3-25 Pediatric Clinical Pathology - Dow Flashcards
What is erythema toxicum?
Common rash-first few days after birth
Small blotchy erythematous areas with a raised yellow/white center
May be anywhere, including palms and soles, esp. on trunk
Usually in first week to ten days of life; up to 4 weeks
How long does erythema toxicum stick around? What causes it?
Usually in first week to ten days of life; up to 4 weeks
Dissipate without treatment in 5-7 days
Cause is unknown
Harmless
What are milia? Are they pathological?
Tiny white bumps occur in 40% of newborns
Most often on the nose and cheek
Not pimples although they look like them
Blocked skin pores & disappear by 1-2 months of age
Benign lesions
What are the 2 forms of miliaria?
2 forms:
Miliaria crystallina
Small clear fluid filled vesicles that rupture and leave scale
Miliaria rubra
Clear fluid filled vesicles that are surrounded by red areas
What causes miliaria? Where does it happen?
Usually found on head, neck, trunk and in skin folds
Blocked sweat gland ducts
Resolves on its own
Reoccurs w/ increased heat/humidity/bundling in warm clothing
What is neonatal acne? How long does it last and what causes it?
>30% of newborns
Begins at 3-4 weeks of age & lasts to 4-6 months of age
Cause is maternal androgens prior to birth
No treatment needed
What is seborrheic dermatitis? How is it treated?
Seborrheic dermatitis (cradle cap, aka baby dandruff)
◦Scaling of scalp or eyebrows
◦Treatment: Nizoral shampoo or cream, Selsun shampoo, frequent hairwashing with baby shampoo
What does transient neonatal pustular melanosis look like? How long does it stick around?
Present at birth
Cause unknown
Tiny 1-2mm pustules on face, neck, ext, palms & soles
Can have scale around them
No erythema or inflammation
Rupture in first few days of life & leave behind freckles which fade in 3 weeks to 3 months
No treatment needed
What are the types of diaper rashes?
irritant diaper dermatitis
moniliasis/monilial diaper dermatitis
What is irritant diaper dermatitis caused by? Tx?
Irritant diaper dermatitis
◦Reddish area in groin from urine or heat
◦Treatment: barrier ointment (zinc oxide), air dry, frequent changes
What does moniliasis look like? Tx?
Moniliasis (monilial diaper dermatitis)
◦Classically described as “beefy red with satellite lesions”
◦Nystatin ointment
What do Mongolian spots look like? What causes them?
Blue-gray flat birthmark (plaque) that is most often found in dark skinned infants
Usually over the back and buttocks but can be anywhere
Big variation in size
Most fade by 2-3 years of age; they may persist into adulthood
Entrapment of melanocytes in dermis during migration from neural crest cells into the epidermis
What does atopic derm look like? Acute v chronic?
Atopic Dermatitis (eczema) ”the itch that rashes”
3-5% of children 6 mo to 10 yr
Ill-defined, red, pruritic, papules/plaques
Diaper area spared
Acute: erythema, scaly, vesicles, crusts
Chronic: scaly, lichenified, pigment changes
How is atopic derm treated?
TREAT WITH TOPICAL STEROIDS!
Antihistamines for itching
After showers, moisturize with thick ointments QUICKLY afterwards, don’t wipe completely dry
Vaseline, Aquaphor, Cetaphil, Eucerin, Vanicream
Dove unscented
What is the general distribution of atopic derm rash for infants, kids, & adults?
What is the difference between alopecia areata v tinea capitis?
Alopecia areata may have associated nail changes
R/o hypothyroidism
No broken hairs
Tinea capitis: black dots
Kerion: inflammatory reaction
What are the general characteristics of acne? Cause? Tx?
Common condition characterized by the inflammation of the pilosebaceous units of the face & trunk
◦Black heads (open comedones)
◦White heads (closed comedones)
◦Pustular/cystic
Propionibacterium acnes
◦Topical antibiotic or benzyl peroxide based solutions, clean with antibacterial soap and water
What causes molluscum contagiosum? What is the Tx?
