11: 4-year-old male with fever and adenopathy

Question 1

normal heart rate for a 4-year-old

Answer 1

65 to 135 beats per minute

Question 2

Causes of Unilateral Cervical Lymphadenopathy: Reactive cervical adenitis (1/5)

Answer 2

Occurs in response to an oral infectious or inflammatory process

Question 3

Causes of Unilateral Cervical Lymphadenopathy: Kawasaki disease (2/5)

Answer 3

• LAD with Kawasaki disease is most often unilateral, w/ LN >1.5 cm in diameter; less commonly diffuse LAD can occur.
• Enlarged LN are nonfluctuant.

Question 4

Causes of Unilateral Cervical Lymphadenopathy: Bacterial cervical adenitis (3/5)

Answer 4

• Typically seen in children ages 1-5yo w/ a h/o a recent upper respiratory tract infection.
• S. aureus and S. pyogenes are the organisms most commonly identified.
• Patients may have high fevers and a toxic appearance.
• Overlying cellulitis and development of fluctuance are common.

Question 5

Causes of Unilateral Cervical Lymphadenopathy: Cat scratch disease (4/5)

Answer 5

• Infections caused by the bacterium Bartonella henselae can be asymptomatic or symptomatic.
• The infection usually is introduced by a scratch from a cat or kitten, with subsequent infection of the node or nodes draining that site.
• The site most commonly involved is the axilla, followed by cervical, submandibular, and inguinal areas.
• Usually a self-limited disease, with regression of the lymph node in four to six weeks.

Question 6

Causes of Unilateral Cervical Lymphadenopathy: Mycobacterial infection (5/5)

Answer 6

• Mycobacterial infections can cause diffuse lymphadenopathy or isolated lymphadenitis.
• Lymphadenitis is the most common manifestation of nontuberculous mycobacteria in children, with a peak age of presentation of 2 to 4 years.
• TB is the m/c c/o mycobacterial lymphadenitis in children >12y.
• Children with these infections usually appear well with minimal if any constitutional s/s.
• The overlying skin may be erythematous initially, but left untreated often becomes violaceous as the nodes enlarge.
• Nodes may rupture through the skin, resulting in a draining sinus tract.
• Tx is surgical excision, as incision and drainage can also result in a sinus tract.

Question 7

Strawberry Tongue

Answer 7

erythematous tongue with prominent papillae, is a characteristic finding of:

• -Streptococcal pharyngitis
• -Kawasaki disease
• -Toxic shock syndrome

Question 8

In addition to high fever for at least five days, four of the following five criteria are needed for a diagnosis of Kawasaki disease:

Answer 8

• Changes in oral mucosa (i.e.: “strawberry tongue”)
• Extremity changes (redness/swelling)
• Unilateral cervical LAD (least likely)
• Rash
• Conjunctivitis (bilateral, nonpurulent)

Question 9

Kawasaki Disease: General

Answer 9

• acute inflammatory panvasculitis of unknown etiology.
• It is thought that the disease results from an ai response to a not yet identified infectious trigger.
• KD is a dz of childhood, with the typical age of patients 15-18 mo; 80% of KD patients are <5y.
• KD “outbreaks” follow seasonal patterns, and children of Asian descent have a higher incidence of KD (suggesting both infectious and genetic influences).

Question 10

Kawasaki Disease: three distinct phases of illness

Answer 10

1. Acute phase: onset through ~10 days. Fever and clinical findings are present, with serologic evidence of systemic inflammation (elevated acute phase reactants).
2. Subacute phase: 10 days through ~3 weeks. Fever resolves and clinical findings largely subside (often with peeling of hands and feet). Serologic evidence of inflammation continues.
3. Convalescent phase: 3 weeks through 6-8 weeks. All clinical findings have resolved. Continued serologic evidence of inflammation.

Question 11

Kawasaki Disease: Late

Answer 11

• Beyond 6-8 wks, serologic evidence for inflammation has resolved.
• KD causes a panvasculitis, impacting any blood vessels, although there is a predilection for small and medium-sized vessels (especially the coronary arteries for unclear reasons).
• This vasculitis can lead to aneurysmal dilation, particularly during the subacute phase of illness.

