Derm/renal/haem Flashcards
Anaemia
Causes, sx, ix, mx
- Causes:
- Blood loss
- Increased destruction (haemolytic)
- Inadequate RBC production (lack of iron, B12, folate, copper, erythropoietin and chronic inflammation)
- Investigations:
• Full Blood Count (FBC): For determining haemoglobin levels, red cell count, mean corpuscular volume (MCV), mean corpuscular Hb (MCH)
• Microcytic anaemia (low MCV) suggests iron deficiency, thalassemia or lead poisoning
• Macrocytic anaemia (high MCV) suggests vitamin B12 or folate deficiency.
• If WCC and platelets are reduced, this may suggest bone marrow failure.
• Reticulocyte Count: To assess bone marrow response.
• Iron studies: For diagnosing iron deficiency anaemia.
• Ferritin levels <30 micrograms / L indicates iron deficiency anaemia- Serum ferritin is acute phase reactant so can show inflammation
- Serum iron reflects iron intake so doesn’t show iron stores
• Blood film to detect poikilocytosis
• Coomb’s test for autoimmune haemolytic anaemia
• Vitamin B12 and Folate levels: To detect deficiencies.
• Genetic testing: For conditions like thalassaemia and sickle cell disease.
- Treatment:
- More iron rich food
- Limit cow milk
- Dietician referral
- If menstruation contributes then mefenamic acid
- Address contributing factors
- Iron is better absorbed with vitamin c
ITP (immune thrombocytopenia)
Def, causes, sx, ix, mx
ITP in children is often triggered by a viral infection or following immunisation.
Secondary ITP is rare in children but it can be due to:
• Autoimmune conditions (i.e. systemic lupus erythematosus)
• Infections (i.e. H pylori and CMV)
• Medications
• Lymphoproliferative disorders
ITP is an autoimmune/idiopathic bleeding disorder characterised byall threeof:
- Isolated thrombocytopenia (platelet count of <100 x109/L, often <20 x109/L)
- Well child with no concerning features on clinical history or examination
- Otherwise normal FBC and film
Sx:
- Sudden onset of pretechial rash or bruising
- Bleeding symptoms eg. Decreased consciousness
- Preceding viral infection
- Well looking
• Easy or excessive bruising (purpura)
• Superficial bleeding into the skin that appears as a rash of pinpoint-sized reddish-purple spots (petechiae), usually on the lower legs
• Prolonged bleeding from cuts
• Spontaneous bleeding from the gums or nose - ITP presents with mucocutaneous bleeding (rather than e.g. haemarthrosis which is often associated with defects in the coagulation cascade like in haemophilia)
• Blood in urine or stools
• Unusually heavy menstrual flow in females
Investigations:
- FBC
- Blood film
Mx:
• The management of ITP is generally conservative, with a watch-and-wait approach typically adopted due to the high rate of spontaneous remission.
• Tranexamic acid (TXA) may be used to help blood clot, particularly used for menorrhagia.
• For persistent cases, steroids (immunosuppressant) can be used for 4-7 days.
• IVIG can also be used as it is immunomodulatory, reducing antibody production.
• In cases that prove refractory for 12-24 months, splenectomy may be considered.
• Platelet transfusions should be avoided unless there is life-threatening bleeding. This is because giving more platelets will increase the rate of platelet destruction.
Ibuprofen should be avoided in children with ITP.
