Aquifer - ID Flashcards
1
Major cause of neonatal bacterial sepsis?
GBS
Without antibacterial prophylaxis, ___% of infants born to women colonized with GBS develop invasive disease (sepsis, pneumonia, meningitis).
1-2
Risk factors for early onset GBS disease?
Prolonged ROM
Prematurity
Intrapartum fever
Previous delivery of infant who developed GBS disease
Intrapartum antimicrobial prophylaxis against GBS should be administered if one of the following is present and the mother is in labor with ruptured membranes:
Previous infant with invasive GBS disease
GBS bacteriuria during any trimester of the current pregnancy
Positive GBS vaginal-rectal screening culture in late gestation during pregnancy (weeks 35-37)
Unknown GBS status at the onset of labor (culture not done, incomplete, or results unknown) AND any of the following: <37 weeks, amniotic membrane rupture for 18+ hours, intrapartum temperature of 100.4+, intrapartum NAAT + for GBS
TORCHZ?
Toxoplasmosis Other: varicella, syphilis Rubella CMV HSV Zika
Dx congenital toxoplasmosis?
Positive toxoplasma-specific IgM/G/A assay, increasing IgG titers in the first year, or persistently positive IgG titers beyond the first year
Presentation of congenital toxoplasmosis (unique)?
CNS - diffuse intracranial calficiations
Hydrocephalus
Eyes - chorioretinitis
Presentation of congenital varicella?
CNS - microcephaly
Skin - cicatricial or vesicular lesions
Presentation of congenital syphilis?
Ears/nose: persistent rhinitis
Skin: maculopapular rash of palms, soles, and diaper areas
Skeletal: osteochondritis and periostitis
Dx congenital rubella?
Rubella-specific IgM usually indicates recent postnatal or congenital infection. Because false-positives can occur, diagnosis can also be confirmed by stable or increasing serum concentration of IgG over several months
Presentation of congenital rubella?
CNS: microcephaly Eyes: cataracts, glaucoma, retionpathy Ears/nose: sensorineural hearing loss Skin: blueberry muffin rash GI: hepatomegaly Skeletal: radiolucent bone disease CV: patent ductus, peripheral pulmonary artery stenosis Hematologic: thrombocytopenia
Dx congenital CMV?
Urine culture (newborns shed a large amount of virus in the saliva and urine) or PCR (CMV in urine, oral fluids, respiratory tract secretions, blood, cSF within 2-3 weeks of life)
Presentation of congenital CMV?
CNS: periventricular calfcifications, microcephaly Eyes: cataracts Skin: petechiae/purpura GI: hepatosplenomegaly Hematology: thrombocytopenia
Presentation of congenital HSV?
Conjunctivitis or kerato-conjunctivitis
Skin: mucocutaneous vesicles and scarring
GI: elevated liver transaminases
Hematologic: thrombocytopenia
Presentation of congenital Zika?
CNS: severe microsephaly, thin cerebral cortices, subcortical calcifications
Eyes: macular scarring, pigmentary retinal scarring
Ear/nose: sensorineural hearing loss
Skeletal: arthrogryposis, early hypotonia
3 TORCHZ infections that cause intracranial calcifications + type?
Toxo - diffuse
CMV - periventricular
Zika - subcoritcal
4 TORCHZ infections that cause microcephaly?
Varicella
Rubella
CMV
Zika (severre)
2 TORCHZ infections that cause cataracts?
Rubella, CMV
2 TORCHZ infections that cause sensorieneural hearing loss?
Rubella, Zika
2 TORCHZ infections that cause GI organ enlargement?
Rubella (hepatomegaly)
CMV (HSM)
3 TORCHZ infections that cause thrombocytopenia?
Rubella, CMV, HSV
What is infectious mononucleosis and how does it present?
Infection of lymphocytes caused by EBV; typical signs and symptoms include extreme fatigue, pharyngitis, and lymphadenopathy
Define lethargy.
LOC characterized by the failure of a child to recognize parents or to interact with persons or objects in the environment; child demonstrates significant sluggishness.
Define listlessness.
No interest in what is happening in the environment
Define toxic.
Appearance of pending physiologic collapse such as may be seen in sepsis, poisoning, acute metabolic crises, or shock. Child may be febrile, pale, or cyanotic, with depressed mental awareness or extreme irritability and may demonstrate tachycardia, tachypnea, and prolonged capillary refill
Define distress.
