Febrile Illness - Exam 3 Flashcards
1
Q
What is considered hypothermia? What is considered a fever? How does a child’s core temp compare to an adults core temp?
A
Hypothermia is defined as a core temperature < 36.5° C (97.7° F)
Fever usually is defined as a core body (rectal) temperature ≥ 38.0° C (100.4° F).
Young children tend to have slightly higher core temps than adults
2
Q
Fever is a ______ of body temperature mediated by the _____
A
regulated elevation
anterior hypothalamus
3
Q
When does a fever occur?
A
Fever occurs when there is a rise in the hypothalamic set-point in response to endogenously produced pyrogens - the result of an insult stimulating the body’s inflammatory defenses
4
Q
An insult, most commonly ____ in kids, induces _____ to release_____that function as endogenous pyrogens (fever producing substance)
A
viral
macrophages
cytokines (IL-1 and 6)
5
Q
_____ stimulate the production of _____by the hypothalamus; ______ readjust and elevate the temperature set point.
A
Cytokines
prostaglandins
prostaglandins
6
Q
What is the core temperature defined as?
A
defined as the temperature of blood within the pulmonary artery
7
Q
How does the body physiologically create more heat to increase the core body temperature to the new up-regulated set point?
A
Setting skeletal muscles to shivering and stimulating cellular metabolism
The body does this by minimizing heat loss to the environment by vasoconstricting the skin and turning off sweat glands
8
Q
Give 3 reasons having a fever be a good thing?
A
Fever can disrupt the growth and reproduction of many invasive pathogenic microorganisms, both bacterial and viral
It also appears to lower the amount of iron that is available to invading bacteria, many of which have a higher iron requirement
It also enhances neutrophil migration, T-Cell proliferation, and interferon activity
9
Q
What is the most accurate way to measure a fever? What age range using this way?
A
rectal
birth to 3 years
10
Q
How does oral temp compare to rectal temp? What age range using oral temps?
A
oral is generally 0.6 ⁰F lower than rectal d/t mouth breathing or recent ingestion of cold liquids
4 years and older
11
Q
How does axillary temp compare to oral?
A
Axillary is 0.5-1 F lower than an oral
12
Q
_____ ways of measuring temperate is one of the MC due to being quick. When can it give a false reading? What age range should you NOT use this in?
A
tympanic
if not positioned properly or the external ear canal is occluded by wax
Not reliable in children under 6 months
13
Q
How does the HR change with a fever in kiddos? What 2 things should you pay close attention to when deciding whether or not to send a febrile child home?
A
10-15 beat pulse increase with every 1◦C
Pay attention to child’s degree of toxicity and hydration status
14
Q
Most febrile illnesses are the result of infections affecting the _____ and _____. Most have a _____ origin
A
respiratory
GI tracts
viral
15
Q
What is the MC reason to treat a kiddos fever?
A
if the child appears uncomfortable!!!
Decision to treat is based on child’s behavior, not on any particular threshold
16
Q
What is the minimum age for APAP? Ibuprofen? ASA?
A
Acetaminophen: 3 months and up
Ibuprofen: 6 months and up
No aspirin!! only approved for 18 years old and up
17
Q
How long is a child considered contagious?
A
Contagious until fever free for 24 hours
18
Q
What are the criteria to see a child immediately in the office/hospital?
A
kiddos is less than 3 months old
fever is greater than 105.8
Child is crying unconsolably or whimpering
Child is crying when moved or even touched
Child is difficult to awaken
Child’s neck is stiff
Purple spots or dots are present on the skin
Drooling or unable to swallow
No urine output in >6 hours or 4 times in 24 hours
Uncontrollable vomiting
19
Q
A
19
Q
What are the fever guidelines to see a kiddos within 24 hours?
A
Child is 3-6 months old (unless fever occurs within 48h after a Dtap vaccine with no other serious symptoms)
Fever exceeds 40◦C or 104◦F
Burning or pain occurs with urination
Fever has subsided for greater than 24h without use of fever reducers, then returned
Fever has been present greater than 72 h
20
Q
_____ account for most bacterial infections in infants under 90 days of age
A
UTI’s
21
Q
What are the risk factors for an invasive bacterial infection (IBI) or serious viral infection?
A
Age - especially under 28 days
Ill appearance: lethargy, listlessness, toxic appearance, respiratory distress, petechiae/purpura, inconsolability
Rectal temp greater than 104F
Not immunized or under immunized (specifically first dose of Hib and pneumococcal )
Prematurity
Comorbidities
Received antibiotics in last 3 to 7 days (can mask s/s)
Risk of maternally transmitted diseases
22
Q
When would a kiddos undergo a complete evaluation with a fever?
A
all ill-appearing children with toxic look will undergo full evaluation regardless of age
23
Q
What would be in a work up of a kiddo less than 3 months old, who is well appearing, has a fever without an apparent source of infection? What is the pt education?