Question 12

Complications of Kawasaki Disease

Answer 12

• Aseptic meningitis or other central nervous system manifestations (90% of pts develop neuro manifestations)
• coronary artery aneurysm (20-25% of untreated pts)
• Liver dysfunction (as evidenced by elevated transaminases and a decreased albumin) (40%)
• Arthritis (30%)
• Hydrops of the gallbladder (10%)

Question 13

Derm Nomenclature

Answer 13

• Macule=Flat, discolored spot
• Papule=Small, well-defined solid palpable bump
• Vesicle=Small, well-defined, fluid-containing bump
• Pustule=Small, well-defined bump containing purulent material
• Plaque=Small, raised, differentiated patch or area on a body surface
• Desquamation=Shedding of the outer layer of skin surface

Question 14

Treatment of Kawasaki Disease: ASA (1/2)

Answer 14

• High-dose aspirin (80-100 mg/kg/day, divided into four doses) is administered for its anti-inflammatory properties.
• ASA shortens the febrile course of the illness but has no effect on the development of aneurysms.
• Following defervescence, low-dose aspirin (3-5 mg/kg/day given in a single dose) is administered for its anti-platelet effects.
• ASA is discontinued altogether after a total of 6-8wks if no coronary artery changes are seen in f/u echo. If there are coronary artery abnormalities, low dose aspirin is continued indefinitely as an anti-platelet agent.

Question 15

Treatment of Kawasaki Disease: IVIG (2/2)

Answer 15

• has dec the incidence of coronary artery aneurysms from 20- 25% to 2-4%.
• A single dose of IVIG at a dose of 2 g/kg administered over 10-12h has been shown to be more effective in reducing the risk of coronary artery aneurysms than multiple lower doses.

Question 16

Laboratory evaluation of Kawasaki Disease: CBC with differential (1/4)

Answer 16

• WBC: usually elevated, w/ a predominance of neutrophils.
• Hgb/Hct: A normochromic, normocytic anemia is common.
• Platelets: Thrombocytosis is a common feature of Kawasaki disease - usually starting in the 2nd wk of the illness.

Question 17

Laboratory evaluation of Kawasaki Disease: Liver enzymes (2/4)

Answer 17

can be elevated in a number of conditions on the differential, including both Kawasaki disease and Stevens-Johnson syndrome. Serum albumin level is frequently low in Kawasaki disease.

Question 18

Laboratory evaluation of Kawasaki Disease: Acute phase reactants (3/4)

Answer 18

negative ESR would argue strongly against Kawasaki disease. The persistence of an elevated ESR after the fever has subsided can help to distinguish Kawasaki disease from other infectious rash/fever illnesses

Question 19

Laboratory evaluation of Kawasaki Disease: Urinalysis (4/4)

Answer 19

A sterile pyuria, secondary to a sterile urethritis, is associated with Kawasaki disease. A clean-catch urine is likely to show white cells, whereas a catheterized urine may not (because the white cells come from the urethra).

Question 20

Differential Diagnosis for a Child with Fever and a Rash: Adenovirus Infection (1/11)

Answer 20

• May cause upper respiratory tract infection, pharyngitis, conjunctivitis, tonsillitis, or otitis media
• Potential for more severe infections in immunocompromised hosts

Question 21

Differential Diagnosis for a Child with Fever and a Rash: Kawasaki disease (2/11)

Answer 21

• Fever > 5 days
• Cervical adenopathy
• Nonpurulent conjunctivitis
• Nonspecific (“polymorphic”) rash
• Swelling and erythema of extremities
• Mucosal inflammation

Question 22

Differential Diagnosis for a Child with Fever and a Rash: Meningococcemia (3/11)

Answer 22

• Fever
• Chills, malaise
• Rash (often petechial)
• May lead to shock and DIC (often rapidly progressing)

Question 23

Differential Diagnosis for a Child with Fever and a Rash: Measles (4/11)

Answer 23

• After a prodrome of fever (over 38.3 C, or 101 F), cough, coryza, and conjunctivitis, this maculopapular rash starts on the neck, behind the ears, and along the hairline
• The rash spreads downward, reaching the feet in two or three days.
• The initial rash appears on the buccal mucosa as red lesions with bluish white spots in the center (known as Koplik spots). These have frequently disappeared by the time the patient presents to medical attention.
• Immunization is very effective in preventing this infxn

Question 24

Differential Diagnosis for a Child with Fever and a Rash: Rocky Mountain spotted fever (RMSF) (5/11)

