Exam 4 Flashcards
Enterobius Vermicularis
Pinworm
Pinworm transmission
- Fecal-oral route
- Direct transfer of infected eggs by hand, to anus, to mouth
- Females die after depositing up to 10,000 eggs/24 hours
- Eggs can live for 2 weeks off humans!
- Are infective within hours of being deposited
- Indirect transmission: from bedding, clothing, in the air
- Incubation period: 1-2 months from ingestion until adults migrate to anal area
Vulvovaginitis
[Pinworm complication]
- Inflammation
- Migration from the anus, can move to the ovaries, liver, and lung (rare)
- Pelvic pain, granuloma in the peritoneal cavity
- 20% of females with pinworm (EV) infestation will have vulvovaginitis
Soil-Transmitted Helminths
- STH diseases (“helminth” means parasitic worm) are of major importance in developing countries
- They are caused by infection with roundworm, hookworm, or whipworm, and can include diarrhea, abdominal pain, intestinal obstruction, anemia, and retarded growth and cognitive development
Hookworm: offending organisms
- Ancylostoma duodenale & Necator americanus
- Nematode parasites
- Live in the small intestine
Necator americanus
- Gray-pink color, 0.5 mm thick
- Male: 5-9 mm long
- Female: 10 mm long
- Lifespan: up to 15 years
- Reproduction: females lay up to 10,000 eggs/day
Ancylostoma duodenale
- 0.5 mm thick
- Males: 5-10 mm long
- Females: 10 mm or more in length
- Lifespan: 6 months
- Reproduction: 30,000 eggs/day
Hookworm: Clinical manifestation
- Itchy rash at site of entrance
- Diarrhea (as hookworms grow in intestines)
- Nausea
- Abdominal pain
- Decreased appetite
- Fever
- Can have bloody stool
- Progressive anemia: “blood suckers”
Hookworm: Diagnostic tests
- CBC: anemia and follow up after Fe started
- Stool sample: to look for eggs
- Soil sample: for larvae
Hookworm: Treatment goals
- Rid of parasites & treat anemia
- Improve nutrition & growth
- Based on complications: hydration (as needed), admission (as needed)
Albendazole
- 400 mg po ONCE
- Take with food
- May take up to 3 days
- Pregnancy Category C
Pyrantel pamoate
- 11 mg/kg PO once a day for 3 days
- Label reads “not for children under 2 years of age”
- WHO has used in ‘mass campaigns’ and approves use <1 y/o
- Few studies under <1 year of age (safety?)
- Pregnancy Category C
Trichuris trichiura
- “Whipworm”
- Soil transmitted helminth (STH)
- Whipworms live in the large intestine
Whipworm: Clinical manifestations
- Can be asymptomatic
- Frequent passage of painful stool –> blood and mucous
- Poor growth
- Pale, tired (anemia)
Whipworm: Diagnosis
- Stool sample: ID eggs
Whipworm: Treatment
- Albendazole, Mebendazole or Ivermectin
- Follow stool samples: 3x in 3 months following treatment
Whipworm: Patient education
- Medications may cause nausea, cramping, stomach pain
- Prevention: improve sanitation, wash hands
- “Wash it, peel it, cook it or forget it”
Giardia
- Most frequently diagnosed intestinal parasitic disease in the US and travelers
- Giardia intestinalis and Giardia lamblia
- Has a protective shell, can live outside the body for long periods & makes it tolerant to chlorine disinfection
- Live in the small intestine
Giardia: Diagnosis
- Stool samples (to ID cysts)
(1) 3 samples on 3 different days
(2) Cysts can be excreted intermittently
(3) Order stool for Ova and Parasites (O and P) - An enzyme linked to immunosorbent assay (ELISA) test commercially available and highly sensitive
- STRING TEST: swallow a capsule with a string attached, as it passes into the small intestine and trophozites stick to it, string removed and examined
- CBC not helpful, WBC should be normal
Giardia: Clinical manifestations
- Begin 1-3 weeks after infected, last 1-2 weeks
- Diarrhea (consider if diarrhea longer than 7 days)
- Gas
- Greasy stools that float
- Stomach pain
- Nausea/vomiting
- Symptoms can resolve and return after several weeks
- Weight loss (failure to absorb fat, Vitamin A, and B 12)
Giardia: Treatment
- Not all need treatment, may resolve on own
- Medications: Metronidazole (Flagyl) = 1st line, 5 mg/kg po TID for 5-7 days
- Tinidazole (Tindamax) for >3 years of age
- Nitazoxanide (Alinia): liquid form, better for children
Types of Malaria
- 4 types
- Plasmodium (P) falciparum most dangerous
