Aquifer - Cardiovascular and Hematology (Part 2) Flashcards
True or false - there is an association between iron deficiency in infancy and later cognitive defects.
True
How does ingestion of cow’s milk in young children increase the risk of iron deficiency anemia?
Excessive ingestion (>24 oz/day) Low concentration and bioavailability of iron Risk fo occult intestinal blood loss
In the setting of mild anemia, what will many providers do first?
Trial iron rather than doing any further workup. If the Hgb recovers to the normal range, this is sufficient evidence of iron-deficiency anemia.
2 classification schemes for anemia?
- Size (MCV - micro/normo/macrocytic)
2. Mechanism (decreased production, increased destruction, blood loss)
Why is the size classification imperfect for anemia?
MCV values in children vary with age and certain conditions do not fit neatly into one category
DDx - microcytic anemia
Iron deficiency Thalassemia Sideroblastic Chronic inflammation/disease* Lead poisoning* *Can be normocytic
DDx - normocytic anemia
Acute blood loss Immune hemolytic anemia Hereditary spherocytosis G6PD deficiency Sickle cell anemia Renal disease Transient erythroblastopenia of childhood (TEC)
DDx - macrocytic anemia
Folate deficiency B12 deficiency Hypothyroidism Neoplasms Bone marrow failure syndromes (aplastic anemia, Diamond-Blackfan anemia, and congenital dyserythropoietic anemia) Liver disease/failure* *Can be normocytic
How does the reticulocyte count indicate mechanism of anemia?
Decreased production - low reticulocyte count
Increased destruction and blood loss - high reticulocyte count (patient is able to adequately make red cells and is trying to compensate for the anemia)
DDx - anemia due to decreased production
Iron, folate, or B12 deficiency Lead toxicity Thalassemia Aplastic anemia Chronic inflammation Neoplasms TEC DBA Renal disease Hypothyroidism CDEA? Sideroblastic anemia
DDx - anemia due to increased destruction
Immune hemolytic disease Hereditary spherocytosis G6PD deficiency Sickle cell disease Thalassemia DIC Mechanical heart valves Burns Paroxysmal nocturanl hemoglobinuria (PNH) Hypersplenism
DDx - anemia due to blood loss
Acute hemorrhage Dysfunctional uterine bleeding (heavy/prolonged menses) Pulmonary hemosiderosis (hemorrhage) Goodpasture's disease GI blood loss (PUD, other GI conditions)
Lab findings of iron deficiency anemia?
Low reticulocyte count
Low iron levels
High iron-binding capacity
Risk factors for obesity in children?
- High birth weight
- Maternal diabetes
- Having an obese parent (strongest predictor before age 3)
- Low SES
- Certain genetic syndromes
- Early menarche
- Shorter extent/duration of breastfeeding
Sequelae of obesity in children?
- (Obstructive) Sleep apnea (cessation of breathing for at least 15 seconds while sleeping)
- Dyslipidemia
- Hypertension
- Slipped capital femoral epiphysis (SCFE) - displacement of the femoral head from the femoral neck through the physeal plate
- DM2
- Steatohepatitis
Characteristics of steatohepatitis in obese adolescents?
Mild increase in liver transaminases, hyperechoic liver on U/S, evidence of fatty infiltration and fibrosis on biopsy
When should an underling endocrinological disorder be suspected in the setting of weight gain in children/adolescents?
Endocrine diseases that cause weight gain usually limit growth and lead to short stature, whereas obesity stimulates stature growth and leads to tall stature for age. It also advances bone age and leads to early puberty.
Only 1% of overweight patients have endocrine problems.
Dx DM?
HbA1c 6.5+ % OR
Fasting plasma glucose of 126 mg/dL (no caloric intake for at least 8 hours) OR
Two-hour plasma glucose of 200+ mg/dL during an oral GTT following a load of 75 g glucose OR
Random plasma glucose of 200+ mg/dL in a patient with symptoms
(#1-3 must be repeated to confirm)
Compare the presentation of DM1 and DM2 in children.