A
UA, blood cultures, inflammatory markers
consider HSV
would want to add LBP if less than 28 days old or abnormal inflammatory markers
mom should continue breastfeeding even while kiddo is sick
24
**What are considered elevated inflammatory markers in a kiddo?
Laboratory values of inflammation are considered elevated at the following levels:
(1) procalcitonin >0.5 ng/mL
(2) CRP >20 mg/L
(3) ANC >4000 to 5200 per mm3
25
When should you consider discontinuing IV abx in a kiddo? to be discharged
1. Culture results are negative for 24 to 36 hours or only positive for contaminants
2. The infant continues to appear clinically well or is improving (eg. no fever, feeding well)
3. No other reasons for hospitalization
ALL criteria must be met
26
For a kiddo between 3 and 36 months old, what does the plan of care depend on?
immunization status!!! and if they present well or sickly
27
What does lesions in the oropharynx make you think?
think more viral causes (ulcers or vesicles in gingivostomatitis and hand, foot, mouth)
28
What is the w/u for a kiddo 3-36 months old, well appearing but NOT UTD?
CBC
blood culture if WBC> or = to 15K
UA and culture: girls under 24m, boys uncircumcised under 12 months and circumcised under 6 months
CXR: if WBC > or = to 20K
WBC > or = to 15K give ceftriazone IM or clinda IV
29
What is the w/u for a kiddo 3-36 months old, well appearing and UTD?
lab work is NOT recommended
can f/u in 24-48 hours if pt remain febrile
30
When is a kiddo at risk of febrile seizures? _____ are the likely culprit
6 months to 5 years
self-limited viral infections the increased risk of febrile seizures
31
describe a simple febrile seizure. What are the common cause?
A generalized tonic or tonic-clonic seizure usually lasting less than 5 minutes and occurring once within 24 hours of the onset of fever; may begin without warning
Viral illnesses are the most common cause
32
What should you do if your kiddo has a febrile seizure?
Child must be evaluated to exclude CNS infection -> could be meningitis or encephalitis
CMP, CBC, blood culture
Most experts recommend LP if child is younger than 6 months
33
What is considered complex febrile seizure? What is the chance of recurrence?
More than one febrile seizure in a 24 hour period is considered
febrile seizures have a 1 in 3 chance of recurrence
34
Define Fever of Unknown Origin (FUO)? What are the general common causes?
Defined as a daily temp greater than 38.3◦C or 101◦F, lasting for at least 8 days, in whom no diagnosis is apparent after initial outpatient or hospital evaluation that includes careful H&P and initial lab test
Usually caused by common disorders often with an unusual presentation
35
What are the 3 MC etiologic categories for FUO?
infectious diseases
connective tissue/rheumatologic diseases
neoplasms
36
What are some infectious causes of FUO that need to be ruled out? What test would you want to order?
cytomegalovirus, EBV, osteomyelitis, hepatitis, adenovirus, enteroviruses, and bartonellosis (cat-scratch disease) are some of the common FUO causes that should be ruled out
Since infectious causes are most common, pursuing specific serological tests for Hepatitis A and B, EBV, toxoplasmosis, bartonellosis, and cytomegalovirus would be reasonable
37
What is the MC AI dz of FUO that need to be ruled out? What 2 malignancies?
systemic idiopathic juvenile arthritis
leukemia and lymphoma
38
When assessed a kiddo for FUO, when should the PE be performed? What are some characteristics you would want to know?
while the pt is febrile
How was assessed?
Confirmed by someone else?
Pattern of fever?
Does respond to antipyretics?
Associated sweating?
39
What does FUO with bilateral red eyes make you think?
Kawasaki disease
40
What would you want to do next in a kiddo with FUO if ill with persistent fever and no diagnosis?
can do IgG, IgA, IgM
41
What are the FUO intervention recommendations for a fever? What are the abx recommendations?
Discontinue nonessential medications. Do NOT give antipyretics RTC or if temperature not >100.4 degrees
We generally AVOID empiric antimicrobial therapy except those where a life-threatening condition is suspected
42
If all testing in FUO is negative, what do you do next?
little can be done other than observation
can refer to ID, rheumatology or hem/onc
Fortunately, most FUO’s for which a cause cannot be found will resolve over time
43
_______ significantly increases the incidence of early onset bacterial sepsis in a newborn. What pathogens?
PROM
group B β-hemolytic strep and E coli
44
How old is the kiddo with bacterial sepsis? What is considered late onset?
MC on day 1 of life, usually preterm infants
late onset: greater than 7 days of life
45
What are risk factors for bacterial sepsis in a newborn?
Chorioamnionitis, Maternal GBS bacteriuria in current pregnancy.
Intrapartum maternal temperature of 100.4F or higher
Maternal GBS colonization
Membrane rupture greater than 18 hours
Prematurity
46
_____ is the MC presenting sign for bacterial sepsis in a newborn
respiratory distress due to pneumonia
Unexplained low Apgar scores without fetal distress, poor perfusion, hypotension
47
How will late onset bacterial sepsis in a newborn present? What pathogen? What is it associated with?
will present in a more subtle manner (poor feeding, lethargy, hypotonia, temperature instability, low perfusion)
mostly like Staph aureus
bacterial meningitis
48
What is the abx of choice for early bacterial sepsis? What is the associated timing?
