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Image courtesy of the Ministry of Health of Argentina. [Public domain.]

Back-to-School Viral Illnesses: 7 Classroom Contagions

Mark P Brady, PA-C | August 17, 2022 | Contributor Information

Schooltime preparations have taken on a completely new meaning due to the impact of the global coronavirus (COVID-19) pandemic. Before the coming year starts, now is a great time to refresh your knowledge of viral infections that may affect your young patients as they return to class. Given the lapses in some children’s vaccination regimens because of the pandemic, along with ongoing spread of COVID-19 variants and the emergence of monkeypox, the 2022-2023 school year has the potential to present clinicians with a remarkably challenging mix of old and new viruses.

The rash shown on this elementary school student's back is associated with the monkeypox virus.

Image from Wikimedia Commons | Grook Da Oger. [Creative Commons Attribution-Share Alike 3.0 Unported (CC-BY-SA-3.0).]

Back-to-School Viral Illnesses: 7 Classroom Contagions

Mark P Brady, PA-C | August 17, 2022 | Contributor Information

This young febrile child presents from daycare with palmar vesicles surrounded by an erythematous halo. Most of the vesicles appear elliptical, with the long axis of the lesions oriented along the skin lines.[1] The patient also has intraoral sores. What is the likely cause of these cutaneous lesions?

Image courtesy of Russell W. Steele, MD.

Back-to-School Viral Illnesses: 7 Classroom Contagions

Mark P Brady, PA-C | August 17, 2022 | Contributor Information

Answer: Hand, foot, and mouth disease (HFMD)

HFMD is an acute viral illness caused by a member of the genus Enterovirus, usually coxsackievirus A16 in the United States; types 5, 10, and 71 are also associated with HFMD. More than 200,000 cases of HFMD occur in the United States each year.[2]

Although HFMD typically affects children younger than 5 years, it can occur in adults. Signs and symptoms include a rash with blisters on the hands and soles of the feet; intraoral (herpangina) and perioral blisterlike sores (arrow); fever; and sore throat. Transmission is through direct contact, by airborne droplets from coughs or sneezes, or via contaminated objects/surfaces. Shed viral particles are present in the infected person's saliva, sputum, nasal mucus, blister fluid, and feces.

While this is a clinical diagnosis, throat or stool cultures can provide confirmation, if needed. There is no specific treatment or vaccine. Management is supportive, including nonprescription analgesics/antipyretics (avoid aspirin in children) and oral mouthwashes and/or sprays.

Image from the CDC. [Public domain.]

Back-to-School Viral Illnesses: 7 Classroom Contagions

Mark P Brady, PA-C | August 17, 2022 | Contributor Information

What is the etiology of the pruritic, generalized skin manifestation that began on this child's face, chest, and back?

Image courtesy of Russell W. Steele, MD.

Back-to-School Viral Illnesses: 7 Classroom Contagions

Mark P Brady, PA-C | August 17, 2022 | Contributor Information

Answer: Chickenpox

Chickenpox is a highly contagious disease caused by the varicella-zoster virus (VZV). It results in fever, malaise, and a pruritic, fluid-filled, vesicular rash (shown) that eventually scabs. The rash appears on the chest, back, and face, and then spreads across the entire body.

Transmission occurs via direct contact with viral particles from skin blisters or respiratory viral particles from infected persons who are coughing or sneezing. Infected persons are contagious from 1-2 days before the rash appears until no new lesions have appeared for 24 hours. Clinical manifestations may not develop for up to 2 weeks after exposure.[3]

This is also a clinical diagnosis that can be confirmed by polymerase chain reaction (PCR) assay (VZV isolation in skin lesions). Treatment usually involves supportive care. Since the introduction of the vaccine in 1995, fewer than 20,000 cases have occurred each year in the United States.[4]

Image courtesy of UK Health Security Agency

Back-to-School Viral Illnesses: 7 Classroom Contagions

Mark P Brady, PA-C | August 17, 2022 | Contributor Information

Although monkeypox (related to smallpox and cowpox) is rare in children, this infection can mimic the more common chickenpox, with fever, aches, and vesicular rash. Clinical differences that may help distinguish the two diseases are that early in its course, monkeypox may feature headache and associated lymphadenopathy, and that chickenpox lesions are more superficial, erupt in crops, and evolve quickly, whereas monkeypox lesions are deep-seated, well-circumscribed, and may become more ulcerative in appearance.[5] The rash in monkeypox, which lasts approximately 2-4 weeks, often begins on the face or genitals and then spreads to other parts of the body. The time from exposure to symptoms can range from 5 to 21 days. Reporting is essential and management is symptomatic.

