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Paediatrics > Febrile Child & Infections > Flashcards

Febrile Child & Infections Flashcards

1
Q

What are the red, amber and green categories in assessing the acutely unwell child?

A

GREEN = LOW RISK:

  • Colour: normal colour
  • Activity: responding normally, content, stays awake
  • Resp: no resp signs
  • Circulation: normal skin, moist mucous membranes
  • Other: nil

AMBER= INTERMEDIATE RISK

  • Colour: pallor
  • Activity: decreased activity, reduced responses
  • Resp: nasal flaring, RR> 50 in 6-12 months, RR>40 in >12months , SpO2 <95% on air
  • Circulation: dry, poor feeding, CRT> 3s, tachycardia (>160bpm in <12 months, >150bpm in 1-2 yr, >140bpm in 2-5 yr)
  • Other: 3-6 mths fever=T >39C , rigors

RED = HIGH RISK:

  • Colour: pale, mottled or blue
  • Activity: no response to cues, unable to rouse, weak crying
  • Resp: grunting, tachypnoea (RR>60bpm), chest indrawing, recessions
  • Circulation: reduced skin turgor
  • Other: 0-3 mths fever= T>38C, non-blanching rash, bulging fontanelle, focal seizures
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2
Q

Life threatening emergencies to always consider in the febrile child…

A
  • Meningitis
  • Sepsis
  • Encephalitis
  • Toxic shock syndrome
  • Necrotising fasciitis
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3
Q

What is the basic management of a febrile child under 3 months?

A
  • Septic screen: FBC, CRP, urine and blood cultures +/- stool culture, CXR and LP (depending on clinical signs)
  • Start IV antibiotics
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4
Q

What procedure should all febrile children under 1 month have?

A

Lumbar puncture

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5
Q

Name some common causes of fever with rash…

A

Maculopapular rash (flat red lesions, surrounded by raised bumps):

  • Viral = Parvovirus, enterovirus
  • Bacterial = Scarlet fever, rheumatic fever
  • Other = Kawasaki disease

Vesicular, bullous rash:

  • Viral = HSV, VZV (blistering rash)
  • Bacterial = impetigo, SSSS

Petechial/ purpuric rash:

  • Bacterial = meningococcal sepsis
  • Other = vasculitis
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6
Q

What is Kawasaki disease?

A

Type of vasculitis that predominantly affecrs children.

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7
Q

How is Kawasaki diagnosed?

A

Diagnosis requires:
3 essential criteria: high fever, persistent and unresponsive to antipyretics
AND
4 out of 5 essential criteria:
1. Conjunctival injection
2. Oral mucositis - development of oral ulcers
3. Cervical lymphadenopathy
4. Erythema and swelling of hands and feet - begin to peel
5. Maculopapular rash

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8
Q

What is the main complication of Kawasaki disease?

A

Coronary artery anuerysm

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9
Q

Management of Kawasaki disease…

A
  • High dose aspirin (not normally given to children) to prevent aneurysm and thrombosis
  • IV Ig - to combat autoimmune process
  • Echocardiogram and ECG - screen for coronary artery aneurysm
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10
Q

Why is aspirin normally contraindicated in young children?

A

Salicylates in aspirin may cause mitochondrial injury which can lead to metabolic non-inflammatory encephalopathy known as Reye’s Syndrome.

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11
Q

What is erythema infectiosum?

A

Common childhood infection causing slapped cheek appearance and rash.

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12
Q

Causes of erythema infectiosum…

A

Viral infection: EVB19 or Parvovirus B19

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13
Q

How does erythema infectiosum present?

A

Initially: viral illness prodrome: mild fever and headache
Few days later: slapped cheek appearance - firm red cheeks which are burning hot (can last for few weeks)
Followed by pink rash of the limbs/ trunk

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14
Q

Management of erythema infectiosum…

A

Self limiting - no specific treatment

Affected children can stay at school as infectious period is 3-5 days before the rash appears.

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15
Q

What is toxic shock syndrome?

A

Severe systemic reaction to the exotoxins released by Staph A / Strep pyogenes infections.

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16
Q

What is the diagnostic criteria for toxic shock syndrome?

A
  1. Body temp > 38.9C
  2. Systolic BP <90 mmHg
  3. Diffuse macular rash
  4. Desquamation - peeling of palms and soles about 1-2 weeks after onset
  5. Involvement of at least 3 organ systems:
    - GI = diarrhoea, vomiting
    - MSK= myalgia
    - Renal failure
    - Hepatitis
    etc. ..
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17
Q

What is the treatment for toxic shock syndrome?

A
  • Admission and IV antibiotics

- May need ICU for organ support

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18
Q

Characteristic features of measles…

A

Prodrome = conjuctivitis, coryza, cough, fever, Koplik spots (small white spots on buccal mucosa)
Rash begins behind ears, then spreads across face and trunk - red-brown blotches

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19
Q

How long do measles patients remain infective?