DM2 - more indolent presentation, weight loss is less common, DKA is rare, accidental diagnosis is common
DM1 - more likely to present in early childhood, weight loss and DKA more common, rare to diagnose accidentally
Who should be screened for DM2 (children)?
Children who are overweight (BMI >85th percentile) PLUS 2 of the following:
Family history of DM2 in first or second degree relatives
Race/ethnicity
Signs of/conditions associated with insulin resistance (acanthosis nigricans, PCOS, HTN, dyslipidemia)
Maternal hx of DM or gestational DM during child’s gestation
Timing of screening for DM2 in children?
Initiate screening at 10 years of age or onset of puberty (whichever is earlier)
Screen every 3 years
Any test may be used
Causes of elevated BP measurements?
- White coat HTN
- Positioning (arm at side can elevate)
- Painful stimuli
- Cuff that is too small
Classification of HTN in children?
Normal: <90th percentile
Prehypertension: 90-95th percentile
Stage 1 HTN: 95th-99th percentile + 5 mmHg
Stage 2 HTN: >99th percentile + 5 mmHg
As with adults, adolescents with BP levels >120/80 but <95th percentile should be considered pre-hypertensive.
Management of prehypertension in children?
Therapeutic lifestyle changes
Follow-up in 6 months
No recommended diagnostic workup for a secondary cause unless there is a concern for an underlying cause in H&P or family history
Management of primary hypertension in children?
Medications (typically reserved for children with stage 2, secondary, or evidence of target-organ effects)
Dietary changes (less sweets, added sugars, fats, red meats, sodium)
Weight loss if overweight
Physical activity
Who should be screened for secondary HTN in children?
Umbilical artery or venous access during the perinatal period
UTI (renal scarring)
Catecholamine excess (pheochromocytoma or neuroblastoma)
Family hx of renal disease
Coarctation of the aorta
What is vasovagal syncope?
Fainting; caused by self-limited systemic hypotension due to altered neurocardiogenic reflexes leading to bradycardia and/or peripheral vasodilation
Prodromal symptoms of vasovagal syncope in chidlren?
Dizziness, lightheadedness, sweating, nausea, weakness, and visual changes; many children experience the prodromal symptoms without syncope
What is syncope?
Transient, usually brief LOC and postural tone that results from inadequate cerebral perfusion; typically self-limited with unconsciousness for less than 1 minute, followed by gradual return of cerebral perfusino and awakening
How should syncope be evaluated initially?
History (duration of symptoms, time of day, last meal, weight changes, activities leading up to the event, patient position, associated symptoms, drug history)
Physical: orthostatic BP measurement, detailed cardiac and neurological exams
EKG to rule out important arrhythmic causes of syncope such as WPW syndrome and QT syndrome
Red flags for syncope?
Family history of seizures, sudden death, MI in family members <30 years of age
All syncope associated with exercise or exertion must be considered dangerous and requires a thorough cardiac evaluation
Association with chest pain or palpitations, an abnormal cardiac exam or history of cardiac diseaseFacial cyanosis, aura, frothing at the mouth, tongue biting, slow recovery, or postictal drowsiness and prolonged mental status changes or confusion after the event suggest a seizure
Syncope in the supine position, prolonged LOC (>5 minutes), convulsion before LOC, warm/flushed/cyanotic skin color rather than pallor and diaphoresis suggest a seizure
Most common cause of sudden cardiac death in pediatric patients?
HCM
EKG of a patient with HCM?
Left ventricular hypertrophy and/or ST/T wave changes indicative of repolarization abnormalities
Note - ~10% will have normal EKG’s
If there are worrisome elements for HCM in the history of a pediatric patient with syncope or chest pain, what should be done?
Echo
What is precordial catch syndrome?
Most common cause of chest pain in adolescents
Thought to be a form of MSK pain of unknown etiology
Benign condition characterized by sudden, sporadic onset of sharp pain, usually along the left sternal border, which is often exacerbated with deep inspiration
Brief, lasts seconds to a few minutes, resolves spontaneously
Pain can often be broken with a forced deep inspiration
Often not associated with exercise
Presentation of costochondritis?