Ampicillin plus aminoglycoside (gentamicin) or 3rd generation cephalosporin (cefotaxime) q12 hours
48-72 hours pending culture results
49
What is the abx of choice for late bacterial sepsis? What is the associated timing?
Ampicillin plus aminoglycoside (gentamicin) or 3rd generation cephalosporin (cefotaxime) q12 hours
PLUS
add Vancomycin
10-14 days IV
50
What is the best way to prevent neonatal GBS infections? How do they achieve it?
intrapartum administration of IV penicillin given more than 4 hours prior to delivery
Current guideline is to perform a vaginal AND rectal GBS culture 35-37 weeks and give PCN if positive
51
______ cause over 80% of aseptic menigitis. Will they have CNS symptoms? What age range?
Non-polio enteroviruses
Most enteroviral infections are subclinical or not associated with CNS symptoms
Incidence much greater in children younger than age 1
52
Acute onset
Marked fever, irritability, and lethargy in infants
Abdominal pain, vomiting, diarrhea
Maculopapular rash, with some petechial rash noted
Full anterior fontanelle
What am I?
What will be present in older children?
viral meningitis
meningeal signs will be present in older children
53
In older and younger children, certain strains of enterovirus viral meningitis can cause _______, similar to that of polio
flaccid paralysis
54
What will the labs show in viral meningitis? What is the most useful dx method?
Early in illness, PMN cells predominate, with a shift to mononuclear within 8-36 hours
In 95% of cases, protein is less than 80mg/dl, and glucose more than 60% of serum values
PCR for enteroviruses
55
What is the tx in infants for viral meningitis? How long does it typically last?
Infants usually hospitalized, isolated, and treated with fluids and antipyretics
Can give prophylactic antibiotics until a negative culture is received
illness lasts for about a week
56
in kiddos less than 1 month old with s/s of viral men, can consider _____ and start ____ until dx is made
herpes virus encephalitis
start empiric acyclovir therapy
57
Abrupt fever, often with chills
Irritability, convulsions, neck stiffness
tense, bulging, fontanelle
may have fever, chills, HA and vomiting
What am I?
**What is the most important sign in very young infants?
pneumococcal bacterial meningitis
**The most important sign in very young infants is a tense, bulging, fontanelle**
58
Pronounced leukocytosis
80-90% polymorphonuclear neutrophils
CSF: Elevated WBC’s, decreased glucose, increased protein
Gram-positive diplococci may be seen on stained smears of CSF sediment
What will the labs show in a pt with pneumococcal bacterial meningitis?
59
What is the tx for pneumococcal bacterial meningitis?
IV Vancomycin and IV Cefotaxime
OR
IV Vancomycin/Ceftriaxone until CSF/blood culture result
+/- steroids
60
_______ is the MC presentation of this bacteria. When is the highest rate of attack?
Neisseria Meningitidis
within the first year of life and again in teen years
61
Severe headache, nausea, vomiting, stupor
Convulsions and shock
Can have complications of permanent CNS damage, deafness, paralysis, or impaired intellectual function
Hydrocephalus
purpuric/petechial rash
What am I?
Neisseria Meningitidis bacterial meningits
62
CSF shows WBCs with many polymorphonuclear neutrophils and gram-negative diplococci
What am I?
CSF analysis of Neisseria Meningitidis bacterial men
63
What are 2 important to note about the tx for Neisseria Meningitidis meningitis? What is the tx?
Treat as though shock is imminent, even if vital signs are stable when first seen!!!
Shock may worsen following antimicrobial treatment d/t release of N. meningitidis release of endotoxins, so treat in ICU
Antimicrobial therapy same as pneumococcal (IV Vanc, Ceftriaxone (or )Cefotaxime, with Penicillin G (if susceptible) for a week
64
What is the chemoprophylaxis for n men menigitis?
Rifampin, ciprofloxacin, or ceftriaxone; azithromycin is an alternative if resistant
for those direct exposure to respiratory secretions
65
What are the MC pathogens for bacterial conjunctivitis? What if contact lens use?
S. Pneumonia, H. influenza, Moraxella catarrhalis, and other Staph. organisms
Pseudomonas - contact lens use
66
Mucopurulent discharge present, one or both eyes
Conjunctival injection
Common complaint is kids will wake up with eyelids stuck together
What am I?
What is the tx?
bacterial conjunctivits
Fluoroquinolones, sulfacetamide, trimethoprim-polymyxin B (Polytrim)
Will resolve on its own but abx speed up healing process
67
What is the prevention for bacterial conjunctivits? When should you refer? How long are they contagious?
Prevention with hand-washing
Refer for severe or if not resolved after 7 days of treatment
Contagious up to 24 hours after starting abx
68
What is the underlying cause of viral conjun? What will the pt complain about?
adenovirus
Tearing, redness, and foreign body sensation
69
What is Pharyngoconjunctival Fever? What are some s/s? How long will it last?
