12. Infectious Diseases Flashcards
1
Q
Define: Fever (1)
A
a practical definition is >38oC/100.4oF oral or rectal
2
Q
Define: Fever without a source/focus (1)
A
acute febrile illness (typically <10d duration) with no cause of fever even after careful history and physical
3
Q
Define: Fever of unknown origin (1)
A
daily or intermittent fevers for at least 2 consecutive wk of uncertain cause after careful history and physical, and initial laboratory assessment
4
Q
Describe etiology: Fever (4)
A
- infectious: anatomic approach (CNS, ears, upper and lower respiratory tract, GI, GU, skin, soft tissue, bones and joints, etc.)
- inflammatory: mainly autoimmune (Kawasaki disease, JIA, IBD, SLE, etc.)
- malignancy: childhood cancers (leukemia, lymphoma, neuroblastoma, etc.)
- miscellaneous: dehydration, drugs and toxins,post-immunization,familial dysautonomia,factitious disorder, etc.
5
Q
Describe diagnosis of fever (3)
A
- history: duration, height and pattern of fever, associated symptoms, exposures, constitutional symptoms, recent antipyretic use, ethnic or genetic background, daycare, sick contacts, travel, tick bites, age of child
- physical exam: toxic vs. non-toxic, vitals, growth, complete exams of the skin, HEENT (head, eyes, ears, nose, and throat) , chest, abdomen, lymph nodes, genitalia
- investigations: guided by history, physical exam, and clinical suspicion
6
Q
Describe: Rochester Criteria (6)
A
Developed to Identify Infants ≤60 d of Age with Fever at Low Risk of Serious Bacterial Infection
- Clinically: Well
- WBC Count: 5-15 x 109/L
- Bands: <1.5 x 109/L
- Urinalysis: <10 WBC/HPF
- Stool (if diarrhea): <5 WBC/HPF
- Past Health
- Born >37 wk
- Home with/before mom
- No hospitalizations
- No prior antibiotic use
- No prior treatment for unexplained hyperbilirubinemia
- No chronic disease
7
Q
Describe: Evaluation of Neonates and Infants with Fever (2)
A
- several protocols exist that attempt to identify neonates and young infants at low risk of serious bacterial infection (e.g. Rochester Criteria)
- such protocols are not as sensitive in the 1-28 d age group; therefore, febrile neonates should be considered high risk regardless of clinical features and laboratory findings
8
Q
Describe management of fever (5)
A
- admit to hospital if appropriate
- treat the source if known
- replace fluid losses (e.g.from vomiting, diarrhea, etc.); maintenance fluid needs are higher in febrile child
- reassure parents that most fevers are benign and self-limited
- antipyretics (acetaminophen and/or ibuprofen) may be given if child is uncomfortable
9
Q
Name criterias for acute otitis media (3)
A
All of:
- presence of middle ear effusion
- presence of middle ear inflammation
- acute onset of symptoms of middle ear effusion and inflammation
10
Q
Describe epidemiology: Acute Otitis Media (3)
A
- 60-70% of children have at least 1 episode of AOM before 3yr of age
- 18mo-6yr most common age group
- 22% of children in this age range will develop AOM in the first wk of a viral URI
- one third of children have had ≥ 3 episodes by age 3; peak incidence January to April
11
Q
Describe etiology: Acute Otitis Media (3)
A
- bacterial S.pneumoniae (decreasing since the introduction of PCV7 and PCV13), H.influenza, M. catarrhalis, GAS
- less common - anaerobes (newborns) , Gram-negative enterics (infants)
- viral–more likely to spontaneously resolve
12
Q
Name risk factors: Acute Otitis Media (4)
A
- Eustachian tube related:
- dysfunction/obstruction (URTI, allergic rhinitis, chronic rhinosinusitis, adenoid hypertrophy, barotrauma)
- inadequate tensor palatine function (cleft palate)
- genetic syndromes (DS, Crouzon, Apert)
- cilia disruption (Kartagenger’s syndrome, CF)
- genetic predisposition (family history, ethnicity – First Nations and Inuit, low levels of secretory IgA or persistent biofilm in middle ear)
- behavioural and environmental exposures (not breastfed or shorter duration of breastfeeding, prolonged bottle feeding, bottle feeding laying down, pacifier use, second-hand smoke exposure, crowded living conditions/daycare, sick contacts)
- immunosuppression/deficiency (chemotherapy, steroids, DM, hypogammaglobulinemia, CF)
13
Q
Describe pathogenesis: Acute Otitis Media (1)
A
- obstruction of Eustachian tube→ air absorbed in middle ear → negative pressure (an irritant to middle ear mucosa) → edema of mucosa with exudate/effusion → infection of exudate from nasopharyngeal secretions
14
Q
Describe clinical features: Acute Otitis Media (6)
A
- acute onset of symptoms
- triad of otalgia, fever (especially in younger children), and conductive hearing loss –not all symptoms such as fever or hearing loss may be present
- rarely tinnitus, vertigo, and/or facial nerve paralysis
- otorrhea if tympanic membrane perforated
- infants/toddlers: ear-tugging (this alone is not a good indicator of pathology), hearing loss,balance disturbances (rare), irritable, poor sleeping, vomiting and diarrhea, anorexia
