Disease | Clinical Manifestations | Therapeutic Management and Complications | Care Management |
Chickenpox (Varicella) |
- Agents: Varicella zoster Virus (VZV)
- Source: Primary secretions of respiratory tract of infected people; to a lesser degree skin lesions (scabs not infectious)
- Transmission: Direct contact, droplet (airborne) spread, and contaminated objects
- Incubation period: 2 to 3 weeks, usually 14 to 16 days
- Period of communicability: Probably 1 day before eruption of lesions (prodromal period) until all lesions have crusted
| - Prodromal stage: Slight fever, malaise, and anorexia for first 24 hours; rash highly pruritic; begins as macule, rapidly progresses to papule and then vesicle (surrounded by erythematous base, becomes umbilicated and cloudy, breaks easily and forms crusts); all three stages (papule, vesicle, crust) present in varying degrees at one time
- Distribution: Centripetal, spreading to face and proximal extremities but sparse on distal limbs and less on areas not exposed to heat (i.e., from clothing or sun)
- Constitutional signs and symptoms: Elevated temperature from lymphadenopathy, irritability from pruritus
| - Supportive: Diphenhydramine hydrochloride or antihistamines to relieve itching; skin care to prevent secondary bacterial infection
- Specific: Antiviral agent acyclovir or valacyclovir for children at high risk; varicella zoster immunoglobulin or intravenous immunoglobulin (IVIG) after exposure in high-risk children only
- Complications: Secondary bacterial infections (abscesses, cellulitis, necrotizing fasciitis, pneumonia, sepsis)
- Encephalitis
- Varicella pneumonia (rare in healthy children)
- Hemorrhagic varicella (tiny hemorrhages in vesicles and numerous petechiae in skin)
- Chronic or transient thrombocytopenia
- Preventive: Childhood immunization
| - Maintain Standard, Airborne, and Contact Precautions if hospitalized until all lesions are crusted; for immunized child with mild breakthrough varicella isolate until no new lesions are seen.
- Keep child in home away from susceptible individuals until vesicles have dried (usually 1 week after onset of disease), and isolate high-risk children from infected children.
- Provide skin care; give bath and change clothes and linens daily; administer topical calamine lotion; keep child’s fingernails short and clean; apply mittens if child scratches.
- Keep child cool (may decrease number of lesions).
- Lessen pruritus; keep child occupied; use oatmeal or baking soda baths to minimize pruritus.
- Remove loose crusts that rub and irritate skin.
- Teach child to apply pressure to pruritic area rather than scratching it.
- Avoid use of aspirin (possible association with Reye syndrome).
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Diphtheria |
- Agent: Corynebacterium diphtheriae
- Source: Discharges from mucous membranes of nose and nasopharynx, skin, and other lesions of infected person
- Transmission: Direct contact with infected person, a carrier, or contaminated articles
- Incubation period: Usually 2 to 5 days, possibly longer
- Period of communicability: Varies; until virulent bacilli are no longer present (identified by three negative cultures); usually 2 weeks, but as long as 4 weeks
| - Vary according to anatomic location of pseudomembrane
- Nasal: Resembles common cold, serosanguineous mucopurulent nasal discharge without constitutional symptoms; may be frank epistaxis
- Tonsillar/pharyngeal: Malaise; anorexia; sore throat; low-grade fever; pulse increased above expected within 24 hours; smooth, adherent, white or gray membrane; lymphadenitis possibly pronounced (“bull’s neck”); in severe cases, toxemia, septic shock, and death within 6 to 10 days
- Laryngeal: Fever, hoarseness, cough, with or without previous signs listed; potential airway obstruction, apprehensive, dyspneic retractions, cyanosis
| - Equine antitoxin (usually intravenously); preceded by skin or conjunctival test to rule out sensitivity to horse serum
- Antibiotics (penicillin G procaine or erythromycin) in addition to equine antitoxin
- Complete bed rest (prevention of myocarditis)
- Tracheostomy for airway obstruction
- Treatment of infected contacts and carriers
- Complications: Toxic cardiomyopathy (second to third week)
- Toxic neuropathy
- Preventive: Childhood immunization
| - Follow Standard and Droplet Precautions until two cultures are negative for C. diphtheriae; use Contact Precautions with cutaneous manifestations.
