26 - Infectious Diseases 1 Flashcards
What are some notifiable disease that may come up in paediatrics?
- Meningococcal septicaemia
- Meningitis
- Whooping cough
- Rubella
- Measles
- Scarlet fever
- Acute encephalitis
- HUS
- Infectious bloody diarrhoea
What device should be used to take the temperature of a child?
- < 4 weeks: electronic thermometer in axilla
- 4 weeks to 5 years of age: either an electronic thermometer or a chemical dot thermometer in the axilla, or infra-red tympanic thermometer
- Do NOT use forehead, oral or rectal thermometers
If a child presents with an acute rash, what differentials do you need to consider from most to least important?
- Meningitis
- Kawasaki
- SSSS
- Anaphylaxis/Hives/Urticaria
- Measles
- Scarlet fever
- Chicken pox
- Hand, foot and mouth disease
- Viral rash/exanthem
What is the definition of fever in a child and what questions do you need to ask the parents when their child presents with fever?
>38 degrees
- Onset, duration, and pattern of fever
- Method of temperature measurement
- Any associated symptoms
- Any perinatal complication e.g maternal fever and/or premature delivery
- Any significant medical conditions e.g immunosuppression
- Any recent antipyretic drug and/or antibiotic use
- Immunisation history
- Any recent foreign travel
- Any recent contact with people with serious infectious diseases
- Parental/carer health beliefs about fever and previous family experience of serious febrile illness
What observations are important to do if a child comes in with fever?
Need all of these to look at the traffic light system
- General appearance
- Temperature
- Heart rate
- Respiratory rate
- Capillary refill time (CRT)
- Fluid status
- Consider measuring child’s BP if the heart rate or CRT are abnormal
What are red features suggesting a serious or life-threatening cause of febrile illness and what should the management be?
Emergency Ambulance Transfer to A and E
- Features of sepsis
- Features of meningitis
- Pneumonia
- Severe dehydration
If a feverish child has red flags but these are not life-threatening then what is the management?
Urgent face to face assessment within 2 hours
If a feverish child has amber features what should the management be?
Consider arranging hospital admission if:
- <3months with suspected UTI
- The feverish illness has no obvious underlying cause
- Significant parental/carer anxiety and/or difficulty coping
If the child can be managed at home, provide the parents/carers with safety net advice:
- Advise on warning signs and when urgent medical review is needed
- Arrange a follow-up appointment in primary care for review
- Ensure direct access for the child if further assessment are required
If a feverish child has green features how are they managed?
At home with safety netting
What do you always need to consider in prolonged fever of children?
Kawasaki Disease
Children under 1 show less signs but more prone to coronary artery aneurysms so be careful
What is some safety net advice for parents with a feverish child?
Urgent medical review if:
- Child develops non-blanching rash or other signs of CNS infection
- Child has a seizure.
- Child is becoming dehydrated
- Fever lasts longer than 5 days
- Child is becoming more unwell
- Distressed or concerned that they are unable to look after the child at home
What is some general advice to give to parents on managing a feverish child at home?
- Do not use aspirin
- Look for signs of dehydration in the child
- Offering regular fluids and encouraging a higher fluid intake
- Dressing the child appropriately for the surrounding environment by not underdressing or over-wrapping
- Avoid use of tepid sponging to lower the child’s temperature.
- Check child regularly, including during the night
- Keeping child away from nursery or school until they are recovered
What are contraindications to live vaccinations?
- Pregnancy
- Immunosuppression/deficiency
What are some examples of live vaccines?
What are some inactivated and conjugated vaccines?
What are some examples of toxin vaccines?
Vaccine contains a toxin that is usually produced by the pathogen
- Tetanus
- Diphtheria
What is the vaccine schedule in children?
What is meningococcus?
Neisseria meningitidis causing meningitis or septicaemia (if in blood)
What is a non-blanching rash in meningitis indicative of?
N.Menigitidis infection causing DIC
What organisms are the most common cause of bacterial meningitis in the following age groups:
- Neonates (up to 4 weeks)
- 1 month to 3 years
- 3 to 10 years
- >10years
GELS
Neonates: GEL, with GBS most common
1 month to 3 years: GELS with N.Meningitidis and HiB
3 to 10 years: Neisseiria Meningitidis and Strep Pneumoniae
>10 years: N.Meningitidis
What is the most common cause of bacterial meningitis in neonates and children?