HSP
Def, cause, dx, ix, sx, mx
- Small vessel vasculitis
- IgA mediated- depositions of IgA into several areas
- Multisystem involvement
- Aetiology unclear but may be linked to URTI
- Palpable pupura
- Diagnosis: rash AND ONE OR MORE OF arthritis, abdominal pain, nephritis
- Investigations: urinalysis, blood pressure, U&E, albumin, FBCm abdo imaging, ASOT, anti-DNAse B, blood culture
- Management: Analgesia and supportive measures, Corticosteroids for symptom control, Severe abdominal pain may require surgical review to assess for the risk of intussusception or bowel infarction, Referral to a renal specialist for further immunosuppression or dialysis if renal involvement is significant
Eczema
Hx, ix, mx, complications
Eczema herpeticum:
• A disseminated viral infection characterised by fever and clusters of itchy blisters
or punched-out erosions
• Complication of eczema
• Cause: type I HSV co-infection with active atopic eczema
• Secondary bacterial infection with Staphylococci or Streptococci may lead to
impetigo or cellulitis
• Clinical diagnosis, can be confirmed by viral swabs, bacterial swabs can be done to
rule in/out impetigo
• Management: oral acyclovir, systemic antibiotics for secondary bacterial infection
and ophthalmology review if any eyes involvement
Impetigo
Pathogen, hx, sx, mx
• Localised non-bullous impetigo: topical treatment with hydrogen peroxide 1% cream (apply two or three times daily for 5 days) is first-line
• If unsuitable, second-line options include fusidic acid or mupirocin (if fusidic acid resistance
• Widespread non-bullous impetigo:
• Topical (fusidic acid/mupirocin) or oral antibiotics for 5 days, such as flucloxacillin
• Clarithromycin (penicillin-allergic) or erythromycin (pregnancy) are alternatives
• Bullous impetigo, or impetigo in those systemically unwell or at high risk of complications:
• Oral antibiotics as above for up to 7 days
children should be off school until or lesions are healed or 48 hours after starting treatment
Measles
Pathogen, hx, sx, mx
sx: conjunctivits and kolik spots (grey discolourations of the mucosal membrane)
child must remain off scholl until at least 4 days after the development of the rash
Rubella
Pathogen, hx, sx, mx
Viral exanthema
Def, sx, types
• A skin eruption occurring as a symptom of a viral illness
• Non-specific systemic symptoms such as fever, malaise may precede, occur simultaneously with or following a viral illness
• Symptoms secondary to a reaction to toxin produced by the organism, damage to the skin by the organism or an immune response
• Include
➢ Chickenpox (VZV)
➢ EBV
➢ Roseola infantum (6th disease)
➢ Erythema infectiosum (5th disease)
➢ Hand-foot-and-mouth disease
➢ Rubella (German measles)
➢ Measles (Rubeola)
➢ Cutaneous herpes simplex
➢ Molluscum contagiosum
➢ Erythema multiforme
Uticaria
Cause, sx, mx
Type 1 diabetes mellitus
Def, sx, ix, mx
Autoimmune destruction of the beta cells of the pancreas, leading to insufficient insulin production and therefore hyperglycemia.
sx:
classic symptoms of insulin deficiency:
• Polyuria
• Polydipsia
• Weight loss
• Excessive tiredness
Ix
• Fasting blood glucose >7
• Random blood glucose >11
- HbA1c to monitor
- OGTT
- urine dip
Mx
- insulin
- education
- MDT (foot and eye checks)
Nephrotic syndrome
Def, causes, sx, mx
Nephrotic syndrome occurs when the basement membrane in the glomerulus becomes highly permeable to protein, allowing proteins to leak from the blood into the urine. It is most common between the ages of 2 and 5 years. It presents with frothy urine, generalised oedema and pallor.
