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12. Infectious Diseases Flashcards

1
Q

Define: Fever (1)

A

a practical definition is >38oC/100.4oF oral or rectal

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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

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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

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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.
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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
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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
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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
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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
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9
Q

Name criterias for acute otitis media (3)

A

All of:

  1. presence of middle ear effusion
  2. presence of middle ear inflammation
  3. acute onset of symptoms of middle ear effusion and inflammation
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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
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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
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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)
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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
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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)
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15
Q

Describe diagnosis: Acute Otitis Media (1)

A

Requires middle ear effusion and signs of inflammation (most important is a bulging TM)

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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
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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
    *
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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
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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
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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
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21
Q

Define: Otitis Media with Effusion (1)

A

presence of fluid in the middle ear without signs or symptoms of ear infection

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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%
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23
Q

Define risk factors: Otitis Media with Effusion (1)

A

Same as AOM

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24
Q

Describe clinical features: Otitis Media with Effusion (4)

A
  • conductive hearing loss ± tinnitus
  • fullness – blocked ear
  • ± pain
  • low grade fever
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25
Q

Describe results of otoscopy of TM in Otitis Media with Effusion (6)

A
  • 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
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26
Q

Describe treatment: Otitis Media with Effusion (5)

A
  • 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
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27
Q

Name complications: Otitis Media with Effusion (5)

A
  • hearing loss, speech delay, learningproblemsinyoungchildren
  • chronic mastoiditis
  • ossicular erosion
  • cholesteatomae specially when retraction pockets involve pars flaccida
  • retraction of tympanic membrane, atelectasis, ossicular fixation
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28
Q

Describe history: Gastroenteritis (3)

A
  • 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
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29
Q
A
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30
Q

Describe physical exam: Gastroenteritis (2)

A
  • febrile
  • dehydrated: must assess extent
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31
Q

Describe investigations: Gastroenteritis (2)

A
  • 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
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32
Q

Name complications: Gastroenteritis (3)

A
  • 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)
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33
Q

Describe etiology: Gastroenteritis (3)

A
  • 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
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34
Q

Describe clinical features: Gastroenteritis

  • Viral (3)
  • Bacterial (3)
A
  • Viral:
    • Associated with URTIs
    • Resolves in 3-7 d
    • Slight fever, malaise, vomiting, vague abdominal pain
  • Bacterial
    • Severe abdominal pain
    • High fever
    • Bloody diarrhea
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35
Q

Name risk factors: Gastroenteritis (2)

A
  • Daycare, young age, sick contacts, immunocompromised
  • Bacterial infection: travel, poorly cooked meat, poorly refrigerated foods, antibiotics
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36
Q

Describe management: Gastroenteritis (6)

A
  • 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
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37
Q

Describe epidemiology: Toddler’s Diarrhea (2)

A
  • most common cause of chronic diarrhea during infancy
  • onset between 6-36 mo of age, ceases spontaneously between 2-4yr
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38
Q

Describe clinical features: Toddler’s Diarrhea (5)

A
  • 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
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39
Q

Describe management: Toddler’s Diarrhea (2)

A
  • reassurance that it is self-limiting
  • 4Fs (adequate Fibre, normal Fluid intake, 35-40% Fat , discourage excess Fruit juice)
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40
Q

Describe: Erythema Infectiosum

  • Pathogen(s)
  • Incubation Period
  • Communicability
  • Mode of Transmission

(i.e. Fifth Disease/ Slapped Cheek)

A
  • Pathogen(s): Parvovirus B19
  • Incubation Period: 4-14 d
  • Communicability: Low risk of transmission once symptomatic
  • Mode of Transmission:
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41
Q

Describe rash: Erythema Infectiosum

(i.e. Fifth Disease/ Slapped Cheek) (3)

A
  • 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
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42
Q

Describe associated features: Erythema Infectiosum

(i.e. Fifth Disease/ Slapped Cheek)

A
  • 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)
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43
Q

Describe management: Erythema Infectiosum

(i.e. Fifth Disease/ Slapped Cheek) (1)

