27 - Infectious Diseases 2 Flashcards

1
Q

How does malaria present in children?

A

ALWAYS CHECK TRAVEL HISTORY

  • Drowsiness
  • Irritability
  • Poor feeding
  • Fever
  • Splenomegaly
  • Jaundiced
  • Seizures
  • Chills, fever, sweating cycling every 2-3 days
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2
Q

What organism causes malaria and when do children present?

A
  • Plasmodium Falciparum (75%)
  • Plasmodium Vivax

Most present within the first month, if not up to 6 months

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3
Q

What are some signs of severe malaria?

A
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4
Q

What investigations are done to diagnose malaria in children?

A
  • Thick and thin films: if initial test negative but suspected, film needs to be repeated up to 3 times (12, 24 and 48 hours)
  • Rapid antigen tests
  • Bloods:
  • FBC
  • Blood glucose rapid test and laboratory sample blood gas
  • U+Es, LFTs, CRP, Clotting screen
  • Blood cultures
  • G6PD if primaquine is required
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5
Q

What investigations are done to diagnose malaria in children?

A
  • Thick and thin films: if initial test negative but suspected, film needs to be repeated up to 3 times (12, 24 and 48 hours)
  • Rapid antigen tests
  • Bloods:
  • FBC
  • Blood glucose rapid test and laboratory sample blood gas
  • U+Es, LFTs, CRP, Clotting screen
  • Blood cultures
  • G6PD if primaquine is required
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6
Q

How are all children with malaria regardless of cause and severity managed?

A
  • Inform public health
  • Admit to hospital for 24h for
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7
Q

How is complicated malaria in children managed?

A
  • Admit to HDU/PICU
  • IV artesunate for 24 hours
  • Then a full course of oral Artemether- lumefantrine when can tolerate
  • Hourly observations including neuro in first 12 hours as risk of rapid deterioration
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8
Q

How is uncomplicated falciparum malaria treated in children?

A

Can be outpatient

First line: Artemether-lumifantrine or DHA-PPQ (Dihydroartemisinin-piperaquine).

  • Quinine with doxycycline or Atovaquone-proguanil can also be used
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9
Q

How is uncomplicated non-falciparum malaria treated?

A

Chloroquine or Primaquine

Always check G6PD

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10
Q

How is a pregnant woman with malaria treated?

A

If neonate infected will present like neonatal sepsis

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11
Q
A

C, E, B

Always be thinking TB and malignancy

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12
Q

What are contraindications to vaccination?

A
  • Previous anaphylaxis to a vaccine or vaccine component (
  • Primary or acquired immunodeficiency
  • Immunosuppressive therapy. e.g. chemotherapy or radiotherapy, high-dose steroids).

Temporary deferral:

  • Acutely unwell e.g. with fever >38.5°C. Postpone immunisation until well.
  • Immunoglobulin therapy
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13
Q
A

A and C

C is DiGeorge syndrome so immunosuppressed

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14
Q

Which vaccines in the routine immunisation schedule are live?

A
  • MMR
  • Rotavirus
  • Nasal flu
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15
Q

What are the different types of adverse events following immunisation? (AEFI)

A
  • Programme-related e.g. wrong dose, vaccine inappropriately prepared, vaccine stored incorrectly.
  • Vaccine-induced Reactions in individuals to a particular vaccine
  • Coincidental. Not a true AEFI but only linked because of the timing of the occurrence
  • Unknown
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16
Q

What are some reasons for under vaccination?

A
  • Vaccine hesitancy/refusal
  • Children in large families
  • Children with lone or single parents
  • Looked after children
  • Children in mobile families
  • Migrant/asylum seeking children
  • Children with disabling or chronic conditions
  • Children in ethnic minority groups
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17
Q

What is toxic shock syndrome and what is it caused by?