Answer 24

• Fever
• Headache
• Rash (typically starts on ankles and wrists and progresses centrally and to palms and soles; may be macular or papular at first, quickly becoming petechial; in 5% of cases, there may be no rash)
• Myalgias

Question 25

Differential Diagnosis for a Child with Fever and a Rash: Scarlet fever (6/11)

Answer 25

• Fever
• A diffuse, erythematous, finely papular rash (described as having a “sandpaper” texture) is pathognomonic
• Rash often begins at neck, axillae, and groin and then spreads over trunk and extremities, typically resolving within four or five days

Question 26

Differential Diagnosis for a Child with Fever and a Rash: SJS (7/11)

Answer 26

• Severe, pruritic rash (erythema multiforme)
• Fever
• Mucosal changes (e.g., stomatitis)
• Conjunctivitis

Question 27

Differential Diagnosis for a Child with Fever and a Rash: Enteroviral infection (8/11)

Answer 27

• Fever lasting 3-5 days
• Nonspecific rash (which may include the palms and soles)
• May also cause conjunctivitis, oral ulcers, diarrhea, aseptic meningitis

Question 28

Differential Diagnosis for a Child with Fever and a Rash: Varicella (9/11)

Answer 28

• “Chicken pox:” rash starts on trunk and spreads to extremities and head
• Each lesion starts as an erythematous macule, then forms a papule followed by a vesicle before crusting over
• Lesions at various stages of development are seen in the same area of the body
• Immunization is effective in preventing this infection

Question 29

Differential Diagnosis for a Child with Fever and a Rash: Erythema Infectiosum (10/11)

Answer 29

• Low grade fever followed by a rash, which starts as a facial erythema to the face (“slapped cheek” appearance), which can spread to the trunk and extremities and appears lacy
• Can lead to pain and swelling of the extremities, as well as development of aplastic anemia

Question 30

Differential Diagnosis for a Child with Fever and a Rash: Roseola (11/11)

Answer 30

• “Exanthem subitum:” erythematous macules start on trunk and spreads to arms and neck (less commonly face and legs)
• Rash is typically preceded by 3-4 days of high fevers, which end as the rash appears
• Usually occurs in children under age 2 years

Question 31

A 5-year-old female, previously healthy, presents with an erythematous, vesicular rash on the palms and soles and a high fever for several days. Upon examination, she is also found to have ulcers in her mouth. A few days later, the fever and rash resolve. What is the most likely pathogen?

Answer 31

This presentation is consistent with infection by cocksackie A, an enterovirus. Following an incubation period of three to five days, patients have fever, tender vesicles on their hands and feet, and oral ulcers. Sometimes the rash also occurs on the buttocks and the genitals. The infection resolves spontaneously within three days, and is spread from person to person via saliva, fluid from the vesicles, stool, or nasal discharge.

Question 32

A 12-month-old previously healthy girl presents with cough and mild subcostal retractions. She is afebrile, and physical exam reveals asymmetric wheezing. Chest x-ray demonstrates unilateral air trapping. What is the most likely diagnosis?

Answer 32

Features of foreign body aspiration include unexplained wheezing and asymmetric breath sounds, as well as air trapping in one lung indicating unilateral airway obstruction. The right main bronchus is the more commonly obstructed due to anatomy (it is wider and more vertical than the left). The most commonly aspirated foods are hot dogs, nuts, hard candy, grapes, and popcorn.

Question 33

Susie is a 3-year-old girl brought into the clinic by her mother because she has a gradually worsening cough and she has been having trouble breathing. Her mother says Susie sounds like she is barking when she coughs. Susie is up to date with her vaccinations. Susie’s mom always watches her when she’s playing. On physical exam, you note that Susie has inspiratory stridor. She does not have wheezing, there are no retractions, and she has symmetrical breath sounds. No pseudomembranes are appreciated on physical exam. What is Susie’s most likely diagnosis?

Answer 33

Croup or laryngotracheobronchitis is due to a viral infection (Parainfluenza type 1). It is most common in the winter, and often occurs in children age 2 to 5 years. Croup can lead to non-specific URI symptoms with some degree of airway obstruction. A barky or seal-like cough and inspiratory stridor (which should be differentiated from expiratory wheezes) is common in croup.