A

Supportive

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44
Q

Describe outcomes and complications: Erythema Infectiosum

(i.e. Fifth Disease/ Slapped Cheek)

A

Rash fades over days to week, but may reappear months later with sunlight, exercise Aplastic crisis

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45
Q

Describe: Gianotti-Crosti Syndrome (i.e. Papular Acrodermatitis)

  • Pathogen(s)
  • Incubation Period
  • Communicability
  • Mode of Transmission
A
  • Pathogen(s): EBV and Hep B (majority)
  • Incubation Period: Variable
  • Communicability: None
  • Mode of Transmission: -
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46
Q

Describe rash: Gianotti-Crosti Syndrome (i.e. Papular Acrodermatitis)

A
  • Appearance: asymptomatic symmetric papules
  • Distribution: face, cheeks, extensor surfaces of the extremities, spares trunk
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47
Q

Describe associated features: Gianotti-Crosti Syndrome (i.e. Papular Acrodermatitis) (2)

A
  • Viral prodrome
  • May have lymphadenopathy and/ or hepatosplenomegaly
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48
Q

Describe management: Gianotti-Crosti Syndrome (i.e. Papular Acrodermatitis) (2)

A
  • Supportive
  • Pain control
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49
Q

Describe outcomes and complications: Gianotti-Crosti Syndrome (i.e. Papular Acrodermatitis) (1)

A

Resolves in 3-12 wk

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50
Q

Describe: Hand, Foot, and Mouth Disease

  • Pathogen(s)
  • Incubation Period
  • Communicability
  • Mode of Transmission
A
  • 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
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51
Q

Describe rash: Hand, Foot, and Mouth Disease (2)

A
  • Appearance: vesicles and pustules on an erythematous base
  • Distribution: acral, but may exentend up the extremity
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52
Q

Describe associated features: Hand, Foot, and Mouth Disease (1)

A

Enanthem: vesicles in the POSTERIOR oral cavity (pharynx, tongue)

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53
Q

Describe management: Hand, Foot, and Mouth Disease

A

Supportive

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54
Q

Describe outcomes and complications: Hand, Foot, and Mouth Disease (1)

A

Mainly dehydration

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55
Q

Describe: Herpes Simplex

  • Pathogen(s)
  • Incubation Period
  • Communicability
  • Mode of Transmission
A
  • 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
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56
Q

Describe rash: Herpes Simplex (1)

A

Grouped vesicles on an erythematous base

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57
Q

Describe associated features: Herpes Simplex (2)

A
  • Enanthem: vesicles/erosions in the ANTERIOR oral cavity (buccal mucosa, tongue)
  • May present with herpetic whitlow (autoinoculation)
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58
Q

Describe management: Herpes Simplex (2)

A
  • Mainly supportive
  • Consider oral or topical antivirals
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59
Q

Describe outcomes and complications: Herpes Simplex (4)

A
  • Local: secondary skin infections, keratitis, gingivostomatitis
  • CNS: encephalitis
  • Disseminated hepatitis, DIC
  • Eczema herpeticum
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60
Q

Describe: Measles

  • Pathogen(s)
  • Incubation Period
  • Communicability
  • Mode of Transmission
A
  • Pathogen(s): Morbillivirus
  • Incubation Period: 8-13 d
  • Communicability: 4 d before and after rash
  • Mode of Transmission:
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61
Q

Describe:

  • Pathogen(s)
  • Incubation Period
  • Communicability
  • Mode of Transmission
A
  • Pathogen(s):
  • Incubation Period:
  • Communicability:
  • Mode of Transmission:
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62
Q

Describe rash: Measles (3)

A
  • Appearance: erythematous maculopapular
  • Timing: 3 d after start of symptoms
  • Distribution: starts at hairline and spreads downwards with sparing of palms and soles
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63
Q

Describe associated features: Measles (4)

A
  • Prodome of cough, coryza, conjunctivitis (3 Cs)
  • Enanthem: Koplik’s spots 1-2 d before rash
  • Desquamation
  • Positive serology for measles IgM
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64
Q