- Administer antibiotics in timely manner.
- Participate in sensitivity testing; have epinephrine available.
- Administer complete care to maintain bed rest.
- Use suctioning as needed.
- Observe respiration for signs of obstruction.
- Administer humidified oxygen as prescribed.
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Erythema Infectiosum (Fifth Disease) |
- Agent: Human parvovirus B19
- Source: Infected persons, mainly school-age children
- Transmission: Respiratory secretions, blood, and blood products
- Incubation period: 4 to 14 days; may be as long as 21 days
- Period of communicability: Uncertain, but before onset of symptoms in children with aplastic crisis
| - Rash appearing in three stages:
- I: Erythema on face, chiefly on cheeks, “slapped face” appearance; disappears by 1 to 4 days
- II: About 1 day after rash appears on face, maculopapular red spots appear, symmetrically distributed on upper and lower extremities; rash progresses from proximal (trunk) to distal surfaces and may last more than 1 week.
- III: Rash subsides but reappears if skin is irritated or traumatized (sun, heat, cold, friction).
- In children with aplastic crisis, rash usually absent; prodromal illness includes fever, myalgia, lethargy, nausea, vomiting, and abdominal pain
- Child with sickle cell disease may have concurrent vaso-occlusive crisis.
| - Supportive: Antipyretics, analgesics, anti-inflammatory drugs
- Possible blood transfusion for transient aplastic anemia
- Complications: Self-limited arthritis and arthralgia (arthritis may become chronic); more common in adult women
- May result in serious complications (anemia, hydrops) or fetal death if other infected during pregnancy (primarily second trimester)
- Aplastic crisis in children with hemolytic disease or immunodeficiency
- Myocarditis (rare)
| - Isolation of child is not necessary, except hospitalized child (immunosuppressed or with aplastic crises) suspected of human parvovirus infection is placed on Droplet and Standard Precautions.
- Pregnant women need not be excluded from workplace where parvovirus infection is present; they should not care for patients with aplastic crises.
- Explain low risk of fetal death to those in contact with affected children; assist with routine fetal ultrasound for detection of fetal hydrops.
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Exanthem Subitum (Roseola Infantum; Sixth Disease) |
- Agent: Human herpesvirus type 6 (HHV-6; rarely HHV-7)
- Source: Possibly acquired from saliva of healthy adult; entry via nasal, buccal, or conjunctival mucosa
- Transmission: Year-round; no reported contact with infected individual in most cases (virtually limited to children under 3 years of age, but peak age is between 6 and 15 months of age)
- Incubation period: Usually 5 to 15 days
- Period of communicability: Unknown
| - Persistent high fever for 3 to 7 days in child who appears well
- Precipitous drop in fever to normal with appearance of rash
- Bulging fontanel
- Rash: Discrete rose-pink macules or maculopapules appearing first on trunk, then spreading to neck, face, and extremities; nonpruritic, fades on pressure, lasts 1 to 2 days
- Associated signs and symptoms: Cervical/postauricular lymphadenopathy, inflamed pharynx, cough, coryza
| - Nonspecific Antipyretics to control fever
- Complications: Recurrent febrile seizures (possibly from latent infection of central nervous system that is reactivated by fever)
- Encephalitis Hepatitis (rare)
| - Use Standard Precautions
- Teach parents measures for lowering temperature (antipyretic drugs); ensure adequate parental understanding of specific antipyretic dosage to prevent accidental overdose.
- If child is prone to seizures, discuss appropriate precautions and possibility of recurrent febrile seizures.
- Ensure adequate oral fluid intake.