- otoscopy of TM: hyperemia, bulging, pus may be seen behind TM, loss of land marks (e.g.handle and long process of malleus not visible), discolouration (hemmorhagic, grey, red, yellow)
15
Q
Describe diagnosis: Acute Otitis Media (1)
A
Requires middle ear effusion and signs of inflammation (most important is a bulging TM)
16
Q
Describe management: Acute Otitis Media (4)
A
- symptomatic therapy: antipyretics/analgesics (e.g.acetaminophen or ibuprophen)
- watchful waiting if criteria met
- antibiotic therapy if <6mo or moderate-severe illness
- signs of a perforated TM should always be treated with antimicrobial therapy (most commonly topical Ciprodex) and examined for complications
17
Q
Describe antibiotic therapy if <6mo or moderate-severe: Acute Otitis Media (2)
A
- 1st line: high dose amoxicillin 75-90mg/kg/d dosed BID (if penicillin allergic: macrolides,TMP-SMX)
- 2nd line: amoxicillin-clavulanic acid, cephalosporins: cefuroxime axetil, ceftriaxone, cefaclor, cefixime
- used when AOM unresponsive and clinical signs/symptoms persist beyond 48 h of antibiotic
- treatment, or for treatment of otitis-conjunctivitis syndrome
18
Q
Describe prevention: Acute Otitis Media (2)
A
- parent education about risk factors, pneumococcal and influenza vaccines, surgery (e.g. tympanostomy tubes)
- choice of surgical therapy for recurrent AOM depends on whether local factors (Eustachian tube dysfunction) are responsible (use ventilation tubes), or regional disease factors (tonsillitis, adenoid hypertrophy, sinusitis) are responsible
19
Q
Name EXTRACRANIAL complications: Acute Otitis Media (8)
A
- hearing loss and speech delay (secondary to persistent middle ear effusion)
- TM perforation
- extension of suppurative process to adjacent structures (mastoiditis, petrositis, labyrinthitis)
- cholesteatoma
- facial nerve palsy
- middle ear atelectasis
- ossicular necrosis
- vestibular dysfunction
20
Q
Name INTRACRANIAL complications: Acute Otitis Media (5)
A
- meningitis
- epidural and brain abscess
- subdural empyema
- lateral and cavernous sinus thrombosis
- carotid artery thrombosis
21
Q
Define: Otitis Media with Effusion (1)
A
presence of fluid in the middle ear without signs or symptoms of ear infection
22
Q
Define epidemiology: Otitis Media with Effusion (4)
A
- most common cause of pediatric hearing loss
- not exclusively a pediatric disease
- follows AOM frequently in children
- middle ear effusions have been shown to persist following an episode of AOM for 1mo in 40% of children, 2 mo in 20%, and >3 mo in 10%
23
Q
Define risk factors: Otitis Media with Effusion (1)
A
Same as AOM
24
Q
Describe clinical features: Otitis Media with Effusion (4)
A
- conductive hearing loss ± tinnitus
- fullness – blocked ear
- ± pain
- low grade fever
25
Describe results of otoscopy of TM in Otitis Media with Effusion (6)
* discolouration – amber or dull grey ■
* eniscus fluid level behind TM
* air bubbles
* retraction pockets/TM atelectasis
* flat tympanogram
* most reliable finding with pneumatic otoscopy is immobility
26
Describe treatment: Otitis Media with Effusion (5)
* expectant: 90% resolve by 3mo
* document hearing loss with audiogram(
* no statistical proof that antihistamines, decongestants, antibiotics clear disease faster
* surgery: myringotomy ± ventilation tubes ± adenoidectomy (if enlarged or on insertion of second set of tubes after first set falls out)
* ventilation tubes to equalize pressure and drainear
27
Name complications: Otitis Media with Effusion (5)
* hearing loss, speech delay, learningproblemsinyoungchildren
* chronic mastoiditis
* ossicular erosion
* cholesteatomae specially when retraction pockets involve pars flaccida
* retraction of tympanic membrane, atelectasis, ossicular fixation
28
Describe history: Gastroenteritis (3)
* non-specific: diarrhea, vomiting, fever, anorexia, headache, myalgias, abdominal cramps
* bacterial and parasitic agents more common in older children (2-4yr)
* recent infectious contacts: symptoms usually begin 24-48h after exposure
29
30
Describe physical exam: Gastroenteritis (2)
* febrile
* dehydrated: must assess extent
31
Describe investigations: Gastroenteritis (2)
* not usually necessary in young children
* stool analysis: leukocytes/erythrocytes suggests bacterial or parasitic etiology; pH\<6 and presence of reducing substances suggests viral etiology
32
Name complications: Gastroenteritis (3)
* viral gastro enteritisus ually self-limiting (lasts 3-7d in most cases)
* adverse effects related to hypovolemia, shock, tissue acidosis, and rapid onset and over-correction of electrolyte imbalances
* death in severe dehydration (rare in developed countries)
33
Describe etiology: Gastroenteritis (3)
* Viral Infection
* Most common cause of gastroenteritis
* Commonly: rotaviruses (most common), enteric adenovirus, norovirus (typically older children)
* Bacterial Infection
* Salmonella, Campylobacter, Shigella, pathogenic E. coli, Yersinia, C. difficile
34
Describe clinical features: Gastroenteritis
* Viral (3)
* Bacterial (3)
* Viral:
* Associated with URTIs
