MEASLES

paramyxovirus infection endemic world-wide. probably the most infectious of all microbial agents Maternal antibody gives protection for the first 6 months of life Natural illness produces life-long immunity.

Clinical features
infection is by droplet spread incubation period of 14 days A prodromal illness 1-3 days before the rash appears heralds the most infectious, 'catarrhal' stage with upper respiratory symptoms, conjunctivitis and the presence of Koplik's spots on the internal buccal mucosa

Koplik's spots
These small white spots surrounded by erythema are pathognomonic of measles on the internal buccal mucosa

Rashes
As natural antibody develops, the rash appears, lasting 5-6 days and gradually fading with 'staining' in the pale-skinned.

 Generalised lymphadenopathy and diarrhoea are common

Complications
bacterial pneumonia Convulsions Otitis media Vitamin A deficiency subacute sclerosing panencephalitis (SSPE) up to 7 years after infection.

 The typical rash may be missing in the immunocompromised and persistent infection with a giant cell pneumonitis or rapidly progressive encephalitis may occur

Management
Normal immunoglobulin attenuates the disease in the immunocompromised or in non-immune pregnant women. Vaccination can be used in outbreaks and vitamin A may improve the outlook in uncomplicated disease. Antibiotic therapy is only effective where signs of superinfection already exist and should not be used empirically

RUBELLA (GERMAN MEASLES)

transmitted by aerosol infectivity from up to 1 week before and 1 week after the onset of the rash

pathogenesis
Initial infection via the upper respiratory tract and local lymph nodes is followed by viraemia to target organs such as skin, joints and placenta

Clinical Features
Adenopathy lasting several weeks occurs, usually with the involvement of post-auricular, postcervical and sub-occipital nodes occasional splenomegaly. A maculo-papular non-confluent rash starts simultaneously on the face and moves to the trunk. Petechial lesions ('Forchheimer spots') appear on the soft palate, associated with a mild coryza/conjunctivitis. Fever occurs only on the first day of the rash.

complications
more common in adult females An immune-mediated arthritis/arthralgia affects 30% of women and involves the fingers, wrists and knees; it takes 1-2 months to resolve Encephalitis hepatitis haemorrhagic manifestations

RUBELLA INFECTION: RISK OF CONGENITAL MALFORMATION

Stage of gestation 1-2 months

Likelihood of malformations 65-85% chance of illness, multiple defects/spontaneous abortion 30-35% chance of illness, usually a singledefect, deafness or congenital heart disease 10% risk of congenital defects, most commonly deafness Occasional deafness

3 months

4 months

> 20 weeks

Diagnosis
Detection of rubella-specific IgG with absent IgM indicates previous infection. Specific IgM or rising IgM is indicative of recent infection

Prevention
Rubella vaccine should be given to all children at the age of 12-15 months and again at about 4 years

HUMAN ERYTHROVIRUS 19 (PARVOVIRUS B19)

Transmission is air-borne blood-borne infection has been described in haemophiliacs

 A week after infection non-specific symptoms occur and a few days later the immune response commences, accompanied by bone marrow depression. Reduction of erythroid precursors progresses to thrombocytopenia, lymphopenia and neutropenia

 The disease is relevant in individuals with a short red cell life, such as those with sickle-cell disease or spherocytosis where significant anaemia may progress to life-threatening levels. Haematopoiesis usually recovers spontaneously after 10-14 days

 Two to three weeks after infection, the immune-mediated, classic red 'slapped cheek' rash with circumoral pallor and arthralgia appears. A second-stage erythematous maculo-papular rash may occur on the trunk and limbs

 Infection during the first two trimesters of pregnancy can result in intra-uterine infection and impact on fetal bone marrow; it causes 10-15% of non-immune (non-Rhesus-related) hydrops fetalis

Diagnosis
Erythrovirus 19 DNA may be detected in the serum and a PCR test will remain positive from then until some 4 months after infection. IgM antibody detection During the early stages of erythropoietic disturbance, haemophagocytosis may be demonstrable in the bone marrow and occasionally in peripheral blood.

