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Pediatrics Clerkship > Aquifer - ID > Flashcards

Aquifer - ID Flashcards

1

1
Q

Major cause of neonatal bacterial sepsis?

A

GBS

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2
Q

Without antibacterial prophylaxis, ___% of infants born to women colonized with GBS develop invasive disease (sepsis, pneumonia, meningitis).

A

1-2

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3
Q

Risk factors for early onset GBS disease?

A

Prolonged ROM
Prematurity
Intrapartum fever
Previous delivery of infant who developed GBS disease

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4
Q

Intrapartum antimicrobial prophylaxis against GBS should be administered if one of the following is present and the mother is in labor with ruptured membranes:

A

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

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5
Q

TORCHZ?

A 
Toxoplasmosis
Other: varicella, syphilis
Rubella
CMV
HSV
Zika
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6
Q

Dx congenital toxoplasmosis?

A

Positive toxoplasma-specific IgM/G/A assay, increasing IgG titers in the first year, or persistently positive IgG titers beyond the first year

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7
Q

Presentation of congenital toxoplasmosis (unique)?

A

CNS - diffuse intracranial calficiations
Hydrocephalus
Eyes - chorioretinitis

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8
Q

Presentation of congenital varicella?

A

CNS - microcephaly

Skin - cicatricial or vesicular lesions

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9
Q

Presentation of congenital syphilis?

A

Ears/nose: persistent rhinitis
Skin: maculopapular rash of palms, soles, and diaper areas
Skeletal: osteochondritis and periostitis

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10
Q

Dx congenital rubella?

A

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

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11
Q

Presentation of congenital rubella?

A 
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
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12
Q

Dx congenital CMV?

A

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)

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13
Q

Presentation of congenital CMV?

A 
CNS: periventricular calfcifications, microcephaly
Eyes: cataracts
Skin: petechiae/purpura
GI: hepatosplenomegaly
Hematology: thrombocytopenia
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14
Q

Presentation of congenital HSV?

A

Conjunctivitis or kerato-conjunctivitis
Skin: mucocutaneous vesicles and scarring
GI: elevated liver transaminases
Hematologic: thrombocytopenia

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15
Q

Presentation of congenital Zika?

A

CNS: severe microsephaly, thin cerebral cortices, subcortical calcifications
Eyes: macular scarring, pigmentary retinal scarring
Ear/nose: sensorineural hearing loss
Skeletal: arthrogryposis, early hypotonia

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16
Q

3 TORCHZ infections that cause intracranial calcifications + type?

A

Toxo - diffuse
CMV - periventricular
Zika - subcoritcal

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17
Q

4 TORCHZ infections that cause microcephaly?

A

Varicella
Rubella
CMV
Zika (severre)

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18
Q

2 TORCHZ infections that cause cataracts?

A

Rubella, CMV

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19
Q

2 TORCHZ infections that cause sensorieneural hearing loss?

A

Rubella, Zika

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20
Q

2 TORCHZ infections that cause GI organ enlargement?

A

Rubella (hepatomegaly)

CMV (HSM)

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21
Q

3 TORCHZ infections that cause thrombocytopenia?

A

Rubella, CMV, HSV

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22
Q

What is infectious mononucleosis and how does it present?

A

Infection of lymphocytes caused by EBV; typical signs and symptoms include extreme fatigue, pharyngitis, and lymphadenopathy

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23
Q

Define lethargy.

A

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.

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24
Q

Define listlessness.

A

No interest in what is happening in the environment

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25
Q

Define toxic.

A

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

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26
Q

Define distress.

A

Appearance of working hard to maintain physiologic stability such as grunting, rapid breathing in order to maintain adequate oxygenation and ventilation

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27
Q

Define fever without a source

A

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

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28
Q

Most common cause of fever without a source in infants?

A

Viral syndrome (small minority have a serious bacterial illness)

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29
Q

Possible serious bacterial causes of fever without a source?