* Resolves in 3-7 d
* Slight fever, malaise, vomiting, vague abdominal pain
* Bacterial
* Severe abdominal pain
* High fever
* Bloody diarrhea
35
Name risk factors: Gastroenteritis (2)
* Daycare, young age, sick contacts, immunocompromised
* Bacterial infection: travel, poorly cooked meat, poorly refrigerated foods, antibiotics
36
Describe management: Gastroenteritis (6)
* Prevention and treatment of dehydration most important
* Early refeeding advisable, with age-appropriate diet upon completion of rehydration
* Ondansetron for suspected gastroenteritis with mild to moderate dehydration or failed ORT and significant vomiting
* Antibiotic or antiparasitic therapy when indicated, antidiarrheal medications not indicated
* Notify Public Health authorities if appropriate
* Promote regular hand-washing and return to school 24 h after last diarrheal episode to prevent transmission Rotavirus vaccine
37
Describe epidemiology: Toddler's Diarrhea (2)
* most common cause of chronic diarrhea during infancy
* onset between 6-36 mo of age, ceases spontaneously between 2-4yr
38
Describe clinical features: Toddler's Diarrhea (5)
* diagnosis of exclusion in thriving child
* 4-6 bowel movements per day
* diet history (e.g.excess juice intake overwhelms small bowel resulting in disaccharide malabsorption)
* stool may contain undigested food particles
* excoriated diaper rash
39
Describe management: Toddler's Diarrhea (2)
* reassurance that it is self-limiting
* 4Fs (adequate Fibre, normal Fluid intake, 35-40% Fat , discourage excess Fruit juice)
40
Describe: Erythema Infectiosum
* Pathogen(s)
* Incubation Period
* Communicability
* Mode of Transmission
| (i.e. Fifth Disease/ Slapped Cheek)
* Pathogen(s): Parvovirus B19
* Incubation Period: 4-14 d
* Communicability: Low risk of transmission once symptomatic
* Mode of Transmission:
41
Describe rash: Erythema Infectiosum
| (i.e. Fifth Disease/ Slapped Cheek) (3)
* Appearance:
* uniform
* erythematous
* maculopapular ‘lacy’ rash
* Timing: 10-17 d after symptoms (immune response)
* Distribution: bilateral cheeks (‘slapped cheeks’) with circumoral sparing; may affect trunk and extremities
42
Describe associated features: Erythema Infectiosum
| (i.e. Fifth Disease/ Slapped Cheek)
* Initial 7-10 d of flu-like illness and fever
* Rash may be warm, non-tender, and pruritic
* Less common presentations include ‘gloves and socks syndrome’ or STAR complex (sore throat, arthritis, rash)
43
Describe management: Erythema Infectiosum
| (i.e. Fifth Disease/ Slapped Cheek) (1)
Supportive
44
Describe outcomes and complications: Erythema Infectiosum
| (i.e. Fifth Disease/ Slapped Cheek)
Rash fades over days to week, but may reappear months later with sunlight, exercise Aplastic crisis
45
Describe: Gianotti-Crosti Syndrome (i.e. Papular Acrodermatitis)
* Pathogen(s)
* Incubation Period
* Communicability
* Mode of Transmission
* Pathogen(s): EBV and Hep B (majority)
* Incubation Period: Variable
* Communicability: None
* Mode of Transmission: -
46
Describe rash: Gianotti-Crosti Syndrome (i.e. Papular Acrodermatitis)
* Appearance: asymptomatic symmetric papules
* Distribution: face, cheeks, extensor surfaces of the extremities, spares trunk
47
Describe associated features: Gianotti-Crosti Syndrome (i.e. Papular Acrodermatitis) (2)
* Viral prodrome
* May have lymphadenopathy and/ or hepatosplenomegaly
48
Describe management: Gianotti-Crosti Syndrome (i.e. Papular Acrodermatitis) (2)
* Supportive
* Pain control
49
Describe outcomes and complications: Gianotti-Crosti Syndrome (i.e. Papular Acrodermatitis) (1)
Resolves in 3-12 wk
50
Describe: Hand, Foot, and Mouth Disease
* Pathogen(s)
* Incubation Period
* Communicability
* Mode of Transmission
* Pathogen(s): Coxsackie group A
* Incubation Period: 3-5 d
* Communicability: Likely 1-7 d after symptoms but may be up to months
* Mode of Transmission: Direct and indirect contact with infected bodily fluids, fecal-oral
51
Describe rash: Hand, Foot, and Mouth Disease (2)
* Appearance: vesicles and pustules on an erythematous base
* Distribution: acral, but may exentend up the extremity
52
Describe associated features: Hand, Foot, and Mouth Disease (1)
Enanthem: vesicles in the POSTERIOR oral cavity (pharynx, tongue)
53
Describe management: Hand, Foot, and Mouth Disease
Supportive
54
Describe outcomes and complications: Hand, Foot, and Mouth Disease (1)
Mainly dehydration
55
Describe: Herpes Simplex
* Pathogen(s)
* Incubation Period
* Communicability
* Mode of Transmission
* Pathogen(s): HSV 1, 2
* Incubation Period: 1-26 d
* Communicability: -
* Mode of Transmission: Direct contact, often through saliva for HSV-1 and sexual contact for HSV-2
56
Describe rash: Herpes Simplex (1)
Grouped vesicles on an erythematous base
57
Describe associated features: Herpes Simplex (2)
* Enanthem: vesicles/erosions in the ANTERIOR oral cavity (buccal mucosa, tongue)
* May present with herpetic whitlow (autoinoculation)
58
Describe management: Herpes Simplex (2)
* Mainly supportive