Describe management: Measles (4)

A
  • 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
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65
Q

Describe outcomes and complications: Measles (3)

A
  • Secondary bacterial infections: AOM, sinusitis, pneumonia
  • Encephalitis
  • Rare: myocarditis, pericarditis, thrombocytopenia, Stevens-Johnson syndrome, GN, subacute sclerosing panencephalitis
66
Q

Describe: Non-Specific Enteroviral Exanthems

  • Pathogen(s)
  • Incubation Period
  • Communicability
  • Mode of Transmission
A
  • Pathogen(s): Enteroviruses
  • Incubation Period: Variable
  • Communicability: Variable
  • Mode of Transmission: Direct and indirect contact with infected bodily fluids
67
Q

Describe rash: Non-Specific Enteroviral Exanthems

A

Polymorphous rash (macules, papules, vesicles, petechiae, urticaria)

68
Q

Describe associated features: Non-Specific Enteroviral Exanthems (1)

A

Systemic involvement is rare, but possible

69
Q

Describe management: Non-Specific Enteroviral Exanthems (1)

A
  • Supportive
  • Diagnosis confirmed using viral cultures (NP and rectal swabs)
70
Q

Describe outcomes and complications: Non-Specific Enteroviral Exanthems (1)

A

Self-limiting

71
Q

Describe:

  • Pathogen(s)
  • Incubation Period
  • Communicability
  • Mode of Transmission
A
  • Pathogen(s):
  • Incubation Period:
  • Communicability:
  • Mode of Transmission:
72
Q

Describe:

  • Pathogen(s)
  • Incubation Period
  • Communicability
  • Mode of Transmission
A
  • Pathogen(s):
  • Incubation Period:
  • Communicability:
  • Mode of Transmission:
73
Q

Describe rash:

74
Q

Describe:

  • Pathogen(s)
  • Incubation Period
  • Communicability
  • Mode of Transmission
A
  • Pathogen(s):
  • Incubation Period:
  • Communicability:
  • Mode of Transmission:
75
Q

Describe associated features:

76
Q

Describe: Roseola

  • Pathogen(s)
  • Incubation Period
  • Communicability
  • Mode of Transmission
A
  • Pathogen(s): HHV 6
  • Incubation Period: 5-15 d
  • Communicability: Unknown
  • Mode of Transmission: -
77
Q

Describe rash: Roseola (3)

A
  • Appearance: blanching, pink, maculopapular
  • Timing: appears once fever subsides
  • Distribution: starts at the neck and trunk and spreads to the face and extremities
78
Q

Describe associated features: Roseola (3)

A
  • 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
Q

Describe management: Roseola (1)

A

Supportive

80
Q

Describe outcomes and complications: Roseola (2)

A
  • CNS: febrile seizures (10-25%), aseptic meningitis
  • Thrombocytopenia
81
Q

Describe: Rubella

  • Pathogen(s)
  • Incubation Period
  • Communicability
  • Mode of Transmission
A
  • Pathogen(s): Rubivirus
  • Incubation Period: 14-21 d
  • Communicability: 7 d before and after eruptions
  • Mode of Transmission: Droplet
82
Q

Describe rash: Rubella (3)

A
  • Appearance: pink, maculopapular
  • Timing: 1-5 d after start of symptoms
  • Distribution: starts on face and spreads to neck and trunk
83
Q

Describe Associated Features: Rubella (4)

A
  • 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
Q

Describe management: Rubella (3)

A
  • Infected: supportive
  • Prevention: MMR vaccine
  • Report to Public Health
85
Q

Describe: Varicella

  • Pathogen(s)
  • Incubation Period
  • Communicability
  • Mode of Transmission
A
  • 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
Q

Describe rash: Varicella (3)

A
  • 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
Q

Describe associated features: Varicella (3)

A
  • Significant pruritis
  • Enanthem: vesicular lesions which may become pustular or ulcerate.
  • Caution to pregnant women
88
Q

Describe management: Varicella (5)

