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MRCPCH GUIDE Inf Varicella–zoster immunoglobulin (VZIG) is recommended for indi

MRCPCH GUIDE Inf Varicella–zoster immunoglobulin (VZIG) is recommended for individuals who are at increased risk of severe varicella and who have no antibodies to varicella–zoster virus and who have significant exposure to chickenpox or herpes zoster. Those at increased risk include neonates of women who develop chickenpox in the period 7 days before to 7 days after delivery, women exposed at any stage of pregnancy, and the immunosuppressed including those who have received corticosteroids in the previous 3 months at the following dose equivalents of prednisolone; 2mg/kg/day for at least 1 week, or 1mg/kg/day for 1 month. Universal BCG immunisation of teenagers has recently been removed from the immunisation schedule, with a targeted strategy now recommended to immunise groups at increased risk in infancy or adulthood. Pneumococcal conjugate vaccine was recommended for children under 5 years with chronic lung, renal, liver and cardiac conditions, diabetes, immunosuppresion / immunocompromised, cochlear implants, CSF shunts and previous invasive pneumococcal disease. Conjugate vaccine produces a better immune response than polysaccharide vaccine in young children and has now been included in the routine vaccination schedule. MMR is indicated for post-exposure prophylaxis within 3 days of exposure to measles as the antibody response to the vaccine is faster than the response to natural infection. Individuals at high risk of severe illness should receive human normal immunoglobulin. Varicella vaccine is not currently recommended in the UK for universal childhood immunisation, but it is recommended for non-immune close contacts of immunocompromised patients and non-immune health care workers. Palivizumab is recommended for specific groups at risk of severe RSV disease, although these individuals represent a very small fraction of the health burden of RSV. Currently use in children under 2 years with chronic lung disease requiring oxygen is recommended, but use in those with chronic lung disease not requiring oxygen requires more evidence. Group B streptococcus (GBS, Streptococcus agalactiae) is the commonest cause of severe early onset (within 7 days of birth) infection in new born infants. About 25% of mothers in the UK are carriers, and the incidence of proven neonatal disease is about 0.7/1000 live births. Universal screening and intrapartum intravenous antibiotic prophylaxis is practised in the United States and has resulted in a decrease in the incidence of early onset neonatal infection with GBS, but has not clearly demonstrated a decrease in neonatal deaths and there are concerns about antibiotic resistance and other organisms replacing GBS infection. GBS is one of the most common causes of early onset neonatal meningitis, but recent studies show that the incidence appears to be declining, probably as a result of antibiotic prophylaxis policies. Blood cultures are probably negative in more than half of cases of probable GBS infection, due to antibiotic prophylaxis or insufficient samples of blood. Late onset GBS infection (after 1 week of age) is well described and accounts for about one-third of all cases. Diseases notifiable by law differ between the three areas of England & Wales, Northern Ireland and Scotland. Generally speaking the diseases against which routine immunisation is recommended, are notifiable with the exception of Haemophilus influenzae. Others include serious imported infections: typhoid, cholera, malaria and viral haemorrhagic fever. It is important that clinicians think about whether an infectious disease is notifiable, as it is the responsibility of the clinician looking after the patient to submit the notification. Syphilis is undergoing a resurgence at present, so paediatricians need to be aware of how to deal with neonates born to mothers with positive serology. Positive non-treponemal tests such as RPR can be caused by a number of conditions other than syphilis eg EBV, TB, SLE. False positive treponeme specific tests (such as TPPA) can occur with other spirochaetal diseases such as Yaws. In this case it is very unlikely that the results represent a false positive, especially as the girl has signs consistent with secondary syphilis, but they should be repeated to confirm. Treatment in pregnancy should be given at least one month before delivery and parenteral penicillin is the treatment of choice. Symptomatic congenital syphilis at birth is unusual, and it is more common for the infant to become unwell during the first three months of life with failure to thrive, rashes and desquamation, nasal discharge and hepatosplenomegaly. In this case it would be advisable to treat the infant with a 10-14 day course of intravenous penicillin. Herpes simplex virus can cause overwhelming infection in the neonate. The risk of infection in the newborn is around 5% if the mother has active recurrent infection, but up to 50% if it