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Neonatal herpes manifests itself in three forms: skin, eyes, and mouth herpes (SEM) sometimes referred to as "localized", disseminated herpes (DIS), and central nervous system herpes(CNS).
- SEM herpes is characterized by external lesions but no internal organ involvement. Lesions are likely to appear on trauma sites such as the attachment site of fetal scalp electrodes, forceps or vacuum extractors that are used during delivery, in the margin of the eyes, the nasopharynx, and in areas associated with trauma or surgery (including circumcision).
- DIS herpes affects internal organs, particularly the liver.
- CNS herpes is an infection of the nervous system and the brain that can lead to encephalitis. Infants with CNS herpes present with seizures, tremors, lethargy, and irritability, they feed poorly, have unstable temperatures, and their fontanelle (soft spot of the skull) may bulge.
CNS herpes is associated with highest morbidity, and DIS herpes has a higher mortality rate. These categories are not mutually exclusive and there is often overlap of two or more types. SEM herpes has the best prognosis of the three, however, if left untreated it may progress to disseminated or CNS herpes with its attendant increases in mortality and morbidity.
Death from neonatal HSV disease in the U.S. is currently decreasing; The current death rate is about 25%, down from as high as 85% in untreated cases just a few decades ago. Other complications from neonatal herpes include prematurity with approximately 50% of cases having a gestation of 38 weeks or less, and a concurrent sepsis in approximately one quarter of cases that further clouds speedy diagnosis.
Late congenital syphilis is a subset of cases of congenital syphilis. By definition, it occurs in children at or greater than 2 years of age who acquired the infection trans-placentally.
Symptoms include
- blunted upper incisor teeth known as Hutchinson's teeth
- inflammation of the cornea known as interstitial keratitis
- deafness from auditory nerve disease
- frontal bossing (prominence of the brow ridge)
- saddle nose (collapse of the bony part of nose)
- hard palate defect
- swollen knees
- saber shins
- short maxillae
- protruding mandible
A frequently-found group of symptoms is Hutchinson's triad, which consists of Hutchinson's teeth (notched incisors), keratitis and deafness and occurs in 63% of cases.
Treatment (with penicillin) before the development of late symptoms is essential.
Though caused by different infections, the signs and symptoms of TORCH syndrome are consistent. They include hepatosplenomegaly (enlargement of the liver and spleen), fever, lethargy, difficulty feeding, anemia, petechiae, purpurae, jaundice, and chorioretinitis. The specific infection may cause additional symptoms.
TORCH syndrome may develop before birth, causing stillbirth, in the neonatal period, or later in life.
The types of neurosyphilis include asymptomatic, acute syphilitic meningitis, meningovascular syphilis, parenchymatous syphilis (which includes general paresis and tabes dorsalis), and optic atrophy.
The secondary stages of syphilis persists to be more dangerous to the systems of the human body. The disseminated disease can cause constitutional symptoms and condylomata lata. Many treponemes are present in chancres in the primary stage; however, condylomata lata is usually present in the secondary stage. The pathogen can spread through blood, which can infect the vessels in the body. The infection of the heart, muscles, and vessels in the body can lead to meningovascular syphilis. Generally, rashes may start developing on the hands and soles of the feet, and it can spread to various parts of skin on the body. Other symptoms may include sore throat, headache, joint pain, fever, and patches of hair loss. As in stage one, lesions may start to form on the body, but in this stage in particular, lesions are found in mucous membranes of the mouth, throat, bones, and internal organs. Also common with stage one, the symptoms and signs of secondary syphilis will go away with or without treatment and medication. The diagnosis includes serology nonspecific and specific, both positive. The secondary stage is however highly infectious because the bacteria is spreading drastically throughout the body.
Neonatal herpes simplex is a rare but serious condition, usually caused by vertical transmission of herpes simplex virus from mother to newborn. Around 1 in every 3,500 babies in the United States contract the infection.
Death from congenital syphilis is usually due to bleeding into the lungs.
A unilateral decrease in visual acuity is the most common symptom of toxoplasmic retinitis.