Neonates: GBS
Child: N.Meningitidis
How does bacterial meningitis present in children?
(specific signs more important)
Non-specific symptoms:
- Fever
- N+V
- Lethargy, irritable or unsettled
- Refusal for food or drink
- Headache
- Cough
- Muscle aches
Specific symptoms and signs
- Stiff neck
- Altered mental state
- Non-blanching rash
- Bulging fontanelle (in children younger than 2 years of age),
- Photophobia
- Kernig’s sign
- Brudzinski’s sign
- Seizures
If meningococcal meningitis is suspected (non-blanching rash), what is the empirical treatment?
Before hospital: Benzylpenicillin IM
In hospital: Ceftriaxone (NO STEROIDS)
What investigations are done for suspected meningitis?
(know off by heart)
- Lumbar puncture
- FBC, U+Es, Clotting, Glucose
- Blood Meningococcal PCR (faster than culture)
- ABG or VBG for lactate
- Blood cultures
- CT Head if suspect raised ICP
What are contraindications to a LP in meningitis?
RAISED ICP
When sending off a CSF sample in meningitis, what testing are you requesting?
- MC+S
- Gram stain
- Viral PCR
- Glucose (don’t forget to send off serum glucose at same time)
What are normal CSF results?
(Appearance, cells, protein, glucose)
<20 WBC is neonate
How do bacterial and viral CSF infections show up on CSF analysis?
How do TB and fungal infections show on CSF analysis?
How is bacterial meningitis managed once in the hospital?
(Don’t forget number 5)
- Antibiotics (take LP and cultures first)
- See image
- Add in Benzylpenicillin if suspect meningococcus
2. Steroids
- If over three months and not meningococcus give Dexamethasone
3. Fluids
- Treat any shock
4. Cerebral monitoring
- If herniation signs (Cushing’s) treat for raised ICP
5. Public health notification and antibiotic prophylaxis of contacts
- ISOLATE PATIENT
- Ciprofloxacin single dose to contacts in last 7 days
Why are steroids given in meningitis?
- S.Pneumoniae can cause hearing loss so reduces this
- Taken 4x a day for 4 days
- Only if >3 months old and LP suggestive of bacterial meningitis
What antibiotics are given for meningitis cause by GBS?
- Benzylpenicillin
- Gentamicin
- Cefotaxime
What are complications of meningitis? (Important for OSCE)
- Hearing loss
- Seizures and epilepsy
- Cognitive impairment and learning disability
- Memory loss
- Cerebral palsy
How should a child with meningitis be followed up after discharge?
- Review with a paediatrician 4–6 weeks after hospital discharge to assess their recovery
- Hearing test 6 weeks after discharge
- Be alert for possible late-onset complications (see image)
What are some causes of viral meningitis in children?
- Herpes simplex
- Varicella Zoster
- Enterovirus e.g Coxsackie
- CMV
- HIV
- Measles
What symptoms are less common in viral meningitis?
- Focal neurological deficits on examination
- Seizures
What antiviral are used for viral meningitis?
Aciclovir
What are some causes of encephalitis in children?
ALWAYS ASK ABOUT IMMUNISATIONS AND RECENT INFECTIONS
Viral
- HSV1 common in children from cold sores
- HSV2 common in neonates from genital herpes
- EBV and CMV in immunocompromise
- Mumps
- Autoimmune
How does encephalitis present in children?
- Fever
- Altered mental status
- New onset seizures
- Unusual behaviour
- Can be prodrome of flu-like symptoms
What investigations should be done for children with suspected encephalitis?
- Lumbar puncture: viral PCR for HSV and other usual bits e.g protein
- Stool and Urine culture: enteroviruses
- CT scan if lumbar puncture contraindicated
- MRI scan after lumbar puncture
- EEG recording
- HIV testing is recommended in all patients with encephalitis
What antibiotic/antiviral is given for encephalitis?
- Aciclovir (or Ganiclovir if CMV)
- Ceftriaxone
Give both for 2 weeks, 21 days if proven HSV
What are the complications of encephalitis?