is a primary infection. Clinically it can be difficult to distinguish primary from recurrent episodes in the mother as primary episodes may be asymptomatic. Empirical aciclovir treatment may be justified for infants born to mothers with primary episodes, but for secondary episodes most experts advise waiting for the results of swabs and specimens submitted for viral culture or PCR (nasopharynx, rectum, mouth, stool and urine). Disease in the newborn occurs within four weeks of birth, and even low-risk infants with no HSV detected from swabs / stool/ urine, should be observed for the appearance of any rash, seizures or sepsis-like illness. Peritonsillar abscess (“quinsy”) typically causes an asymmetrical appaearance of the tonsils with displacement of the uvula away from the affected side. Lemiere’s disease is retropharyngeal abscess caused by fusobacterium necrophorum, with thrombosis of the internal jugular vein and metastatic abscesses. Streptococcal throat infection is a possibility in this case but the fact that the spleen is palpable, the palatal petechiae and the failure to respond to antibiotics makes this less likely. Diphtheria is rare in the UK and classically a grey- white membrane develops which is firmly adherent to the throat. The most damaging effects are due to an exotoxin acting on local tissues, motor nerves and myocardium. Cutaneous Leishmaniasis Leishmaniasis is caused by an intracellular protozoal organism, transmitted by the bite of sandflies. In cutaneous leishmaniasis there is usually a papule which develops into a nodule before ulcerating. It will frequently resolve by itself after months or even years. Most cutaneous leishmaniasis is acquired is South America, Afghanistan, Iran, Syria and Saudia Arabia. It is important to evaluate “New World” cases thoroughly because some species cause cutaneous lesions which are later followed by destructive mucosal lesions (mucocutaneous leishmaniasis). Tinea Tinea capitis can present in six different patterns. 1. Extensive scaling in circular patches of hair loss. 2. Black dots where hair follicles have broken off. 3. Kerion – a boggy inflammatory swelling. 4. Diffuse dandruff like scaling. 5. “Moth-eaten” patchy hair loss. 6. Widespread pustules often with cervical lymphadenopathy. Treatment should be systemic with griseofulvin and terbinafine. Diseases associated with EBV include: · Stevens Johnson syndrome · Hepatitis · Herpes · Infectious mononucleosis (glandular fever) · Alice in Wonderland syndrome · Non-Hodgkin's lymphoma, including Burkitt's lymphoma and primary cerebral lymphoma · Hodgkin's disease · Post-transplant lymphoproliferative disorder · nasopharyngeal cancer · Herpangina MMR is the best protection against these viruses. There is no credible link with bowel disease or autism. It is contraindicated in those with suppressed immunity. According to the WHO, measles vaccine is not given to HIV positive children with severe immunosuppression (i.e. CD4 <15%). However the majority of children under age 15 months with HIV do not (yet) have sufficient immunosuppression to mean that measles vaccine is unsafe, and it is particularly important to follow national guidelines in immunising these children, on time, to protect them against wild measles. Like wild measles, measles vaccine virus may rarely cause a fatal giant cell pneumonitis, but only in individuals with profound immunosuppression. MMR is useful in measles outbreaks, but it is less helpful in providing individual protection in mumps or rubella epidemics since the antibody response is too slow to provide protection for those already exposed. The contraindications include those who are allergic to gelatine or neomycin. The contraindications to MMR are :  Untreated malignant disease or altered cell-mediated immunity  Another live vaccine within 3 weeks  Allergies to gelatine or neomycin  Acute febrile illness  Pregnancy within 1 month  Within 3 months of an immunoglobulin injection Palivizumab is an intramuscular injection to prevent serious lower respiratory tract infection caused by respiratory syncitial virus (RSV) given in chronic lung disease and haemodynamically significant congenital heart disease infants. The injections are monthly for 5 months during the winter RSV season and it reduces hospitalisations and oxygen requirement in protected children. Rabies vaccination consists of pre-exposure immunisation to those at risk (3 injections, with booster doses). Post exposure treatment for fully protected individuals is just 2 more doses of immunisation, but for unprotected individuals is also rabies immunoglobulin. Most children are unprotected. Cholera immunisation is no longer recommended. Yellow fever immunisation is recommended under 9 months of age if the risk of yellow fever is unavoidable. Malaria prophylaxis with chloroquine or mefloquine is not appropriate for those with a history of epilepsy. Hepatitis A vaccine is the preferred prophylaxis and is likely to be effective even if given shortly before uploads/Sante/ mrcpch-guide-inf.pdf