Under ophthalmic examination, toxoplasmic chorioretinitis classically appears as a focal, white retinitis with overlying moderate inflammation of the vitreous humour. A unifocal area of acute-onset inflammation adjacent to an old chorioretinal scar is virtually pathognomonic for toxoplasmic chorioretinitis. Focal condensation of vitreous and inflammatory cells may be seen overlying the pale yellow or gray-white raised lesion in the posterior pole.
Secondary syphilis occurs approximately four to ten weeks after the primary infection. While secondary disease is known for the many different ways it can manifest, symptoms most commonly involve the skin, mucous membranes, and lymph nodes. There may be a symmetrical, reddish-pink, non-itchy rash on the trunk and extremities, including the palms and soles. The rash may become maculopapular or pustular. It may form flat, broad, whitish, wart-like lesions known as condyloma latum on mucous membranes. All of these lesions harbor bacteria and are infectious. Other symptoms may include fever, sore throat, malaise, weight loss, hair loss, and headache. Rare manifestations include liver inflammation, kidney disease, joint inflammation, periostitis, inflammation of the optic nerve, uveitis, and interstitial keratitis. The acute symptoms usually resolve after three to six weeks; about 25% of people may present with a recurrence of secondary symptoms. Many people who present with secondary syphilis (40–85% of women, 20–65% of men) do not report previously having had the classic chancre of primary syphilis.
Gummas have a firm, necrotic center surrounded by inflamed tissue, which forms an amorphous proteinaceous mass. The center may become partly hyalinized.
These central regions begin to die through coagulative necrosis, though they also retain some of the structural characteristics of previously normal tissues, enabling a distinction from the granulomas of tuberculosis where caseous necrosis obliterates preexisting structures. Other histological features of gummas include an "intervening zone" containing epithelioid cells with indistinct borders and multinucleated giant cells, and a "peripheral zone" of fibroblasts and capillaries. Infiltration of lymphocytes and plasma cells can be seen in the peripheral zone as well. With time, gummas eventually undergo fibrous degeneration, leaving behind an irregular scar or a round fibrous nodule.
It is restricted to necrosis involving spirochaetal infections that cause syphilis. Growths that have the appearance of gummas are described as gummatous.
Progressive disseminated histoplasmosis is an infection caused by Histoplasma capsulatum, and most people who develop this severe form of histoplasmosis are immunocompromised or taking systemic corticosteroids. Skin lesions are present in approximately 6% of patients with dissemination.
Tertiary syphilis may occur approximately 3 to 15 years after the initial infection, and may be divided into three different forms: gummatous syphilis (15%), late neurosyphilis (6.5%), and cardiovascular syphilis (10%). Without treatment, a third of infected people develop tertiary disease. People with tertiary syphilis are not infectious.
Gummatous syphilis or late benign syphilis usually occurs 1 to 46 years after the initial infection, with an average of 15 years. This stage is characterized by the formation of chronic gummas, which are soft, tumor-like balls of inflammation which may vary considerably in size. They typically affect the skin, bone, and liver, but can occur anywhere.
Neurosyphilis refers to an infection involving the central nervous system. It may occur early, being either asymptomatic or in the form of syphilitic meningitis, or late as meningovascular syphilis, general paresis, or tabes dorsalis, which is associated with poor balance and lightning pains in the lower extremities. Late neurosyphilis typically occurs 4 to 25 years after the initial infection. Meningovascular syphilis typically presents with apathy and seizure, and general paresis with dementia and tabes dorsalis. Also, there may be Argyll Robertson pupils, which are bilateral small pupils that constrict when the person focuses on near objects but do not constrict when exposed to bright light.
Cardiovascular syphilis usually occurs 10–30 years after the initial infection. The most common complication is syphilitic aortitis, which may result in aneurysm formation.
Eczema herpeticum is a rare but severe disseminated infection that generally occurs at sites of skin damage produced by, for example, atopic dermatitis, burns, long term usage of topical steroids or eczema. It is also known as Kaposi varicelliform eruption, Pustulosis varioliformis acute and Kaposi-Juliusberg dermatitis.