Benign cause of chest pain, but less common
Pain due to inflammation, lasts for hours or days
Presentation of GI causes of chest pain (GERD, gastritis, esophagitis)?
Often retrosternal, burning, non-radiating, associated with meals
+medication history (non-prescription meds, OC’s, meds that cause gastric irritation)
Substance use
DDx - Chest Pain
children and adolescents
- Cardiac cause (HCM, etc.)
- Precordial catch syndrome
- Costochondritis
- GI causes (GERD, gastritis, esophagitis)
- Asthma or exercise-induced bronchospasm
Physical exam findings when assessing chest pain in children?
Vital signs
BP w/appropriately sized cuff
Palpate brachial and femoral pulses for possible coarctation
Auscultation supine and standing
Fever (infectious etiology - pericarditis, pneumonia, etc.)
Thrill, hyperdynamic precordium, murmurs
Body habitus suggesting a genetic disorder associated with cardiac disease (Marfan’s)
Chest wall inspection for signs of injury; reproducible pain implies MSK origin
Symptoms and signs of cardiac chest pain in pediatric patients?
Pain triggered by exertion or stress Pressure or crushing sensation 10-15 minutes in length Syncope, palpitations Murmur, thrill, hyperdynamic precordium
Murmurs that should be further evaluated?
Louder than III/VI
Diastolic
Increases with standing or Valsalva
What is Kawasaki disease?
Acute inflammatory panvasculitis of unknown etiology that impacts any blood vessel, although there is a predilection for small and medium-sized vessels, especially the coronary arteries for unknown reasons
It is thought that it results from an AI response to a not-yet-identified infectious trigger
Epidemiology of Kawasaki disease (age, timing, genetics)
Disease of childhood, with typical patients 15-80 months; 80% of patients with KD are under the age of 5 years
Outbreaks follow seasonal patterns
Children of Asian descent have a higher incidence
Three distinct phases of Kawasaki disease?
- Acute phase (onset through 10 days) - fever, clinical findings, elevated APRs
- Subacute phase (10 days-3 weeks) - fever resolves, clinical findings largely subside often with peeling of hands and feet, elevated APRs
- Convalescent phase (3-6/8 weeks) - all clinical findings resolved, continued serologic evidence of inflammation
Diagnostic criteria for Kawasaki disease?
High fever for at least 5 days + 4 of the following:
- Change in oral mucosa (i.e., strawberry tongue)
- Extremity changes (redness/swelling)
- Unilateral cervical lymphadenopathy (least likely to be present)
- Rash (non-specific, polymorphic)
- Conjunctivitis (bilateral, non-purulent)
Irritability is common
Consider other illnesses with similar features before diagnosing KD
Lab evaluation of Kawasaki disease?
- CBC with differential (elevated WBCs, neutrophilic predominance, normochromic/normocytic anemia is common, thrombocytosis is common, usually starting in week 2)
- Liver enzymes (transaminases can be elevated)
- Serum albumin (frequently low)
- Acute phase reactants (ESR and CRP) - a negative ESR would argue strongly against KD; persistently elevated ESR after the fever supports KD
- UA - sterile pyuria secondary to sterile urethritis is associated with KD (clean-catch will show white cells, catheterized urine may not)
Complications of KD?
- Aspetic meningitis or other CNS manifestations
- Coronary artery aneurysm (risk with greatest morbidity, main purpose of treatment is to minimize this risk) - all patients should receive a baseline echo during the acute phase
- Liver dysfunction
- Arthritis
- Hydrops of the gallbladder
When is the greatest risk for the development of coronary artery aneurysms during KD?
In the subacute phase (beyond 10 days, almost always within 4 weeks of onset)
Rx - Kawasaki Disease
Aspirin and IVIG (standard therapy)
High-dose aspirin for its anti-inflammatory properties (shortens the febrile course, no effect on development of aneurysms)
Low-dose aspirin following defervescence for its anti-paletlet effects - d/c after 6-8 weeks if no coronary artery changes are seen in follow-up echoes (if abnormalities - continue low-dose aspirin indefinitely)
IVIG to decrease the incidence of coronary artery aneurysm (single dose over 10-12 hours)
Role of other antipyretics, antibiotics, and steroids in treating KD?