- P. vivax and P. ovale can live dormant in the liver for years and reactivate after 2-4 years
Mosquito that transmits Malaria
Anopheles mosquito
Malaria: Clinical presentation
- Incubation period: 7-30 days
- Cold stage (cold/shivering)
- Hot stage (Fever, headache, vomiting, seizures)
- Sweating/Convalescent stage (sweats, normal temp, tired)
Malaria most common symptoms
- Fever
- Chills
- Headache
- Dry cough
- Body aches
- N/V
- Malaise
Malaria: Diagnosis
- Blood smear for parasites
- CBC: mild to severe anemia
Malaria: Treatment
- Atovaquone-proguanil (Malarone), expensive
- Mefloquine (Coartem)
- Doxycycline, cheap but not for children <8 years
- Artersunate (not in US but can get on CDC malaria hotline)
- Chlorquine (much resistance)
Malaria: Prophylactic drugs
- Malarone
- Chlorquine
- Doxycycline
Malarone
[Malaria: Prophylactic drugs]
- Good for last minute travelers & short trips
- Starts 1-2 days before leave and take for 7 days after
- Peds tabs available
- Expensive
Chlorquine
[Malaria: Prophylactic drugs]
- Weekly med, areas have high level of resistance
- Not for last minute traveler; need to start 1-2 weeks before travel
Doxycycline
[Malaria: Prophylactic drugs]
- Cheapest
- Daily med
- Not for children <8 yo
- Good for last minute travel (start 1-2 days before)
- Side effects = upset stomach, diarrhea
Ova and Parasites
Test you will order with your stool sample to rule out parasites in your patient with diarrhea, bloody stool, cramping, recent travel or prolonged diarrhea for greater than 7 days
HOT stage of Malaria infection
- Most commonly presents to the PCP office or ER with this presentation in pediatrics
- Fever, headache, vomiting, seizures may occur
Check the CBC when……..
With a patient that you are following for or are suspicious of having HOOKWORM - remember HOOKWORM are the blood suckers and can cause anemia. So check a CBC and start of Fe supplements as needed
What presents with greasy stools that float, gas and diarrhea for > 7 days
Giardia should be on your radar! Ask about where they have been and when this started. Remember this typically starts 1-3 weeks after infected and can wax and wane - Send stool samples - 3 samples on 3 different days to capture the cysts
Passage of gastric contents into the esophagus without distress
- GER (no D)
- Normal in most newborns
- Most often post-prandial
- Results from a relaxation of the lower esophageal sphincter
You are seeing an infant that was born at 32 weeks but is now 6 months and doing well. No significant history except prematurity with a benign course in the NICU. Mom reports he arches a lot and has rigid posturing, neck movements and arches his back when she holds him. He has a long history of “spitting up” but no vomiting, no blood or bile reported. What is the most likely diagnosis?
Sandifer syndrome. ? GERD? ? Hiatal hernia - high association with Sandifer - refer to Peds GI
GERD medication approved for infants?
- Histamine 2 receptor antagonists (H2RAs); Ranitidine (Zantac) is one example
- Dose is 5-10mg/kg/day divided Q12 hours for over 1 month of age
- No PPIs or Antacids approved (although Peds GI may use PPIs)
Vomiting bile is suggestive of……….
- Intestinal atresia
- Can be Malrotation of Volvulus
- Needs further evaluation
- Both of the listed are surgical EMERGENCIES!
Most common symptom of GERD?
Regurgitation or “spitting”
Mother of a 2 week old male infant born full-term (FT) calls for an appointment because her son has a swollen scrotum. “He has a water balloon on one side, Help me!” You know that this is most likely?
- Hydrocele.
- Transilluminate to confirm if you are unsure in the office- should not be hard/firm…if it is consider a torsion! - Hydroceles are nontender and most resolve without intervention.
Lump at the groin area, firm but reducible - you know this is an inguinal hernia - you reassure the parents and your next step is:
A. Refer to urology
B. Ultrasound
C. Refer to surgery for consult and follow closely
C - you refer to surgery for consult in case it becomes incarcerated - you will need to follow closely and educate the parents on what to look for between visits.
What is the age you will refer to urology or surgery if testes remain undescended
6 months
What is the time frame that a hydrocele should spontaneously resolve?
