Febrile Illness in Children and Pediatric Infectious Disease Flashcards
One of the m/c symptoms in pediatric illness
fever
definition of hypothermia and fever?
- core temperature < 36.5° C (97.7° F)
- core body (rectal) temperature ≥ 38.0° C (100.4° F)
T/F: Young children tend to have higher core temps than adults
T
Fever is a regulated elevation of body temperature mediated by what part of the brain?
the anterior hypothalamus
An insult, MC ____ in kids, induces macrophages to release ____ that function as endogenous pyrogens (fever producing substance)
- viral
- cytokines (IL-1 and 6)
stimulates the production of prostaglandins by the hypothalamus; prostaglandins readjust and elevate the temperature set point
Cytokines
why do we get chills when we have a fever?
- core temp < thermostat setting = feels chilled
- Chills = generate more internal heat - shivering, vasocontricting skin and turnin goff sweat glands
how can fevers be good?
- disrupts growth and reproduction of many invasive pathogenic microorganisms, both bacterial and viral
- lower amount of iron available to invading bacteria, which have a higher iron requirement
- enhances neutrophil migration, T-Cell proliferation, and interferon activity
ways to measure temperature and which is most accurate?
- Rectal (most accurate) - birth to 3 years
- Oral: >4 yrs
- 0.5-1 ⁰F < rectal d/t mouth breathing, recent ingestions of cold liquids - Axillary - 0.5-1 ⁰F < oral
- Fever if the axillary temp 99.0F or 37.2 C - Forehead - Temporal arteries
- MC way due to being quick and requiring little patient cooperation
- Can have false readings if not positioned properly or the external ear canal is occluded by wax
- Not reliable < 6m
tympanic
s/s fever
- Young children desire close contact with warm person
- Wish to be covered by a blanket
- Somewhat lethargic
- dec ability to concentrate
- Irritability and anorexia (esp small infant)
- Hypermetabolic state with flushed cheeks
- Hot and dry feeling of skin
- Dry mouth and lips (dehydration)
- Sweating
- Febrile seizure
- Unusual glitter in eyes
- Sleepy
- Some exceptionally alert and excited (MC kids 5-10y)
- 10-15 beat pulse increase with every 1◦C
what type of fever patient may be safely sent home with symptomatic treatment and careful return precautions
A well-appearing, well-hydrated child with evidence of a routine viral infection
causes of fever
- MC rsp and GI tracts infections - MC viral (rsv, influenza, croup, adenovirus)
- Other sources: autoimmune disease, Neoplastic, Metabolic disease (hyperthyroidism)
supportive measures for fever
- Educate parents
-
MC reason to treat fever is if child is uncomfortable
- Decision to tx is based on child’s behavior, not on any particular threshold
- Some tolerate fevers w/o ill effect, while some become irritable and cranky - Acetaminophen and NSAIDS
- NSAIDS: >6 months, short term safe if >3 months
- Tylenol: >3 months - No aspirin
- Physical cooling
febrile kids are still contagious until when?
fever free for 24 hours
when to seek immediate help with fever
- < 3 months of age
- Fever > 40.6◦C / 105.8◦F
- crying inconsolably or whimpering
- crying when moved or even touched
- difficult to awaken
- Stiff neck
- Purple spots or dots on skin
- breathing is difficult and not better after nasal passages are cleared
- drooling saliva and is unable to swallow
- convulsion
- acts or looks “very sick”
when to seek help within 24 hrs for fever?
- 3-6 months old (unless fever occurs within 48h after a dtap vaccine with no other serious sx)
- Fever > 40◦C / 104◦F
- Burning or pain occurs with urination
- Returned fever afterit has subsided for >24h
- Fever present > 72 h
A ____ infection usually disseminates faster in a younger child
bacterial
Children between ______ of age have been of special interest to researchers and clinicians because fever is most common in this group
they may be difficult to assess, particularly during the first ___ months of age
- birth and 36 months
- 6
When evaluating the febrile young infant, the goal is to ?