Viral
Usually no treatment recommended when less than 50 lesions or not on face
How is verruca vulgaris treated?
Pare, pare, pare!
Benign neglect (may go away in 2 yrs)
Salicylic acid topically
Cryotherapy
What is Henoch-Schonlein purpura? What does it look like?
Systemic vasculitis of small vessels of skin, GI tract, kidneys, joints
Abdominal pain, rash on legs, arthritis in ankles
“anaphylactoid purpura” characterized by 2- to 10-mm erythematous hemorrhagic papules in a symmetric acral distribution, over the buttocks, and extremities à palpable purpura
How is Henoch-Schonlein prupura Dx’ed? What are some DDx?
Urinalysis, which may be positive for blood or protein in 50% of the patients (other labs usually normal)
DDx: drug reactions, erythema multiforme, urticaria, and even physical abuse, other causes of purpura such as bleeding disorders, and/or infection (meningococcemia)
What are some complications of Henoch-Schonlein purpura? How are these patients managed?
Renal involvement is the most frequent and serious complication, usually acute glomerulonephritis. Hypertension is uncommon
Usually managed as outpatients. Severe abdominal pain, gastrointestinal hemorrhage, intussusception, and severe renal involvement are indications for admission.
Name 11 different structural pathologies/murmurs in kids, and where to auscultate for them.
What are some normal variants of heart rhythms in pedes? Name ages, correlation with respiration, effect of exercise on tachycardia, rhythm characteristics, and severity.
What is a closing ductus murmur? Where is it located, and what ages get them?
Common benign murmurs in children
Low pitched (non-turbulent, not high velocity)
Newborn
Transient, soft, ejection
Location: upper left sternal border
Explain the characteristics of a periphery pulmonary flow murmur.
Newborn to 1 year
Soft, slightly ejectile, systolic
Location: to the left of upper left sternal border & in lung fields & axillae upper left sternal border.
High pitched - best heard with the diaphragm
Also seen in adolescents or in children with pectus excavatum.
Prominent in high-flow situations, such as when a child has a fever or is anemic
What is a Still’s murmur? What are the characteristics?
Older child
Still’s: low-pitched sounds heard at the lower left sternal area, “musical.” These most commonly occur between age 3 and adolescence.
Low pitched - best heard with the bell of the stethoscope.
Can change with alteration of position and then can decrease or disappear with the Valsalva maneuver.
No clicks are present
What is a venous hum?
Low pitched (non-turbulent, not high velocity)
Venous hum: low-pitched continuous murmurs made by blood returning from the great veins to the heart - bell
What is a PDA? What types of patients are they more common in?
Failure of closure of ductus arteriosus within a few days after birth
Girls>boys
More common in premature infants, neonatal respiratory distress, infants w/ genetic d/o (such as Down syndrome) & those w/ congenital heart lesions
Premature infants closure up to 2 years
Full term infants closure rarely after first week of life w/o intervention
What are the symptoms of a PDA? How is it treated?
Small PDAs usu. asymptomatic
Large PDAs:
◦Bounding pulse, murmur
◦Tachypnea
◦Poor feeding habits
◦Shortness of breath
◦Sweating while feeding
◦Tiring very easily
◦Poor growth
Tx: Indomethacin or surgery
What is the physiology behind pathological heart murmurs in kids?
Changes in pulm vascular resistance
Obstructive lesions
Pressure gradient differences
Changes associated with growht
What types of murmurs cause a change in pulm vascular resistance? When do they become audible?
Changes in pulmonary vascular resistance
◦VSD or PDA
◦Audible 7-10 days after birth
What murmurs can cause an obstructive lesion? When are they audible?
Obstructive lesions
◦Pulmonic & aortic stenosis
◦Coarctation of the aorta
◦Audible at birth
What murmurs can cause pressure gradient differences? When are they audible?
Pressure gradient differences
◦Atrioventricular valve regurgitation
Audible at birth
What structural problems can manifest as murmurs? Why are they associated with growth?
