Febrile Child & Infections Flashcards
What are the red, amber and green categories in assessing the acutely unwell child?
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
Life threatening emergencies to always consider in the febrile child…
- Meningitis
- Sepsis
- Encephalitis
- Toxic shock syndrome
- Necrotising fasciitis
What is the basic management of a febrile child under 3 months?
- Septic screen: FBC, CRP, urine and blood cultures +/- stool culture, CXR and LP (depending on clinical signs)
- Start IV antibiotics
What procedure should all febrile children under 1 month have?
Lumbar puncture
Name some common causes of fever with rash…
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
What is Kawasaki disease?
Type of vasculitis that predominantly affecrs children.
How is Kawasaki diagnosed?
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
What is the main complication of Kawasaki disease?
Coronary artery anuerysm
Management of Kawasaki disease…
- 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
Why is aspirin normally contraindicated in young children?
Salicylates in aspirin may cause mitochondrial injury which can lead to metabolic non-inflammatory encephalopathy known as Reye’s Syndrome.
What is erythema infectiosum?
Common childhood infection causing slapped cheek appearance and rash.
Causes of erythema infectiosum…
Viral infection: EVB19 or Parvovirus B19
How does erythema infectiosum present?
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
Management of erythema infectiosum…
Self limiting - no specific treatment
Affected children can stay at school as infectious period is 3-5 days before the rash appears.
What is toxic shock syndrome?
Severe systemic reaction to the exotoxins released by Staph A / Strep pyogenes infections.
What is the diagnostic criteria for toxic shock syndrome?
- Body temp > 38.9C
- Systolic BP <90 mmHg
- Diffuse macular rash
- Desquamation - peeling of palms and soles about 1-2 weeks after onset
- Involvement of at least 3 organ systems:
- GI = diarrhoea, vomiting
- MSK= myalgia
- Renal failure
- Hepatitis
etc. ..
What is the treatment for toxic shock syndrome?
- Admission and IV antibiotics
- May need ICU for organ support
Characteristic features of measles…
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
How long do measles patients remain infective?
Infective throughout incubation period (10-14 days) and 4 days from when rash appears.
What is the management of measles?
Mainly supportive - normally self limiting and will resolve within 7-10 days.
Notifiable disease as it is highly infective.
What are the main complications from measles?
- Otitis media = most common
- Pneumonia = most common cause of death
- Febrile convulsions
- Encephalitis - including very rare ‘subacute sclerosing panencephalitis’
- Myocarditis
What is the cause of rubella infection?
Togavirus
How does rubella present?
Prodrome: low-grade fever, suboccipital and post-auricular lymphadenopathy
Rash: pink maculopapular rash which starts on the face and then spreads to whole body
What is the main risk of rubella infection?
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
How does mumps present?
- Fever
- Malaise
- Myalgia
- Parotitis ( unilateral painful swelling of the parotid gland, then may become bilateral)
Management of mumps…
- Rest and simple analgesia for fever/pain
- Notifiable disease - need to inform PHE
Complications of mumps…
- Orchitis in young post-pubertal males - may lead to subfertility
- Hearing loss
- Meningoencephalitis
- Pancreatitis
Presentation of diphtheria…
- 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
Complications of diphtheria…
Systemic distribution of infection may cause necrosis of other tissue:
- Myocardial = myocarditis
- Renal = renal disease
- Neural = peripheral neuropathy
How does polio present?
- 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.
How does pertussis present?
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
How is pertussis diagnosed?
- Nasal swab
- PCR/ serology is now increasingly used
Management of pertussis…
- 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)
What are the complications of pertussis?
- Persistent coughing can cause subconjunctival haemorrhage and anoxia leading to seizures
- Bronchopneumonia
Clinical features of tetanus…
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
Management of tetanus…
- IM human tetanus Ig
- Metronidazole = antibiotic of choice
What are the modes of transmission of HIV to infants?
- In-utero
- During labour
- Breastfeeding
- Blood trasnfusion
- Sexual abuse
Typical signs of AIDS seen in infants?
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
How is HIV diagnosed in infants?
- > 18 months: Detection of HIV antibodies
- <18 months: Detection of HIV RNA
What measures can reduce vertical transmission of HIV?
- Pregnant women receive antiretroviral therapy - aiming for undetectable viral load at time of delivery (<50 copies/ml)
- If viral load is still detectable at delivery (>50 copies/ml) - C section is recommended.
- Babies receive oral antiretroviral therapy e.g. AZT (zidovudine) as post exposure prophylaxis for 4-6 weeks
- Infants should be exclusively bottle fed
- Babies have checks at; birth, 6 weeks, 3 months, 18 months
What causes scarlet fever?
Erythrogenic toxins produced by group A streptococci e.g. strep pyogenes
How does scarlet fever present?
- 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
How is scarlet fever diagnosed?
Throat swab - but antibiotic treatment should begin immediately, not wait for the results.
Management of scarlet fever…
- Oral Pen V for 10 days
- Penicillin allergy = azithromycin
- Notifiable disease
Complications of scarlet fever…
- Otitis media = most common
- Rheumatic fever - 20 days after infection
- Post-streptococcal glomerulonephritis - 10 days after infection
What causes rheumatic fever?
Immunological reaction to strep pyogenes infection
How is rheumatic fever diagnosed?
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
What is the current UK immunisation schedule…
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
What complications should parents be warned of with regards to vaccinations?
- 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
General contraindications to immunisation…
- 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
Contraindications to live vaccines…
- Immunosuppression
- Pregnancy
Reasons to defer immunisation …
- Acute febrile illness
- Evolving neurological condition - specifically DTP (diphtheria, tetanus, polio) vaccine so new symptoms are not wrongly attributed to vaccine
What factors are NOT contraindications to immunisation?
- 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
Causes of meningitis in children..
0-3 months:
- Group B strep
- E. coli
- Listeria monocytogenes
1 month -6 years:
- N. meningitidis
- Strep pneumoniae
Presentation of meningitis in children…
- Fever (absent in <3 months)
- Severe headache
- Bulging fontanelle
- Non-blanching rash
- Dislike of bright lights
- Very sleepy
- Confusion
- Seizures
Investigations for meningitis…
- Lumbar puncture - contraindicated if raised ICP signs (papilloedema, bulging fontanelle)
- Blood cultures
- PCR
Management of meningitis…
- <3 months = IV amoxicillin + IV cefotaxime
>3 months= IV cefotaxime - Steroids (if >3 months) - dexamethsone if LP shows bacterial cause
- Fluids to treat shock
- Cerebral monitoring - mechanical ventilation if resp impairment
- Abx prophylaxis of household contacts