Appearance of working hard to maintain physiologic stability such as grunting, rapid breathing in order to maintain adequate oxygenation and ventilation
Define fever without a source
Complete history has been obtained and a detailed physical exam performed and there is no identified source of the child’s fever
Temperature >38.3C (101F) for at least 8 days duration with no apparent diagnosis after initial workup in the inpatient or outpatient setting
Most common cause of fever without a source in infants?
Viral syndrome (small minority have a serious bacterial illness)
Possible serious bacterial causes of fever without a source?
UTI (most common) Meningitis Sepsis/bacteremia Pneumonia Bacteral gastroenteritis Osteomyelitis Septic arthritis
Presentation of bacteremia as a fever without a source?
Febrile, well-appearing children ages 3-36 months without a discernible focus of infection may have occult bacteremia, but this is rare with current immunization against Hib and S. pneumonia
At risk for a more serious bacterial infection (meningitis, osteomyelitis) through bacterial seeding
Presentation of bacterial meningitis as a fever without a source?
Signs and symptoms can be subtle in young children; persistent irritability may be the only finding
Very young infants (<3-6 months) may not show any signs of nuchal rigidity, but can present with a variety of findings including fever, hypothermia, bulging fontanelles, lethargy, irritability, restlessness, paroxysmal crying (crying when picked up), poor feeding, vomiting, and/or diarrhea
Presentation of UTI?
Most common cause of SBI in children
Commonly presents as fever without a focus on physical exam and a relatively unremarkable review of systems
Fussiness and lack of appetite are common associated symptoms
Risk factors for UTI in male and female infants?
Males: non-black race, temperature >39F, absence of another source of infection, fever >24 hours, non-circumcised
Females: white race, age <12 months, temperature >39F, absence of another source of infection, fever >2 days
Management of fever without a source in an infant?
- CBC + empiric antibitoics for WBC of 15,000+ (unless previously healthy and well-appearing)
- Blood culture (ill-appearing or un/underimmunized)
- UA and urine culture (catheterized)
- LP (ill-appearing, un/underimmunized, meningitis not excluded by exam)
Define sepsis.
SIRS in the presence of suspected or proven infection
Systemic response to an infectious agent, whether bacterial, viral, or fungal; inflammation occurs in tissues throughout the body, resulting in vasodilation, leukocyte accumulation, and increased capillary permeability
SIRS = abnormal temperature or leukocyte count for age + abnormal HR, tachypnea, or acute need for mechanical ventilation
Kernig’s sign?
Resistance to extension of the knee
Brudzinski’s sign?
Flexion of the hip and knee in response to flexion of the neck
Nuchal rigidity?
Involuntary resistance to neck flexion when the clinician flexes a patient’s neck forward
DDx - fever in an infant
- UTI
- Pneumonia
- Sepsis/bacteremia
- Occult bacteremia
- Bacterial meningitis
- Viral meningitis
- Roseola
- Primary herpes simplex virus gingivostomatitis
- Otitis media
- Viral URI
Presentation of pneumonia?
Cough, tachypnea, fever, rales, lower SaO2
Not impossible for a child with pneumonia to have no symptoms referable to the respiratory symptom
Guidelines to get a CXR for possible pneuonia?
Respiratory findings and/or a WBC count >20,000
Presentation of sepsis?
Fever usually present (not universal) -> infants may present with hypothermia
Ill-appearing
Elevated HR may be the only early sign
Late signs include evidence of end-organ hypoperfusion -> delayed capillary refill, low BP, altered mental status, and other evidence of organ failure
Presentation of occult bacteremia?
Well-appearing
Positive blood culture
Why is a distinction made between occult bacteremia and sepsis?
Most children with occult bacteremia will not develop a SBI whereas a child with sepsis represents a medical emergency
Most common cause of bacterial meningitis in children?
S. pneumonia and N. meningitidis
Common cause of viral meningitis?
Enterovirus
Presentation of primary HSV gingivostomatitis?
Young children between 10 months and 3 years
Fever and irritability initially, oral lesions that start as vesicles and evolve to ulcerations seen shortly after onset of symptoms
When infection of the urine must be ruled out in an infant or child who is not toilet-trained, the sample should always be obtained by…?