Other antipyretics are not usually effective for fever control
Ibuprofen antagonizes the irreversible platelet inhibition induced by aspirin
Antibiotics have no effect on clinical course
Role of steroids is unclear
Follow-up care for KD?
- Cardiology follow-up visit at 1-2 weeks
- Aspirin: low-dose for 6-8 weeks after febrile phase, parents should watch for warning signs of GI bleeding, such as stomachache or blood in the stool
- Flu vaccine - children taking aspirin are at risk for Reye syndrome, a potentially fatal illness that causes multi-organ damage if infected with certain viruses, including influenza and varicella. Parents should avoid exposure to anyone with known flu or chicken pox and children should receive the IM flu vaccine.
What does ESR measure?
Indirect measurement of fibrinogen elevation (levels of fibrinogen increase with inflammation) -> higher levels of fibrinogen lead to increased cohesion of erythrocytes and a faster sedimentation rate
What does CRP measure?
Direct quantification of an acute phase reactant discovered in blood from patients with pneumococcal pneumonia and named because it reacted with the C-polysaccharide on the cell wall of S. pneumo
Compare elevation time course of ESR and CRP.
ESR: rises comparatively slowly in response to an inflammatory stimulus and may not return to normal for weeks after clinical improvement
CRP: elevation is relatively quick, beginning at 4-6 hours after initial insult, peaking at 36-50 hours, and returning to normal within 3-7 days after the stimulus is withdrawn
Compare the specificity of ESR and CRP.
ESR: not specific for inflammation, also abnormal in pregnancy and anemia; low to moderate reproducibility
CRP: more specific than ESR, high reproducibility
(Similar in cost)
DDx - Fatigue
adolescent female
- Anemia
- Bleeding disorder
- Hypothyroidism
- Depression
- Substance abuse
Causes of anemia leading to fatigue in an adolescent female?
- Bleeding disorder
2. Iron deficiency
Presentation suggesting anemia due to a bleeding disorder in an adolescent female with fatigue?
Commonly cause menorrhagia (20% of women with heavy periods have a bleeding disorder)
Significant fatigue (rapid loss of Hgb)
Family hx of anemia
ROS negative unless there is severe systemic illness leading to DIC
Presentation suggesting iron deficiency anemia in an adolescent female with fatigue?
Typically not as much fatigue (slow decline allows the body to decompensate)
Lab tests to check for a bleeding disorder?
CBC with platelets, RBC indices, and a smear, reticulocyte count Pt/PTT Platelet function test Factor VIII activity vWF antigen Ristocetin cofactor (aka vWF activity)
Presentation of hypothyroidism causing fatigue in adolescent female?
Menstrual abnormalities (menorrhagia, shorter cycles)
Constipation, weight gain, decreased appetite
Cold skin, slowness, fatigue, prefer hot weather to cold, doing poorly in school, coarse hair
[Rash on legs and edema of the feet are signs, but more often seen in adults)
Most common hereditary bleeding disorder?
VW disease
Inheritance pattern of VW disease?
AD w/variable penetrance (Type 1 and 2)
More rare Type 3 is AR
Symptoms of VW disease?
Ecchymoses Epistaxis Menorrhagia Bleeding post-tonsillectomy and dental extractions Gingival bleeds
Most common type of VWD?
Type I (70%)
Dx VW disease?
Careful clinical history is often the most sensitive indicator
Lab dx can be challenging - prolonged platelet function or bleeding time and mild prolongation of PTT point to this diagnosis, but this can be normal
To confirm, check VW factor Ag and/or platelet function analysis and factor VIII levels
Rx - VW disease?
Intranasal or IV desmopressin
Sometimes can give human plasma-derived virally inactivated VWF concentrate
Dx prediabetes?
Fasting blood glucose of 100-125 mg/dL OR
Hgb A1C 5.7-6.4%