Causes
- minimal change disease
- intrinsic kidney disease
- HSP
- diabetes
- infection
Nephrotic syndrome features a classic triad of:
- Low serum albumin
- High urine protein content (>3+ protein on urine dipstick)
- Oedema
Other sx
- Deranged lipid profile, with high levels of cholesterol, triglycerides and low density lipoproteins
- High blood pressure
- Hyper-coagulability, with an increased tendency to form blood clots
Ix
- urine dip (proteinuria)
- bloods (hypoalbuminaemia)
Mx
- High dose steroids (i.e. prednisolone)
- Low salt diet
- Diuretics may be used to treat oedema
- Albumin infusions may be required in severe hypoalbuminaemia
- Antibiotic prophylaxis may be given in severe cases
- ACE inhibitors if steroid resistant
Glomerulonephritis
Causes, sx, mx
Causes
- post-infection
- vasculitis
- IgA nephropathy
- antiglomerular basement membrane disease
Sx
- decreased urine output
- HTN
- oedema
- heamaturia and proteinuria
Mx
- monitor water/sodiaum balance and use diuretics when necessary
- supportive
Leukaemia
Types, path, sx, ix, mx
Types:
- Acute lymphoblastic leukaemia (ALL) is the most common in children
- Acute myeloid leukaemia (AML) is the next most common
- Chronic myeloid leukaemia (CML) is rare
Path:
Leukaemia is a form of cancer of the cells in the bone marrow. A genetic mutation in one of the precursor cells in the bone marrow leads to excessive production of a single type of abnormal white blood cell. The excessive production of a single type of cell can lead to suppression of the other cell lines, causing underproduction of other cell types. This results in a pancytopenia, which is a combination of low:
- Red blood cells (anaemia),
- White blood cells (leukopenia)
- Platelets (thrombocytopenia)
Sx:
Persistent fatigue
Unexplained fever
Failure to thrive
Weight loss
Night sweats
Pallor (anaemia)
Petechiae and abnormal bruising (thrombocytopenia)
Unexplained bleeding (thrombocytopenia)
Abdominal pain
Generalised lymphadenopathy
Unexplained or persistent bone or joint pain
Hepatosplenomegaly
Ix:
- FBC (anaemia, leukopenia, thrombocytopenia and high numbers of the abnormal WBCs)
- blood film (blast cells)
- bone marrow biopsy
- lymph node biopsy
- CXR
- CT
- lumbar puncture
- genetic analysis and immunophenotyping
Mx:
- Radiotherpy
- bone marrow transplant
- surgery
Infectious mononucleosis
Cause, sx, ix, mx
Infectious mononucleosis (IM) is a condition caused by infection with the Epstein Barr virus (EBV). It is commonly known as the “kissing disease”, “glandular fever” or “mono”. This virus is found in the saliva of infected individuals. Infection may be spread by kissing or by sharing cups, toothbrushes and other equipment that transmits saliva. EBV is secreted in the saliva of infected individuals and can be infectious several weeks before the illness begins and intermittently for the remainder of the patient’s life. Most people are infected with EBV as children, when it causes very few symptoms. When infection occurs in teenagers or young adults, it causes more severe symptoms. It is the symptomatic infection with EBV that is called infectious mononucleosis.
Sx:
Fever
Sore throat
Fatigue
Lymphadenopathy (swollen lymph nodes)
Tonsillar enlargement
Splenomegaly and in rare cases splenic rupture
It is possible to test for specific EBV antibodies. These antibodies target something called viral capsid antigen (VCA):
- The IgM antibody rises early and suggests acute infection
- The IgG antibody persists after the condition and suggests immunity
Mx:
- avoid alcohol
- avoid contact sports
UTI
Sx, urine dip findings, mx
Sx:
Babies will present with very non-specific symptoms:
Fever
Lethargy
Irritability
Vomiting
Poor feeding
Urinary frequency
Signs and symptoms in older infants and children are more specific:
Fever
Abdominal pain, particularly suprapubic pain
Vomiting
Dysuria (painful urination)
Urinary frequency
Incontinence
Urine dip:
- Nitrites – gram negative bacteria (such as E. coli) break down nitrates, a normal waste product in urine, into nitrites. The presence of nitrites suggest bacteria in the urine.
- Leukocytes – leukocytes are white blood cells. There are normally a small number of leukocytes in the urine, however a significant rise can be the result of an infection or another cause of inflammation. A urine dipstick tests for leukocyte esterase, a product of leukocytes that give an indication about the number of leukocytes in the urine.
- Nitrites are a better indication of infection than leukocytes. If both are present the patient should be treated as a UTI. If only nitrites are present it is worth treating as a UTI. If only leukocytes are present the patient should not be treated as a UTI unless there is clinical evidence they have one.