Follow up appointment with paediatrics in 6-8 weeks!!!!!!!!!!!
- Lasting fatigue and prolonged recovery
- Change in personality or mood
- Changes to memory and cognition
- Learning disability
- Headaches
- Chronic pain
- Movement disorders
- Sensory disturbance
- Seizures
- Hormonal imbalance
What other part of management in encephalitis is there about from supportive and antimicrobial?
INFORM PUBLIC HEALTH
What is first to sixth disease? (viral exathems in children)
- First disease: Measles
- Second disease: Scarlet Fever
- Third disease: Rubella (AKA German Measles)
- Fourth disease: Dukes’ Disease
- Fifth disease: Parvovirus B19
- Sixth disease: Roseola Infantum
Measles, Scarlet Fever and Rubella = NOTIFIABLE DISEASES
What is measles caused by, what is the method of spread and what is the incubation period?
Measles Morbillivirus (Paramyxovirus)
- Spread by respiratory droplets
- Infective from prodrome until 4 days after rash starts
- Incubation period = 10-14 days
What are the features of measles?
Prodromal phase
- Irritable
- Conjunctivitis
- Fever over 40 degrees
Koplik spots
- White spots on buccal mucosa before rash
Rash (MORBILLIFORM)
- Starts behind ears then to the whole body
- Discrete maculopapular rash that starts blanching becoming blotchy & confluent and non-blanching
- Desquamation that typically spares palms and soles may occur after a week
- Diarrhoea
How is measles diagnosed and managed?
Dx
- Measles specific IgM and IgG serology 3-14 days after onset of rash
- PCR for type
Mx
- Self-limiting over 7-10 days
- Inform PHE
- Isolate child until 4 days after rash starts
- Analgesia and antipyretics
What contact tracing needs to be done in measles?
If had more than 15 minutes contact with confirmed case need MMR vaccination if not already had one within 72 hours
Most people have had them at age 1 and 3
Complications occur in ⅓ of patients with measles. What are the complications?
- Otitis media: most common
- Diarrhoea
- Pneumonia: most common cause of death
- Encephalitis: 1-2 weeks following the onset of the illness
- Subacute sclerosing panencephalitis: may present 5-10 years later
- Febrile convulsions
- Keratoconjunctivitis, corneal ulceration
- Myocarditis
What is Scarlet fever caused by and what is the mode of transmission?
NOT VIRAL
- Reactions to toxins produced by Group A streptococcus (usually S.Pyogenes from tonsillitis)
- Peak at 4 years, common between 2-6 years
- Spread via respiratory droplets
How does Scarlet Fever present and what is the incubation period?
Red-pink, blotchy, macular rash with rough “sandpaper” skin that starts on the trunk and spreads outwards
Other features:
- Red flushed cheeks
- Fever
- Lethargy
- Sore throat
- Strawberry tongue
- Cervical lymphadenopathy
How is Scarlet Fever diagnosed and managed?
Dx
- Throat swab but don’t wait for results
Mx
- Phenoxymethylpenicillin (penicillin V) for 10 days
- Inform public health
- Keep off school until had antibiotics for 24 hours
What are some complications of Scarlet fever?
- Otitis media: most common
- Rheumatic fever: typically occurs 20 days after infection
- Acute glomerulonephritis: typically occurs 10 days after infection
What are some other conditions caused by Group A strep?
- Post streptococcal GN
- Rheumatic fever
What is Rubella and the epidemiology of this?
- Highly contagious virus spread by respiratory droplets
- Symptoms 2 weeks after exposure
- Infectious from 7 days before symptoms and 4 days after rash appears
Only around 5 cases per year due to MMR vaccine
What are the features of Rubella?
- Prodrome: low-grade fever, joint pain, sore throat
- Rash: maculopapular, initially on the face before spreading to the whole body, usually fades by the 3-5 day
- Lymphadenopathy: suboccipital and postauricular
How is Rubella managed?
- Supportive self-limiting
- Inform public health
- Avoid pregnant women
- Keep off school until 5 days after rash
What are some complications of Rubella?
- Arthritis
- Thrombocytopaenia
- Encephalitis
- Myocarditis
Congenital Rubella Syndrome: deafness, blindness, cardiac abnormalities
What are the different ways that a Parvovirus B19 infection can present?