A

Acute, multi-system inflammatory response to an exotoxin-mediated bacterial infection

Life-threatening with rapid progression to septic shock

Common pathogens: Staphylococcus aureus and Group A Streptococcus (GAS; S pyogenes)

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18
Q

What are some risk factors for toxic shock syndrome in children?

A

Always consider in burns!!!!!

Usually small surface area burn presenting 2 days after burn

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19
Q

What is the centre for disease control and prevention diagnostic criteria for TSS?

A

Fever, Hypotension, Rash

PLUS

3 or more organ systems involved

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20
Q

Why are children more susceptible to severe toxic shock syndrome?

A
  • Immature immune systems that cannot produce antitoxin antibodies
  • Infants under 1 are protected by passive immunity at birth and in breast milk
  • Small burns worse as less aggressively treated
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21
Q

When should you suspect toxic shock syndrome?

A

An unwell child with a burn or other risk factors is TSS until proven otherwise

Similar presentation to sepsis, multi system involvement

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22
Q

What are some non-specific signs of TSS?

A
  • High fever ≥38.9
  • Tachycardia
  • Tachypnoea
  • Capillary refill >3 seconds
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23
Q

How is toxic shock syndrome managed acutely?

A

Same as sepsis!!!

  1. High flow oxygen
  2. Obtain IV/IO Access
  3. Obtain bloods
  4. Empirical sepsis antibiotics plus IV clindamycin
  5. Consier fluid resuscitation: fluid bolus: 10-20ml/kg saline over 5-10 mins, beware fluid overload (crepitations, gallop rhythm, hepatomegaly) Consider catheterisation
  6. Observe minimum every 15-30 minutes
  7. Analgesia
  8. Gentle clean and dressing of wound, take wound swabs for MC+S
  9. Refer to Paediatrics, (Plastic Surgery if burns/skin loss), PICU, Microbiology
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24
Q

What are empirical antibiotics for TSS once microbiology results are back?

A

If not improving give Fresh Frozen Plasma and IVIG

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25
Q

What is the most common cause of neonatal encephalitis?

A

Herpes Simplex Virus

Can present up to 4 weeks after delivery, give IV aciclovir if mother infected with vulval herpes

That is why shouldn’t kiss newborns

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26
Q

What do investigations show with herpes simplex encephalitis?

A

Temporal changes on CT

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27
Q

How does Herpes Simplex tend to present in children?

A
  • Gums
  • Lips
  • Eyes
  • Genitals
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28
Q

What is chicken pox caused by and how does it present?

A

Varicella Zoster Virus

  • Prodrome: Fever is often the first symptom, fatigue and malaise
  • Vesicular rash: starting papular on trunk or face and spreading outwards
  • Lesions scab over
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29
Q

What is the management of chicken pox in children?

A
  • Encourage fluids and give paracetamol
  • Trim nails
  • Calamine lotion
  • School exclusion until crusted over
  • Immunocompromised patients and Newborns need varicella zoster immunoglobulin (VZIG). If chickenpox develops then give IV aciclovir
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30
Q

What are some rare complications of chicken pox?

A
  • Bacterial superinfection: AVOID NSAIDs
  • Pneumonia
  • Encephalitis (cerebellar involvement may be seen)
  • Disseminated haemorrhagic chickenpox
  • Arthritis, nephritis and pancreatitis
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31
Q

What are the five types of nappy rash?

A
  • Irritant/Ammonia dermatitis
  • Candida
  • Seborrhoeic dermatitis
  • Psoriasis
  • Atopic eczema
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32
Q

How does candidate nappy rash occur?

A

Erythematous rash which involve the flexures and has characteristic satellite lesions

  • Rash extending into skin folds
  • Larger red macules
  • Well demarcated scaly border
  • Circular pattern to the rash spreading outwards, similar to ringworm
  • Satellite lesions
  • May have oral thrush, check tongue
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33
Q

How is candidal nappy rash managed?