- If nitrites or leukocytes are present, the urine should be sent to the microbiology lab. If neither are present the patient is unlikely to have a UTI.
- Send a midstream urine (MSU) sample to the microbiology lab to be cultured and have sensitivity testing.
Mx:
- Trimethoprim
- Nitrofurantoin
- Cefalexin
- Amoxicillin
Reactive lymphadenopathy
Causes, sx, dx, mx
Causes:
Viral infections (like colds, Epstein-Barr virus, or cytomegalovirus)
bacterial infections (such as strep throat),
localised inflammation (e.g., tonsillitis or dental issues)
Sx:
Swollen lymph nodes are often noticed in areas like the neck, armpits, or groin. These nodes are usually soft, mobile, and tender.
Dx:
A physical examination is often enough to diagnose reactive lymphadenopathy.
Blood tests or imaging (like ultrasound) may be used to rule out more serious conditions if the swelling persists or shows unusual characteristics.
Mx:
Most cases resolve on their own as the underlying infection or inflammation subsides. Treatment, if necessary, targets the primary cause (e.g., antibiotics for bacterial infections).
Cellulitis
Sx, dx, mx
Sx:
Redness
Swelling
Pain
Fever
Dx:
Physical exam
Infection markers in bloods
Mx:
Antibiotics
Analgesia
Enuresis
Types, causes, dx, mx
- Primary Enuresis: The child has never achieved consistent nighttime dryness for six months or longer. It is the most common form.
- Secondary Enuresis: The child had been dry for at least six months but then started wetting the bed again. This may be linked to stress, infections, or other underlying conditions.
Causes:
1. Delayed bladder maturation: In many cases, the bladder or the communication between the bladder and brain may not be fully mature, causing difficulty in controlling urination.
2. Genetics: Bedwetting often runs in families. If one or both parents experienced enuresis, there is a higher likelihood that their child may also have it.
3. Sleep patterns: Some children sleep so deeply that they don’t wake up when their bladder is full.
4. Hormonal factors: A deficiency in antidiuretic hormone (ADH), which reduces urine production at night, can contribute to bedwetting.
5. Stress or emotional factors: Changes in routine, family stress, or school difficulties may trigger enuresis, especially in secondary enuresis.
6. Urinary tract infections (UTIs): Infections can irritate the bladder and cause both daytime and nighttime wetting.
7. Constipation: Full bowels can press on the bladder, reducing its capacity and causing accidents.
8. Medical conditions: Conditions like diabetes, neurological disorders, or anatomical abnormalities can sometimes be the cause, though these are less common.
Dx:
• Urine tests: To rule out infection or other causes.
• Bladder function tests
Mx:
1. Behavioral interventions:
• Bladder training: Encouraging the child to hold urine for increasing amounts of time during the day.
• Nighttime routines: Reducing evening fluid intake and ensuring the child uses the bathroom before bed.
• Enuresis alarms: These devices wake the child when wetness is detected, helping them learn to respond to a full bladder.
2. Medications (for severe cases):
• Desmopressin (DDAVP): Reduces urine production at night.
• Anticholinergics: Help increase bladder capacity in cases of small bladder size.
3. Counseling: In cases where emotional or psychological factors may be contributing, therapy or counseling might be beneficial.
Haemolytic uremic syndrome
Types, sx, ix, mx
- Typical (or Shiga-toxin-associated) HUS: This is the most common form and usually follows an infection by certain strains of Escherichia coli (E. coli), particularly those producing Shiga toxin (such as E. coli O157:H7). This type often follows a gastrointestinal illness, particularly bloody diarrhea.
- Atypical HUS: This form is not associated with an infection and is less common. It can be related to genetic factors, abnormal immune responses, or other underlying conditions that affect the regulation of the complement system (part of the immune system).
Sx:
Diarrhoea
Paleness and fatigue
Decreased urine output
Swelling
Lethargy
HTN
Petechiae
Ix:
Bloods: anemia, thrombocytopenia, high creatinine
Stool culture
Urine dip
Mx:
Supportive
Antihypertensives