- Asymptomatic
- Slapped Cheek/Erythema Infectiosum
- Aplastic anaemia
- Pancytopenia in immunosuppressed
- Hydrops fetalis
How does Slapped Cheek Syndrome present?
- Prodrome: mild fever, coryza and non-specific viral symptoms such as muscle aches and lethargy
- Rash: diffuse bright red rash on both cheeks after 2-5 days. A few days later a reticular mildly erythematous rash affecting the trunk and limbs appears that can be raised and itchy
- Rash fades over 1-2 weeks
How is Slapped Cheek Syndrome managed and how long are they contagious for?
- If low risk then supportively with analgesia and fluids
- Infectious until rash comes out so don’t need to exclude from school
Which children are higher risk with Slapped Cheek Syndrome and how are they managed differently?
High risk
- Immunosuppressed
- Sickle cell anaemia
- Thalassaemia, hereditary spherocytosis and haemolytic anaemia
- Pregnant
Mx
- Need serological testing for diagnosis
- Need to check FBC and reticulocyte count for aplastic anaemia
What should a pregnant mum do if their child has slapped cheek syndrome?
- Contact midwife to check IgG and IgM serology
- If exposed before 20 weeks can cause hydrops fetalis due to anaemia so need intrauterine blood transfusions
- Can cause miscarriage
What is Roseola infantum (sixth disease) caused by and who does it affect?
Human Herpes Virus 6 (sometimes HHV7)
Incubation of 5-15 days
6months to 2 years
How does roseola present?
- Sudden high fever up to 40 for 3-5 days that disappears suddenly
- Coryzal symptoms, sore throat, swollen lymph nodes (NAGAYAMA SPOTS)
- After temperature settled rash appears for 1-2 days, not itchy, macular
How long do children with roseola need to be kept off of school?
Not necessary
Will recover in a week
What are complications of roseola?
- Febrile convulsions
- If immunosuppressed: myocarditis, GBS, aseptic meningitis, hepatitis
How long do children need to be kept off of school with the following infectious diseases?
Which infectious diseases need no school exclusion?
- Conjunctivitis
- Fifth disease (slapped cheek)
- Roseola
- Infectious mononucleosis
- Head lice
- Threadworms
- Hand, foot and mouth
What is the epidemiology and aetiology of hand, foot and mouth disease?
Coxsackie A16 Virus or Enterovirus
Common in late summer early autumn in nurseries
Usually affects under 4’s but can spread through families
How does hand, foot and mouth disease present?
- Mild systemic upset: sore throat, fever, like URTI
- Oral ulcers after 1-2 days, usually painful.
- Followed later by vesicles on the palms and soles of the feet, can be itchy
How is hand, foot and mouth disease managed?
- Supportive: adequate fluid, analgesia, paracetamol
- Will self resolve within a week
- Highly contagious so hygiene measures
What is mumps caused by and how long are you infectious for?
RNA Paramyxovirus
- Spread by saliva droplets
- Infective 7 days before and 9 days after parotid swelling starts
- Incubation period = 14-21 days
How does mumps present?
Prevalence decreased due to MMR vaccine
- Prodromal fever, malaise, muscular pain
- Parotitis (‘earache’, ‘pain on eating’): unilateral initially then bilateral
What is the management of mumps?
- Salivary IgM swab
- Supportive treatment only: fluids, analgesia, antipyretics
- Isolate until 5 days after parotitis
- Inform PHE
What are some complications of mumps?
- Orchitis leading to infertility - more in post-pubertal males, 4-5 days after start of parotitis
- Hearing loss - usually unilateral and transient
- Meningoencephalitis
- Pancreatitis
What can malaria cause in children?
- Renal failure
- Anaemia
- Encephalitis
How is bacterial meningitis managed acutely?
VERY IMPORTANT TO KNOW ANTIBIOTICS FOR OCE
How will a child with pneumonia present on examination?
How is the severity of pneumonia in children defined?
What investigations should you do for suspected pneumonia in children?
How should you manage pneumonia in children?
How can you tell the difference between viral and bacterial pneumonia in children?
What are differentials for fever and the following rash:
- Maculopapula
- Vesicular, bullous, pustular
- Petechial, Purpuric