Catheterization
Typical CSF findings in bacterial vs. viral meningitis?
Glucose: low vs. normal
Protein: elevated vs. normal or slightly elevated
WBC: elevated (both)
Predominant WBC type: PMNs vs. lymphocytes
Gram stain: Positive or negative vs. negative
Define pyuria.
> 5 WBCs/hpf in centrifuged urine; if counting chamber is used, then >10 is +
What does a positive nitrite test mean?
Occurs when GN bacteria (especially E. Coli, Klebsiella, Proteus) are present in the urine (reduce urinary nitrate to nitrite) for an adequate amount of time
Negative - poor sensitivity for bacteruria
What does a positive leukocyte esterase test mean?
Detects esterases released from broken-down leukocytes and thus indicates the presence of WBCs in the urine
+ test is insufficient to dx a UTI
If nitrites and leukocyte esterase are +, it is strongly suggestive of a UTI
Oral vs. parenteral antibiotics for treating children with UTIs?
Most children with UTIs can be treated orally
Patients who are toxic, cannot tolerate PO, or concern for compliance with oral medications can be treated parentally
In a child who has not recently been on antibiotics, the most likely cause of an initial episode of pyelonephritis is ___. Other causes?
E. coli; enteric GN organisms (Klebsiella or Proteus) or enterococcus
Empiric parenteral treatment for pyelonephritis?
- Ampicillin + gentamicin (E. coli resistance to ampicillin is increasing -> excellent activity against coliforms when combined with gent)
- Ceftriaxone (excellent GN bacilli coverage except P. aeruginosa, does not cover enterococci, excellent safety profile in children)
- Meropenem (ESBLs)
- Ciprofloxacin (approved for children >1 year for complicated UTI with resistant organisms, not the best choice due to cost and AE in children)
Why should calcium-containing medication not be given through the same IV line as ceftriaxone?
Can interact to form precipitates in the lungs and kidneys
Empiric oral treatment for pyelonephritis?
- Cephalexin (Keflex) - E. coli and other enteric GN rods (inexpensive, well-tolerated)
- TMP-SMX - effective against UTIs with the exception of Pseudomonas and resistant E. coli
- Amoxicillin/clavulanate (Augmentin) - effective, but potential for skin and GI adverse reactions
Rare but serious side effect of TMP-SMX?
SJS
Why is nitrofurantoin only approved to treat cystitis, not pyelonephritis?
Reaches an acceptable concentration level in the urine, but not in the blood
Follow-up studies for UTI and pyelonephritis?
- U/S of kidneys and bladder
- Renal technetium scan (provides evidence of pyelonephritis, not required in a patient who has responded well to treatment)
- VCUG (demonstrates vesicoureteral reflux, should be done only in children after a first febrile UTI with findings of hydronephrosis, and after a second febrile UTI)
DDx - Fever and Rash
toddler
- Adenovirus infection (viral infection - may cause URI, pharyngitis, conjunctivitis, tonsillitis, OM)
- Kawasaki disease
- Meningococcemia
- Measles
- RMSF
- Scarlet fever
- SJS
- Enteroviral infection (Coxsackie, echo, entero)
- Varicella
- Erythema infectiosum (5th disease)
- Roseola
Presentation of meningococcemia?
Fever, chills, malaise, rash (often petechial), may lead to shock and DIC
Presentation of measles?
Prodrome of fever (>38.3/101), cough, coryza, conjunctivitis
Maculopapular rash starting on the neck, behind the ears, and along the hairline, spreads downward (reaching the feet in 2-3 days). Initial rash appears on the buccal mucosa as Koplik spots (red lesions with bluish white spots in the center)
Marked generalized lymphadenopathy and splenomegaly
Presentation of RMSF?
Fever, headache, myalgias
Macular or papular rash initially, becomes petechial (starts on ankles and wrists, progresses centrally and to palms and soles)
5% of cases have no rash
Presentation of scarlet fever?
Fever
Diffuse, erythematous, finely papular rash (sandpaper texture) often beginning at the neck, axillae, and groin and then spreading over the trunk and extremities (typically resolving within 4-5 days)
Presentation of SJS?
Fever, mucosal changes (e.g., stomatitis), conjunctivitis
Macular rash or diffuse erythema, often tender, with subsequent vesicles or bullae that may progress to erythema multiforme.