Changes associated with growth
Due to alterations in normal blood flow & occur or change w/ growth
Aortic stenosis (obstructive) but not often seen until considerable growth has occurred
Pulmonary flow murmur of ASD
When is aortic stenosis often noticed?
Often not seen until adulthood; despite congenital cause
Why does ASD cause a murmur? When is it usually heard?
Pulmonary flow murmur of ASD
Right ventricular compliance gradually increases & shunt becomes larger
Resulting in too much blood flow across normal pulmonary valve
May not be heard for a year or more
What is hypertrophic cardiomyopathy?
Asymmetrical thickening of left ventricle
◦Causing increase work on heart to pump
Inherited
Younger people are likely to have a more severe form
What are the SSXs of hypertrophic cardiomyopathy?
◦Chest pain
◦Dizziness
◦Fainting, especially during exercise
◦Heart failure (in some patients)
◦High blood pressure
◦Light-headedness, especially with or after activity or exercise
◦Palpitations
◦Shortness of breath
Sudden collapse/death occurs due to arrhythmia or blockage of blood flow
What makes up the tetralogy of fallot?
5 T’s:
◦Tetralogy of Fallot
- VSD
- Overriding aorta
- RV outflow obstruction
- RV hypertrophy
In addition to ToF, what else causes ‘blue babies’?
Cyanotic Congenital Heart Disease
5 T’s:
◦Tetralogy of Fallot
◦Transposition of the Great Arteries
◦TAPVR
◦Truncus arteriosus
◦Tricuspid Atresia
What are the SSXs of Neonatal Respiratory Distress Syndrome?
Sx: (seen within minutes to a few hours after birth)
◦Cyanosis
◦Apnea
◦Decreased urine output
◦Grunting, nasal flaring
◦Puffy or swollen arms or legs
◦Rapid breathing &/or shortness of breath
What is the cause of RDS in neonates?
Most common complication seen in premature infants that affects breathing
Due to lack of surfactant
Most cases seen in premies <28 weeks
What increases the risk of neonatal RDS?
Increased risks of RDS:
A brother or sister who had RDS
Diabetes in the mother
Cesarean delivery
Delivery complications that lead to acidosis in the newborn at birth
Multiple pregnancy (twins or more)
Rapid labor
What does neonatal RDS look like on CXR? Tx?
CXR: ground glass appearance
Tx: surfactant, intubation or CPAP
How many colds do children get a year, on average? What is the role of daycare?
Children younger than six years have an average of six to eight colds per year (up to one per month, September through April), with a typical symptom duration of 14 days
Young children in daycare appear to have more colds than children cared for at home. However, when they enter primary school, children who attended daycare are less vulnerable to colds than those who did not.
Older children and adults have an average of two to four colds per year, with a typical symptom duration of five to seven days
Acute, self-limiting viral syndrome of the upper respiratory tract
What are the Sx of an average URI?
Symptoms: rhinorrhea, congestion, sneezing, and may include fever
What are the Sx’s of acute OM? What causes it?
Fever, otalgia, cough, rhinorrhea
May be a complication of URI
Pathogens:
Viral
Bacterial: Strep pneumoniae, Moraxella catarrhalis, H. flu nontypables
What is the Tx of acute OM?
First line: amoxicillin (high dose = 80-90 mg/kg/day)
Second line: amoxicillin-clavulinic acid (Augmentin) or second generation cephalosporin
How is sinusitis dx’ed?
Diagnosis is based on:
- Persistence of nasal discharge: if the child has a very congested and/or runny nose for 10 days without improvement, especially when it is associated with a daytime cough (may also have a night cough)
- Severe symptoms: if the child has a high fever (over 39 C, which is 102.2 F) for 72 hours or has a high fever and is not eating or drinking and is difficult to calm
- Worsening symptoms: A child’s cold got better and then in a day or two the child is suddenly much more ill with a fever and/or pus-filled nasal discharge
What is croup? What is it the most common cause of?