Management
In the normal individual, this infection is selflimiting and symptomatic relief for arthritic symptoms should be given. Passive prophylaxis with normal immunoglobulin has been suggested for nonimmune pregnant women exposed to infection. The pregnancy should be closely monitored by ultrasound scanning, and any suggestion of hydrops should result in consideration of fetal transfusion

HUMAN HERPES VIRUS 6 AND 7 (HHV6 AND HHV-7)

associated with a benign febrile illness of children with a maculo-papular erythematous rash: 'roseola infantum'/'exanthem subitum In the immunocompromised they cause lymphadenopathy

CHICKENPOX
Varicella zoster virus (VZV) is dermo- and neurotropic Spread by the aerosol route it is highly infectious to susceptible individuals.

 The incubation period is 14-21 days a vesicular eruption begins often on mucosal surfaces first, followed by rapid dissemination in a centripetal distribution (most dense on trunk and sparse on limbs). New lesions occur every 2-4 days, each crop associated with fever. The rash progresses from small pink macules to vesicles and pustules within 24 hours. These then crust. Infectivity lasts until crusts separate.

Complications
secondary bacterial infection from scratching is the most common complication of primary chickenpox. Self-limiting cerebellar ataxia may rarely occur 7-10 days after recovery from the rash. Maternal infection in early pregnancy carries a 3% risk of neonatal damage, and disease within 5 days of delivery can lead to severe neonatal varicella

Diagnosis
Usually this is clinically obvious from the classical appearance of the rash Aspiration of vesicular fluid and PCR or tissue culture will confirm the diagnosis. Serological examination for rising titres of antibody is only useful in primary infection

Management
Aciclovir, valaciclovir and famciclovir, effective if commenced within 48 hours of rash appearance

Human VZV immunoglobulin may be used to attenuate infection in highly susceptible contacts of chickenpox such as: 1. bone marrow recipients 2. patients with debilitating disease 3. HIV-positive contacts without VZV immunity 4. pregnant women with no known VZV antibody (screen for antibody if in doubt) 5. immunosuppressed contacts who have received high-dose corticosteroids in the previous 3 months 6. neonates whose mothers develop chickenpox between 1 week before and 4 weeks after delivery 7. neonates in contact with chickenpox/shingles whose mothers have no history of chickenpox or any demonstrable antibody 8. premature infants of less than 30 weeks' gestation, or weighing less than 1 kg at birth who contact chickenpox or shingles

SHINGLES (HERPES ZOSTER)

This is produced by reactivation of latent VZV from the dorsal root ganglion of sensory nerves. Commonly seen in the elderly, it may present in younger patients with immune deficiency or after intra-uterine infection.

 thoracic dermatomes are most commonly involved the ophthalmic division of the trigeminal nerve is frequently implicated; vesicles may appear on the cornea and lead to ulceration. Geniculate ganglion involvement causes the Ramsay Hunt syndrome of facial palsy, ipsilateral loss of taste and buccal ulceration, plus a rash in the external auditory canal. This may be mistaken for Bell's palsy Bowel and bladder dysfunction occurs with sacral nerve root involvement. The virus occasionally causes myelitis or encephalitis.

Clinical features
Burning discomfort in the affected dermatome progresses to frank neuralgia. Discrete vesicles appear in the dermatome 3-4 days later and often coalesce. This is associated with a brief viraemia and influenza-like features, and potentially produces distant satellite 'chickenpox' lesions elsewhere

 Severe disease, multiple dermatomal involvement or recurrence suggests underlying immune deficiency

 Chickenpox may be contracted from a case of shingles but not the reverse.

Complications
The most common and troublesome complication is post-herpetic neuralgia: persistence of pain for 1-6 months or more following healing of the rash

Management
Early therapy with aciclovir 800 mg 5 times daily or valaciclovir 1 g 8-hourly, or aciclovir 10 mg/kg i.v. 8hourly in severe infection and in the immunocompromised has been shown to reduce both early- and late-onset pain, especially in patients over 65 Post-herpetic neuralgia requires aggressive analgesia and the use of transcutaneous nerve stimulation (a 'TENS' machine), along with neurotransmitter modification with agents such as amitriptyline 25-100 mg daily or gabapentin (commencing at 300 mg daily and building slowly to 300 mg 12-hourly or more.