Case #1 Wrap Up Flashcards
Pediatric trends in pulse, blood pressure, and respiratory rate
Pulse - high as a newborn, slowly decreasing until adolescenceBP - low as a newborn, slowly increasing to adult normal by adolescenceRR - high as a newborn, slowly decreasing until adolescence
A rapid formula for estimating normal systolic blood pressure in children
80 + (2 x age, in years)
Streptococcal pharyngitis is caused by
strep pyogenes aka GABHS
In strep, the roof of the mouth may have ..
fine red lesions called palatal petechiae
Symptoms of streptococcal pharynigitis
- sore throat2. fever3. swollen tender lymph nodes in the anterior cervical neck4. tonsil hypertrophy5. fatigue
When strep throat is accompanied by a red rash and fever, it is called …What are the manifestations of this?
scarlet fevermanifestations1. slapped checks appearance2. strawberry tongue3. scarlatinoform (sand paper) rash
Symptoms that generally do not accompany streptococcal infections
coughhoarsenessrunny nosethese symptoms more likely indicate viral URI … remember, most sore throats are not due to strep infections
How long do symptoms of streptococcal pharyngitis last?
Untreated - 2 to 5 daysWith antibiotic treatment - 1 to 3 daysScarlet fever rash fades after several days but can be followed by flaking or peeling skin, especially around the fingertips, 1 to 3 weeks later
How does a person get streptococcal pharyngitis?
Usually from DIRECT CONTACT with another person with strep pharyngitisAsymptomatic carriers (5-20%) can play a role in transmission, particularly during outbreaks
Who can get streptococcal pharyngitis?
Anyone can get strep pharyngitis, even after tonsillectomy, but the infection is most common in school-aged children
How long does it take to develop streptococcal pharyngitis following exposure?
incubation period of 1 to 3 days
How is strep pharyngitis diagnosed?What does this detect?How reliable is the test?
- Rapid strep testDetects the presence of a carbohydrate antigen by agglutinationHigh sensitivity but low specificity(SPecifity rules IN = SPIN)(SeNsitivity rules OUT = SNOUT)2. Culturing a swab of the throatGrow on blood agar
What kind of serology can be done to detect strep?If you could only be two things to test for, which should you pick?Which is good at detecting a skin infection?
Streptozyme test which includes1. Anti-streptolysin O2. Anti-streptokinase3. Anti-nicotinamide-adenine dinucleotidase4. Anti-DNAse B antibodies5. Anti-hyaluronidaseIf only two, pick 1 and 4For skin, 4 is best
How is strep pharyngitis treated?Should asymptomatic contacts of persons with strep pharyngitis receive antibiotics?
Either a single injection of penicillin or with a 10-day course of oral antibiotics: penV, amoxicillin, cephalosporin, marcolide, or clindamycinAsymptomatic contacts should not be treated
How long is a person with streptococcal pharynigitis infectious?When can children return to school?
until after 24 hours of appropriate antibiotic therapy(children don’t return to school until after 24 hours of treatment and until fever has resolved)without treatment, communicability may last for several weeks after the symptoms of pharyngitis have stopped
What can be done to prevent strep pharynigitis and its complications?
- early recognition and treatment2. take the entire course of antibiotics3. avoiding consumption of raw milk
What are complications of streptococcal infections?
Suppurative1. Direct spread from nasopharynx - sinusitis, OM, mastoiditis, cervical adenines, abscess, bronchopneumonia2. Breaches of skin barrier - impetigo, cellulitis, erysipelas3. Hematogenous dissemination - meningitis, osteomyelitis, septic arthritisNonsuppurative1. Rheumatic fever2. PSGN3. PANDAS (pediatric autoimmune neuropsychiatric disorder associated with group A strep)
What still remains the primary reason to treat strep pharyngitis?
Preventing rheumatic fever
Systolic ejection murmur-definition-special name
Hyperdynamic blood flow over a normal pulmonic/aortic valveQuite common in children and adolescents: called still’s murmur
What are some physiologic causes of systolic ejection murmurs?What are some structural causes of systolic ejection murmurs?