A
  • Supportive
  • Avoid salicylates (due to risk of Reye syndrome)
  • Consider antivirals
  • Respiratory and contact isolation, report to Public Health
  • Prevention: varicella vaccine
89
Q

Describe outcomes and complications: Varicella (4)

A
  • Skin: bacterial suprainfection, necrotizing fasciitis
  • CNS: acute encephalitis and cerebellar ataxia
  • Systemic: hepatitis, DIC
  • Congenital varicella syndrome if intrapartum infection
90
Q

Define: Infectious Mononucleosis (1)

A

systemic viral infection caused by EBV with multi visceral involvement; often called “the great imitator”

91
Q

Describe epidemiology: Infectious Mononucleosis (2)

A
  • 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
Q

Describe etiology: Infectious Mononucleosis (3)

A
  • 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
Q

Name risk factors: Infectious Mononucleosis (3)

A
  • infectious contacts
  • sexually active
  • multiple sexual partners in the past
94
Q

Describe risk factors: Infectious Mononucleosis (3)

A
  • 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
Q

Describe physical exam: Infectious Mononucleosis (5)

A
  • 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
Q

Describe investigations: Infectious Mononucleosis (5)

A
  • 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
Q

Describe management: Infectious Mononucleosis (4)

A
  • 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
Q

Describe prognosis: Infectious Mononucleosis (2)

A
  • most acute symptoms resolve in 1-2wk, though fatigue may last for months
  • short-term complications: splenic rupture, Guillain-Barré syndrome
99
Q

Define: Infectious Pharyngitis/Tonsillitis (1)

A

inflammation of the pharynx, especially the tonsils if present, causing a sore throat

100
Q

Describe etiology: Infectious Pharyngitis/Tonsillitis (4)

A
  • 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
Q

Describe epidemiology: Infectious Pharyngitis/Tonsillitis (2)

A
  • 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
Q

Describe presentation: Infectious Pharyngitis/Tonsillitis GAS (12)

A
  • 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
Q

Describe presentation: Infectious Pharyngitis/Tonsillitis viral (11)

A
  • 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
Q

Describe investigations: Infectious Pharyngitis/Tonsillitis (3)

A
  • 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
Q

Describe management: Infectious Pharyngitis/Tonsillitis (4)

A
  • 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
Q

Describe complications: Infectious Pharyngitis/Tonsillitis (2)

A
  • 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
Q

Describe: Rheumatif Fever (2)

A
  • 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
Q

Describe diagnosis: Rheumatif Fever (2)

A
  • 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
Q

Describe treatment and phrophylaxis: Rheumatif Fever (2)

A
  • treatment: penicillin or erythromycin for acute course x 10d, prednisone if severe carditis
  • secondary prophylaxis with daily penicillin or erythromycin
110
Q

Describe complications: Rheumatif Fever (3)

A
  • 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
Q

Describe scarlet fever (7)

A
  • 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
Q

Describe: Post-Streptococcal Glomerulonephritis (3)

A
  • 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
Q

Describe clinical features: Post-Streptococcal Glomerulonephritis (1)

A
  • clinical feature varies from asymptomatic, microscopic and macroscopic hematuria (cola-coloured urine) to all features of nephritic syndrome
114
Q

Describe diagnosis: Post-Streptococcal Glomerulonephritis (1)

A

diagnosis is confirmed with elevated serum antibody titres against streptococcal antigens (ASOT,anti-DNAse B), low serum complement (C3)

115
Q

Describe management: Post-Streptococcal Glomerulonephritis (3)

A
  • 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
Q

Describe prognosis: Post-Streptococcal Glomerulonephritis (2)

A
  • 5% of children recover completely within 1-2 wk;
  • 5-10% have persistent hematuria
117
Q

Define: Meningitis (1)

A

inflammation of the meninges surrounding the brain and spinal cord

118
Q

Describe epidemiology : Meningitis (2)

A
  • peak age: 6-12mo
  • 90% of cases occur in children <5yr old
119
Q

Describe etiology : Meningitis (4)