Exposed persons can receive monkeypox or smallpox vaccine for post-exposure prophylaxis. Vaccination within 4 days after exposure provides the best chance to prevent onset of the disease; vaccination between 4 and 14 days afterward may reduce the severity of disease, but may not prevent it.[6]

Image courtesy of Russell W. Steele, MD.

Back-to-School Viral Illnesses: 7 Classroom Contagions

Mark P Brady, PA-C | August 17, 2022 | Contributor Information

This child has a diffuse rash, in addition to cough, coryza, and conjunctivitis. Because of the parents' concerns related to vaccines and the inability to see their pediatrician, this child remains unvaccinated. What is the suspected etiology of his illness?

Image courtesy of Russell W. Steele, MD.

Back-to-School Viral Illnesses: 7 Classroom Contagions

Mark P Brady, PA-C | August 17, 2022 | Contributor Information

Answer: Measles

Measles (rubeola) is a highly contagious respiratory disease that spreads via contact with an infected person and by way of an infected individual's coughs and sneezes. After exposure, the incubation period lasts 7-14 days. Patients then develop prodromal high fevers (often >104°F [40°C]) with the classic triad of cough, coryza, and conjunctivitis. After a few days, Koplik spots can develop on the buccal mucosa to the soft palate (shown).

Laboratory confirmation includes detection of measles-specific immunoglobulin (Ig) M antibody and measles RNA by real-time PCR assay. Treatment involves supportive care and oral vitamin A.[7] Although widespread use of measles vaccine has led to a more than 99% reduction in historic cases in the United States, measles remains a leading cause of death in young children worldwide secondary to progressive encephalitis and pneumonia. In 2021, there were 49 new cases of measles in the U.S.[8]

Image courtesy of Russell W. Steele, MD.

Back-to-School Viral Illnesses: 7 Classroom Contagions

Mark P Brady, PA-C | August 17, 2022 | Contributor Information

A young girl presents with facial swelling and pain while chewing. She has a fever of 101.1°F (38.4°C) and is unvaccinated for mumps. What is the treatment for mumps? How do you advise the parents?

Image from the CDC. [Public domain.]

Back-to-School Viral Illnesses: 7 Classroom Contagions

Mark P Brady, PA-C | August 17, 2022 | Contributor Information

Answer: There is no specific treatment for mumps.

Mumps is a contagious yet relatively benign viral disease that is uncommon in the United States owing to routine measles, mumps, rubella vaccinations. Although most infected patients are relatively asymptomatic, signs and symptoms may include a few days of fever, myalgia, fatigue, anorexia, and headache, followed by parotitis (arrows).

Severe complications are rare; however, prior to widespread immunizations, mumps was the leading cause of deafness in children. Viral meningitis can occur in about 1 in 7 cases; encephalitis is rare.[9]

The diagnosis of mumps is usually made clinically; treatment is supportive. Enteroviruses cause most cases of parotitis, but mumps should still be considered in the differential.

Image courtesy of Medscape.

Back-to-School Viral Illnesses: 7 Classroom Contagions

Mark P Brady, PA-C | August 17, 2022 | Contributor Information

This child presents with a rash on both cheeks after several days of fever and rhinitis. What diagnosis should be suspected?

Image courtesy of Medscape.

Back-to-School Viral Illnesses: 7 Classroom Contagions

Mark P Brady, PA-C | August 17, 2022 | Contributor Information

Answer: Fifth disease (erythema infectiosum)

Caused by parvovirus B19, fifth disease commonly manifests as a mild rash following symptoms that may include fever, rhinitis, and headache.[10] Patients may develop a "slapped cheek" facial rash, which is the most recognized feature of this disease. Afterward, a generalized, occasionally pruritic rash may develop (shown).

