Fiebre escarlatina, kawasaki y mononucleosis infecciosa

FIEBRE ESCARLATINA,
KAWASAKI Y MONONUCLEOSIS
INFECCIOSA
Dr. Alcibíades Batista González
Pediatría II (MED-530)
UNACHI

ESTREPTOCOCOS GRUPO A
(GAS)
• La infección aguda más frecuente por
GAS es la faringoamigadalitis aguda.
• Complicaciones purulentas ocurren en
algunos pacientes, con mayor frecuencia
los no tratados, e incluyen:
– Otitis media
– Sinusitis
– Abscesos peritonsilares y retrofaríngeos
– Adenitis cervicales supurativas

Copyright ©2006 American Academy of Pediatrics
Red Book Online Visual Library, 2006. Image 124_63. Available at:
http://aapredbook.aappublications.org/visual. Accessed May 26, 2007
Group A Streptococcal Infections. Streptococcus pyogenes, 24h sheep Blood Agar Plate, beta hemolysis
(close-up view)

Group A streptococcal pharyngitis with inflammation of the tonsils and uvula.

Erythematous tonsils in a child with group A streptococcal pharyngitis.

Group A streptococcal pharyngitis with petechiae on the soft palate.

Group A streptococcal nasopharyngitis in toddlers often is associated with tender anterior cervical
lymphadenopathy. A throat culture is not always positive when the infection has localized to the cervical
lymph nodes.

(GAS)
• En menores de 3 años (1 a 3 años) puede
presentarse una infección de vías
respiratorias altas por GAS.
• Se le conoce como:
– Estreptococosis
– Fiebre estreptocócica
• Su importancia clínica se relaciona con la
morbilidad aguda y no con las secuelas
no supurativas.

(GAS)
• Características clínicas de la fiebre
estreptocócica:
– 1-3 años con cuadro febril agudo.
– Rinitis con descarga serosa,
serosanguinolenta o mucopurulenta.
– Irritabilidad e hiporexia.
– Lesiones impetiginizadas alrededor de las
narinas.

(GAS)
• Características clínicas de la fiebre
estreptocócica:
– Puede presentarse artritis reactiva.
– El cuadro clínico puede presentarse asociado
a H. influenzae y S. pneumoniae.
– La clásica presentación de la infección por
GAS con faringitis es poco frecuente en < 3
años.
– La fiebre reumática es muy rara en < 3 años.

Protracted nasopharyngitis is the most common presentation of group A streptococcal infection in
toddlers. Inflammation of the skin beneath the nares often is present as in this child.

FIEBRE ESCARLATINA
• Resulta de una infección por GAS que
produzca cualquiera de las 3 exotoxinas
pirogénicas (eritrogénicas).
• Foco primario de infección es con mayor
frecuencia una faringitis.
• También puede ocurrir secundaria a una
herida infectada o a una infección de la
piel.

FIEBRE ESCARLATINA
• El inicio es agudo y se caracteriza por:
– Fiebre
– Escalofríos
– Vómitos
– Cefalea
– Toxicidad
– Exantema generalizado que parece
quemadura solar (escarlatiniforme).

FIEBRE ESCARLATINA
Figure 35-2 Schematic diagram of a typical case of untreated uncomplicated scarlet
fever. The rash usually appears within 24 hours of onset of fever and sore throat.
Gershon: Krugman's Infectious Diseases of Children, 11th ed. 2004

FIEBRE ESCARLATINA
Figure 35-3 Schematic drawing
illustrating development and
distribution of scarlet fever rash.
Gershon: Krugman's Infectious Diseases of Children, 11th ed. 2004

FIEBRE ESCARLATINA
• El exantema es más acentuado en las
axilas, áreas inguinales y el cuello.
• Punteado de máculas rojas o finas
pápulas que blanquean con la presión.
• Puede haber petequias en partes distales
de las extremidades.
• En algunos individuos el exantema da la
sensación de papel de lija.

A 4-1/2 year-old white male with the rash and strawberry tongue of scarlet fever.