identify infants who are at high risk for invasive bacterial infection (IBI) or serious viral infection who therefore require empiric antimicrobial treatment and hospitalization
types of IBIs
UTI, bacteremia, meningitis, pneumonias, skin/soft tissue infections, septic arthritis, osteomyelitis, bacterial gastroenteritis
MCC of most bacterial infections in infants under 90 d
UTI
Risk Factors for IBI/Serious Viral infections:
- < 28 d old
- Ill appearance: lethargy, listlessness, or toxic appearance, rsp distress, petechiae/purpura, inconsolability
- Rectal Temp >104F
- Not immunized (esp first dose of Hib and pneumococcal)
- Prematurity
- Comorbidities
- abx in last 3-7 d
- Risk of maternally transmitted diseases (maternal fever, PROM, cx (+) GBS, genital herpes)
Treatment plans differ on age of child?
what is the one exception?
- Birth - 21 d
- 22-28 d , 29-60 d, 61-90 d.
- 90 d - 36 mo
exception: all ill-appearing children with toxic look will undergo full evaluation
should mothers continue to breastfeed for febrile children?
yes
encourage and provide lactation support including access to breast pumps for nursing mothers
DC parenteral antimicrobial agents and DC hospitalized patients when all of the following criteria are met:
- Negative Cx results x 24-36 h or only positive for contaminants
- appears well or is improving
- No other reasons for hospitalization
labs to obtain for 22-28 d old febrile infants?
- procalcitonin
- ANC/CRP
admit all febrile infants if they are ages ?
8-21 days old
for infants 61-90 days old, a full septic work-up is warranted when?
- Ill, toxic appearing
- Signs of a focal infection (cellulitis, abscess, osteomyelitis, pneumonia) AND
- Abnml WBC count
- inc inflammatory markers (CRP, procalcitonin)
- abnml U/A
febrile infants 61-90 days do not have to have full work up if they meet this criteria:
- Well-appearing with no bacterial focus of infection
- Or a recognizable viral infection (bronchiolitis or rhinovirus)
- Can get U/A and culture (at this age, concurrent UTI is common)
- Can f/u outpatient
The approach to a child who has a fever w/o a source is greatly determined by ?
3 months to 36 months
immunization status
s/s of fever in 3-36 mo infant
- Lesions in oropharynx that can help with viral illness (ulcers or vesicles in gingivostomatitis and hand, foot, mouth)
- Inc work of breathing, nasal flaring, accessory muscle breathing
- O2 <= to 95%
- Abd tenderness, skin findings such as viral exanthems, petechiae
for a 3-36 mo febrile infant who is well-appearing and has incomplete immunization, what w/u and tx?
- CBC
- Blood Cx if WBC is >= 15k
- UA and CX girls < 24 mo, boys uncircumcised < 12 mo, and circumcised < 6 mo
- CXR if WBC count >= 20k
- If WBC >= 15k - Ceftriaxone / Clindamycin
- outpatient f/u 24 hours, if unable, admit
f/u for febrile 3-36 mo old with complete immunization
- An otherwise healthy child who is completely immunized and remains on schedule, routine lab work is not clinically effective and not recommended
- f/u in 24-48 hours if pt remains febrile
what is a simple febrile seizure?
A generalized tonic or tonic-clonic seizure, usually lasting < 15 min and occurring once within 24 hrs of the onset of fever, may begin w/o warning
MCC of febrile seizures
viral infections
At risk 6 months-5 years.