* Consider oral or topical antivirals
59
Describe outcomes and complications: Herpes Simplex (4)
* Local: secondary skin infections, keratitis, gingivostomatitis
* CNS: encephalitis
* Disseminated hepatitis, DIC
* Eczema herpeticum
60
Describe: Measles
* Pathogen(s)
* Incubation Period
* Communicability
* Mode of Transmission
* Pathogen(s): Morbillivirus
* Incubation Period: 8-13 d
* Communicability: 4 d before and after rash
* Mode of Transmission:
61
Describe:
* Pathogen(s)
* Incubation Period
* Communicability
* Mode of Transmission
* Pathogen(s):
* Incubation Period:
* Communicability:
* Mode of Transmission:
62
Describe rash: Measles (3)
* Appearance: erythematous maculopapular
* Timing: 3 d after start of symptoms
* Distribution: starts at hairline and spreads downwards with sparing of palms and soles
63
Describe associated features: Measles (4)
* Prodome of cough, coryza, conjunctivitis (3 Cs)
* Enanthem: Koplik’s spots 1-2 d before rash
* Desquamation
* Positive serology for measles IgM
64
Describe management: Measles (4)
* Infected: supportive
* Unimmunized contacts: measles vaccine within 72 h of exposure or IgG within 6 d of exposure
* Respiratory isolation, report to Public Health
* Prevention: MMR vaccine
65
Describe outcomes and complications: Measles (3)
* Secondary bacterial infections: AOM, sinusitis, pneumonia
* Encephalitis
* Rare: myocarditis, pericarditis, thrombocytopenia, Stevens-Johnson syndrome, GN, subacute sclerosing panencephalitis
66
Describe: Non-Specific Enteroviral Exanthems
* Pathogen(s)
* Incubation Period
* Communicability
* Mode of Transmission
* Pathogen(s): Enteroviruses
* Incubation Period: Variable
* Communicability: Variable
* Mode of Transmission: Direct and indirect contact with infected bodily fluids
67
Describe rash: Non-Specific Enteroviral Exanthems
Polymorphous rash (macules, papules, vesicles, petechiae, urticaria)
68
Describe associated features: Non-Specific Enteroviral Exanthems (1)
Systemic involvement is rare, but possible
69
Describe management: Non-Specific Enteroviral Exanthems (1)
* Supportive
* Diagnosis confirmed using viral cultures (NP and rectal swabs)
70
Describe outcomes and complications: Non-Specific Enteroviral Exanthems (1)
Self-limiting
71
Describe:
* Pathogen(s)
* Incubation Period
* Communicability
* Mode of Transmission
* Pathogen(s):
* Incubation Period:
* Communicability:
* Mode of Transmission:
72
Describe:
* Pathogen(s)
* Incubation Period
* Communicability
* Mode of Transmission
* Pathogen(s):
* Incubation Period:
* Communicability:
* Mode of Transmission:
73
Describe rash:
74
Describe:
* Pathogen(s)
* Incubation Period
* Communicability
* Mode of Transmission
* Pathogen(s):
* Incubation Period:
* Communicability:
* Mode of Transmission:
75
Describe associated features:
76
Describe: Roseola
* Pathogen(s)
* Incubation Period
* Communicability
* Mode of Transmission
* Pathogen(s): HHV 6
* Incubation Period: 5-15 d
* Communicability: Unknown
* Mode of Transmission: -
77
Describe rash: Roseola (3)
* Appearance: blanching, pink, maculopapular
* Timing: appears once fever subsides
* Distribution: starts at the neck and trunk and spreads to the face and extremities
78
Describe associated features: Roseola (3)
* High grade fever
* Common: irritability, anorexia, lymphadenopathy, erythematous TM and pharynx, Nagayama spots (erythematous papules on soft palate and uvula)
* Less common: cough, coryza, bulging fontanelles
79
Describe management: Roseola (1)
Supportive
80
Describe outcomes and complications: Roseola (2)
* CNS: febrile seizures (10-25%), aseptic meningitis
* Thrombocytopenia
81
Describe: Rubella
* Pathogen(s)
* Incubation Period
* Communicability
* Mode of Transmission
* Pathogen(s): Rubivirus
* Incubation Period: 14-21 d
* Communicability: 7 d before and after eruptions
* Mode of Transmission: Droplet
82
Describe rash: Rubella (3)
* Appearance: pink, maculopapular
* Timing: 1-5 d after start of symptoms
* Distribution: starts on face and spreads to neck and trunk
83
Describe Associated Features: Rubella (4)
* Prodrome of low grade fever and occipital/retroauricular nodes
* STAR complex (sore throat, arthritis, rash)
* Positive serology for rubella IgM.
* Caution to pregnant women with expsoure
84
Describe management: Rubella (3)
* Infected: supportive
* Prevention: MMR vaccine
* Report to Public Health
85
Describe: Varicella
* Pathogen(s)
* Incubation Period
* Communicability
* Mode of Transmission
* Pathogen(s): Varicella zoster virus
* Incubation Period: 0-21 d
* Communicability: 1-2 d pre-eruptions and 5 d post-eruption
* Mode of Transmission: Mainly airborne, but also through direct contact with vesicle fluid
86
Describe rash: Varicella (3)
* Appearance: groups of skin lesions, polymorphic, from macules to papules to vesicles to crusts
* Timing: 1-3 d after start of symptoms
* Distribution: generalized
87
Describe associated features: Varicella (3)
* Significant pruritis
* Enanthem: vesicular lesions which may become pustular or ulcerate.
