Emerging and reemerging diseases were highlighted in a talk on infections in the pediatric population given by Sheila Fallon Friedlander, M.D., during the MauiDerm 2016 meeting.
In her presentation, Dr. Friedlander said dermatologists should be aware of recent increases in cases of Zika virus infection, Chikungunya virus infection, and syphilis in newborns.
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The concern with Zika virus, which is a flavivirus related to dengue and transmitted by the same Aedes mosquito, relates to the potential association between maternal infection and infants born with microcephaly. Dr. Friedlander noted that accompanying the recent outbreak of Zika virus infections in Brazil there has been a tremendous uptick in the number of newborns with microcephaly — from 147 in 2014 to 2,782 in 2015, according to information from the Centers for Disease Control.
The information is worrisome considering the consequences of microcephaly, which can range from mild developmental delay to severe motor and intellectual deficits, and the growing number of cases of Zika virus infection in countries outside Brazil, including the United States. “Fortunately, no local cases have yet been identified in the U.S., but it is probably just a matter of time, given that the responsible mosquito species does inhabit the U.S.,” said Dr. Friedlander. She is professor of clinical dermatology and pediatrics, Rady Children's Hospital and UCSD School of Medicine, San Diego, Calif.
“Although a causal association between maternal Zika virus infection and congenital microcephaly is still under investigation, most everyone is convinced that it is real. This is not something we can ignore because the virus has already been found in multiple states in this country among travellers who contracted it elsewhere. If they are bitten by a mosquito while they are infected, and this bug then bites someone else, local transmission could then occur.”
Cases of Chikungunya virus infection have also been noted in the United States. Also transmitted through the bite of the Aedes mosquito, Chikungunya virus infection is sometimes referred to as “dengue light” because its symptoms tend to be milder than those of dengue virus infection. However, in newborn infants, Chikungunya virus infection has been associated with severe disease and fatalities. Recently as well, a report from Colombia has linked an epidemic of Chikungunya virus infection with cases of congenital infection and a high stillbirth rate, Dr. Friedlander said.
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Cutaneous findings of Chikungunya virus infection in neonates include a maculopapular and sometimes blistering rash, black streaks in the nails, and persistent hyperpigmentation after recovery from the acute disease.
Rising syphilis rates
The incidence of congenital syphilis has also been on the rise in recent years and has been linked to an increase in the prevalence of this sexually transmitted infection among young women.
Dr. Friedlander noted that according to data from the Centers for Disease Control, the incidence of congenital syphilis decreased from 10.5 to 8.4 cases per 100,000 live births between 2008 and 2012. In 2013, however, there was a slight uptick in the rate, and that trend continued, approaching 12 per 100,000 live births in 2014.
“Although it is still very uncommon, congenital syphilis is something that pediatricians need to be thinking about when they are called to examine a newborn with a rash, and the manifestations are different than what we think of in older patients,” Dr. Friedlander said.
The cutaneous features of congenital syphilis include erosions and blisters (“pemphigus syphiliticus”), especially occurring on the hands and feet, crusting around the nose and mouth, and a polymorphous rash that favors the trunk and extremities. Coryza (“snuffles”) is another clue to congenital syphilis, and other findings include chorioretinitis, hepatosplenomegaly, and lymphadenopathy.
“Infection in the neonatal period is the rare time when syphilis manifests with blistering, and it can be very dramatic,” Dr. Friedlander said.
Serologic diagnosis of congenital syphilis may be confounded by the fact that maternal antibodies from a treated mother can be transferred through the placenta, and so VDRL testing in the baby may be falsely positive. In addition, testing of cord blood can yield false negative results, and the outcome when testing peripheral blood may also be falsely positive if a child has measles, mononucleosis, or hepatitis.
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“The diagnosis of syphilis is confirmed if the VDRL titer in the baby is at least four-fold higher than in the mother. Alternatively, dark field examination can be performed to look for spirochetes in a sample scraped from the base of a moist skin lesion or using mucus from the nose of a child with coryza,” Dr. Friedlander said.
“Appropriate evaluation and treatment of affected mothers is crucial. Congenital syphilis can be prevented if an infected mom is appropriately treated. Penicillin G is easily available and inexpensive, and maternal treatment can spare a child a lifetime with deformities.”
Where to go for more information on Zika