Consists of URI (pharyngitis and fever) with bilateral conjunctivitis
Severe, watery conjunctival discharge, hyperemic conjunctivitis
Preauricular lymphadenopathy common, as well as foreign body sensation in eye
lasts approx 2-3 weeks
70
Severe bilateral conjunctivitis
With conjunctival hyperemia, watery discharge, eyelid swelling, ptosis
One eye, then the other
What am I?
What age groups?
1/3 of patients can get a ______
Epidemic Keratoconjunctivitis
Occurs most often in older children and adolescents
corneal inflammation (keratitis)
71
How long is a person with Epidemic Keratoconjunctivitis contagious for?
Will be contagious up to two weeks
Observe isolation precautions
72
Itchy, watery, red eyes, severe tearing
Generally accompanied with coughing, sneezing and rhinitis
What am I?
What is the tx?
allergic conjunctivitis
Olopatadine (patanol) BID and decrease exposure to allergens
Treatment of other allergies also helps (ex: nasal corticosteroids, oral antihistamines)
73
______ is a topical ophthalmic solutions that combine antihistamine and mast cell stabilizer. What dx?
Olopatadine (patanol) BID
allergic conjunctivitis
74
Severe allergic condition
Severe itching, tearing, mucus production
Giant papillae of upper tarsal conjunctiva
Ptosis and keratitis common, resulting in squinting in bright light
Papillae found at limbus
With characteristic white dots
What am I?
What are the white dots?
Vernal Keratoconjunctivitis
represent accumulation of inflammatory cells, mostly eosinophils
75
What dx? What is the tx?
Vernal Keratoconjunctivitis
same as allergic conjunctivitis
76
______ form of conjun it associated with eczema
atopic conjunctivitis
77
______ MC reason children in the US receive antibiotics. More than 90% of all antibiotic use in the first 2 years
acute OM
78
What is the pathopsy behind acute otitis media?
79
What are the 3 MC pathogens for AOM? What usually precedes AOM?
S. Pneumoniae (#1 bacteria),
H. Influenzae,
M. Catarrhalis
viral URI for the past 4-7 days
80
What are some risk factors for AOM?
smoke exposure
eustachian tube dysfunction
Children with craniofacial anomalies (cleft palate)
impaired host defenses
bottle feeding
Genetic susceptibility
Pacifier use
Limited resources-lack of access to medical care
81
Why is breastfeeding good for reducing AOM?
Breastfeeding reduces the incidence of acute respiratory infections, provides IgA antibodies that reduce colonization with otitis pathogens
82
if _____ is present, indicates a perforated tympanic membrane
Otorrhea
83
What 3 things are required to make the dx of AOM?
1) A history of acute signs and symptoms (abrupt fever)
2) The presence of middle ear effusion indicated by bulging of tympanic membrane, absent mobility of tympanic membrane, and/or otorrhea.
3) Signs/symptoms of middle ear inflammation indicated by either distinct erythema of tympanic membrane or distinct otalgia that results in decreased sleep and normal activity
84
What is the tx for AOM? What is the first line abx?
supportive care!!: pain relievers, fever reducers
1st: amoxicillin
2nd: augmentin if amox fails
85
What is the treatment for AOM with a mild allergic reaction to amoxicillin/augmentin? What is severe allergy to amox/augmentin?
mild allergic: cefdinir
severe: macrolide or clinda or bactrim
86
What is the tx for AOM with TM perforation? What if the pt has tymponastomy tubes?
Tympanic membrane perforation: same oral meds as previously
tubes: in the absence of systemic symptoms : can use cipro/ofloxacin drops
87
What is the treatment for AOM with systemic symptoms?
both topical and oral therapy
so amox/augmentin AND cipro drops
88
What are the 2 complications of AOM?
Tympanosclerosis
Cholesteatoma
89
_______ white plaque-like appearance on the TM caused by chronic inflammation
tympanosclerosis
90
______ a greasy-looking or pearly white mass seen in a retraction pocket,
Occasionally with perforation, a temporary conductive hearing loss may be present. What is this a complication of? When will it heal?
cholesteatoma
AOM complication
Most perforations heal within 2 weeks
When fail to heal within 3-6 months, surgical repair is indicated
91
When should you start to see improvement when treating AOM?
Children who fail to improve after 48-72 hours should be re-evaluated
92
What is considered recurrent AOM? What is the tx? What is considered chronic AOM?
recurrent: 4 episodes in 6 months, or 6 in 12 months -> tx with tympanostomy tubes
OME that lasts for greater than 3 months, or a purulent middle-ear process that fails to respond to initial antibiotic therapy
93
What is OME? otitis media with effusion
What is the tx? When will these resolve?
Persistence of middle ear effusion after an episode of AOM
These effusions are sterile and in the absence of other acute signs and symptoms do not require antibiotic therapy
Watchful waiting, 85% resolve in 6 months
94
What is the tx for OME that does NOT resolve in 6 months?
If not, tubes are placed due to possible speech and language developmental delays
Usually asymptomatic, however, if not, follow up in 3 months
If, at 3 months, hearing is normal, can do watchful waiting for spontaneous resolution
If, at 3 months, MEE are persistent, bilateral, and causing delays, refer to audiologist
95
What am I?