* Caution to pregnant women
88
Describe management: Varicella (5)
* Supportive
* Avoid salicylates (due to risk of Reye syndrome)
* Consider antivirals
* Respiratory and contact isolation, report to Public Health
* Prevention: varicella vaccine
89
Describe outcomes and complications: Varicella (4)
* Skin: bacterial suprainfection, necrotizing fasciitis
* CNS: acute encephalitis and cerebellar ataxia
* Systemic: hepatitis, DIC
* Congenital varicella syndrome if intrapartum infection
90
Define: Infectious Mononucleosis (1)
systemic viral infection caused by EBV with multi visceral involvement; often called “the great imitator”
91
Describe epidemiology: Infectious Mononucleosis (2)
* peak incidence between 15-19 yr old
* ~50% of children in developed countries have a primary EBV infection by 5 yr old, but \<10% of children develop clinical infection
92
Describe etiology: Infectious Mononucleosis (3)
* EBV: a member of herpes viridae
* transmission is mainly through infected saliva (“kissing disease”) and sexual activity (less commonly);
* incubation period of 1-2 mo
93
Name risk factors: Infectious Mononucleosis (3)
* infectious contacts
* sexually active
* multiple sexual partners in the past
94
Describe risk factors: Infectious Mononucleosis (3)
* prodrome: 2-3d of malaise, anorexia
* infants and young children: often asymptomatic or mild disease
* older children and adolescents: malaise, fatigue, fever, sore throat, abdominal pain (often LUQ), headache, myalgia
95
Describe physical exam: Infectious Mononucleosis (5)
* classic triad: febrile, generalized non tender lymphadenopathy, pharyngitis/tonsillitis (exudative)
* ± hepatosplenomegaly
* ± periorbital edema, ± rash (urticarial, maculopapular, or petechial) – more common after
* inappropriate treatment with β-lactam antibiotics
* any“-itis” (including arthritis, hepatitis, nephritis, myocarditis, meningitis, encephalitis,etc.)
96
Describe investigations: Infectious Mononucleosis (5)
* heterophil anti body test (Monospot®test)
* 85% sensitive in adults and older children, but only 50% sensitive if \<4 yr of age
* false positive results with HIV, SLE, lymphoma, rubella, parvovirus
* EBV titres
* CBC and differential, blood smear:reactive lymphocytes, lymphocytosis, Downey cells ± anemia± thrombocytopenia
* throat culture to rule out streptococcal pharyngitis
97
Describe management: Infectious Mononucleosis (4)
* supportive: adequate rest, hydration, saline gargles, and analgesics for sore throat
* splenic enlargement is often not clinically apparent so all patients should avoid contact sports for 6-8wk
* if airway obstruction secondary to nodal and/or tonsillar enlargement is present (especially younger children), admit for steroid therapy
* acyclovir does NOT reduce duration of symptoms or result in earlier return to school/work
98
Describe prognosis: Infectious Mononucleosis (2)
* most acute symptoms resolve in 1-2wk, though fatigue may last for months
* short-term complications: splenic rupture, Guillain-Barré syndrome
99
Define: Infectious Pharyngitis/Tonsillitis (1)
inflammation of the pharynx, especially the tonsils if present, causing a sore throat
100
Describe etiology: Infectious Pharyngitis/Tonsillitis (4)
* viral (~80%): adeno viruses, enteroviruses, coxsackie, upper respiratory tract viruses, EBV, CMV
* bacterial (~20%): mainly GAS, M.pneumoniae (older children), N.gonorrhoeae (sexually active),
* C. diphtheriae (unvaccinated), Fusobacterium necrophorum (anaerobe causing Lemierre syndrome)
* fungal:Candida
101
Describe epidemiology: Infectious Pharyngitis/Tonsillitis (2)
* season: GAS pharyngit is more common in late winter or early spring; viral all year long
* age: GAS pharyngitis peak incidence at 5-12 yr of age and uncommon \< 3yr; viral pharyngitis affects all ages
102
Describe presentation: Infectious Pharyngitis/Tonsillitis GAS (12)
* sore throat (may be severe)
* febrile
* malaise
* headache
* abdominal pain
* N/V
* absence of other URTI symptoms
* pharyngeal/tonsillar serythema and exudates enlarged (\>1 cm)
* tender anterior cervical lymph nodes
* palatal petechiae
* strawberry tongue
* scarlatiniform rash
103
Describe presentation: Infectious Pharyngitis/Tonsillitis viral (11)
* Sore throat (often mild)
* afebrile
* conjunctivitis
* cough
* rhinorrhea
* hoarseness
* diarrhea
* flu-like symptoms (fever, malaise, myalgias)
* absent/mild tonsillar exudates
* minor and non-tendor adenopathy
* viral exanthems
104
Describe investigations: Infectious Pharyngitis/Tonsillitis (3)
* no single sign or symptom reliably identifies GAS as the causative organism in children with sore throat
* scores are used to predict if throat culture will be positive (e.g.m-CENTOR score)
* these score systems have not been found to be sensitive or specific enough to diagnose GAS in children and adolescents with sore throat
* suspected diagnosis of GAS pharyngitis should be confirmed with a rapid streptococcal antigen test and a follow-up throat culture if the rapid test is negative
105
Describe management: Infectious Pharyngitis/Tonsillitis (4)
* antibiotics (for GAS/S.pyogenes)
* penicillin V or amoxicillin or erythromycin (if penicillin allergy) x 10 d
* can prevent rheumatic fever if given within 9 d of symptoms; does NOT alter risk of post-streptococcal GN
* supportive: hydration and acetaminophen for discomfort due to pain and/or fever
* follow-up: if uncomplicated course, no follow-up or post-antibiotic throat cultures needed
* prophylaxis: consider tonsillectomy for proven, recurrent streptococcal tonsillitis
106
Describe complications: Infectious Pharyngitis/Tonsillitis (2)
* preventable with antibiotics: AOM, sinusitis, cervical adenitis, mastoiditis, retropharyngeal/peritonsillar abscess, sepsis
* immune-mediated complications: scarlet fever, acute rheumatic fever, post-streptococcal GN,reactive arthritis, pediatric autoimmune neuropsychiatric disorder associated with group A streptococci (i.e. PANDAS)