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Measles (Rubeola) |
- Agent: Virus\
- Source: Respiratory tract secretions, blood, and urine of infected person
- Transmission: Usually by direct contact with droplets of infected person; primarily in winter
- Incubation period: 10 to 20 days
- Period of communicability: From 4 days before to 5 days after rash appears but mainly during prodromal (catarrhal) stage
| - Prodromal (catarrhal) stage: Fever and malaise, followed in 24 hours by coryza, cough, conjunctivitis, Koplik spots (small, irregular red spots with a minute, bluish-white center first seen on buccal mucosa opposite molars 2 days before rash); symptoms gradually increasing in severity until second day after rash appears, when they begin to subside
- Rash: Appears 3 to 4 days after onset of prodromal stage; begins as erythematous maculopapular eruption on face and gradually spreads downward; more severe in earlier sites (appears confluent) and less intense in later sites (appears discrete); after 3 to 4 days, assumes brownish appearance, and fine desquamation occurs over area of extensive involvement
- Constitutional signs and symptoms: Anorexia, abdominal pain, malaise, generalized lymphadenopathy
| - Administer vitamin A for children with acute illness: 200,000 International units for children 12 months of age and older; 100,000 International units for children 6 to 11 months of age, 50,000 International units for infants younger than 6 months of age
- Supportive: Bed rest during febrile period; antipyretics
- Antibiotics to prevent secondary bacterial infection in high-risk children
- Complications: Otitis media
- Pneumonia (bacterial)
- Obstructive laryngitis and laryngotracheitis
- Encephalitis (rare but has high mortality)
- Preventive: Childhood immunization
| - Isolate until fifth day of rash; if hospitalized, institute Airborne Precautions.
- Encourage rest during prodromal stage; provide quiet activity.
- Fever: Instruct parents to administer antipyretics; avoid chilling; if child is prone to seizures, institute appropriate precautions.
- Eye care: Dim lights if photophobia present; clean eyelids with warm saline solution to remove secretions or crusts; keep child from rubbing eyes.
- Coryza, cough: Use cool-mist vaporizer; protect skin around nares with layer of petrolatum; encourage fluids and soft, bland foods.
- Skin care: Keep skin clean; use tepid baths as necessary.
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Mumps |
- Agent: Paramyxovirus
- Source: Saliva of infected persons
- Transmission: Direct contact with or droplet spread from an infected person
- Incubation period: 14 to 21 days
- Period of communicability: Most communicable immediately before and after swelling begins
| - Prodromal stage: Fever, headache, malaise, and anorexia for 24 hours, followed by “earache” that is aggravated by chewing
- Parotitis: By third day, parotid gland(s) (either unilateral or bilateral) enlarges and reaches maximum size in 1 to 3 days; accompanied by pain and tenderness; other exocrine glands (submandibular) may also be swollen
| - Supportive: Analgesics for pain and antipyretics for fever
- Intravenous fluid may be necessary for child refusing to drink or vomiting because of meningoencephalitis
- Complications: Sensorineural deafness
- Postinfectious encephalitis
- Myocarditis
- Arthritis
- Hepatitis
- Epididymo-orchitis
- Oophoritis
- Pancreatitis
- Sterility (extremely rare in adult males)
- Meningitis
- Preventive: Childhood immunization
| - Maintain isolation during period of communicability; institute Droplet and Contact Precautions during hospitalization.
- Encourage rest and decreased activity during prodromal phase until swelling subsides.
- Give analgesics for pain; if child is unable to swallow pills or tablets, use elixir form.
- Encourage fluids and soft, bland foods; avoid foods requiring chewing.
- Apply hot or cold compresses to neck, whichever is more comforting.
- To relieve orchitis, provide warmth and local support with tight-fitting underpants.
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Pertussis (Whooping Cough) |
- Agent: Bordetella pertussis
- Source: Discharge from respiratory tract of infected person
- Transmission: Direct contact or droplet spread from infected person; indirect contact with freshly contaminated articles
- Incubation period: 6 to 20 days; usually 7 to 10 days
- Period of communicability: Greatest during catarrhal stage before onset of paroxysms
| - Catarrhal stage: Begins with symptoms of upper respiratory tract infection, such as coryza, sneezing, lacrimation, cough, and low-grade fever; symptoms continue for 1 to 2 weeks when dry, hacking cough becomes more severe
- Paroxysmal stage: Cough most often occurs at night and consists of short, rapid coughs followed by sudden inspiration associated with a high-pitched crowing sound or “whoop”; during paroxysms, cheeks become flushed or cyanotic, eyes bulge, and tongue protrudes; paroxysm may continue until thick mucus plug is dislodged; vomiting frequently follows attack; stage generally lasts 4 to 6 weeks, followed by convalescent stage.