w/u for febrile seizures
- MC benign; can be first indication of meningitis or encephalitis
- must r/o CNS infection
- CMP, CBC, blood culture
- LP if child < 6 mo - Prophylactic anticonvulsants not recommended
- > 1 febrile seizure < 24 h = complex febrile seizure
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
Fever of Unknown Origin (FUO)
3 MC causes of FUO
- infectious diseases
- connective tissue/rheumatologic diseases
- neoplasms
- Other: drug fever, factitious fever, CNS dysfunction, and others that do not fit into above categories
6 MC infectious causes of FUO
CMV, EBV, osteomyelitis, hepatitis, adenovirus, enteroviruses, and bartonellosis (cat-scratch disease)
MC autoimmune cause of FUO
systemic idiopathic juvenile arthritis
MC malignant causes of FUO
leukemia, lymphoma
w/u for FUO
- CBC with peripheral smear
- CMP
- ESR, CRP
- Blood cx
- UA and cx
- NP Viral Swab
- Chest radiographs
- specific serological tests for Hep A and B, EBV, toxoplasmosis, bartonellosis, and CMV
- Certain radiograph studies, bone marrow exams, and ct exams may be indicated
disposition for FUO
- Return if new complaints arise or change in clinical status
- If FUO persists and child is well appearing: subsequent eval and order labs only as necessary (new sx arise)
- If ill with persistent F and no dx: get IgG, IgA, IgM
- Imaging of GI tract, US, CT
interventions for FUO
- DC nonessential medications
- NSAIDS
- AVOID empiric abx therapy except those where a life-threatening condition is suspected
- Can interfere with isolation of an organism from cx - refer if persistent F and ill-appearance with no dx after initial eval; ID, rheum, or hem-onc
MCC of bacterial sepsis in newborn?
- group B β-hemolytic strep (GBS)
- gram-negative enteric pathogens (MC E. Coli)
- Listeria; Staph. Aureus
bacterial sepsis MC affects at what age?
- Most commonly occur on day 1 of life
- Majority < 12 hours old
RF for bacterial sepsis in 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
- Additional in premature children: Low circulating IgG, Nosocomial infections d/t premature epithelial barrier, Other invasive devices
s/s of early bacterial sepsis
- Early onset, mostly GBS and e. coli
- Rsp distress d/t pneumonia is MC presenting sign
- Unexplained low Apgar scores w/o fetal distress
- Poor perfusion
- HoTN
- Low WBC, NEUT, hypoglycemia, hyperglycemia, and or unexplained metabolic acidosis
s/s of late onset bacterial sepsis
- s. aureus
- Presents in a more subtle manner
- Poor feeding
- Lethargy
- Hypotonia, temperature instability, low perfusion
- Inc oxygen requirements
- Apnea
- MC associated with bacterial meningitis
- Similar lab values as early onset
- CBC
- Blood cultures
- CSF
- Pleural fluid from effusion (diagnosis of pneumonia)
- CXR
- Any preterm infant with rsp disease requires blood cx and broad-spectrum abx
tx for preterm infants for bacterial sepsis
Blood cx and broad-spectrum abx x 48-72 hrs pending results
- Early: Ampicillin + gentamicin/cefotaxime
- Late - same, but add Vanc
prevention of bacterial sepsis
- PCN 4 hrs prior to delivery
- vaginal and rectal GBS cx at 35-37 wk
- Prophylatic PCN if GBS (+) or unknown GBS status at delivery
what virus causes over 80% aseptic meningitis
non-polio enteroviruses
- Onset acute
- MC < 1 y/o
- Marked F, irritability, and lethargy
- Abd pain, V/D
- Maculopapular rash, w/ some petechial rash
- Full anterior fontanelle
- Older children - frontal HA, photophobia, and myalgia; abd pain, N/V/D; Meningeal signs; flaccid paralysis possible
viral meningitis
w/u findings of viral meningitis
- Early: PMN cells, then MN cells 8-36 hours
- protein < 80mg/dl, and glucose >60% of serum values; mild subtle changes in CSF
- Dx: PCR for enteroviruses
tx for viral meningitis
- No specific tx therapy; supportives
- Infants usually hospitalized, isolated, and treated with fluids and antipyretics - make sure their fever is under control!!
- Can give prophylactic abx until a negative cx is received
- If older child, can withhold abx and observe
what vaccine is responsible for a decrease in bacterial meningitis incidence?
pneumocccal
Can be recurrent; can complicate serious head trauma
s/s of bacterial meningitis
- Abrupt F, often with chills
- Irritability, convulsions, neck stiffness
- most important sign in very young infants: tense, bulging, fontanelle
- older children: fever and chills, HA and vomiting
- Classic signs: nuchal rigidity + brudzinski and Kernig signs
w/u for bacterial meningitis
- Pronounced leukocytosis
- 80-90% PMNs
- CSF inc wbc count and protein, dec glucose
- G+ diplococci may be seen on some stained smears of CSF sediment
tx for bacteria meningitis
- IV Vancomycin + Cefotaxime/Ceftriaxone until bacteriological confirmation
- +/- steroids
- If isolate is PCN susceptible: IV Penicillin G, or ceftriaxone if cephalosporin susceptible
- Meningitis MC form of this bacteria
- Highest attack rate is within the first year of life
- Also elevated again in teen years
tx too?