A

Infective throughout incubation period (10-14 days) and 4 days from when rash appears.

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20
Q

What is the management of measles?

A

Mainly supportive - normally self limiting and will resolve within 7-10 days.
Notifiable disease as it is highly infective.

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21
Q

What are the main complications from measles?

A
  • Otitis media = most common
  • Pneumonia = most common cause of death
  • Febrile convulsions
  • Encephalitis - including very rare ‘subacute sclerosing panencephalitis’
  • Myocarditis
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22
Q

What is the cause of rubella infection?

A

Togavirus

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23
Q

How does rubella present?

A

Prodrome: low-grade fever, suboccipital and post-auricular lymphadenopathy
Rash: pink maculopapular rash which starts on the face and then spreads to whole body

24
Q

What is the main risk of rubella infection?

A

If pregnant woman contracts it during first trimester, it can cause congenital rubella syndrome.
This can lead to complications: sensorineural deafness, cataracts, congenital heart disease, cerebral palsy

25
Q

How does mumps present?

A
  • Fever
  • Malaise
  • Myalgia
  • Parotitis ( unilateral painful swelling of the parotid gland, then may become bilateral)
26
Q

Management of mumps…

A
  • Rest and simple analgesia for fever/pain

- Notifiable disease - need to inform PHE

27
Q

Complications of mumps…

A
  • Orchitis in young post-pubertal males - may lead to subfertility
  • Hearing loss
  • Meningoencephalitis
  • Pancreatitis
28
Q

Presentation of diphtheria…

A
  • URTI causing sore throat and low grade fever
  • Swollen tonsils may lead to “bull neck” appearance
  • Pseudomembrane formation: layer of dense, grey debris of necrotic mucosal cells in the posterior pharynx/ larynx
29
Q

Complications of diphtheria…

A

Systemic distribution of infection may cause necrosis of other tissue:

  • Myocardial = myocarditis
  • Renal = renal disease
  • Neural = peripheral neuropathy
30
Q

How does polio present?

A
  • 70% of cases = asymptomatic
  • 25% of cases = mild sx e.g. fever, sore throat- back to normal within a few weeks
  • 0.5% of cases= muscle weakness leading to paralysis (infantile paralysis) , many people fully recover from this.
31
Q

How does pertussis present?

A

2-3 days of coryza, followed by:

  • Paroxysmal coughing bouts - frequent, violent coughing usually occurring at night/ after feeding, leading to vomiting
  • Inspiratory whoop - forced inspiration against closed glottis
  • Spells of apnoea
  • symptoms can last 10-14 weeks
32
Q

How is pertussis diagnosed?

A
  • Nasal swab

- PCR/ serology is now increasingly used

33
Q

Management of pertussis…

A
  • Admission if <6 months
  • Oral antibiotics - macrolide e.g. clarithromycin indicated if onset of cough is within previous 21 days
  • Household contacts receive abx prophylaxis (macrolide)
34
Q

What are the complications of pertussis?

A
  • Persistent coughing can cause subconjunctival haemorrhage and anoxia leading to seizures
  • Bronchopneumonia
35
Q

Clinical features of tetanus…

A

Tetanus = bacterial infection causing fever prodrome followed by prolonged contraction of skeletal muscle:

  • Lockjaw
  • Rictus (grin appearance caused by spasm of facial muscles)
  • Opsithotonus -backward arching of the back and neck
  • Spasms = dysphagia
36
Q

Management of tetanus…

A
  • IM human tetanus Ig

- Metronidazole = antibiotic of choice

37
Q

What are the modes of transmission of HIV to infants?

A
  • In-utero
  • During labour
  • Breastfeeding
  • Blood trasnfusion
  • Sexual abuse
38
Q

Typical signs of AIDS seen in infants?

A

AIDS develops rapidly in children who don’t receive treatment for HIV:

  • Hepatosplenomegaly - abdominal distension
  • Lymphadenopathy
  • Recurrent infections
  • Global developmental delay
  • Failure to thrive
  • Oral thrush
  • Fevers and night sweats
39
Q

How is HIV diagnosed in infants?

A
  • > 18 months: Detection of HIV antibodies

- <18 months: Detection of HIV RNA

40
Q

What measures can reduce vertical transmission of HIV?

A
  1. Pregnant women receive antiretroviral therapy - aiming for undetectable viral load at time of delivery (<50 copies/ml)
  2. If viral load is still detectable at delivery (>50 copies/ml) - C section is recommended.
  3. Babies receive oral antiretroviral therapy e.g. AZT (zidovudine) as post exposure prophylaxis for 4-6 weeks
  4. Infants should be exclusively bottle fed
  5. Babies have checks at; birth, 6 weeks, 3 months, 18 months
41
Q

What causes scarlet fever?