Parvovirus B19 spreads through respiratory secretions.[10] Patients typically become ill within 14 days after being infected, but about 20% of infected persons can be asymptomatic. The diagnosis is usually made clinically, although IgM assay, dot blot hybridization, PCR assay, and loop-mediated isothermal amplification can be used for confirmation.[11]

Infection in pregnant women can cause fetal hydrops and fetal death; therefore, inform pregnant mothers and teachers of the risk from exposure to infected children. Parvovirus B19 can also lead to aplastic crisis in patients with sickle cell disease and other hemoglobinopathies, as well as cause chronic anemia in immune-deficient patients.[10,11]

Image from the CDC. [Public domain.]

Back-to-School Viral Illnesses: 7 Classroom Contagions

Mark P Brady, PA-C | August 17, 2022 | Contributor Information

The mother of this child calls the day before school starts to report the new onset of fever, chills, and body aches. She says that her daughter was completely healthy the previous day. What might you suspect?

Transmission electron microscopic image of a small grouping of H1N1 influenza virus particles from National Institute of Allergy and Infectious Diseases (NIAID). [Creative Commons Attribution 2.0 Generic (CC BY 2.0).]

Back-to-School Viral Illnesses: 7 Classroom Contagions

Mark P Brady, PA-C | August 17, 2022 | Contributor Information

Answer: Influenza

The past 2 years have certainly added complexity to this discussion. Although the common cold, influenza, and COVID-19 may have similar symptoms, the acuity of onset, severity of symptoms, and absence of nasal congestion may suggest influenza. However, symptoms alone cannot always differentiate between the illnesses.

Commonly transmitted by respiratory droplets, influenza can also be spread through contact with surfaces contaminated with respiratory droplets.[12] Signs and symptoms usually start suddenly within 2-3 days after infection and include fever, cough, pharyngitis, myalgia, headache, and malaise. Vomiting and diarrhea can also occur. The diagnosis is clinical, although rapid testing is available.

Patients generally recover after a few days; those with chronic medical conditions or at extremes of age are at risk for serious complications. Management is primarily supportive; antiviral drugs may be given early in more severe or complicated cases or to at-risk patients. The best way to prevent the disease is annual influenza vaccination (for those aged >6 months).[12]

Image from Zhang Y, Xie RM, He YL, et al. Ital J Pediatr. 2020;46:153. [Open access.] PMID: 33054802.

Back-to-School Viral Illnesses: 7 Classroom Contagions

Mark P Brady, PA-C | August 17, 2022 | Contributor Information

Above, computed tomography (CT) images of the chest show multiple ground-glass opacities (small arrows) and patchy lesions (arrowhead) in a 4-year-old boy with a 5-day history of fever and cough.[13]

After the first week of school, your child becomes ill with new onset of fever, cough, and congestion. The child is immunized and your family has been following current mitigation practices for COVID-19. What might you anticipate from your child’s healthcare provider?

Transmission electron microscopic image of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) particles emerging from the surface of lab-cultured cells from NIAID-Rocky Mountain Laboratories. [Public domain.]

Back-to-School Viral Illnesses: 7 Classroom Contagions

Mark P Brady, PA-C | August 17, 2022 | Contributor Information

Answer: COVID-19 testing

Common symptoms of COVID-19 in children are cough and fever, although symptoms may differ by variant type. Other symptoms include fatigue, headache, myalgia, nasal congestion or rhinorrhea, loss of taste or smell, pharyngitis, dyspnea, abdominal pain, diarrhea, and nausea or vomiting. Infected children may be asymptomatic.[13,14]

Multisystem inflammatory syndrome in children (MIS-C) is a rare complication associated with COVID-19. Patients with MIS-C require broad medical testing and typically present with persistent fever, severe illness with multisystem organ involvement, and elevated levels of laboratory markers of inflammation.[15]

The CDC and the American Academy of Pediatrics recommend COVID-19 vaccination for all children 6 months and older and boosters for everyone 5 years and older, if eligible.[14,15,16] Due to ongoing COVID-19 variants, updated vaccines are anticipated in late 2022.[17]

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