107
Describe: Rheumatif Fever (2)
* inflammatory disease due to antibody cross-reactivity following GAS infection
* affects~1:10,000 children in developed world; much more prevalent in developing nations; peak incidence at 5-15 yr of age
108
Describe diagnosis: Rheumatif Fever (2)
* diagnosis based on Jones Criteria (revised)
* requires 2 major OR 1 major and 2 minor PLUS evidence of preceding strep infection (history of scarlet fever, GAS pharyngitis culture, positive rapid Ag detection test, ASOTs)
109
Describe treatment and phrophylaxis: Rheumatif Fever (2)
* treatment: penicillin or erythromycin for acute course x 10d, prednisone if severe carditis
* secondary prophylaxis with daily penicillin or erythromycin
110
Describe complications: Rheumatif Fever (3)
* acute: myocarditis, conduction system aberrations (sinus tachycardia, atrial fibrillation), valvulitis (acute MR), pericarditis
* chronic: valvular heart disease (mitral and/or aortic insufficiency/stenosis), infectious endocarditis ± thromboembolic phenomenon
* onset of symptoms usually after 10-20 yr latency from acute carditis of rheumatic fever
111
Describe scarlet fever (7)
* diffuse erythematous eruption
* delayed-type hypersensitivity reaction to pyrogenic exotoxin produced by GAS
* acute onset of fever, sore throat, strawberry tongue
* 24-48h after pharyngitis, rash begins in the groin, axillae, neck, antecubital fossa; Pastia’s lines may be accentuated in flexural areas
* within 24h, sand paper rash becomes generalized with perioral sparing, non-pruritic, non-painful, blanchable
* rash fades after 3-4d, maybe followed by desquamation
* treatment is penicillin, amoxicillin, orerythromycin x 10d
112
Describe: Post-Streptococcal Glomerulonephritis (3)
* most common in children aged 4-8 yr old; M\>F
* antigen-antibody mediated complement activation with diffuse, proliferative GN
* occurs 1-3wk following initial GAS infection (skin or throat)
113
Describe clinical features: Post-Streptococcal Glomerulonephritis (1)
* clinical feature varies from asymptomatic, microscopic and macroscopic hematuria (cola-coloured urine) to all features of nephritic syndrome
114
Describe diagnosis: Post-Streptococcal Glomerulonephritis (1)
diagnosis is confirmed with elevated serum antibody titres against streptococcal antigens (ASOT,anti-DNAse B), low serum complement (C3)
115
Describe management: Post-Streptococcal Glomerulonephritis (3)
* symptomatic: fluid and sodium restrictions; loop diuretics for HTN and edema
* in severe cases, may require dialysis if renal function significantly impaired
* treat with penicillin or erythromycin if evidence of persistent GAS infection
116
Describe prognosis: Post-Streptococcal Glomerulonephritis (2)
* 5% of children recover completely within 1-2 wk;
* 5-10% have persistent hematuria
117
Define: Meningitis (1)
inflammation of the meninges surrounding the brain and spinal cord
118
Describe epidemiology : Meningitis (2)
* peak age: 6-12mo
* 90% of cases occur in children \<5yr old
119
Describe etiology : Meningitis (4)
* viral: enteroviruses, HSV
* bacterial: age-related variation in specific pathogens
* fungal and parasitic meningitis also possible
* most often due to hematogenous spread or direct extension from a contiguous site
120
Name risk factors: Meningitis (5)
* unvaccinated
* immunocompromised: asplenia, DM, HIV, prematurity
* recent or current infections: AOM, sinusitis, orbital cellulitis
* neuroanatomical: congenital defects, dermal sinus, neurosurgery, cochlear implants, recent head trauma
* exposures: day care centres, household contact, recent travel
121
Describe history: Meningitis (3)
* signs and symptoms variable and dependent on age, duration of illness, and host response to infection
* infants: fever, lethargy, irritability, poor feeding, vomiting, diarrhea, respiratory distress, seizures
* children: fever, headache, photophobia, N/V, confusion, back/neckpain/stiffness, lethargy, irritability
122
Describe physical exam: Meningitis (2)
* infants: toxic, hypothermia, bulging anterior fontanelle, respiratory distress, apnea, petechial/purpuric rash, jaundice
* children: toxic, ⬇LOC, nuchal rigidity, Kernig’s and Brudzinski’s signs, focal neurologic findings, petechial/purpuric rash
123
Describe investigations: Meningitis (2)
* bloodwork: CBC, electrolytes, Cr, BUN, glucose, C&S
* LP required for definitive diagnosis
124
Describe LP in meningitis (5)
* Gram stain, bacterial C&S, WBC count and differential, RBC count, glucose, protein concentration
* acid-fast stain if suspect TB
* PCR for specific bacteria if available (helpful if already treated with antibiotics)
* urinalysis and urine C&S in infants, Gram stain and culture of petechial/purpuric lesions
* HSV and enterovirus PCR if suspected
125
Describe findings of meningitis in LP
126
Describe management of meningitis (2)
* preservation of adequate cerebral perfusion by maintaining normal BP and managing ⬆️ ICP
* close monitoring of fluids, electrolytes, glucose, acid-base disturbances, coagulopathies
127
Describe management of bacterial meningitis (6)
* if suspected or cannot be excluded, commence empiric antibiotic therapy while awaiting cultures or if LP contraindicated or delayed
* adjuvant dexamethasone BEFORE antibiotic for Hib meningitis; consider for those \>6 wk with pneumococcal meningitis
* isolation with appropriate infection control procedures until 24 h after culture-sensitive antibiotic
* therapy fluid restrict if any concern for SIADH
* hearing test
* report to Public Health; prophylactic antibiotics for close contacts of Hib and N. meningitidis meningitis
128
Desribe: Antibiotic Management of Bacterial Meningitis
* 0 to 28 d
* 28 to 90d
* \>90 d
129
Name: Signs of Meningismus (4)
BONK on the head
* Brudzinski’s sign
* Opisthotonos
* rigid spasm of the body, with the back fully arched and the heels and head bent back
* Nuchal rigidity