Otitis Media with Effusion
96
_____ is the MC viral infection of the URI and is the MC pediatric infectious disease. How many episodes will a kiddo under 5 usually have?
viral rhinitis
Kids under 5 have 6-12 colds per year
97
What virus usually causes viral rhinits?
Caused commonly by rhinoviruses, also caused by adenoviruses, coronaviruses, enteroviruses
98
Sudden onset of clear OR mucoid rhinorrhea
Nasal congestion, sneezing, sore throat and cough
Fever may develop (more often in kids younger than 5 or 6)
The nose, throat, and TMs may appear red
What am I?
When does it tend to subside?
How long can the cough/mild rhinorrhea last?
viral rhinitis
Usually subsides around 7-10 days
Cough and mild rhinorrhea may last 2-3 weeks after cold clears
99
What is the tx for viral rhinitis?
Supportive measures
Acetaminophen/NSAIDS. No aspirin
Cool mist humidifier
Vicks vapor rub for cough
Hydration
Nasal saline
Bulb suction
Honey for cough (if over 1 y/o)
100
_____ is the MC form of HSV-1 seen in children
Acute gingivostomatitis
101
High fever, irritability, and drooling occur in infants
Multiple oral ulcers seen on tongue, buccal and gingival mucosa, anterior tonsillar pillars, inner lips, and perioral area may display vesicles and small ulcers that coalesce
Cervical and submandibular adenopathy noted
What am I?
What is the tx?
Is it contagious?
Acute herpetic gingivostomatitis
Treatment is supportive, bland diet, no salty or acidic foods, tylenol or ibuprofen
YES!! active lesions are very contagious
102
Where are herpes labialis seen? How long does it take to heal?
Herpes labialis (cold sores) crust and heal without scarring in 7-10 days and can be found on upper or lower lip
Most kids will report stinging or itching of mouth/lips before outbreak
103
_____ is the topical therapy for herpetic gingivostomatitis. What is the pt education?
Mylanta mouthwash (magic mouthwash)
DO NOT swallow it!!!
104
When is rx treatment indicated in herpetic gingivostomatitis? How long does it tend to last?
Antiviral therapy not indicated unless very severe
Will last around 7-14 days
105
Adherent creamy white plaques on the buccal, gingival, or lingual mucosa, which CANNOT be washed away after feeding
May be painful - infants may refuse to eat and swallow
Older children may complain of “cottony” feeling in mouth, loss of taste, and sometimes pain
What am I?
What age group is very common to see this in?
What are the 2 risk factors?
Oral Candidiasis (Thrush)
Very common in infants in the first few months/weeks of life
Can last several weeks despite treatment
Corticosteroid inhalation treatment for asthma
or broad spectrum abx therapy
106
What is the tx for thrush? What is the pt education?
nystatin oral suspension
If infant that is breastfeeding, have mom wash breast before and after feeding, and put small amount of nystatin on nipple/areola.
Wash and pacifiers (dishwasher)
107
What is the tx for prolonged thrush?
Oral fluconazole may be used as alternative to nystatin with treatment failure or if pt is immunocompromised
108
What virus causes hand, foot and mouth disease? What age range? What time of the year?
Usually caused by coxsackie virus
Mostly occurs in infants and children, particularly those younger than 5-7 years of age
summer and early autumn
109
Characterized by ulcers surrounded by erythematous halos located in the posterior pharynx
Along with these lesions, also get blanching red macules or vesicles appearing on the palms, soles, and buttocks
Erythematous halos may also surround the macules
Systemic symptoms of fever, malaise, dysphagia, and poor appetite can occur
What am I?
**What are the highlighted findings?
When will it resolve?
Hand, Foot, and Mouth Disease
**ulcers surrounded by erythematous halos located in the posterior pharynx
**Along with these lesions, also get +blanching red macules or vesicles appearing on the palms, soles, and buttocks+
Spontaneous resolution occurs in about 1 week
110
hand foot mouth dz
111
Generally non-pruritic
Generally start macular
Proceed to maculopapular
Then papulovesicular
Ultimately vesicular
May see all lesions at one time
Will also typically involve the buttocks
What am I?
What is the tx?
skin lesions of hand, foot, mouth disease
Supportive care!!! for HFM dz
Ibuprofen/acetaminophen
Hydration
Benadryl:Maalox rinse
Viscous lidocaine
112
______ are ulcers surrounded by erythematous halos found on anterior tonsillar pillars, soft palate, and uvula. Where are these ulcers NOT found? What is the tx? What is it caused by? When will it resolve?
Herpangina
NOT on anterior mouth
same supportive care as HFM dz
coxsackie virus causes it
spontaneous resolution in 1 week
113
Herpangina
114
What causes strep pharyngitis? What age group?
Caused by Group A streptococcus (GAS)
Most common in school-aged children
115
Enlarged inflamed tonsils and/or posterior pharynx
Palatal petechiae
Enlarged cervical adenopathy - may be tender
Inflamed uvula
Scarlatiniform rash, "sand paper" rash
"strawberry tongue"
What am I?
When does the rash start? What is the distribution?
What age group?