- Infants younger than 6 months of age may not have characteristic whoop cough but have difficulty maintaining adequate oxygenation with amount of secretions, frequent vomiting of mucus and formula or breast milk.
- Pertussis may occur in adolescents and adults with varying manifestations; cough and whoop may be absent, however, as many as 50% of adolescents may have a cough for up to 10 weeks
- Additional symptoms in adolescents include difficulty breathing and post-tussive vomiting.
| - Antimicrobial therapy (e.g., erythromycin, clarithromycin, azithromycin)
- Supportive: Hospitalization sometimes required for infants, children who are dehydrated, or those who have complications Increased oxygen intake and humidity
- Adequate fluid intake
- Intensive care and
- Mechanical ventilation may be necessary for infants younger than 6 months of age
- Complications: Pneumonia (usual cause of death in younger children)
- Atelectasis
- Otitis media
- Seizures
- Hemorrhage (scleral, conjunctival, epistaxis; pulmonary hemorrhage in neonate)
- Weight loss and dehydration
- Hernias (umbilical and inguinal)
- Prolapsed rectum
- Complications reported among adolescents include syncope, sleep disturbance, rib fractures, incontinence, and pneumonia
- Preventive: Immunization; childhood immunizations for pertussis does not confer lifelong immunity, so a pertussis booster is recommended for adolescents.
| - Maintain isolatation during catarrhal stage; if hospitalized, institute Droplet and Standard Precautions.
- Obtain nasopharyngeal culture for diagnosis.
- Encourage oral fluids; offer small amount of fluids frequently.
- Ensure adequate oxygenation during paroxysms; position infant on side to decrease chance of aspiration with vomiting.
- Provide humidified oxygen; suction as needed to prevent choking on secretions.
- Observe for signs of airway obstruction, such as increased restlessness, apprehension, retractions, cyanosis.
- Encourage compliance with antibiotic therapy for household contacts.
- Encourage adolescents to obtain pertussis booster (Tdap).
- Use Standard and Droplet Precautions in health care workers exposed to children with persistent cough and high suspicion of pertussis.
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Poliomyelitis |
- Agent: Enteroviruses, three types: type 1, most frequent cause of paralysis (paralytic form), both epidemic and endemic; type 2, least frequently associated with paralysis; type 3, second most frequently associated with paralysis
- Source: Feces and oropharyngeal secretions of infected persons, especially young children
| - May be manifested in three different forms:
- Abortive or inapparent: Fever, uneasiness, sore throat, headache, anorexia, vomiting, abdominal pain; lasts few hours to few days
- Nonparalytic: Same manifestations as abortive but more severe, with pain and stiffness in neck, back, and legs
| - Supportive: Complete bed rest during acute phase
- Mechanical or assisted ventilation in case of respiratory paralysis
- Physical therapy for muscles following acute stage
| - Institute Contact Precautions.
- Participate in physical therapy procedures (use of moist hot packs and range-of motion exercises).
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- Transmission: Direct contact with persons with apparent or inapparent active infection; spread is via fecal-oral and pharyngeal-oropharyngeal routes
- Vaccine-acquired paralytic polio may occur as result of live oral polio vaccination (no longer available in the United States)
- Incubation period: Usually 7 to 14 days, with range of 5 to 35 days
- Period of communicability: Not exactly known; virus present in throat and feces shortly after infection and persists for about 1 week in throat and 4 to 6 weeks in feces
| - Paralytic: Initial course similar to nonparalytic type, followed by recovery and then signs of central nervous system paralysis
| - Complications: Permanent paralysis
- Respiratory arrest
- Hypertension
- Kidney stones from demineralization of bone during prolonged immobility
- Preventive: Childhood immunization
| - Position child to maintain body alignment and prevent contractures or skin breakdown; use footboard or appropriate orthoses to prevent footdrop; use pressure mattress for prolonged immobility.
- Encourage child to perform activities of daily living to capability, promote early ambulation with assistive devices; administer analgesics for maximum comfort during physical activity; give high-protein diet and bowel management for prolonged immobility.