* Kernig’s sign
130
Describe management: Viral meningitis (3)
* mainly supportive (except for HSV)
* acyclovir for HSV meningitis
* report to Public Health
131
Describe prophylaxis: Viral meningitis (1)
Appropriate vaccinations significantly decrease incidence of bacterial meningitis
132
Describe complications: Viral meningitis (3)
* mortality: neonate 15-20%, children4-8%; pneumococcus \> meningococcus \> Hib
* acute: SIADH, subdural effusion/empyema, brain abscess, disseminated infection (osteomyelitis,septic arthritis, abscess), shock/DIC
* chronic: hearing loss, neuromotor/cognitive delay, learning disabilities, neurological deficit, seizure disorder, hydrocephalus
133
Define: Mumps (1)
* acute,self-limited viral infection that is most commonly characterized by adenitis and swelling of the parotid glands
134
Describe epidemiology: Mumps (3)
* incidence in Ontario has declined since introduction of two-dose MMR vaccination schedule
* average of 25 reported cases per yr
* majority of reported cases in children between 5-10 yr of age
135
Describe etiology: Mumps (5)
* mumps virus (RNA virus of the genus Rubula virus in the Paramyxoviridae family)
* transmission via respiratory droplets, direct contact, fomites
* incubation period: 14-25d
* infectivity period: 7d pre-parotitis to 5d post-parotitis
* upper respiratory tract, lymph nodes, salivary glands, gonads, pancreas, meninges, kidney, heart, thyroid
136
Describe history: Mumps (4)
* non-specificprodome of fever, headache, malaise, myalgias (especially neck pain)
* usually followed within 48h by parotid swelling secondary to parotitis (bilateral, preauricular, ear pushed up and out)
* parotid gland is tender and pain worsened with spicy or sour foods
* one third of infections do not cause clinically apparent salivary gland swelling and may simply present as an URTI
137
Describe investigations: Mumps (3)
* clinical diagnosis, but may be confirmed with IgM positive serology within 4wk of acute infection
* may also use PCR or viral cultures from oral secretions, urine, blood, and CSF
* blood work: CBC (leukopenia with relative lymphocytosis), serum amylase (elevated)
138
Describe management: Mumps (4)
* mainly supportive: analgesics, antipyretics, warm or cold packs to parotid may be soothing
* admit to hospital if serious complications (meningitis, pancreatitis)
* droplet precautions recommended until 5d after onset of parotid swelling
* prophylaxis: routine vaccination
139
Describe complications: Mumps (2)
* common: aseptic meningitis, orchitis/oophoritis
* less common: encephalitis, pancreatitis, thyroiditis, myocarditis, arthritis, GN, ocular complications, hearing impairment
140
Define: Pertussis (1)
* prolonged respiratory illness characterized by paroxysmal coughing and inspiratory “whoop”
141
Describe epidemiology: Pertussis (2)
* ~10 million children \< 1yr old affected worldwide, causes up to 400,000 deaths/yr
* greatest incidence among children \< 1 yr (not fully immunized) and adolescents (waning immunity)
142
Describe etiology: Pertussis (3)
* Bordetella pertussis: Gram negative pleomorphic rod
* highly contagious; transmitted via respiratory droplets released during intense coughing
* incubation period: 6-20d; most contagious during catarrhal phase but may remain contagious for weeks after
143
Describe history: Pertussis (9)
* prodromal catarrhal stage
* lasts 1-7 d; URTI symptoms (coryza, mild cough, sneezing) with NO or low-grade fever
* paroxysmal stage
* lasts 4-6 wk; characterized by paroxysms of cough (“100 day cough”), sometimes followed by
* inspiratory whoop (“whooping cough”)
* infants \<6 mo may present with post-tussive apnea, whoop is often absent
* onset of attacks precipitated by yawning, sneezing, eating, physical exertion
* ± post-tussive emesis, may become cyanotic before whoop
* vomiting after whooping episodes
* convalescent stage
* lasts 1-2 wk; characterized by occasional paroxysms of cough, but decreased frequency and severity
* non-infectious but cough may last up to 6 mo
144
Describe investigations: Pertussis (2)
* NP specimen using aspirate or NP swab
* gold standard: culture using special media (Regan-Lowe agar)
* PCR to detect pertussis antigens
* blood work: CBC (lymphocytosis) and serology (antibodies against B.pertussis)
145
Describe management: Pertussis (5)
* admit if paroxysms of cough are associated with cyanosis and/or apnea and give O2
* supportive care
* antimicrobial therapy indicated if B.pertuss is isolated, or symptoms present for \< 21d
* use macrolide antibiotics (azithromycin, erythromycin, or clarithromycin)
* droplet isolation until 5d of treatment and report to Public Health
* prophylaxis
* macrolide antibiotics for all household contacts
* prevention with vaccination in infants and children (Pentacel®), and booster in adolescents (Adacel®) (see Routine Immunization, P4)
146
Describe complications: Pertussis (4)
* pressure-related from paroxysms: subconjunctival hemorrhage, rectal prolapse, hernias, epistaxis
* respiratory: sinusitis, pneumonia, aspiration, atelectasis, pneumomediastinum, pneumothorax, alveolar rupture
* neurological: seizures(~3%), encephalopathy, ICH
* mortality: ~0.3%; highest risk in infants \<6 mo old
147
Name: Cardinal Signs of Orbital Cellulitis (3)
* Ophthalmoplegia/diplopia
* Decreased visual acuity
* Pain with extraocular eye movement
148
Describe: Sinusitis (4)
* complication of ≤10% of URTIs in children
* clinical diagnosis
* diagnostic imaging is NOT required to confirm diagnosis in children
* routine CT not recommended, but consider if suspect complications of sinusitis, persistent/ recurrent disease, need for surgery
* antibiotictherapy (Amoxicillin) for all children (although nearly half resolve spontaneously within 4 wk)
149
Name complications: Sinusitis (3)
* preseptal/orbital (preseptal/orbitalcellulitis, orbitalabscess, osteomyelitis,etc.),
* intracranial (meningitis, abscess, etc.)