Streptococcal Pharyngitis
24-48 hours after symptoms start
Starts in groin and axilla and then spreads to trunk and extremities
kiddos older than 3, younger than 3 years old the s/s are not always typical and under 1 the symptoms are non-specific
116
PE findings of _____
strep pharyngitis
117
PE findings with strep pharyngitis
118
What are the possible strep s/s in a kiddo older than 3 that warrant a test?
pharyngitis
fever
headache
vomiting
abd pain
enlarged tender cervical anterior lymph nodes
palatal petechiae
NO COUGH, anterior stomatitis, or ulcers/vesicles in the throat (aka these are viral s/s so do NOT need to test for bacterial strep throat)
119
What are the possible strep s/s in a kiddo younger than 3 that warrant a test?
prolonged nasal drainage
tender anterior cervical adenopathy
low grade fever
120
What are the 2 options for strep pharyngitis tests?
RADT: Rapid Antigen Detection Test (RADT) -> needs 2 swabs and if NEGATIVE need to send out for TC
Nucleic acid amplification test (NAAT) -> only needs 1 swab and if negative do NOT need tc because it is highly sensitive and specific
121
What is the tx for strep pharyngitis? What if allergic to the first line abx?
Penicillin V or Amoxicillin
Amoxicillin is preferred due to better taste
PCN allergy:
Cephalosporins
Macrolides
Clindamycin
122
**What is the pt education for strep pharyngitis?
Contagious until 24 hours after first dose
Change toothbrush next day
123
What are 6 complications of strep throat?
Rheumatic fever
Glomerulonephritis
Post-strep reactive arthritis
Otitis media
Peritonsillar abscess
Cellulitis
124
What is the underlying cause of infectious mononucleosis? What is the incubation period?
Caused by the Epstein Barr Virus
Incubation period of 2-6 weeks; average usually 20-30 days
125
What are the 3 classic signs of infectious mononucleosis?
fever, sore throat, and lymphadenopathy (will be enlarged, firm and tender) POSTERIOR lymph nodes
may have 2-3 days of vague symptoms of fatigue, malaise, chills, HA and anorexia
126
sore throat seen with infectious mononucleosis
127
_____ is likely to develop in a kiddo who has mono and has taken _____
A rash develops in 70-90% of patients with mono who are taking ampicillin or amoxicillin
128
What labs should you order in mono? When is ____ not reliable?
monospot and EBV antibody titers
monospot can provide false negative tests in kiddos younger than 5
129
**What are 3 other lab findings that are consistent with mono?
Lymphocytosis
Atypical lymphocytosis (comprising over 10% of the total leukocytes at some time in the illness) is most notable
Elevated liver enzymes
130
What is the tx for mono?
131
_____ is a very common pharyngitis in kiddos that is NOT strep or mono. What is the season preferance? How does it present?
Adenoviral Pharyngitis
no particular seasonal preference
presents exactly the same as strep throat
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______ is a self-limiting virus that involves the eyes and may also have pharyngitis with tender cervical adenopathy. What is the exact cause?
Adenoviral Conjunctivitis
D 8/19/37
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______ is more serious bilateral conjunctivitis, eye pain, preauricular tender LN, and causes corneal opacities. What should you do next?
Epidemic keratoconjunctivitis
refer to ophthalmology
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**What is the main cause of croup? What age range? What season?
**Parainfluenza type 1 (lesser extent 2 and 3) viral illness that is characterized by the acute laryngeal and subglottic swelling resulting in hoarseness, cough, respiratory distress, and inspiratory stridor
affects children between 3 months and 3 years of age usually in the fall
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Viral croup is MC caused by ______. Name 3 additional causes
parainfluenza type 1
RSV, influenza virus and adenovirus
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The cough may be spasmodic, with a deep brassy cough (non-productive, high pitched), or a harsh, barking quality
seal's bark
Laryngitis with a raspy-sounding or hoarse voice may develop
fever
inspiratory stridor
What am I?
When is the cough worse?
viral croup
Spasms of cough mostly noted at night/early morning
Inspiratory stridor may be noted
mild cases: only when the kiddo is agitated
severe: stridor at rest, retractions and cyanosis
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What is stridor a result of? When is a child in most distress?
Stridor results from obstruction of airflow during both inspiration and expiration, but is most marked on inspiration
Child’s distress is most evident during inspiration
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What is the incubation period of whooping cough? What is the cause? What seaons?
Incubation period 7 - 10 days (up to 20 days)
Bordatella Pertussis
worse in summer and fall
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What are the 3 stages of pertussis?
Catarrhal Stage
Paroxysmal Stage
Convalescent Stage
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______ Lasts 1 - 2 weeks. Mild cough and runny nose; as the runny nose improved, the cough worsens
catarrhal stage of pertussis
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_____ Lasts 2 - 8 weeks. Increased severity of the coughing spells. Repetitious cough with little to no inspiratory effort. Tends to be worse at night. The classic “whoop” is not always present. Common to have posttussive emesis.
paroxysmal stage of pertussis
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_____ Variable duration. Cough gradually resolves.
convalescent stage of pertussis
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What is the atypical presentation of pertussis?