Confluent rash of scarlet fever over the posterior surfaces of the 4-1/2 year old white
male in the previous image.

Erythema and desquamation of the palms and confluent rash of scarlet fever over the anterior surfaces of
the 4-1/2 year old white male in the 2 previous images.

Group A streptococcal rash in a white male with a positive throat culture for group A streptococci and an
elevated antistreptolysin O titer.

Pastias lines in the antecubital space of a 12-year-old white male with scarlet fever

SÍNDROME DE KAWASAKI
• Síndrome mucocutáneo-nódulo linfático.
• Enfermedad febril, exantemática.
• Vasculitis aguda de niños pequeños.
– 1-8 años (80% son < 4 años).
• Aneurismas coronarios en 20% de los
pacientes no tratados.
• Muerte súbita puede resultar de IAM,
miocarditis o ruptura de aneurisma
coronario.

• Descrito en 1967, en Japón,
cuando Tomisaku Kawasaki
describió su experiencia
con 50 casos.
• Desarrolló los criterios
diagnósticos que aún
se utilizan.

• Causa desconocida.
• Gatillo infeccioso – Marcada respuesta
inmune inflamatoria.
• Hallazgos patológicos ampliamente
descritos y virtualmente idénticos en todos
los pacientes afectados, con variaciones
en la severidad.

• Lesiones inflamatorias sistémicas:
– Vasculares (arterias de mediano calibre)
– Sistema cardiovascular:
• Miocarditis
• Pericarditis
• Endocarditis (menos frecuente)
– Sistema respiratorio:
• Bronquitis
• Neumonía intersticial

– Sistema digestivo:
• Estomatitis
• Adenitis sialoductal
• Enteritis
• Hepatitis, colangitis
• Pancreatitis
• Ductitis pancreática

– Sistema urinario:
• Nefritis intersticial focal
• Cistitis
• Prostatitis
– Sistema nervioso:
• Meningitis aséptica
• Neuritis
– Sistema hematopoyético:
• Linfadenitis y esplenitis.

• El cuadro clínico es la base del
diagnóstico.
• No existe una prueba de laboratorio que
apoye o confirme el diagnóstico.
• El diagnóstico se basa en los criterios
diagnósticos del síndrome de Kawasaki.

DIAGNOSTIC CRITERIA FOR
KAWASAKI SYNDROME
Fever, daily for more than 5 days, high spiking and intermittent, with
four of the five following clinical features:
•Bulbar conjunctival injection, generally nonpurulent
•Changes in the oral mucosa, consisting of:
- Red, fissured lips
- Redness of the mouth
- Strawberry tongue
•Changes in the hands and feet, consisting of:
- Redness of the palms and soles
- Swelling of the hands and feet
- Peripheral desquamation in the subacute stage of illness

DIAGNOSTIC CRITERIA FOR
KAWASAKI SYNDROME
Fever, daily for more than 5 days, high spiking and intermittent, with
four of the five following clinical features:
•Rash, erythematous and polymorphous but nonvesicular:
- Maculopapular
- Erythema multiforme–like
- Scarlatiniform
•Cervical lymphadenopathy, greater than 1.5 cm in diameter

ASSOCIATED
FEATURES OF
KAWASAKI SYNDROME

• Tratamiento:
– Inmunoglobulina Intravenosa 2 g/kg en 10-12
horas.
– ASA 80-100 mg/kg/día divididos c/6h
– Medidas de sostén.
– Seguimiento con ecocardiograma.

Some clinical signs of
Kawasaki syndrome. A,
Discrete vascular injection
of the bulbar conjunctiva.
B, Generalized
lip erythema with mild
edema, cracking, and
bleeding fissures.
C, Diffuse red-purple
discoloration of the
palm(s).
D, Desquamation
beginning at the fingertips
just below the nailbeds.
E, Diffuse
erythematous,
nonvesicular and
nonbullous, polymorphic
rash.
F, Unilaterally enlarged
cervical lymph node.

Image 068_01. Kawasaki Disease. Child with Kawasaki syndrome with striking facial rash and erythema
of the oral mucous membrane.