A 
UTI (most common)
Meningitis
Sepsis/bacteremia
Pneumonia
Bacteral gastroenteritis
Osteomyelitis
Septic arthritis
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30
Q

Presentation of bacteremia as a fever without a source?

A

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

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31
Q

Presentation of bacterial meningitis as a fever without a source?

A

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

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32
Q

Presentation of UTI?

A

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

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33
Q

Risk factors for UTI in male and female infants?

A

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

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34
Q

Management of fever without a source in an infant?

A
  1. CBC + empiric antibitoics for WBC of 15,000+ (unless previously healthy and well-appearing)
  2. Blood culture (ill-appearing or un/underimmunized)
  3. UA and urine culture (catheterized)
  4. LP (ill-appearing, un/underimmunized, meningitis not excluded by exam)
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35
Q

Define sepsis.

A

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

36
Q

Kernig’s sign?

A

Resistance to extension of the knee

37
Q

Brudzinski’s sign?

A

Flexion of the hip and knee in response to flexion of the neck

38
Q

Nuchal rigidity?

A

Involuntary resistance to neck flexion when the clinician flexes a patient’s neck forward

39
Q

DDx - fever in an infant

A
  1. UTI
  2. Pneumonia
  3. Sepsis/bacteremia
  4. Occult bacteremia
  5. Bacterial meningitis
  6. Viral meningitis
  7. Roseola
  8. Primary herpes simplex virus gingivostomatitis
  9. Otitis media
  10. Viral URI
40
Q

Presentation of pneumonia?

A

Cough, tachypnea, fever, rales, lower SaO2

Not impossible for a child with pneumonia to have no symptoms referable to the respiratory symptom

41
Q

Guidelines to get a CXR for possible pneuonia?

A

Respiratory findings and/or a WBC count >20,000

42
Q

Presentation of sepsis?

A

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

43
Q

Presentation of occult bacteremia?

A

Well-appearing

Positive blood culture

44
Q

Why is a distinction made between occult bacteremia and sepsis?

A

Most children with occult bacteremia will not develop a SBI whereas a child with sepsis represents a medical emergency

45
Q

Most common cause of bacterial meningitis in children?

A

S. pneumonia and N. meningitidis

46
Q

Common cause of viral meningitis?

A

Enterovirus

47
Q

Presentation of primary HSV gingivostomatitis?

A

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

48
Q

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…?

A

Catheterization

49
Q

Typical CSF findings in bacterial vs. viral meningitis?

A

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

50
Q

Define pyuria.

A

> 5 WBCs/hpf in centrifuged urine; if counting chamber is used, then >10 is +

51
Q

What does a positive nitrite test mean?

A

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

52
Q

What does a positive leukocyte esterase test mean?

A

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

53
Q

Oral vs. parenteral antibiotics for treating children with UTIs?

A

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

54
Q

In a child who has not recently been on antibiotics, the most likely cause of an initial episode of pyelonephritis is ___. Other causes?

A

E. coli; enteric GN organisms (Klebsiella or Proteus) or enterococcus

55
Q

Empiric parenteral treatment for pyelonephritis?

A
  1. Ampicillin + gentamicin (E. coli resistance to ampicillin is increasing -> excellent activity against coliforms when combined with gent)
  2. Ceftriaxone (excellent GN bacilli coverage except P. aeruginosa, does not cover enterococci, excellent safety profile in children)
  3. Meropenem (ESBLs)
  4. Ciprofloxacin (approved for children >1 year for complicated UTI with resistant organisms, not the best choice due to cost and AE in children)
56
Q

Why should calcium-containing medication not be given through the same IV line as ceftriaxone?

A

Can interact to form precipitates in the lungs and kidneys

57
Q

Empiric oral treatment for pyelonephritis?