Short/absent catarrhal stage; +/- paroxysmal cough, gagging/posttussive emesis; gasping; cyanosis; and bradycardia
aka the kiddo does NOT have to whoop
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What will the CXR show in a pt with pertussis? Give both uncomplicated and complicated cases
Uncomplicated: normal or may see subtle perihilar infiltrates, peribronchiolar cuffing, or even atelectasis.
Complicated: may see pneumonia, pleural effusion, pulmonary edema, or lung collapse
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What is the prevention for Perutssis?
DTaP vaccine and booster at 11-12 years old
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What is the abx of choice for pertussis? What is the associated timeframe?
Macrolides are treatment of choice:
Azithromycin
Erythromycin
Clarithromycin
abx if dx within the first 7 days from symptom onset
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______ is used if the pt has an allergy to macrolides in pertussis treatment. How old? Why?
bactrim if allergic to macrolides
must be older than 2 months old due to risk of kernicterus
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When is pertussis prophylaxis most effective? Who needs tx? What is the tx?
within 21 days of onset of cough in the index patient
living in same household, face to face exposure within 3 feet of symptomatic patient, direct contact with respiratory, oral, or nasal secretions, and sharing confined space for at least 1 hour
same tx: macrolide
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____ is the MC cause of bacterial pneu in children 6 months and older
S. pneumoniae
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______ is the MC cause of pneuomonia in kiddos less than 6 months old
C. trachomatis
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______ usually predominate as the cause of pneuomonia in early childhood. What is CAP due to ?
viral etiologies
mycoplasma pneumoniae
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Fever (may or may not be high)
Tachypnea
Cough
Crackles/Rales
Decreased breath sounds
Dyspnea
Decreased appetite
Vomiting
What am I?
What will labs show?
elevated WBC and lobar consolidation on chest xray
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When should you admit a kiddo with bacterial pneumonia? What is the tx?
Admit if child is younger than 3 months and febrile for empiric therapy with Ampicillin and Gentamicin
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What is the tx for a febrile infant that is 1-6 months old with c. trachomatis?
Azithromycin
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______ is the first line treatment for bacterial pneumo from 6 months to just under 5 years old. What are the 2 alternatives?
amoxicillin
cefdinir or macrolide if allergic
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_____ is considered an atypical pneumonia. What age group?
Mycoplasma Pneumonia
Usually in kids older than 5
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Fever, cough, headache, and malaise
Cough dry at first, then progresses to productive cough
Sore throat and/or otitis media may also be present
Decreased breath sounds, dullness to percussion
Extrapulmonary involvement of blood, CNS, heart, skin, and joints can occur
Erythema multiforme type rash
What am I?
What is the tx?
mycoplasma pneumonia
macrolide
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What is the tx for a mycoplasma pneumo?
macrolides
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Spreads quickly over the face and trunk, then out to extremities and coalesces into red patches
The rash fades about 3 - 4 days and resolves in about 1 week (clears in same way appeared), followed by some desquamation
Fever spikes when the rash appears and usually falls 2-3 days thereafter
Koplik spots
What am I?
**What are the 3 hallmark symptoms?
What is important to note about the spread?
rubeola (measles)
cough, coryza, and conjunctivitis
starts face then goes trunk
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What is the timeline for rubeola vaccine if a pt has been exposed?
Vaccine given within 72 hours if exposed to person with measles (patients over 6 months) may preven
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What is a Koplik spot? What dx?
white macular lesions on the buccal mucosa, typically opposite the lower molars
rubeola (measles)
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When does the maculopapular rash begin in rubeola? What is the tx?
Discrete, erythematous, maculopapular rash begins when respiratory symptoms are maximal
tx: supportive care
can consider vit A supplementation
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What can happen if a pregnant women contracts rubeola?
LBW, IUFD, spontaneous abortion, and premature birth
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Koplik spots
measles
165
measles
will be blanchable and elevated
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When is rubella (german measles) contagious? When will the rash dissappear?
Infectious 5 days before and 5 days after rash
Gone by day 4
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Low-grade fever, ocular pain, sore throat, myalgia
Postauricular and suboccipital adenopathy
Maculopapular rash that begins on face, spreads to trunk and extremities after fading from face
What am I?
Why is this dz important to know?
rubella
More than 80% of women infected in the first 4 months of pregnancy deliver affected infants
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Growth retardation
Cardiac anomalies (VSD, PDA)
Ocular anomalies (cataracts, glaucoma, retinitis)
Deafness
Cerebral disorders
Hematologic disorders
Hepatitis, osteomyelitis, diabetes
What am I?
things that could negatively affect a pregnancy should a women get rubella while pregnant
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Erythema Infectiosum (Fifth’s Disease) is caused by _____. What season?
Parvovirus B19
Spread is respiratory, occurring in winter-spring epidemics
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Nonspecific, mild flu-like illness may occur 7-10 days prior to the rash
Typically, the first sign of illness is the rash, which begins as raised, red maculopapular lesions on the cheeks that give a “slapped cheek” appearance
Lesions are warm, nontender, and may be pruritic
What am I?
