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Back-to-School Illnesses: Classroom Contagions in 2023
Mark P Brady, PA-C | July 20, 2023
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Image from the US Centers for Disease Control and Prevention (CDC). (Public domain.)
Back-to-School Illnesses: Classroom Contagions in 2023
Mark P Brady, PA-C | July 20, 2023 | Contributor Information
Long gone are the days of the routine school preparation including updating basic vaccines, a list of school supplies, a new pair of shoes, and a backpack. The downstream impact of the global coronavirus (COVID-19) pandemic, viral emergence of monkeypox, increased screentime and social media dependence, along with increasing rates of obesity in our school-aged population, has dramatically changed our perspective on how to start a healthy school year.
Just the same, now is a great time to refresh your knowledge of common infections that may affect your young patients as they return to class. While headway has been made on vaccine lapses during the pandemic, it is beneficial to stay aware of school and campus illnesses.
Image from Wikimedia Commons | Grook Da Oger. [Creative Commons Attribution-Share Alike 3.0 Unported (CC BY-SA-3.0).]
Back-to-School Illnesses: Classroom Contagions in 2023
Mark P Brady, PA-C | July 20, 2023 | 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 Illnesses: Classroom Contagions in 2023
Mark P Brady, PA-C | July 20, 2023 | 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 blister-like 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 Illnesses: Classroom Contagions in 2023
Mark P Brady, PA-C | July 20, 2023 | Contributor Information
This pruritic, generalized skin manifestation that began on this child's face, chest, and back is concerning for which illness?
Image courtesy of Russell W. Steele, MD.
Back-to-School Illnesses: Classroom Contagions in 2023
Mark P Brady, PA-C | July 20, 2023 | 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 vaccine initiation in 1995, chickenpox-related hospitalizations and deaths are rare.[4]
Image from UK Health Security Agency via the CDC. (Public domain.)
Back-to-School Illnesses: Classroom Contagions in 2023
Mark P Brady, PA-C | July 20, 2023 | 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. Conversely, 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 Illnesses: Classroom Contagions in 2023
Mark P Brady, PA-C | July 20, 2023 | Contributor Information
This unvaccinated child has a diffuse rash along with cough, coryza, and conjunctivitis. What is the suspected etiology of his illness?
Image courtesy of Russell W. Steele, MD.
Back-to-School Illnesses: Classroom Contagions in 2023
Mark P Brady, PA-C | July 20, 2023 | 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 2022, there were 121 new cases of measles in the US.[8]
Image courtesy of Russell W. Steele, MD.
Back-to-School Illnesses: Classroom Contagions in 2023
Mark P Brady, PA-C | July 20, 2023 | 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?
Adapted image from the CDC | Heinz F. Eichenwald, MD. (Public domain.)
Back-to-School Illnesses: Classroom Contagions in 2023
Mark P Brady, PA-C | July 20, 2023 | Contributor Information
Answer: Symptomatic management. 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 from Medscape.
Back-to-School Illnesses: Classroom Contagions in 2023
Mark P Brady, PA-C | July 20, 2023 | Contributor Information
This child presents with a rash on both cheeks after several days of fever and rhinitis. What diagnosis should be suspected?
Image from Medscape.
Back-to-School Illnesses: Classroom Contagions in 2023
Mark P Brady, PA-C | July 20, 2023 | 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, although 20% of infected persons can be asymptomatic. Typically a clinical diagnosis, 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 courtesy of Victoria Regen via Pixabay. (Public domain).
Back-to-School Illnesses: Classroom Contagions in 2023
Mark P Brady, PA-C | July 20, 2023 | 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 son 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 Illnesses: Classroom Contagions in 2023
Mark P Brady, PA-C | July 20, 2023 | 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. [Creative Commons Attribution 4.0 International (CC BY 4.0).] PMID: 33054802.
Back-to-School Illnesses: Classroom Contagions in 2023
Mark P Brady, PA-C | July 20, 2023 | 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 Illnesses: Classroom Contagions in 2023
Mark P Brady, PA-C | July 20, 2023 | 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]
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Contributor Information
Author
Mark P Brady, PA-C
Adjunct Faculty and Preceptor
Physician Assistant Program
University of New England;
Physician Assistant
Department of Emergency Medicine
Cambridge Hospital, Cambridge Health Alliance
Cambridge, MA
Disclosure: Mark P Brady, PA-C, has disclosed no relevant financial relationships.
Reviewer
Bret A Nicks, MD, MHA, FACEP
Professor, Emergency Medicine
Director, Masters of Healthcare Leadership
Director, EM Administrative and Leadership Fellowship
Director, EM Global Health Fellowship
Wake Forest Baptist Health
Winston-Salem, NC
Disclosure: Bret A Nicks, MD, MHA, FACEP, has disclosed no relevant financial relationships.
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References
Graham BS. Dermatologic manifestations of hand-foot-and-mouth disease. Medscape Drugs & Diseases from WebMD. Updated: March 5, 2020. Available at: https://emedicine.medscape.com/article/1132264-overview. Accessed: August 5, 2020.
Centers for Disease Control and Prevention. Hand, foot, and mouth disease (HFMD). Reviewed: May 11, 2023. Available at: https://www.cdc.gov/hand-foot-mouth/. Accessed: July 3, 2023.
Centers for Disease Control and Prevention. Chickenpox (varicella). Reviewed: April 28, 2021. Available at: https://www.cdc.gov/chickenpox/. Accessed: July 3, 2023.
Centers for Disease Control and Prevention. Varicella vaccination information for healthcare professionals. Reviewed: April 28, 2021. Available at: https://www.cdc.gov/vaccines/vpd/varicella/hcp/index.html. Accessed: July 3, 2023.
Centers for Disease Control and Prevention. Measles (rubeola). Reviewed: November 5, 2020. Available at: https://www.cdc.gov/measles/index.html. Accessed: July 3, 2023.
Center for Disease Control and Prevention. Measles Cases and Outbreaks. Reviewed: June 9, 2023. Available at Measles Cases and Outbreaks | CDC AccessedL July 3, 2023.National Health Service. Mumps: complications. Reviewed: September 24, 2021. Available at: https://www.nhs.uk/conditions/mumps/complications/. Accessed: July 4, 2023.
Centers for Disease Control and Prevention. Influenza (flu). Reviewed: June 30, 2023. Available at: https://www.cdc.gov/flu/index.htm. Accessed: June 5, 2023.
Zhang Y, Xie RM, He YL, et al. Clinical and imaging features of pediatric COVID-19. Ital J Pediatr. 2020 Oct 14;46:153. doi: 10.1186/s13052-020-00917-1. PMID: 33054802. [Full text]
Centers for Disease Control and Prevention. Information for Healthcare Providers about Multisystem Inflammatory Syndrome in Children (MIS-C). Reviewed: January 3, 2023. Available at https://www.cdc.gov/mis/mis-c/hcp/ Accessed: July 5, 2023.
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