Physiologic: May have a high cardiac output due to: anemia, infection, thyrotoxicosis, pregnancy, peripheral AV fistula, volume overloadStructural: turbulent blood flow across abnormal aortic and pulmonary valves
What do the grades of murmurs mean?
1 - nearly inaudible2 - faint, but identifiable3 - loud, no palpable thrill4 - loud, palpable thrill5 - audible w/ stethoscope barely on chest6 - audible with stethoscope not touching chest
Rheumatic fever
Rare serious complication that may occur among untreated cases of strep pharyngitisDevelops 2-5 weeks after strep pharyngitisThe valves of heart may be permanently damagedPreventable with antibiotic treatment and improved hygiene
Rheumatic fever diagnostic criteria
Jones major criteriaJ - joints (migrating polyarthritis)O - obvious (heart)N - nodes (subcutaneous nodules, not painful)E - erythema marginatum (skin rash)S - Sydenham’s chorea (involuntary movements)Jones minor criteria-fever-arthralgia-previous rheumatic fever/rheumatic heart disease
Puffy face/edema - ddx/things to consider
-allergic response-trauma-sinusitis w/ periorbital cellulitis-renal insufficiency-congestive heart failure
What is often the first noticeable change in renal disease?
Facial puffiness - it is caused by edema. Since there is very little periorbital subQ tissue, edema can accumulate there easily
What can cause hematuria?
infection, kidney stones, trauma, tumor
What can cause hemoglobinuria?
hemolytic anemia
What can cause myoglobinuria?
rhabdomyolysis
What can cause bilirubinura?
cholestasis
What can cause concentrated urine?
dehydration, fever, increased exercise
Red cell casts
PCVT leaks red cells and protein, clumps formed in DCVT and retain shape of tubule when passed
Nephrotic Syndrome Criteria
- Increased glomerular permeability2. HEAVY PROTEINURIA > 3.5 g/day (50 mg/kg/day in children)3. Hypoalbuniemia < 3 g/dL4. Edema due to decreased oncotic pressure5. Hyperlipidemia6. Hematuria is usually absent7. Minimal change disease, focal segmental glomerulosclerosis, DM, SLE, amyloidosis
Nephrotic syndrome vs nephritic syndrome
nephrOtic syndrome = damage by an ObjectnephrItic syndrome = damage by Inflammation
What is the most common cause of nephrotic syndrome in children?
Minimal change disease-individual food processes have fused together (podocyte effacement)
Acute nephritic syndrome
Presents with: -hypertension-hematuria-RBC casts-pyuria-mild to moderate proteinuriaAlso see-edemaazotemia (retention of nitrogenous waste products, so increased BUN and creatinine)Extensive inflammatory damage to glomeruli causes a fall in GFR and eventually produces uremic symptoms with salt and water retention, leading to edema and hypertensionSHOULD BE CONSIDERED IN ANY CHILD PRESENTING WITH SYMPTOMS OF VOLUME OVERLOAD
PSGN-most common in-infection after
most common in children (5-15) and elderly (>60)More often in malesMore often in developing countries and areas with poor hygieneGABHS infection - strep pharyngitis and impetigo
Nephritic risk after infection with GABHS is?
10-15%
Clinical presentation of PSGN
Interval b/t GABHS infection and acute PSGN-pharyngitis: 1-2 weeks-impetigo: 3-6 weeksClassically presents with overt nephritic syndrome and oliguric ARFSymptoms can include-hematuria-hypertension-hypervolemia and edema-systemic features: headache, measles, anorexia, flank pain
Acute Nephritic Syndromes - Differential Diagnosis
- PSGN2. Lupus nephritis3. IgA nephropathy4. Membranoproliferative GN5. Antiglomerular basement membrane disease6. Subacute bacterial endocarditis7. ANCA small vessel vasculitis8. Mesangioproliferative GN
What is the most useful serologic testing in differentiating acute glomerulonephrities?How so?