A
  • 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
Q

Name risk factors: Meningitis (5)

A
  • 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
Q

Describe history: Meningitis (3)

A
  • 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
Q

Describe physical exam: Meningitis (2)

A
  • 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
Q

Describe investigations: Meningitis (2)

A
  • bloodwork: CBC, electrolytes, Cr, BUN, glucose, C&S
  • LP required for definitive diagnosis
124
Q

Describe LP in meningitis (5)

A
  • 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
Q

Describe findings of meningitis in LP

126
Q

Describe management of meningitis (2)

A
  • preservation of adequate cerebral perfusion by maintaining normal BP and managing ⬆️ ICP
  • close monitoring of fluids, electrolytes, glucose, acid-base disturbances, coagulopathies
127
Q

Describe management of bacterial meningitis (6)

A
  • 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
Q

Desribe: Antibiotic Management of Bacterial Meningitis

  • 0 to 28 d
  • 28 to 90d
  • >90 d
129
Q

Name: Signs of Meningismus (4)

A

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
Q

Describe management: Viral meningitis (3)

A
  • mainly supportive (except for HSV)
  • acyclovir for HSV meningitis
  • report to Public Health
131
Q

Describe prophylaxis: Viral meningitis (1)

A

Appropriate vaccinations significantly decrease incidence of bacterial meningitis

132
Q

Describe complications: Viral meningitis (3)

A
  • 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
Q

Define: Mumps (1)

A
  • acute,self-limited viral infection that is most commonly characterized by adenitis and swelling of the parotid glands
134
Q

Describe epidemiology: Mumps (3)

A
  • 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
Q

Describe etiology: Mumps (5)

A
  • 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
Q

Describe history: Mumps (4)

A
  • 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
Q

Describe investigations: Mumps (3)

A
  • 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
Q

Describe management: Mumps (4)

A
  • 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
Q

Describe complications: Mumps (2)

A
  • common: aseptic meningitis, orchitis/oophoritis
  • less common: encephalitis, pancreatitis, thyroiditis, myocarditis, arthritis, GN, ocular complications, hearing impairment
140
Q

Define: Pertussis (1)

A
  • prolonged respiratory illness characterized by paroxysmal coughing and inspiratory “whoop”
141
Q

Describe epidemiology: Pertussis (2)

A
  • ~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
Q

Describe etiology: Pertussis (3)

A
  • 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
Q

Describe history: Pertussis (9)

A
  • 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
Q

Describe investigations: Pertussis (2)

A
  • 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
Q

Describe management: Pertussis (5)

A
  • 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
Q

Describe complications: Pertussis (4)

A
  • 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
Q

Name: Cardinal Signs of Orbital Cellulitis (3)

A
  • Ophthalmoplegia/diplopia
  • Decreased visual acuity
  • Pain with extraocular eye movement
148
Q

Describe: Sinusitis (4)

A
  • 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
Q

Name complications: Sinusitis (3)

A
  • 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
Q

Define: Urinary Tract infection (1)

A

infection of the urinary bladder (cystitis) and/or kidneys (pyelonephritis)

151
Q

Describe epidemiology: Urinary Tract infection (3)

A
  • 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
Q

Describe etiology: Urinary Tract infection (3)

A
  • 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
Q

Name risk factors: Urinary Tract Infection

  • non-modifiable (4)
  • modifiable (8)
A
  • 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
Q

Name history: Urinary Tract Infection (2)

A
  • 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
Q

Describe physical exam: Urinary Tract Infection (2)

A
  • 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
Q

Describe investigations: Urinary Tract Infection (2)

A
  • 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
Q

Describe management: Urinary Tract Infection (6)

A
  • 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
Q

Describe antibiotics for: Urinary Tract Infection (5)

A
  • 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
Q

Describe imaging for: Urinary Tract Infection (2)

A
  • 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
Q

Describe complications: Urinary Tract Infection (1)

A

long-term morbidity: focal renal scarring develops in 8% of patients; long-term significance unknown

TN Pédiatrie (14 decks)

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