- Observe for respiratory paralysis (difficulty in talking, ineffective cough, inability to hold breath, shallow and rapid respirations); report such signs and symptoms to practitioner.
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Rubella (German Measles) |
- Agent: Rubella virus
- Source: Primarily nasopharyngeal secretions of person with apparent or inapparent infection; virus also present in blood, feces, and urine
- Incubation period: 14 to 21 days
- Period of communicability: 7 days before to about 5 days after appearance of rash
- Constitutional signs and symptoms:
- Occasionally low-grade fever, headache, malaise, and lymphadenopathy
| - Prodromal stage: Absent in children, present in adults and adolescents; consists of low-grade fever, headache, malaise, anorexia, mild conjunctivitis, coryza, sore throat, cough, and lymphadenopathy; lasts 1 to 5 days, subsides 1 day after appearance of rash
- Rash: First appears on face and rapidly spreads downward to neck, arms, trunk, and legs; by end of first day, body is covered with discrete, pinkish-red, maculopapular exanthema; disappears in same order as it began, and is usually gone by third day
| - No treatment necessary other than antipyretics for low-grade fever and analgesics for discomfort
- Complications: Rare (arthritis, encephalitis, or purpura); most benign of all childhood communicable diseases; greatest danger is teratogenic effect on fetus
- Preventive: Childhood immunization
| - Institute Droplet Precautions.
- Reassure parents of benign nature of illness in affected child.
- Use comfort measures as necessary.
- Avoid contact with pregnant woman.
- Monitor rubella titers in pregnant adolescent.
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Scarlet Fever |
- Agent: Group A β- hemolytic streptococci
- Source: Usually from nasopharyngeal secretions of infected persons and carriers
- Transmission: Direct contact with infected person or droplet spread; indirectly by contact with contaminated articles or ingestion of contaminated milk or other food
- Incubation period: 2 to 5 days, with range of 1 to 7 days
- Period of communicability: During incubation period and clinical illness, approximately 10 days; during first 2 weeks of carrier phase, although may persist for months
| - Prodromal stage: Abrupt high fever, pulse increased out of proportion to fever, vomiting, headache, chills, malaise, abdominal pain, halitosis
- Enanthema: Tonsils enlarged, edematous, reddened, and covered with patches of exudates; in severe cases, appearance resembles membrane seen in diphtheria; pharynx is edematous and beefy red; during first 1 to 2 days, tongue coated and papillae become red and swollen (white strawberry tongue); by fourth or fifth day, white coat sloughs off, leaving prominent papillae (red strawberry tongue); palate covered with erythematous punctate lesions
- Exanthema: Rash appears within 12 hours after prodromal signs; red pinhead-size punctate lesions rapidly become generalized but are absent on face, which becomes flushed with striking circumoral pallor; rash more intense in folds of joints; by end of first week, desquamation begins (fine, sandpaper-like on torso; sheetlike sloughing on palms and soles), which may be complete by 3 weeks or longer
| - Full course of penicillin (or erythromycin in penicillin-sensitive children), or oral cephalosporin
- Antibiotic therapy for newly diagnosed carriers (nose or throat cultures positive for streptococci)
- Supportive: Rest during febrile phase, analgesics for sore throat; antipruritics for rash if bothersome
- Complications: Peritonsillar and retropharyngeal abscess
- Sinusitis
- Otitis media
- Acute glomerulonephritis
- Acute rheumatic fever
- Polyarthritis (uncommon)
| - Institute Standard and Droplet Precautions until 24 hours after initiation of treatment.
- Ensure compliance with oral antibiotic therapy; intramuscular benzathine penicillin G (Bicillin) may be given.
- Encourage rest during febrile phase; provide quiet activity during convalescent period.
- Relieve discomfort of sore throat with analgesics, gargles, lozenges, antiseptic throat sprays, and inhalation of cool mist.
- Encourage oral fluids during febrile phase; avoid irritating liquids (certain citrus juices) or rough foods (chips); when child is able to eat, begin with soft diet.
- Advise parents to consult practitioner if fever persists after beginning therapy.
- Discuss procedures for preventing spread of infection; discard toothbrush; avoid sharing drinking and eating utensils.
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