Neisseria Meningitidis
tx: rifampin
s/s Neisseria Meningitidis
- Severe HA, N/V, stupor
- Convulsions and shock
- complications of permanent CNS damage, deafness, paralysis, or impaired intellectual function
- Hydrocephalus
- Preceded by Meningococcemia with similar sx and purpuric/petechial rash
w/u for N. Meningitidis
- Blood Cultures
- CSF shows WBCs with many PMN NEUT and gram-negative diplococci
tx for N. meningitidis
- tx like shock
- If hypotension present, treat accordingly and aggressive
- Shock may worsen following abx d/t release of N. Meningitidis releasing of endotoxins, so treat in ICU
- same as Pneumococcal: Vanc, Ceftriaxone/Cefotaxime, with PCN G (if susceptible)
- constantly exposed to bacteria, but conjunctival and tear defense mechanisms work to prevent infection
- Common in children, especially kids in day-care
Conjunctiva/conjunctivitis
MCC of bacterial conjunctivitis
- S. Pneumonia, H. Influenza, Moraxella Catarrhalis, and other Staph. organisms
- Psuedomonas in contact lens
- Mucopurulent discharge present, one or both eyes
- Conjunctival injection
- Common complaint is kids will wake up with eyelids stuck together
- May be associated with URI
- May also be associated with sinusitis/otitis media, esp if H. flu
Bacterial Conjunctivitis
tx for Bacterial Conjunctivitis
- Can resolve on its own
- Abx speed up healing process
- FQ, sulfacetamide, trimethoprim-polymyxin B (Polytrim)
- Prevention with hand-washing
- Refer for severe or if not resolved after 7 days of tx
- Contagious up to 24 hours after starting abx
MCC viral conjunctivitis
adenovirus
- Extremely contagious
- Often starts in one eye, then spreads to other
- A history of other friends/family having pink eye can be found
- Tearing, redness, and FB sensation
Viral Conjunctivitis
- URI (pharyngitis and fever) with BL conjunctivitis
- Severe, watery conjunctival discharge, hyperemic conjunctivitis
- Preauricular LAD, FB sensation
- Highly contagious, lasts approx 2-3 weeks
Pharyngoconjunctival Fever
- MC older children and adolescents
- Occurs only in eyes
- Severe BL conjunctivitis
- With conjunctival hyperemia, watery discharge, eyelid swelling, ptosis
- One eye, then the other
- 1/3 can get a corneal inflammation (keratitis)
Epidemic Keratoconjunctivitis
tx for viral conjunctivitis
- Prevention of further transmission w/ hand wash
- Will be contagious up to 2 wks
- Observe isolation precautions
- Common (10% of general population)
- Often associated with other allergy symptoms, and allergic rhinitis (type 1 hypersensitivity reaction
- MC in spring, pollen levels high
- FHx of allergies, atopic disease (eczema), or asthma found
Allergic Conjunctivitis
s/s of Allergic Conjunctivitis
- Itchy, watery, red eyes, severe tearing
- Generally accompanied with coughing, sneezing and rhinitis, other allergy sx
tx for allergic conjunctivitis
- antihistamine + mast cell stabilizer solution
- Eye drops: Olopatadine (patanol) BID
- prednisone if severe
- Tx other allergies (nasal CS, oral antihistamines)
- Dec exposure to allergens
what is Vernal Keratoconjunctivitis?
tx?
- Severe allergic condition
- Severe itching, tearing, mucus production
- Giant papillae of upper tarsal conjunctiva
- Ptosis and keratitis = squinting in bright light
- Papillae found at limbus(junction of sclera and cornea)
- Characteristic white dots (accumulation of inflammatory cells, MC eosinophils)
- Same as allergic conjunctivitis
what is atopic conjunctivitis?
tx?