By 1 year of life
What is Epispadias
- Opening on the top less common than hypospadias
- Urethral opening on dorsal aspect, associated with bladder complications/namely control problems
GER: Clinical presentation
- Infants with benign GER are called “happy spitters”
- Occurs most often in the postprandial period
- Occurs several times per day
- Commonly causes caregiver distress
GER: Physiology
- Decreased LES pressure (relaxation of the LES is transient in healthy infants)
- Increased abdominal pressure (over-feeding, several times per day)
- Alterations in gastric motility (delayed gastric emptying can increase episodes of sphincter relaxation)
GERD: Common Presenting Symptoms (Infants)
- Feeding refusal
- Recurrent vomiting
- Poor weight gain
- Irritability
- Sleep disturbance
- Respiratory symptoms
GERD: Common Presenting Symptoms (Child/Adolescent)
- Abdominal pain/Heartburn
- Recurrent vomiting
- Dysphagia
- Upper airway symptoms (chronic cough/hoarse voice)
- Sleep disturbance (Recurrent pneumonia)
- Respiratory symptoms (Asthma)
GERD: Diagnostic work-up
LAB
- CBC (anemia)
- Electrolytes
- Sepsis work up for infants including urine
Gold standard: pH probe (intra-esophageal pH monitoring)
Sandifer syndrome
- Present like seizures
- Arching of the back, spasmodic torsional dystonia, and rigid posturing
- Mainly involves the neck, back and upper extremities
Hernias
- Patent process vaginalis
- “Lump” with straining/crying
- Firm and reducible
- If cannot reduce, call surgery!
Hydrocele
- Intra-abdominal fluid leakage through a patent inguinal ring
- Appears like a “water balloon” - bulging scrotum
- Testes not palpable
- Soft, non-tender
- Transilluminate
- Spontaneous resolution by 1 year, if not then surgical repair
Cryptochidism
- Undescended testes
- Most common genital condition at birth
- If unresolved by 6 months, refer to surgery
- Bilateral undescended testes should be referred for genetic testing
- No ultrasound, just thorough Hx and PE
Hypospadias
- Opening of the urethra is on the underside of the penis
- 1 in 300 males
- Grading
- Refer to urology
- Surgical repair
- No circumcision clearance
Epispadias
- Defect in the urethra
- Often occurs with bladder extrophy
- Shorter than normal urethra with opening on the dorsal aspect
- Short and flat penis that may curve upward
- Bladder control problems
Coxsackie: Epidemiology
- Fecal-oral route
- May to October
- Most commonly in 1-4 year olds
Coxsackie: Incubation period
- 3-6 days (relatively short)
- Shed for several weeks (how it spreads)
- Viable on environmental surfaces for 2 weeks
Hand-foot-mouth disease
[Coxsackie Type A]
- Fever, vesicular eruption of the buccal mucosa of the mouth, and a maculopapular rash involving the hands and feet
- Evolves into vesicles, especially on the dorsa of the hands and soles of the feet
- 1-2 weeks duration
Aseptic meningitis
[Coxsackie Type A]
- Fever, stiff neck, and headache
- Altered sensorium and seizures are common
- Epidemics or as unique cases
- Recover completely
Congenital or Neonatal Coxsackie Infection
[Coxsackie Type B]
- Symptoms occur within 2 weeks of birth
- Transplacental infection occurs
- Serious disseminated disease affects the fetal liver, heart, meninges, and adrenal cortex
SYMPTOMS:
- sudden onset of vomiting
- coughing
- fits
- cyanosis, dyspnea
- pallor and tachycardia leads to myocarditis and CHF
- cardiac collapse and death can occur
Pleurodynia
[Coxsackie Type B]
- Aka “Bornholm’s disease” or “Devil’s Grip”
- Generally epidemic but isolated cases happen
- Can happen with A, but less likely
- Sudden severe chest pain, pleuritic in nature and aggravated by deep breathing, coughing, or sudden movements
- Waves of SPASMS 15-30 mins duration (like being stabbed with a knife)
- Prodrome 1-10 days before onset of chest pain: Headache, malaise, anorexia, myalgia
- Pleural friction rub is often heard
- Lasts 1-10 days (mean 3.5 days)
Coxsackie: Diagnostic tests
- Viral cultures: Throat, stool and rectum
- Polymerase Chain Reaction (PCR) sensitive for CSF
- Serologic specific titers (2-4 weeks apart)
Cytomegalovirus
[Herpes Viral Family]
- Affects about 1% of newborns
- Most infections are asymptomatic at birth, but can develop hearing loss in toddler/preschool years
- Can be asymptomatic
- You can give Gancyclovir
Herpes Simplex Type I and II
- Common, contagious, and often recurrent infection of skin and mucous membranes
- Discrete red, swollen mucosal ulcerations
- Numerous yellow ulcerations with thin red halos
- Thick walled vesicles on an erythematous base (IN GROUPS)
- The whole process is at least 10 days no matter what we do
Neonatal Herpes Simplex
- Can present (day 10-11 most common) with
1. Skin, eye, mucous membrane (SEM) disease
2. Systemic
3. CNS disease - Infant progresses to develop sudden onset of fever, lethargy, poor feeding, with vesicular lesions, hepatosplenomegaly
- When identified, give Acyclovir
Roseola
Human Herpes Virus 6 and 7
- for HHV 6: incubation of 9-10 days
- Can have GI symptoms, respiratory tract signs, post occipital adenopathy
- Fever without rash
- Febrile convulsions (#1 reason for febrile convulsions!)