Some sources reserve the term "eczema herpeticum" when the cause is due to human herpes simplex virus, and the term "Kaposi varicelliform eruption" to describe the general presentation without specifying the virus.
This condition is most commonly caused by herpes simplex virus type 1 or 2, but may also be caused by coxsackievirus A16, or vaccinia virus. It appears as numerous umbilicated vesicles superimposed on healing atopic dermatitis. it is often accompanied by fever and lymphadenopathy. Eczema herpeticum can be life-threatening in babies.
A gumma is a soft, non-cancerous growth resulting from the tertiary stage of syphilis. It is a form of granuloma. Gummas are most commonly found in the liver ("gumma hepatis"), but can also be found in brain, heart, skin, bone, testis, and other tissues, leading to a variety of potential problems including neurological disorders or heart valve disease.
TORCH syndrome is caused by in utero infection with one of the TORCH agents, disrupting fetal development.
Disseminated disease refers to a diffuse disease-process, generally either infectious or neoplastic. The term may sometimes also characterize connective tissue disease.
A disseminated infection, for example, has extended beyond its origin or nidus and involved the bloodstream to "seed" other areas of the body. Similarly, one can view metastatic cancer as a disseminated infection in that it has extended into the bloodstream or into the lymphatic system and thus "seeded" distant sites (a process known as metastasis).
Disseminated disease often contrasts localized disease.
Toxoplasma chorioretinitis, more simply known as ocular toxoplasmosis, is probably the most common cause of infections in the back of the eye (posterior segment) worldwide. The causitive agent is "Toxoplasma gondii", and in the United States, most cases are acquired congenitally. The most common symptom is decreased visual acuity in one eye. The diagnosis is made by examination of the eye, using ophthalmoscopy. Sometimes serologic testing is used to rule out the disease, but due to high rates of false positives, serologies are not diagnostic of toxoplasmic retinitis.
If vision is not compromised, treatment may not be necessary. When vision is affected or threatened, treatment consists of pyrimethamine, sulfadiazine, and folinic acid for 4–6 weeks. Prednisone is sometimes used to decrease inflammation.
Possible symptoms include:
- General symptoms: Fever, weight loss
- Skin: Palpable purpura, livedo reticularis
- Muscles and joints: Myalgia or myositis, arthralgia or arthritis
- Nervous system: Mononeuritis multiplex, headache, stroke, tinnitus, reduced visual acuity, acute visual loss
- Heart and arteries: Myocardial infarction, hypertension, gangrene
- Respiratory tract: Nose bleeds, bloody cough, lung infiltrates
- GI tract: Abdominal pain, bloody stool, perforations
- Kidneys: Glomerulonephritis
Vasculitis can be classified by the cause, the location, the type of vessel or the size of vessel.
- "Underlying cause". For example, the cause of syphilitic aortitis is infectious (aortitis simply refers to inflammation of the aorta, which is an artery.) However, the causes of many forms of vasculitis are poorly understood. There is usually an immune component, but the trigger is often not identified. In these cases, the antibody found is sometimes used in classification, as in ANCA-associated vasculitides.
- "Location of the affected vessels". For example, ICD-10 classifies "vasculitis limited to skin" with skin conditions (under "L"), and "necrotizing vasculopathies" (corresponding to systemic vasculitis) with musculoskeletal system and connective tissue conditions (under "M"). Arteritis/phlebitis on their own are classified with circulatory conditions (under "I").
- "Type or size of the blood vessels" that they predominantly affect. Apart from the arteritis/phlebitis distinction mentioned above, vasculitis is often classified by the caliber of the vessel affected. However, there can be some variation in the size of the vessels affected.
According to the size of the vessel affected, vasculitis can be classified into:
- Large vessel: Polymyalgia rheumatica, Takayasu's arteritis, Temporal arteritis
- Medium vessel: Buerger's disease, Kawasaki disease, Polyarteritis nodosa
- Small vessel: Behçet's syndrome, Eosinophilic granulomatosis with polyangiitis, Cutaneous vasculitis, Henoch–Schönlein purpura, Microscopic polyannulomatosis ConditionofSome disorders have vasculitis as their main feature. The major types are given in the table below:
Takayasu's arteritis, polyarteritis nodosa and giant cell arteritis mainly involve arteries and are thus sometimes classed specifically under arteritis.