A
  • Clotrimazole +/- Hydrocortisone depending on severity
  • Use highly absorbent disposable nappies not towel
  • Change nappy as soon as possible
  • Expose napkin area to air when possible
  • DO NOT use barrier preparation like sudocrem
34
Q

How should cellulitis in children be managed?

A
  • Take a swab if high risk
  • Draw around area of redness
  • Antibacterial
  • Manage any underlying condition that may predispose to cellulitis e.g diabetes, venous insufficiency, eczema, oedema
  • Reassess if not improving in 2-3 days of antibacterial or if spreading/pain out of proportion
35
Q

What children need hospital admission for IV antibiotics for cellulitis?

A
  • Under 1
  • Orbital cellulitis
  • Osteomyelitis
  • Septic arthritis
  • Necrotising fasciitis
  • Sepsis
36
Q

What antibacterial is used for the following conjunctivitis:

  • Purulent
  • Chalmydial
  • Conjunctival
A
37
Q

What are the different types of conjunctivitis in children?

A
  • Allergic
  • Viral
  • Bacterial
38
Q

What is influenza caused by and how does it present?

A
  • Highly infectious caused by influenza viruses types (A, B, and C)
  • Influenza A more virulent and occurs more frequently; Influenza B is milder; and influenza C causes mild or asymptomatic disease, similar to common cold
  • Symptoms usually appear suddenly: chills, fever, headache, extreme fatigue, myalgia, dry cough, sore throat and nasal congestion
39
Q

What is the typical course of influenza and which children are more likely to develop it severely?

A

Self limiting between 2-7 days

  • Under 6 months
  • Pregnant and up to 2 weeks post partum
  • Severe immunosuppression
  • Long-term conditions such as respiratory, renal, hepatic, neurological or cardiac disease
  • Diabetes
  • Morbid obesity (BMI ≥ 40 )
40
Q

How is influenza managed?

A
  • If simple treat at home supportively
  • If high risk give Oseltamivir or Inhaled Zanamivir within 48 hours of symptom onset
41
Q

When do influenza vaccines take place and which children are eligible for them?

A

Late September to Late November

  • Children 6months or over who are high risk
  • All children aged 2–15 years
  • Children living in long-stay residential homes
  • Household contacts of immunocompromised individuals
42
Q

What type of vaccine is given to children?

A

Live attenuated nasal spray

Does contain gelatin!!!

43
Q

When are children offered the BCG vaccination?

A
44
Q

How may TB present in children?

A
  • Persistent cough
  • Weight loss and night sweats
  • Fever
  • Persistent oral candida
  • Persistent UTIs
  • Widespread lymphadenopathy
  • Hepatosplenomegaly
  • Failure to thrive
  • Developmental delay
45
Q

How is active TB diagnosed?

A

Screened

  • Mantoux (affected by BCG)
  • Interferon GRA (not affected by BCG but cannot tell active from latent)

Diagnosis

  • CXR
  • 3 x Sputum Smear
  • Sputum culture (gold standard)
  • NAAT
46
Q

How is TB in children managed?

A

Decide whether directly observed or not

Initial Phase (2 months)

  • Rifampicin
  • Isoniazid
  • Pyrazinamide
  • Ethambutol

Continuation Phase (4 months, 10 months if CNS involvement)

  • Rifampicin
  • Isoniazid
47
Q

Children with CNS TB need 12 months of eradication therapy, what else do they need?

A

Oral prednisolone or Dexamethasone slowly withdrawn over 4-8 weeks

48
Q

What children with latent TB are at risk of become active TB so need full eradication therapy?

A
  • HIV positive
  • Diabetes
  • Anti-TNFa treatment
  • Immunosuppressed
49
Q

How is latent TB in children managed?