Aka laryngotracheobronchitis
Steeple sign ◦ Subglottic narrowing of trachea
Most common cause of inspiratory stridor in peds
Viral in origin
What are the Sx and Tx of croup?
Sx:
◦Coryza 1-2d prior to croupy cough, hoarseness, & stridor
Tx: if severe, inhaled epinephrine & oral steroids
What is bacterial tracheitis?
Invasive exudative bacterial infection of the soft tissues of the trachea
“Acute bacterial laryngotracheobronchitis” – with similarities to croup but worse
What are the pathogens that cause bacterial tracheitis?
◦Bacterial: Staphylococcus aureus, Streptococcus pneumoniae, gram-negative enteric bacteria, Pseudomonas aeruginosa
◦Predisposing viral infections with: influenza A, influenza B, respiratory syncytial virus (RSV), parainfluenza virus, measles, and enterovirus
What viruses can cause acute pharyngitis?
◦CMV, adenoviruses, HSV, influenza viruses, and enterovirus, EBV
How is EBV pharyngitis treated? tested for?
◦EBV
Monospot testing is not accurate under 4-5 years of age or before 2nd week of illness
remember it has a really long incubation period
Exudative pharyngitis is accompanied by fever, generalized adenopathy, hepatosplenomegaly, heterophile antibodies
Sometimes treated with steroids
What bacteria cause acute pharyngitis in kids? How common is it?
Group A beta hemolytic streptococcus
◦15 to 30 percent of all cases of pharyngitis in children between the ages of 5 and 15 years
◦Peaks during the winter and early spring
◦Rapid strep in office, back up culture
Other bacterial pathogens
◦Group C and group G strep: acute rheumatic fever is not a complication of infection due to these organisms
◦Arcanobacterium hemolyticum
◦Corynebacterium diphtheriae
◦Tularemia
What is the typical Hx of strep pharyngitis?
History:
◦Typically has an abrupt onset of symptoms
◦Typically the school aged child
◦Sore throat
◦Fever
◦Headache
◦GI symptoms: abdominal pain, nausea, and vomiting
◦Poor oral intake
◦NO cough or rhinorrhea!! Aka, no viral symptoms ( coryza, conjunctivitis, hoarseness, anterior stomatitis, discrete ulcerative lesions or vesicles).
What are the typical PE findings for strep pharyngitis?
Physical:
◦Exudative pharyngitis or erythema of posterior orophayngeal mucosa
◦Enlarged tender anterior cervical lymph nodes
◦Palatal petechiae
◦Inflamed uvula
◦Scarlatiniform rash
◦Pastia’s lines
How is strep pharyngitis worked up?
Work Up:
Rapid strep with back up culture if negative
- How can you possibly get a sample??
- Use two swabs at once; double tongue depressor for stronger kids, have smaller child pant like a puppy dog
- Wear a mask because you’ll probably get coughed on
What is the most common deep neck infection in kids?
◦Peritonsillar abscess
Most common deep neck infection in children and adolescents, accounting for at least 50 percent of cases – can be a complication of strep pharyngitis
What are the Sxs of peritonsillar abscess?
Symptoms:
Severe sore throat (usually unilateral)
Fever
“Hot potato” or muffled voice
Pooling of saliva or drooling may be present
Trismus
neck swelling and pain
What is the Tx of peritonsillar abscess?
needle aspiration:
antimicrobial therapy (amoxicillin/clavulinic, cephalosporins, and clindamycin),
and supportive care (hydration, analgesia)
What population are retropharyngeal abscesses more common in?
◦Retropharyngeal abscess
Most commonly in young children between the ages of two and four years
What are the Sxs of retropharyngeal abscess?
Difficulty swallowing (dysphagia)
pain with swallowing (odynophagia)
drooling with decreased oral intake
Unwillingness to move the neck secondary to pain (torticollis), particularly unwillingness to extend the neck
”hot potato” quality [dysphonia]
Gurgling sound, or stertor (snoring sound)
Respiratory distress (stridor, tachypnea, or both); stridor develops as disease progresses
Neck swelling, mass, or lymphadenopathy
Trismus (in approximately 20 percent
What is RSV? Who does it affect?
