 days
 Treatment is supportive
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› Hydration and analgesics
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Acyclovir
› If patients present in the first 72-96 hrs of disease,
unable to drink or have significant pain
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After resolution, reside in trigeminal ganglia
Typically found in older children and
adults
 Not associated with infection
 Can be associated with autoimmune
disease (SLE, IBD)
 Exquisitely painful ulcers
 Large, yellow, pseudomembranous
slough with erythematous border
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Topical creams may help
Usually not recommended
 Benzocaine (orajel)
› associated with methemoglobinemia
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viscous lidocaine
› may cause problems if absorbed
systemically
› may choke on secretions
› may chew their buccal mucosa
Herpangina
ages
Hand, Foot, Mouth
Disease
1-4 yo
Aphthous Stomatitis
3-10 yo
Herpetic
Gingivostomatitis
6mos – 5 yo
Incubation
3-7 days
4-14 days
2 days – 2 weeks
N/A
prodrome
Malaise, sore throat,
mouth pain, anorexia
Malaise, HA, N/V, sore
throat, mouth pain,
anorexia
Usually none
fever
Usually low grade
Usually low grade
irritability, malaise, HA,
anorexia,
submandibular and
cervical lymphadenitis
Low-High grade fever
Description of
lesions
Mildly painful Vesicles
surrounding erythema
(may ulcerate)
Painful Vesicles/ulcers
with surrounding
erythema
Vesicles that ulcerate
and coalesce
Beefy red gingiva
Location of
lesions
Hands, feet, mouth
(buccal mucosa and
tongue), occasionally
nonvesicular lesions on
buttocks, genitals and
extremities
Anterior tonsillar pillars, Buccal mucosa, tongue,
soft palate, posterior
gingival, hard palate,
pharynx
pharynx, lips, perioral
skin
Exquisitely painful
Large Ulcers , yellow
pseudomembranous
with erythematous
border
lips, tongue, buccal
mucosa
Most common
virus, season
Coxsackie A16
summer
1 week
Symptomatic tx
Group A Coxsackie
summer
1 week
symptomatic tx
Duration and
treatment
HSV 1
Year round
10-14 days
Acyclovir, symptomatic
tx
Older children , adults
Usually none
none
Variable, can recur,
symptomatic tx
MEASLES
Coxsackie A - HFM
Rubella
Parvovirus B19- Fifth’s
Disease- Erythema
Infectiosum
Varicella
RMSF
HHV6- Roseola
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Clue: This patient had a h/o 3 days of fever (that has
since defervesced) before the appearance of the rash
Scarlet Fever- Group A
Strep
Toxic Shock Syndrome
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Clue: You might be more suspicious of this
illness if this picture was a hypotensive woman
Staph Scalded Skin
Steven-Johnson-Syndrome
Kawasaki Disease
Meningococcemia
EBV- mono
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Clue: This patient was recently treated with
Ampicillin
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Who can name the original 6 childhood
exanthems? (1st disease, etc)
1st disease: Rubeola, Measles
 2nd disease: Scarlet Fever (s. pyogenes)
 3rd disease: Rubella, German Measles
 4th disease: Staph Scalded Skin Syndrome,
Filatow-Duke’s Disease, Ritter’s Disease
 5th disease: Erythema Infectiousum (parvo)
 6th disease: exanthem subitum, roseola
(HHV 6 or HHV 7)
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