Furthermore, there are many conditions that have vasculitis as an accompanying or atypical feature, including:
- Rheumatic diseases, such as rheumatoid arthritis, systemic lupus erythematosus, and dermatomyositis
- Cancer, such as lymphomas
- Infections, such as hepatitis C
- Exposure to chemicals and drugs, such as amphetamines, cocaine, and anthrax vaccines which contain the Anthrax Protective Antigen as the primary ingredient.
In pediatric patients varicella inflammation may be followed by vasculitis of intracranial vessels. This condition is called post varicella angiopathy and this may be responsible for arterial ischaemic strokes in children.
Several of these vasculitides are associated with antineutrophil cytoplasmic antibodies. These are:
- Granulomatosis with polyangiitis (formerly known as Wegener's granulomatosis)
- Eosinophilic granulomatosis with polyangiitis (formerly known as Churg-Strauss syndrome)
- Microscopic polyangiitis
Mendelian susceptibility to mycobacterial disease, also called familial disseminated atypical mycobacterial infection, is a rare genetic disease characterized by susceptibility to mycobacteria and Salmonella infection outside of the intestinal tract.
These are only local and no systemic manifestations are present.
The ulcer characteristically:
- Ranges in size dramatically from 3 to 50 mm (1/8 inch to two inches) across
- Is painful
- Has sharply defined, undermined borders
- Has irregular or ragged borders
- Has a base that is covered with a gray or yellowish-gray material
- Has a base that bleeds easily if traumatized or scraped
- painful swollen lymph nodes occurs in 30 to 60% of patients.
- dysuria (pain with urination) and dyspareunia (pain with intercourse) in females
About half of infected men have only a single ulcer. Women frequently have four or more ulcers, with fewer symptoms.
The initial ulcer may be mistaken as a "hard" chancre, the typical sore of primary syphilis, as opposed to the "soft chancre" of chancroid.
Approximately one-third of the infected individuals will develop enlargements of the inguinal lymph nodes, the nodes located in the fold between the leg and the lower abdomen.
Half of those who develop swelling of the inguinal lymph nodes will progress to a point where the nodes rupture through the skin, producing draining abscesses. The swollen lymph nodes and abscesses are often referred to as buboes.
CNS demyelinating autoimmune diseases are autoimmune diseases which primarily affect the central nervous system.
Examples include:
- Diffuse cerebral sclerosis of Schilder
- Acute disseminated encephalomyelitis
- Acute hemorrhagic leukoencephalitis
- Multiple sclerosis (though the cause is unknown, it is sure that immune system is involved)
- Transverse myelitis
- Neuromyelitis optica
Granuloma inguinale (also known as donovanosis) is a bacterial disease caused by "Klebsiella granulomatis" (formerly known as "Calymmatobacterium granulomatis") characterized by ulcerative genital lesions. It is endemic in many less developed regions. It is also known as donovanosis, granuloma genitoinguinale, granuloma inguinale tropicum, granuloma venereum, granuloma venereum genitoinguinale, lupoid form of groin ulceration, serpiginous ulceration of the groin, ulcerating granuloma of the pudendum, and ulcerating sclerosing granuloma.
The disease often goes untreated because of the scarcity of medical treatment in the countries in which it is found. In addition, the painless genital ulcers can be mistaken for syphilis. The ulcers ultimately progress to destruction of internal and external tissue, with extensive leakage of mucus and blood from the highly vascular lesions. The destructive nature of donovanosis also increases the risk of superinfection by other pathogenic microbes.
Gonococcemia (also known as "Arthritis–dermatosis syndrome" and "Disseminated gonococcal infection") is a condition characterized by a hemorrhagic vesiculopustular eruption, bouts of fever, and arthralgia or actual arthritis of one or several joints.
It's characterized by a triad of symptoms: migratory polyarthritis, tenosynovitis, and dermatitis (pustular skin lesions).
This infection affects multiple organs, including the eyes, brain, lung, and liver, and can be fatal.