Serum C3 and C4 complement levelsIn PSGN C3 and CH50 are decreased, C4 usually normalIf both C3 and C4 are low, consider lupus nephritis, hep BIf both C3 and C4 are normal, consider IgA nephropathy, henoch-schonlein purpura, or good pasture syndrome
What is the complement system?
System of over 20 different interacting protein molecules always found in the blood that play a role in immunity & inflammationWith an infection, this system of molecules is activated, leading to a sequence of events on the surface of the pathogen that helps destroy the pathogen and eliminate the infection
When should you consider renal biopsy?
-if you are considering other glomerular diseases-persistently low C3 >6 weeks-recurrent episodes of hematuria-progressive increase in creatinine
What is the main complication of renal biopsy?
bleeding
HUS
Thrombotic microangiopathy after bloody diarrhea caused by shiva verotoxin producing E. coli which damage glomerular vascular endotheliumpeaks 6 mo - 4 years (see slides for symptoms)Tx: supportive, AB, etc.
Lupus Nephritis
1/2 of children with SLE will present with this
IgA nephropathy aka Berger’s Disease
Immune complex mediated glomerulonephritis defined by the presence of diffuse granular mesangial IgA deposits often associated with mesangial hypercellularityMost common presentation is recurrent macroscopic hematuria following URI (5 days)normal C3 and C4 complement levels
IgA vasculitis aka Henoch-Schonlein Purpura
Systemic vasculitis w/ deposition of IgA immune complexesSigns/symptoms: purpura, arthritis, etcNormal C3 and C4 complement levels
Anti-glomerular basement membrane disease AKA good pasture syndrome
Disorder in which circulating antibodies are directly mainly against the NC1 domain of the a-3 chain of type IV collagen (highly expressed in the GMB and alveoli)Triggered by viral URI or breathing hydrocarbon solvents
Description of electron microscopy of postinfectious glomerulonephritis capillary
Subepithelial deposits which appear as “humps” or “lumpy bumpy” appear ants of glomeruli on immunofluorescence
Rapidly progressive glomerulonephritis
~1% of PSGNpoor prognosis w/ fulminant renal failure over several weeksproteinuria, hematuria w/ RBC casts and PAS stainingBiopsy demonstrates circumferential and cellular CRESCENT FORMATION with interstitial nephritis
Membranoproliferative GN-presents with-patients with MPGN continue to have …
Presents with-hematuria-hypertension-proteinuria-hypocomplementemiafollowing URIPatients with MPGN continue to have persistent nephritis & hypocomplementemia beyond 4-6 weeks and possibly a further elevation in serum creatinine
Type II MPGN is also called…when viewed under a microscope …
dense deposit diseasecontinuous, dense, ribbon-like deposits are found along the basement membranes of the glomeruli, tubules, and Bowman’s capsule
PSGN Course
Resolution usually quick, diuresis begins within 1 week, plasma Cr usually returns to previous levels by 3-4 weeksHematuria resolves within 3-6 monthsProteinuria falls at a slower rateSome patients experiences-presistent HTN-recurrent proteinuria-renal insufficiency
PSGN Treatment
Eliminate strep infection with antibiotics as well as cohabitantsSupportive therapy of volume overloadMonitor for renal failure complications
What should you look for when monitoring for complications of renal failure?
- fluid overload2. hyperkalemia3. hyperphosphatemia w/ hypocalcemia4. metabolic acidosis5. azotremia6. oligouria7. anuria8. hyponatremia9. hypertensive encephalopathy10. congestive heart failure
What are some causes of renal failure?
Prerenal-hypovolemia (diminshing renal perfusion)-occlusion of renal arteryIntrarenal-damaged nephronsPostrenal-obstruction of urinary tract -venous occlusion
Indications for Dialysis
(AEIOU)A - acid/base refractory imbalanceE - electrolyte uncontrolled disturbanceI - intoxication/ingestion of substancesO - overload of fluidsU - Uremia symptoms
Poison prevention phone #
1-800-222-1222