Describe the rash
fifth's disease
Central clearing of confluent lesions produces a characteristic lace-like pattern
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What can fifth's dz lead to? What happens if a pregnant women get it?
Can lead to arthritis, aplastic crisis
Infection of pregnant women may produce fetal infection with hydrops fetalis
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fifth's disease
173
fifth's disease
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Roseola Infantum is caused by _______. Can cause _____ in kids because of the moderate to high fever
HHV-6 (or 7)
febrile seizures
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Major cause of acute febrile illness in children
Can last up to 3 days
The fever ceases abruptly, then a characteristic rash appears
Mild fatigue and irritability
Dissociation between systemic symptoms and febrile course
URI symptoms
Rose-pink macules, or maculopapular, 2-3mm in diameter are nonpruritic, tend to coalesce, and disappear in 1-2 days
What am I?
Where does the rash begin?
How should you manage the fever?
roseola infantum
If rash appears it coincides with lysis of fever and begins on the trunk and spreads to the face, neck, and extremities
Tylenol and is otherwise benign
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______ is the most common recognized cause of exanthematous fever in kiddos 6 months to 3 years
Roseola Infantum
177
roseola infantum
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______ is an acquired form of heart disease. What pathogen?
Rheumatic Fever
Group A Strep infection of upper respiratory tract
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What are the major manifestations of rheumatic fever?
Carditis
polyArthritis
Sydenham chorea
Erythema marginatum
Subcutaneous nodules (CASES)
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What are the minor manifestations of rheumatic fever?
previous rheumatic fever rheumatic heart disease
polyarthralgia
fever
elevated ESR or C-reactive protein
leukocytosis
plus supporting evidence of strep throat infection
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What are the criteria to dx rheumatic fever?
Two major OR one major and two minor manifestations are needed for the diagnosis
based on the Jones criteria
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_____ is the most serious consequence of rheumatic fever. What specifically?
Carditis
valvulitis-> most commonly mitral valve
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______ is a major manifestation of rheumatic fever. macular, erythematous rash with sharply demarcated border on trunk and extremities
Erythema marginatum
184
Subcutaneous nodules seen in rheumatic fever
185
Erythema marginatum seen in rheumatic fever
186
What is the tx for rheumatic fever?
Antibiotic therapy to eradicate GAS:
Penicillin G IM
aspirin or naproxen for the arthritis management
chorea is generally self limiting
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Who needs secondary prevention for rheumatic fever? What is the prophylaxis?
Those who have had an attack and are at risk for recurrence
Continuous antimicrobial prophylaxis until a young adult - age 21 OR 10 years from initial attack with no recurrence
Penicillin G administered IM every 21-28 days
Can use macrolide if penicillin allergy
pt education that secondary prophylaxis is SUPER IMPORTANT even though they most likely are asymptomatic
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______ is an acute, multisystem vasculitis of infancy and early childhood. What is it characterized by?
Kawasaki Disease
-high fever
-rash
-conjunctivitis
-inflammation of mucous membranes
-erythematous induration of the hands and feet
-cervical adenopathy.
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_____ is the main cause of acquired heart disease in kiddos in the US. What is the peak page of onset?
Kawasaki Disease
Peak age is 2nd yr of life
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How is Kawasaki disease dx? What are the 5 criteria?
4 of 5 clinical characteristics have to be present to make diagnosis
1. Lip or oral cavity changes
2. Bilateral, painless, nonexudative conjunctivitis
3. Cervical lymphadenopathy ≥ 1.5cm diameter and unilateral
4. Polymorphous exanthem that starts on the extremities and moves centrally
5. Extremity changes: redness/swellig of hand/fett with desquamation
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What are the fever requirments to dx Kawasaki dz?
Fever for 5+ days
A fever always has to be present
192
lip/oral cavity changes seen in Kawasaki dz
193
What is important to note about the conjunctivitis seen in KD? What size in the cervical lymphadenopathy?
must be BILATERAL!!
Cervical lymphadenopathy ≥ 1.5cm
194
What will the CBC, LFTs, ESR/CRP and UA show in a pt with KD? **What additional dx test should you order?
**Echocardiography should be performed in all patients with KD as soon as the diagnosis is suspected
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What are some complications of KD?
Myocarditis, pericarditis, valvular heart disease (usually mitral or aortic regurgitation), coronary arteritis, MI, arrhythmias, heart failure, CA rupture
Coronary artery aneurysms
Gastrointestinal obstruction/Intussusception/Paralytic ileus
196
What is the tx for KD? _____ is given if above tx fails
Initial treatment with IVIG infusion (2 gm/kg) over 8-12 hours
High dose aspirin 30-50 mg/kg/day divided four times daily reduces length and severity
Steroids if ASA and IVIG both fail
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When should you reduce the ASA dose in KD? When should you continue it?
Reduce dose when fever subsides so platelet count can return to normal
Continues aspirin if aneurysms are recognized
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Why do you give IVIG and ASA in KD?
IVIG and aspirin can prevent coronary artery lesions
199
Give the long-term management for who a KD pt needs to follow up with and tx recommendations? level 1-5
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