Image 068_02. Kawasaki Disease. Child with Kawasaki syndrome with conjunctivitis. Note the absence of
conjunctival discharge.

Image 068_06. Kawasaki Disease. Periungual desquamation of a patient with Kawasaki syndrome. This is
the same patient as in images 068_03, 068_04, and 068_05.

Image 068_08. Kawasaki Disease. Distal desquamation of Kawasaki syndrome. This is the same patient as
in image 068_07.

Image 068_09. Kawasaki Disease. A child with the characteristic desquamation of the hands in a later
stage of Kawasaki syndrome.

Image 068_10. Kawasaki Disease. Bulbar conjunctivitis in a patient with Kawasaki syndrome. Exudation
generally is absent.

Image 068_11. Kawasaki Disease. Erythematous lips and injection of the oropharyngeal membranes in a
patient with Kawasaki syndrome. Scarlet fever, toxic shock syndrome, staphylococcal scalded skin
syndrome, and measles may be confused with this disease.

Image 068_12. Kawasaki Disease. Hyperemia and fissuring of lips in a patient with Kawasaki syndrome.

Image 068_19. Kawasaki Disease. Desquamation of the skin of the toes following Kawasaki syndrome.
This is the same patient as shown in image 068_18.

Image 068_20. Kawasaki Disease. A 20-month old white male with acute erythroderma and fever
associated with Kawasaki Disease

Image 068_21. Kawasaki Disease. This one-year old white child presented with fever, generalized
erythroderma, and conjunctivitis compatible with Kawasaki Disease

Image 068_22. Kawasaki Disease. Erythroderma of the palm of the hand of the child in the previous image
with Kawasaki disease

Image 068_23. Kawasaki Disease. Erythroderma of the plantar foot surface of the child in the previous 2
images with Kawasaki disease

Image 068_24. Kawasaki Disease. The one-year old white child in the above 3 images presented with this
erythema multiforme-like rash most pronounced over the back. The clinical course was characteristic of
Kawasaki disease

MONONUCLEOSIS INFECCIOSA
• Etiología viral
– Epstein Barr virus.
– Incubación: 4-6 semanas.
– Características clínicas:
• Fiebre
• Linfadenopatía
• Tonsilofaringitis
• Esplenomegalia
• Hepatitis
• Rash
• Neumonitis
• Compromiso del Sistema Nervioso

Image 043_01. Epstein-Barr Virus Infections (Infectious Mononucleosis). Atypical lymphocyte in a
peripheral blood smear of a patient with infectious mononucleosis. This lymphocyte is larger than normal
lymphocytes with a higher ratio of cytoplasm to nucleus. The cytoplasm is vacuolated and basophilic. This
may also be present in cytomegalovirus infections.

Image 043_02. Epstein-Barr Virus Infections (Infectious Mononucleosis). Epstein-Barr virus disease.
Bilateral cervical lymphadenopathy.

Image 043_04. Epstein-Barr Virus Infections (Infectious Mononucleosis). Epstein-Barr virus disease with
pharyngeal and tonsillar exudate.

Image 043_06. Epstein-Barr Virus Infections (Infectious Mononucleosis). Cervical lymphadenopathy in a
7-year-old girl with infectious mononucleosis.

Image 043_08. Epstein-Barr Virus Infections (Infectious Mononucleosis). Rash in the same patient as in
image 043_07 with infectious mononucleosis who was receiving ampicillin. These morbilliform rashes are
considered nonallergic.

Image 043_09. Epstein-Barr Virus Infections (Infectious Mononucleosis). A preadolescent child with
infectious mononucleosis with petechiae on the soft palate and uvula without exudation.

Image 043_10. Epstein-Barr Virus Infections (Infectious Mononucleosis). A conjunctival hemorrhage of
the right eye of a patient with infectious mononucleosis. At times, noninfectious conjunctivitis, as well as
other corneal abnormalities, may manifest itself due to the body's systemic response to viral infections
such as infectious mononucleosis.

Fiebre escarlatina, kawasaki y mononucleosis infecciosa

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