- Associated with eczema
- Itching, burning, mucus discharge
- Tx same as allergic conjunctivitis
M/C reason children in the US receive antibiotics
Acute Otitis Media
- an inflammatory process of the upper respiratory tract and usually results from a viral infection
- As viruses infect rsp mucosa, edema = ET dysfunction
- Inflammatory fluid and pathogenic rsp bacteria that reflux into middle ear space do not drain properly = abscess in middle ear
AOM
MC bacterial Causes of AOM
- S. Pneumoniae (#1 bacteria),
- H. Influenzae,
- M. Catarrhalis
other causes/RF of AOM besides infection
- Smoke exposure
- ET dysfunction
- Children with craniofacial anomalies (cleft palate)
- Impaired host defenses
- Bottle feeding
- Genetic susceptibility
- Pacifier use
- Limited resources-lack of access to medical care
s/s of AOM
- 4-7 day URI
- fever, otalgia, otorrhea, irritability, excessive fussiness/clinging, decrease appetite, decreased sleep, vomiting, tugging at ear
- otoscope, signs of inflammation of TM
- Bulging TM, impaired visibility of landmarks, a yellow or white color
- erythematous - Otorrhea is purulent, foul smell = indicative of perforated TM
According to American Academy of Pediatrics, a diagnosis of AOM requires:
1) h/o acute s/s (abrupt fever)
2) presence of middle ear effusion indicated by: bulging of TM, absent mobility of TM, otorrhea,
3) s/s of middle ear inflammation as indicated by either: distinct erythema of TM, or distinct otalgia that results in dec sleep and normal activity
Guidelines to AOM treatment
- < 6mos: immediate tx
- 6mos-24mos: immediate tx (can observe, but ultimately get treated)
- > = 24 mos who have at least 48h of ear pain, fever, otorrhea: immediately tx
- > = 24 mos who are normal hosts, with mild s/s, no otorrhea: observation
tx for AOM
- supportives
- amoxicillin - 1st line
- augmentin - 2nd line (failed amoxicillin)
- Mild allergic reaction (Rash or non IgE mediated) - Cefdinir
- Severe rxn - Macrolide, clinda, Bactrim
- If Perforation: same tx
- If tympanostomy tubes, infection in absence of systemic sx: ciprodex, ofloxacin drops
- If systemic sx: topical + oral therapy
2 complicaitons of AOM
- tympanosclerosis
- cholesteatoma
white plaque-like appearance on the TM caused by chronic inflammation
Tympanosclerosis
a greasy-looking or pearly white mass seen in a retraction pocket,
Occasionally with perforation, a temporary conductive hearing loss may be present
dx?
tx?
Cholesteatoma
- Most perforations heal < 2 wks
- When fail to heal within 3-6m: surgery
f/u guidelines for AOM
- fail to improve after 48-72 hours should be re-evaluated
- < 2y or >= 2y w/ language/learning delay: 8-12 wks after dx
- > = 2 w/o delays: next WCC
definition of recurrent AOM
3 or more episodes in 6 months, or 4 in a year
definition of chronic OM
OME that lasts for greater than 3 months, or a purulent middle-ear process that fails to respond to initial antibiotic therapy
- given with recurrent OM
- Allows for drainage and decreases OM episodes; creates an airway that ventilates the middle ear and prevents the accumulation of fluid behind middle ear
an intervention
Tympanostomy tubes
Persistence of middle ear effusion after an episode of AOM
dx?
mgmt?