- Hemiplegia, aseptic meningitis
- When the fever breaks, they break out in a rash
#1 reason for MISDIAGNOSED AMOXIL ALLERGY
Mononucleosis: Symtpoms
- Symptoms are variable and can last up to 2-3 weeks
- Fever, Sore throat, lymphadenopathy, splenomegaly, hepatomegaly, skin rash, periorbital edema, myalgia, arthralgia, chest pain, ocular pain, etc.
Mononucleosis: Diagnostic testing
- CBC
- Serological tests (Monospot, serum heterophile test)
- Viral culture
- EBV specific core and capsule antibody testing
- Test for CMV in patients with negative EBV serology
Varicella: Clinical presentation
- Generalized pruritic vesicular rash in varying stages of healing (truncal), usually
- Establishes latency in the dorsal root ganglia
- Incubation period: 14-16 days
Measles
- Erythematous maculopapular rash, spreads from the ears to the face and down
- Biliform, confluent and affects the palms and soles
Varicella: Diagnosis
- Largely clinical
- VZV can be identified with PCR or direct fluorescent antibodies
- Serum varicella IgG antibody can be sued to confirm infection
Varicella: Treatment
- Use in: Children >12, Long term salicylate, Children on corticosteroids, Child w/ chronic pulmonary or metabolic disease
- Oral acyclovir
- Must be given within 72 hours of onset of the rash
First disease
[MEASLES]
- Acute disease: fever, cough, coryza, conjunctivitis (3 c’s), and erythematous maculopapular rash, and koplik spots
- Incubation: 8-12 days before onset of rash
- It’s a disease that makes you feel really sick
- No treatment, no antivirals
Third disease
[RUBELLA]
- Mild: generalized erythematous maculopapular rash with lymphadenopathy (usually posterior occipital, post-auricular, and cervical) with slight fever
- Transient polyarthralgia and polyarthritis rarely in children but more common in adolescent
- Incubation period: 14-23 days (relatively long)
- Does not really cause a “sick kid”
- We worry because of congenital rubella syndrome
Fifth disease
[PARVOVIRUS B19]
- “Spring disease”
- 3 phases:
(1) Prodrome = malaise, headaches, low-grade fever
(2) Slapped cheek appearance with arthritis/arthralgia in adolescent
(3) Lacy symmetric maculopapular rash which waxes and wanes for 6 weeks - Infection in pregnancy = HYDROPS and DEATH (regardless of trimester)
- Aplastic crisis in patient with SCD
- Prolonged course with HIV/BMT
- Incubation period: 4-14 days
Sixth disease
[ROSEOLA]
- Classic presentation is a well-appearing 6 mo. to 3 year old with a fever
- Can have a little diarrhea and anorexia
- Fever breaks and the child breaks out in a rash
- Rash can last 3-4 days and requires no treatment
- # 1 cause of febrile convulsions
Pharyngoconjunctival Fever
[ADENOVIRUS]
- Fever, sore throat, and conjunctivitis
- Rhinitis and cervical adenitis may be present
- Outbreaks: Exposure to contaminated ponds and inadequately chlorinated pools
- VERY contagious; parents end up getting it, and maybe even providers
- Pretty sick kid with a high fever and sore throat, with blood conjunctiva
- Hallmarked by preauricular adenopathy and cervical adenitis
- Lasts 7-10 days, up to 2 weeks
Poliovirus: Symptoms
- Asymptomatic or mild febrile undifferentiated illness, such as fever, malaise, headache, nausea, GI disturbances, and sore throat (or combinations of these)
- 1% of cases progresses to the paralytic form when it goes into the CNS
- Alimentary phase, lymphatic phase, and viremic phase
Staph Aureus: Sensitivity tests
- Kirby-Bauer sensitivies: the larger the area of inhibition around the disc, the more sensitive that organism is
- E-test: For penicillin G susceptibility of an anaerobic isolate
- D Test for CA-MRSA: Positive, cannot use clinda. Negative, may use clinda.