A

Erythrogenic toxins produced by group A streptococci e.g. strep pyogenes

42
Q

How does scarlet fever present?

A
  • Fever lasting 24-48 hrs
  • Malaise, headache, nausea and vomiting
  • Sore throat
  • Strawberry tongue
  • Fine punctate erythematous rash (sandpaper texture) appearing on torso first then spreading
  • Flushed appearance of face - with circumoral pallor
43
Q

How is scarlet fever diagnosed?

A

Throat swab - but antibiotic treatment should begin immediately, not wait for the results.

44
Q

Management of scarlet fever…

A
  • Oral Pen V for 10 days
  • Penicillin allergy = azithromycin
  • Notifiable disease
45
Q

Complications of scarlet fever…

A
  • Otitis media = most common
  • Rheumatic fever - 20 days after infection
  • Post-streptococcal glomerulonephritis - 10 days after infection
46
Q

What causes rheumatic fever?

A

Immunological reaction to strep pyogenes infection

47
Q

How is rheumatic fever diagnosed?

A

Diagnosis is based on the Jone’s criteria:
Recent streptococcal infection along with
2 major criteria OR 1 major with 2 minor criteria…

Major criteria:

  • Erythema marginatum = pink circles with clear centre (annular) found on trunk, upper arms and legs. Painless and may fade and reappear
  • Subcutaneous nodules = small lumps under the skin
  • Sydenam’s chorea (rapid, uncoordinated jerky movements of limbs and trunk)
  • Polyarthritis
  • Carditis and valvulitis

Minor criteria:

  • Raised ESR/ CRP
  • Fever
  • Arthralgia
  • Prolonged PR interval
48
Q

What is the current UK immunisation schedule…

A

At birth = BCG (if risk factors for TB present)

2 months = 6 in 1 (diphtheria, tetanus, pertussis, polio, Hib and hep B), Rotavirus, Men B

3 months = 6 in 1 (diphtheria, tetanus, pertussis, polio, Hib and hep B), Rotavirus, PCV (pneumococcal)

4 months = 6 in 1 (diphtheria, tetanus, pertussis, polio, Hib and hep B), Men B

12-13 months = Hib/Men C, MMR , PCV, Men B

2-8 years = annual flu vaccine

3-4 years = 4 in 1 preschool booster (diphtheria, tetanus, pertussis, polio) , MMR

12-13 years = HPV vaccination

13-18 years = 3 in 1 teenage booster (tetanus, diphtheria and polio) , Men ACWY

49
Q

What complications should parents be warned of with regards to vaccinations?

A
  • Swelling/ discomfort at injection site
  • Mild fever/ malaise (if persisting >24hrs, seek medical advice)
  • Mild disease seen 7-10 days after measles/ rubella vaccination
  • Anaphylaxis - very rare
  • Pertussis can cause big swelling
50
Q

General contraindications to immunisation…

A
  • Confirmed anaphylactic reaction to a previous dose of a vaccine containing same antigens
  • Confirmed anaphylactic reaction to another component present in vaccine e.g. egg protein
51
Q

Contraindications to live vaccines…

A
  • Immunosuppression

- Pregnancy

52
Q

Reasons to defer immunisation …

A
  • Acute febrile illness
  • Evolving neurological condition - specifically DTP (diphtheria, tetanus, polio) vaccine so new symptoms are not wrongly attributed to vaccine
53
Q

What factors are NOT contraindications to immunisation?

A
  • Asthma/ eczema
  • Afebrile minor illness
  • Febrile convulsions - give advice on antipyretics
  • Breastfeeding
  • Prematurity - no need to adjust immunisation schedule, should not be further delayed!
  • Neuro conditions e.g. cerebral palsy
54
Q

Causes of meningitis in children..

A

0-3 months:

  • Group B strep
  • E. coli
  • Listeria monocytogenes

1 month -6 years:

  • N. meningitidis
  • Strep pneumoniae
55
Q

Presentation of meningitis in children…

A
  • Fever (absent in <3 months)
  • Severe headache
  • Bulging fontanelle
  • Non-blanching rash
  • Dislike of bright lights
  • Very sleepy
  • Confusion
  • Seizures
56
Q

Investigations for meningitis…

A
  • Lumbar puncture - contraindicated if raised ICP signs (papilloedema, bulging fontanelle)
  • Blood cultures
  • PCR
57
Q

Management of meningitis…

A
  1. <3 months = IV amoxicillin + IV cefotaxime
    >3 months= IV cefotaxime
  2. Steroids (if >3 months) - dexamethsone if LP shows bacterial cause
  3. Fluids to treat shock
  4. Cerebral monitoring - mechanical ventilation if resp impairment
  5. Abx prophylaxis of household contacts

Paediatrics (12 decks)

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