A

Neonates: If contact, give Isoniazid (with pyridoxine hydrochloride) followed by a Mantoux test after 6 weeks of treatment. If positive continue for 6 months, if negative stop and give BCG

4 weeks to 2 years: Close contact with a person with tuberculosis which has not been treated for at least two weeks, should start treatment for latent tuberculosis and have a Mantoux test. Either isoniazid (with pyridoxine hydrochloride) alone for 6 months or rifampicin and isoniazid (with pyridoxine hydrochloride) for 3 months

> 2 years: Mantoux test, and if positive (and active tuberculosis is not present), then treat as above for children aged 4 weeks to 2 years. If the test is negative, then offer an interferon-gamma release assay after 6 weeks and repeat the Mantoux test

50
Q

What are the side effects of antiTB drugs?

A
51
Q

When should you suspect gastroenteritis in children?

A
52
Q

What is the most common cause of acute gastroenteritis in children and what is the biggest risk with this?

A

Rotavirus (also noro and adenovirus)

Risk of dehydration

Starts with vomiting then diarrhoea

53
Q

What children are at increased risk of dehydration with gastroenteritis?

A
54
Q

What are some red flag features of vomiting and diarrhoea that point away from simple gastroenteritis?

A

Differentials

  • Systemic infection (UTI, pneumonia, meningitis, sepsis).
  • Appendicitis, intussusception, bowel obstruction, Hirschsprung’s
  • HUS
55
Q

What are some important questions to ask a parent when a child presents with gastroenteritis symptoms?

A
  • Onset, frequency and duration of symptoms
  • Number of times child has urinated in past 24 hours
  • Any other family/contacts unwell?
  • Recent foreign travel?
  • Consumption of possible unsafe foods (takeaway, BBQ)?
  • Recent medication use (especially antibiotics)
56
Q

How do you assess dehydration in gastroenteritis?

A
57
Q

What investigations are done for children presenting with gastroenteritis?

A
  • BM
  • If IV fluids being given check U+Es, VBG and glucose
58
Q

How is acute gastroenteritis managed based on the level of dehydration?

(USE IMAGE)

A

REHYDRATION

No dehydration

  • Consider giving 5 ml/kg of ORS (Dioralyte) or Apple juice after each large watery stool if at increased risk of dehydration
  • Ondansetron
  • Encourage breastfeeding, other milk feeds and fluid intake
  • Give full strength milk straight away.
  • Reintroduce child’s usual solid food
  • Avoid fizzy drinks and fruit juices until diarrhoea has stopped
59
Q

If a child has prolonged diarrhoea what needs to be investigated?

A

Stool culture for MC and S

60
Q

What are some complications of acute gastroenteritis?

A
  • Dehydration
  • Hypoglycaemia
  • Malnutrition
  • Lactose intolerance
61
Q

What are some causes of chronic gastroenteritis?

A
  • Cows’ milk intolerance
  • Toddler diarrhoea
  • Coeliac disease
  • post-gastroenteritis lactose intolerance
62
Q

How do we prevent vertical HIV transmission from mother to child?

A

Avoid breastfeeding

At birth

Mode of delivery:

  • Normal vaginal delivery if viral load < 50 copies / ml
  • C section if > 50 copies copies / ml and in all women with > 400
  • IV zidovudine during caesarean if viral load unknown or > 10000

Prophylaxis treatment to baby:

  • Low risk babies (mums viral load is < 50): zidovudine for 4 weeks
  • High risk babies (mums viral load is > 50 copies): zidovudine, lamivudine and nevirapine for 4 weeks
63
Q

When and how do we test babies born from HIV positive mothers to see if they have caught it?

A

HIV PCR/Viral Load: birth, 3 months, 6 months

HIV Antibodies: done at 18-24 months as before mother’s antibodies still present

If both negative and mum is not breastfeeding then baby is HIV -ve

64
Q

When should we test for HIV in children and what do we need to do before testing?