Impetigo: treatment
- If localized, use Bactroban (mupirocin) or Altabax
- If extensive, Keflex (1st gen cephalosporin) if you don’t suspect MRSA
- If MRSA, Clinda or Bactrim (Clinda if you suspect it might be strep)
Acute Paronychia
- Collection of pus underneath the nail
- In this case, block the area and cut it out and let it drain, no abx.
- If you want, try Clinda… but not usually needed
MRSA: treatment
- 1st line: Clindamycin/Clinda with rifampin, or TMP/SMX
- 2nd line: Linezolid ($), Daptomycin (5th gen cephalosporin)
Staphylococcal Scalded Skin Syndrome (SSSS)
- Presents with fever, malaise, irritability, and skin tenderness
- Nikolsky’s sign: large portion of the epidermis separates in sheets after light friction
- Exfoliation, bullae
Nikolsky’s sign
Large portion of the epidermis separates in sheets after light friction
Staphylococcal Scalded Skin Syndrome (SSSS): Labs
- Increased WBC, ESR
- Blood culture (usually negative)
- Gram stain and culture from remote infection site
Staphylococcal Scalded Skin Syndrome (SSSS): Treatment
- Burn care
- IV antibiotics: Clindamycin
Toxic Shock Syndrome: Clinical presentation
- Prodrome: Fever, malaise, myalgias, vomiting
- Followed abruptly by worsening symptoms
- Abdominal pain, dizziness, and weakness
- Diffuse erythroderma (resembles sunburn)
- Desquamation (beings 1 wk after rash)
TSS: Criteria
- Fever
- Rash
- Desquamation
- Hypotension
- Multisystem involvement
- Otherwise negative culture and studies
TSS: Treatment
- Fluid management
- Anticipation of multi-system organ failure
- Parenteral antibiotics [B-lactamase resistant PCN and Clinda]
- Remove source of toxin production
- Consider IVIG (if they’re in REALLY bad shape)
5 signs to evaluate for Appendicitis
- Obturator
- Psoas
- Markle jar heel test
- Rovsing’s
- Rebound tenderness
Diagnostic Criteria for Childhood Functional Abdominal Pain
Must include all of the following criteria at least once a week for at least two months prior to diagnosis:
- Continuous or episodic abdominal pain
- Insufficient criteria for other functional GI disorders
- No evidence of an inflammatory anatomic, metabolic, or neoplastic process that explains the subjects’ symptoms
At least 8 episodes of continuous or functional abdominal pain
Abdominal pain: Diagnostic testing to consider
- CBC with diff
- ESR
- CRP
- UA
Osmotic diarrhea
Caused by failure to absorb luminal solutes with resulting secretion of fluids and net water retention across osmotic gradient
- Caused by eating things like apple juice (Toddler’s diarrhea)
- Volume <200cc
- Fasting will result in resolution of the diarrhea
- Lower stool sodium and chlorides
- Osmolality greater than this serum osmolality indicates osmotic diarrhea
Secretory diarrhea
Net secretion of electrolytes and fluids from intestine without compensatory absorption
- Caused by things like bacterial diarrhea.
- Increased volume of stool
- Fasting dose not effect the diarrhea
- Higher stool sodium and chloride
- Stool osmolality Na + K multiplied by 2
Dysmotility diarrhea
Occurs in a setting of intact absorption but transit time is changed and time allowed for absorption is minimized
- Example short gut syndrome and small intestinal bacterial overgowth (SIBO)
Inflammatory diarrhea
Malabsorption of dietary nutrients which cause luminal osmotic gradient (Like B12 deficiency)
Hematuria
- Defined as the presence of 5 or more RBCs per high-power (40) field in 3 consecutive fresh, centrifuged specimens obtained over the span of several weeks
- Differential diagnosis for hematuria is extensive, most cases are isolated and benign
- Hematuria is a medical rather than a urologic disease
Hallmarks of Glomerular Bleeding
- Discolored urine
- RBC casts
- Distorted RBC morphology
- *If there’s blood mixed with protein, get complement level…Glomerulonephritis elevates C3
Adenovirus incubation period
5-10 days