- Otitis Media with Effusion (OME)
- asx: observe, resolves in 6 mo; effusions are sterile
- unresolved: tubes
asx, however, if noted, f/u 3 mo
- nml hearing: watchful waiting for spontaneous resolution
- MEE are persistent, BL, and causing delays: refer to audiologist
- MC pediatric infectious disease
- Kids < 5 have 6-12 colds per year
- Very common in daycares
- Caused by rhinovirus, also caused by adenoviruses, coronaviruses, enteroviruses
Viral Rhinitis (common cold)
- Sudden onset of clear or mucoid rhinorrhea
- Nasal congestion, sneezing, sore throat and cough
- Fever (MC kids < 5-6)
- irritable, have changes in feeding, and diarrhea
- Clear rhinorrhea may turn mucoid >4-5 d
- nose, throat, and TMs may appear red
- Usually subsides around 7-10 days
- Cough and mild rhinorrhea last 2-3 wks after
Viral Rhinitis (common cold)
If no symptomatic improvement after 10-14 days, consider what instead of the cold?
sinusitis
tx for viral rhinitis
- Supportive measures
- Acetaminophen/NSAIDS
- Cool mist humidifier
- Vicks vapor rub for cough
- Hydration
- Nasal saline
- Bulb suction
- Honey for cough (if over 1 y/o)
most common form of HSV-1 seen in children
Acute Gingivostomatitis
- Group vesicles on an erythematous base, typically in or around the mouth
- High F, irritability, and drooling occur in infants
- Multiple oral ulcers seen on tongue, buccal and gingival mucosa, anterior tonsillar pillars, inner lips, and perioral area - vesicles and small ulcers that coalesce
- Cervical and submandibular adenopathy noted
Acute Gingivostomatitis
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
dx?
Herpes labialis (cold sores)
tx for herpetic gingivostomatitis
- Active lesions very contagious
- supportive
- Bland diet, no salty or acidic foods
- Acetaminophen or ibuprofen
- magic mouthwash for kids who will not swallow
- Antivirals only if very severe
- Will last around 7-14 days
- Adherent creamy white plaques on the buccal, gingival, or lingual mucosa, which cannot be washed away after feeding
- May be painful, may refuse to eat and swallow
- “cottony” feeling in mouth, loss of taste
- Lesions may be few in number and asx, or extensive, extending into esophagus
- Very common in infants in the first few months/weeks of life
- Can last several weeks despite tx
thrush
what specific tx may predispose older children to thrush?
- inhaled CS
- abx
tx for thrush
-
nystatin oral suspension
- alt: Oral fluconazole if treatment failure or immunocomp - breastfeeding - wash breast before and after feeding, miconazole or clotrimazole around nipple; wash and boil pacifiers
MCC of HFM disease?
coxsackie virus
- One of the most recognizable viral exanthems in children and adults
- MC infants and children, < 5-7 years of age
- during the summer and early autumn
- ulcers surrounded by erythematous halos located in the posterior pharynx
- get blanching red macules or vesicles appearing on the palms, soles, and buttocks
- Erythematous halos may also surround the macules
- Systemic sx of fever, malaise, dysphagia, and anorexia can occur
- Spontaneous resolution occurs in about 1 week
dx?
HFM disease
lesion progression of HFM disease?
- Generally non-pruitic
- Generally start macular
- Proceed to maculopapular
- Then papulovesicular
- Ultimately vesicular - May see all lesions at one time
- Will also typically involve the buttocks
- Resolve in about 3-5 days
tx for HFM disease
Supportive
- Ibuprofen/acetaminophen
- Hydration
- +/- magic mouthwash
what is Herpangina? tx?
- Ulcers surrounded by erythematous halos found on anterior tonsillar pillars, soft palate, and uvula; anterior mouth spared
- linearly arranged
- acute onset of fever
- Anorexia, emesis, fussiness, sore throat, abdominal pain
- Coxsackie virus
- Spontaneous resolution in 3-5 days
- tx same as HFM
Streptococcal Pharyngitis is MC in who?
- school-aged children, however, can be seen in younger children
- esp if they have regular contact with school-aged children
s/s of strep throat for children >3
- Abrupt onset
- Fever
- Sore throat
- Abdominal pain
- Nausea/Vomiting
- Absence of Cough
- Exudative tonsillopharyngitis
- Enlarged inflamed tonsils
- Palatal petechiae
- Tender enlarged cervical adenopathy
- Inflamed uvula
- Scarlatiniform rash
- White coated tongue, enlarged bright red papillae, or tongue itself is beefy red (both termed strawberry tongue
s/s of strep throat in kids < 3
- Findings not typical
- Protracted sx of nasal congestion
- Discharge
- Low grade fever
- Sore throat
- Tender cervical adenopathy
< 1: sx nonspecific; dec appetite, low grade fever, fussiness
who to test for strep pharyngitis?