Respiratory virus affecting nasal passages and lungs
Almost all children will be infected by 2 years of age
Recovery within 1-2 weeks of infection
May be severe in premature or very young infants
What are the risk factors for severe RSV disease?
young age
preterm birth (specific guidelines for immunization with Synagis = palivizumab)
low birth weight
chronic pulmonary disease
cyanotic or complicated cardiac disease
neurologic disease
immunodeficiency or immunosuppression
congenital defects of the airway
What is the most common cause of bronchiolitis? What are some additional causes?
RSV is the most common cause of bronchiolitis
◦Inflammation of small airways of lung
◦Other causes of bronchiolitis include: rhinovirus, parainfluenza, influenza, human metapneumovirus, and adenovirus
◦Seen most often in fall, winter & early spring
What is an important cause of chronic cough in toddlers? What are the SSXs associated with it?
Foreign Body
Important cause of chronic cough in toddler
◦Nasal
Unilateral purulent drainage
Foul smelling
◦Lower respiratory tract
DDx: recurrent viral infections and asthma
PE and CXR may be unrevealing
When does gastroesophageal reflux (GER) often begin? What are the Sx’s?
Often begins in infancy
Sx:
◦Vomiting
◦Poor weight gain
◦Substernal CP
◦Abd pain
◦Dysphagia
◦Esophagitis
How can GER be dx’ed? What is the Tx?
Dx often based on clinic sx only
Tests:
◦Upper GI (r/o other abn.)
◦24 hr esophageal pH probe
Tx:
◦Dec. feedings, positioning
◦Acid suppressive meds
◦OMT
What does rotavirus cause? What is the course of the disease like?
Rotavirus causes viral gastroenteritis
◦Most common cause of diarrhea in young children throughout the world
◦Normally self-limiting but can cause severe dehydration
◦Sx: fever, vomiting, diarrhea
◦Highly contagious, lasting 3-9 days
How is diarrhea in infants prevented?
Usually, it’s a sisyphean effort
However:
Rotavirus vaccination in early infancy
◦Rotateq 3 dose series
◦Rotarix 2 dose series
What are the potential dangers of esophageal foreign bodies?
aspiration or ingestion
When are esophageal foreign bodies an emergency?
Tracheal or esophageal – how can you tell?
Urgent or emergent intervention:
When the object is sharp, long, or consists of magnets
When the object is a disk battery in the esophagus
If airway compromise, such as tracheal compression, is present
If there is evidence of esophageal obstruction (eg, the patient is unable to swallow secretions)
If there are signs or symptoms suggesting inflammation or intestinal obstruction (fever, abdominal pain, or vomiting)
If the object is in the esophagus and the suspected ingestion occurred 24 or more hours prior to the evaluation, or if the time of ingestion is unknown
What is a buried penis in neonates?
Neonates
Result of thick suprapubic fat
Resolve as infant grows
How common is hypospadias? When should it be treated?
1:250 male births
Infants should not be circumcised
◦Dorsal preputial skin may be need repair
Repair usu. at 6 months of age
What are labial adhesions? What problems can it cause?
Common in prepubertal age group
Fusion of labia minora
inflammation of thin labial mucosa that adheres in midline
Severe fusion may result in dysuria& urinary problems including UTIs
How are labial adhesions Tx’ed?
Tx: mechanical separation then petroleum ointment to diminish irritation
◦estrogen creams (Premarin)
What is vesicoureteral reflux (VUR)?
Congenital
Normal valve mechanics of uretervesicular jxn is impaired
Reflux from bladder to ureter or kidney
How are VURs graded? Treated?
Grades I to III high rate of spontaneous resolution, grades go up to 5
Suppressive Abx
How are UTIs dx’ed in children?
Girls>boys
Don’t trust a culture from a bag urine sample!!
Catheterized sample only in infants
Clean catch if potty trained