A

GAIN INFORMED CONSENT

  • PUO
  • Lymphadenopathy
  • Hepatosplenomegaly
  • Persistent diarrhoea
  • Parotid enlargement
  • Shingles
  • Recurrent slow-to-clear infections
  • Failure to thrive
  • TB; pneumocystosis; toxoplasmosis; cryptococcosis; histoplasmosis;
65
Q

How is paediatric HIV managed?

A

MDT Approach

  • Antiretroviral therapy (ART): aim for normal CD4 and undetectable viral load
  • Normal childhood vaccines, avoiding or delaying live vaccines
  • Prophylactic co-trimoxazole (Septrin) for children with low CD4 counts, to protect against pneumocystis jirovecii pneumonia (PCP)
  • Treatment of opportunistic infections
  • Safe sex talk
66
Q

Children can get Hep B via vertical transmission. What is the typical prognosis with this?

A
  • Majority clear within 2 months
  • Chronic Hep B: 5% will develop cirrhosis and 0.05% will develop hepatocellular carcinoma before adulthood
67
Q

What do the following mean on Hep B testing:

HBsAg

HBeAg

HBcAb

HbSAb

(watch Z2F’s youtube)

A
  • Surface antigen (HBsAg) – active infection
  • E antigen (HBeAg) – implies high infectivity
  • Core antibodies (HBcAb) – past or current infection
  • Surface antibody (HBsAb) – vaccination, past or current infection
  • Hepatitis B virus DNA (HBV DNA) – direct count of the viral load
68
Q

When screening for Hep B infection what are you screening for and which children need Hep B screening?

(watch Z2F YouTube video)

A
  • HBcAb (past infection if IgG, current it IgM)
  • HBsAg (current infection)

If above are positive then test for HBeAg and HBDNA

69
Q

How are children born to Hep B positive mothers managed?

A

Given both of the following in first 24 hours of life:

  • Hepatitis B vaccine
  • Hepatitis B immunoglobulin infusion
  • Additional hep B vaccine at 1 and 12 months of age, in addition to normal 2, 3, 4 months 6 in 1
  • Tested for HBsAg at 1 year
70
Q

Can Hep B positive mothers breast feed?

A

Yes if baby had all vaccinations

71
Q

When are babies vaccinated for Hep B?

A

Injection of HBsAg at 8, 12, 16 weeks as part of 6 in 1

72
Q

How are Hep B positive children managed?

A

Regular specialist follow up to assess monitor serum ALT, HbeAg, HBV DNA, physical examination and Liver US

73
Q

How common is vertical transmission of Hep C to babies?

A
  • 5 – 15% of the time
  • Hep C antivirals and precautions not recommended in pregnancy
  • Very unlikely that children will pass on hep C to others as they do not engage in sexual activity or IV drug use
74
Q

Can mothers with Hep C breastfeed?

A

Yes as long as nipples are not cracked and bleeding

75
Q

How are children tested for HepC?

A

Hep C antibody test at 18 months

76
Q

Most children can clear Hep C. How are children with chronic hep C managed?

A
  • Regular specialist follow up to monitor LFTs and hepatitis C viral load
  • Treatment is typically delayed until adulthood unless child is significantly affected, because children are usually asymptomatic
  • Pegylated interferon and ribavirin if aged over 3 and symptomatic
77
Q

What is PIMS?

A

Associated with COVID

Mimics Kawasaki and Toxic shock syndrome. KAWASHOCKI

78
Q

What is the main complication with PIMS-TS that differs from Kawasaki?

A

Do echocardiogram

  • Myocarditis: raised troponin and pro-BNP

Coronary artery aneurysms in Kawasaki

79
Q

Why is clindamycin in toxic shock syndrome and PIMS-TS?

A

To cover Group A strep

80
Q

How is PIMS-TS managed?

A
  • IV methylprednisolone
  • Aspirin for thrombosis prevention
  • IV immunoglobulins
  • Clindamycin cover

ALWAYS BE DOING ECHOCARDIOGRAMS