- acute tonsillopharyngitis or scarlatiniform rash + no of cough/congestion/coryza, anterior stomatitis, ulcers/vesicles in throat
- Exposure to GAS
- Kids >3: pharyngitis, F, HA, V, abd pain, enlarged tender cervical anterior LN, palatal petechiae
- < 3: prolonged nasal drainage, tender anterior cervical adenopathy, low grade F
who to NOT test for strep pharyngitis
Manifestations suggestive of viral illness (cough/cong/coryza, anterior stomatitis, ulcers/vesicles in throat, diarrhea)
w/u for strep pharyngitis
- Rapid Antigen Detection - Two swabs; Before abx tx; BL tonsils and posterior pharynx
- If negative, send for bacterial cx
tx for strep throat
- PCN V or Amoxicillin (Amoxicillin preferred d/t better taste)
- PCN allergy: Cephalosporins, Clindamycin, Macrolides
- Contagious until 24 hours after first dose
- Change toothbrush next day
complications of strep throat
- Rheumatic fever
- Glomerulonephritis
- Post-strep reactive arthritis
- Otitis Media
- Peritonsillar abscess
- Cellulitis
what is Infectious Mononucleosis?
MCC?
Epstein Barr Virus
“Kissing Disease” - spreads through saliva
Incubation: 2-6 wks, avg 20-30 d
s/s of mono
- fever (39.5 C, or 103 F), sore throat, and Posterior cervical adenopathy
- Palatal exanthem (rash on mucous membranes and palate)
- May be preceded by 2-3 days of vague sx of fatigue, malaise, and anorexia
- Hepatomegaly and splenomegaly often noted, with elevation of liver enzymes
- other: Cough, rhinorrhea, erythematous rash can be present (if taken ampicillin or amoxicillin)
- In children < 4: URI or mild pharyngitis type sx
w/u for mono
- Monospot test (can provide false-negative results in children < 5)
- Anti-EBV antibodies if monospot is unreliable
- Lymphocytosis
- Atypical lymphocytosis (comprising over 10% of the total leukocytes at some time in the illness) is most notable
- Elevated LFTs
tx for mono
- Supportive, Bed Rest, Fluids
- No contact sports for approx 4-5 weeks
The decision to return to school should be guided by the level of fatigue and other constitutional sx
Family of viruses that are an important cause of febrile illness in young children
URI symptoms, most notable is severe pharyngitis with tonsillitis and cervical adenopathy
Over 50 types, very common in early life
Occurs in winter and spring, especially in day care and schools
Adenovirus Pharyngitis
s/s of adenovirus?
tx?
- Pharyngitis MC
- F and adenopathy are common
- May have tonsillar exudate - Can be indistinguishable from strep throat
- Rhinitis and influenza-like symptoms present
- Conjunctivitis
- Pneumonia
- Mild diarrhea
- Symptoms can last up to 2 wks
- May cause pneumonia
tx: supportives
- age-specific viral syndrome characterized by acute laryngeal and subglottic swelling, resulting in hoarseness, cough, rsp distress, and inspiratory stridor
- MC 3 months and 3 years of age
- MC in the fall (some can occur in spring)
croup
MCC of croup
- Parainfluenza virus type 1
- Can also be caused by RSV, influenza virus, and adenovirus
- Prodromal of upper rsp tract sx x 1-2 days
- followed by a characteristic cough, which indicates progression of the illness
- cough may be spasmodic, with a deep brassy cough (non-productive, high pitched), or a harsh, barking quality
- Laryngitis with a raspy-sounding, or hoarse voice
- Fever is common
- Spasms of cough can occur at night
- Inspiratory stridor
- mild: stridor noted only when child is agitated
- severe: stridor noted at rest, retractions occur, air hunger and cyanosis are present
croup
prevention and tx for pertussis
- DTaP vaccine; Booster dose at age 11
- Abx if found early,
- Erythromycin; Clarithromycin or Azithromycin
- If < 1 y/o: azithromycin
- Bactrim if allergies
indications for prophylaxis for pertussis
- for all household and close contacts of index case and those at high risk for complications
- Most effective < 21 days of onset of cough in the index pt
- Close contacts: living in same household, face to face exposure within 3 ft of sx pt, direct contact with rsp, oral, or nasal secretions, sharing confined space for at least 1 hour
- Same medications: azithromycin
MCC of bacterial pneumonia for children >6 months?