Nikolsky sign may be present.
Presentation of enteroviral infection?
Fever lasting 3-5 days, may also cause conjunctivitis, oral ulcers, diarrhea, aseptic meningitis
Non-specific rash including the palms and soles
Presentation of varicella?
Rash starts on trunk and spreads to extremities and head
Lesion starts as an erythematous macule, then forms a papule followed by a vesicle before crusting over
Lesions at various stages of development in the same area of the body
Presentation of erythema infectiosum (5th disease)?
Low grade fever followed by a rash
Starts as a facial erythema (slapped cheek) which can spread to the trunk and extremities and appear lacy
Can lead to pain and swelling of the extremities, as well as development of transient pure red cell aplasia, which can lead to severe anemia in patients with underlying hemolytic disease
Presentation of roseola (exanthem subitum, sixth disease)?
Maculopapular rash is typically preceded by 3-4 days of high fevers, which end as the rash appears, erythematous macules start on the trunk and spread to the arms and neck (less common on face and legs)
Usually <2 years
May see a bulging fontanelle
Associated with ~20-30% of first febrile seizures in children
Size and location of lymph nodes in healthy children?
Small (<2 cm) lymph nodes often palpated in the cervical, axillary, and inguinal regions
[Lymph nodes >2 cm or nodes palpable in other areas suggest the presence of disease; supraclavicular nodes are highly concerning for lymphoma]
Discuss localized vs. diffuse adenopathy.
Localized: usually occurs with infection in an area that drains to the affected node
Diffuse: generalized infection, malignancy, storage diseases, chronic inflammatory disease
Texture of normal lymph nodes?
Smooth, soft to mildly firm, non-tender, mobile
Tenderness, warmth, fluctuance, overlying erythema or edema suggests local infection or infection of the node itself (lymphadenitis)
Features of lymph nodes concerning for malignancy?
Nodes that are hard, rubbery, matted together, or affixed to skin or soft tissue
True or false - bilateral cervical adenopathy is common in children.
True
What causes reactive cervical adenitis?
Occurs in response to an oral infectious or inflammatory process
Presentation of bacterial cervical adenitis?
Ages 1-5 with a history of recent URI
High fevers and toxic appearance
Overlying cellulitis and fluctuance
(S. aureus and S. pyogenes are most common)
What is cat scratch disease?
Infection with Bartonella henselae introduced by a scratch from a cat/kitten with subsequent infection of the node or nodes draining that site, usually self-limited with regression of the lymph node in 4-6 weeks
Most commonly involved sites of lymphadenopathy in cat scratch disease?
Axilla (most common), cervical, submandibular, inguinal
Most common cause of mycobacterial lymphadenitis in children over 12 years of age?
TB
Most common manifestation of nontuberculous mycobacteria in children?
Lymphadenitis (peak age of presentation of 2-4 years)
Presentation of lymphadenitis due to mycobacterial infection?
Well-appearing with minimal if any constitutional signs and symptoms
Overlying skin may be erythematous and will become violaceous as the nodes enlarge. Nodes may rupture through the skin, resulting in a draining sinus tract.
Treatment of lymphadenitis due to mycobacterial infection?
Surgical excision
Presentation of primary tuberculosis due to M. tuberculosis in children?
Often few to none, in sharp contrast to the degree of radiographic changes
Infants and toddlers are more likely to experience symptoms such as non-productive cough, mild dyspnea or wheezing due to bronchial compression by enlarged regional lymph nodes
May present with FTT
Severe cough and sputum production, together with systemic complaints such as fever, night sweats, and anorexia usually signify intrapulmonary dissemination
Most common radiographic abnormality in primary TB in children?
Hilar adenopathy
Describe lung findings in TB in children.
- All lobar segments are at equal risk of initial infection
- 2+ primary foci are present in 1/4 of cases
- Hallmark: primary complex
- Common sequence: hilar adenopathy, focal hyperinflation and then atelectasis, with minimal evidence of the primary focus itself
- Small local pleural effusions are common; large effusion rare in children <6 years
Dx of TB?
PPD - practical tool for diagnosing TB infections in asymptomatic children - considered positive if >5 mm in high-risk children, >10 mm in moderate-risk children, and >15 mm in low-risk children
Quantiferon gold - may be considered in children 5 years and older
Symptomatic children - culture sputum sample