* Pott’s Puffy tumour (presents with tender soft tissue erythematous swelling of the forehead, symptoms include headache, photophobia, and fever; managed with IV antibiotics and ENT consult)
150
Define: Urinary Tract infection (1)
infection of the urinary bladder (cystitis) and/or kidneys (pyelonephritis)
151
Describe epidemiology: Urinary Tract infection (3)
* overall prevalence in infants and young children presenting with fever is 7%
* \< 4-6 wk old: more common in boys
* \> 1yr old: females have two-to four-fold higher prevalence
152
Describe etiology: Urinary Tract infection (3)
* majority (\>95%) have a single cause (~70% E.coli)
* Gram-negative bacilli: E.coli, Klebsiella, Proteus, Enterobacter, Pseudomonas
* Gram-positive cocci: S.saprophyticus, Enterococcus
153
Name risk factors: Urinary Tract Infection
* non-modifiable (4)
* modifiable (8)
* non-modifiable:
* female gender
* Caucasian
* previous UTIs
* family history
* modifiable:
* urinary tract abnormalities (VUR,neurogenic bladder,obstructive uropathy, posterior urethral valve),
* dysfunctional voiding
* repeated bladder catheterization
* uncircumcised males
* labial adhesions
* sexually active
* constipation
* toilet training
154
Name history: Urinary Tract Infection (2)
* infants and young child: often just fever or non-specific symptoms (poor feeding,irritability, FTT, jaundice if \<28 d old, vomiting)
* older child: fever,urinary symptoms (dysuria,urgency,frequency,incontinence,hematuria), abdominal, and/or flank pain
155
Describe physical exam: Urinary Tract Infection (2)
* older child: febrile, suprapubic and/or CVA tenderness, abdominal mass (enlarged bladder or kidney); may present with short stature, FTT, or HTN secondary to renal scarring from previously unrecognized or recurrent UTIs
* infants and young child: toxic vs.non-toxic, febrile, FTT, jaundice; look for external genitalia abnormalities (phimosis, labial adhesions) and lower back signs of occult myelodysplasia (e.g. hair tufts), which may be associated with neurogenic bladder
156
Describe investigations: Urinary Tract Infection (2)
* sterile urine specimen
* clean catch, catheterization, suprapubic aspiration or ‘Tap and Rub’ technique
* urinalysis (leukocyte esterase, nitrites, erythrocytes, hemoglobin), microscopy (bacteria and leukocytes, erythrocytes), C&S
* diagnosis established if urinalys is suggests infection AND if ≥ 50,000 colony-forming units per mL of a uropathogen cultured
157
Describe management: Urinary Tract Infection (6)
* admitif:\<2 mo old, urosepsis, persistent vomiting, inability to tolerate oral medication, moderate-severe dehydration, immunocompromised, complex urologic pathology, inadequate follow-up, failure to respond to outpatient therapy
* supportive care: maintenance of hydration and adequate pain control
* antibiotics
* imaging
* follow-up
* out patients to return in24-48h if no clinical response and seek prompt medical evaluation for future febrile illnesses
* prophylaxis: generally not recommended unless higher grades of VUR
158
Describe antibiotics for: Urinary Tract Infection (5)
* base on local antimicrobial susceptibility patterns
* commence broad empiric therapy until results of urine C&S known, and then tailor as appropriate
* neonates: IV ampicillin and gentamicin
* infants and older children: oral antibiotics (based on local E. coli sensitivity) if outpatient; IV ampicillin and gentamicin if inpatient
* duration 7-10 d
159
Describe imaging for: Urinary Tract Infection (2)
* renal and bladder U/S for all febrile infants (\<2 yr) with UTIs looking for anatomical abnormalities, hydronephrosis, abscess
* VCUG not recommended after 1st febrile UTI unless U/S reveals hydronephrosis, obstructive uropathies or other signs suggestive of high-grade VUR
160
Describe complications: Urinary Tract Infection (1)
long-term morbidity: focal renal scarring develops in 8% of patients; long-term significance unknown