A
  1. Cephalexin (Keflex) - E. coli and other enteric GN rods (inexpensive, well-tolerated)
  2. TMP-SMX - effective against UTIs with the exception of Pseudomonas and resistant E. coli
  3. Amoxicillin/clavulanate (Augmentin) - effective, but potential for skin and GI adverse reactions
58
Q

Rare but serious side effect of TMP-SMX?

A

SJS

59
Q

Why is nitrofurantoin only approved to treat cystitis, not pyelonephritis?

A

Reaches an acceptable concentration level in the urine, but not in the blood

60
Q

Follow-up studies for UTI and pyelonephritis?

A
  1. U/S of kidneys and bladder
  2. Renal technetium scan (provides evidence of pyelonephritis, not required in a patient who has responded well to treatment)
  3. 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)
61
Q

DDx - Fever and Rash

toddler

A
  1. Adenovirus infection (viral infection - may cause URI, pharyngitis, conjunctivitis, tonsillitis, OM)
  2. Kawasaki disease
  3. Meningococcemia
  4. Measles
  5. RMSF
  6. Scarlet fever
  7. SJS
  8. Enteroviral infection (Coxsackie, echo, entero)
  9. Varicella
  10. Erythema infectiosum (5th disease)
  11. Roseola
62
Q

Presentation of meningococcemia?

A

Fever, chills, malaise, rash (often petechial), may lead to shock and DIC

63
Q

Presentation of measles?

A

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

64
Q

Presentation of RMSF?

A

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

65
Q

Presentation of scarlet fever?

A

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)

66
Q

Presentation of SJS?

A

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.

67
Q

Presentation of enteroviral infection?

A

Fever lasting 3-5 days, may also cause conjunctivitis, oral ulcers, diarrhea, aseptic meningitis
Non-specific rash including the palms and soles

68
Q

Presentation of varicella?

A

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

69
Q

Presentation of erythema infectiosum (5th disease)?

A

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

70
Q

Presentation of roseola (exanthem subitum, sixth disease)?

A

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

71
Q

Size and location of lymph nodes in healthy children?

A

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]

72
Q

Discuss localized vs. diffuse adenopathy.

A

Localized: usually occurs with infection in an area that drains to the affected node

Diffuse: generalized infection, malignancy, storage diseases, chronic inflammatory disease

73
Q

Texture of normal lymph nodes?

A

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)

74
Q

Features of lymph nodes concerning for malignancy?

A

Nodes that are hard, rubbery, matted together, or affixed to skin or soft tissue

75
Q

True or false - bilateral cervical adenopathy is common in children.

A

True

76
Q

What causes reactive cervical adenitis?

A

Occurs in response to an oral infectious or inflammatory process

77
Q

Presentation of bacterial cervical adenitis?

A

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)

78
Q

What is cat scratch disease?

A

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

79
Q

Most commonly involved sites of lymphadenopathy in cat scratch disease?

A

Axilla (most common), cervical, submandibular, inguinal

80
Q

Most common cause of mycobacterial lymphadenitis in children over 12 years of age?

A

TB

81
Q

Most common manifestation of nontuberculous mycobacteria in children?

A

Lymphadenitis (peak age of presentation of 2-4 years)

82
Q

Presentation of lymphadenitis due to mycobacterial infection?

A

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.

83
Q

Treatment of lymphadenitis due to mycobacterial infection?

A

Surgical excision

84
Q

Presentation of primary tuberculosis due to M. tuberculosis in children?

A

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

85
Q

Most common radiographic abnormality in primary TB in children?

A

Hilar adenopathy

86
Q

Describe lung findings in TB in children.

A
  1. All lobar segments are at equal risk of initial infection
  2. 2+ primary foci are present in 1/4 of cases
  3. Hallmark: primary complex
  4. Common sequence: hilar adenopathy, focal hyperinflation and then atelectasis, with minimal evidence of the primary focus itself
  5. Small local pleural effusions are common; large effusion rare in children <6 years
87
Q

Dx of TB?

A

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

Pediatrics Clerkship (14 decks)

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