< 6mo?
- s. pneumo
- C. trachomatis
w/u for pneumonia
- clinical
- Elevated WBC count
- Lobar consolidation on radiograph
Follow up if outpatient in 24-72 hours
tx for bacterial pneumonia
- < 3 mo and febrile: Admit, Ampicillin + Gentamicin
- Afebrile, 1-6 mo w/ C. trachomatis: Azithromycin
- 6m - 5 y/o: Amoxicillin; Cefdinir (or other 3rd gen cephalo) or macrolide if allergic
Mycoplasma Pneumonia MC in who?
> 5y/o
s/s of Mycoplasma Pneumonia
- Fever, cough, HA, and malaise
- Cough dry at first, then progresses to productive cough
- Sore throat, otitis media, otitis externa
- Dec breath sounds, dullness to percussion
- Extrapulmonary involvement of blood, cns, heart, skin, and joints can occur
- Erythema multiforme type rash
tx for m. pneumonia
azithromycin
- Rarely seen in US due to immunizations
- Exposure 9-14 days previously
- High fever and lethargy
- Sneezing, eyelid edema, tearing, cough, coryza, conjunctivitis
- Photophobia
- Koplik spots
- Discrete maculopapular rash begins when respiratory sx are max - Spreads quickly over face and trunk, coalescing to a bright red
Rubeola (measles)
Vaccine given within ? hours if exposed to person with measles (patients over 6 months)
72
when is rubella infectious?
5 days before and 5 days after rash
- 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
complications of rubella in the first 4 months of pregnancy:
- Growth retardation
- Cardiac anomalies (VSD, PDA)
- Ocular anomalies (cataracts, glaucoma, retinitis)
- Deafness
- Cerebral disorders
- Hematologic disorders
- Hepatitis, osteomyelitis, diabetes
cause of Erythema Infectiosum (Fifth’s Disease)?
Parvovirus B19
Spread is respiratory, occurring in winter-spring epidemics
- Nonspecific, mild flu-like illness occurs for 7-10 days,
- 1st sign - rash - raised, fiery red maculopapular lesions on the cheeks; “slapped cheek” appearance
- Lesions are warm, nontender, and pruritic
- Forehead, chin, postauricular area, perioral spared - 1-2 days - similar lesions on proximal extensor surfaces of extremities and spread distally in a symmetric fashion
- Central clearing of confluent lesions = lace-like pattern
- Rash fades over several days, but could reappear in response to local irritation, heat, sunlight, and stress
erythema infectiosum - Fifth’s Disease
complications of Fifth’s disease
- Can lead to arthritis, aplastic crisis
- Infection of pregnant women may produce fetal infection with hydrops fetalis.
cause of roseola infantum
HHV-6 or 7
- Mild lethargy, irritability
- Dissociation between systemic sx and febrile course
- URI sx
- If rash appears it coincides with lysis of fever and begins on the trunk and spreads to the face, neck, and extremities
- Rose-pink macules, or maculopapular, 2-3mm in diameter are nonpruritic, tend to coalesce, and disappear in 1-2 days
- Fever is managed with acetaminophen, otherwise benign
Roseola Infantum
cause of Rheumatic Fever
- Acquired form of heart disease
- Group A Strep infection of upper respiratory tract
major criteria of rheumatic fever
- carditis: most serious, valvulitis (MC mitral valve)
- polyarthritis
- sydenham chorea
- erythema marginatum
- subcutaneous nodules: 2cm, nontender, movable, MC joints, scalp, and spinal column
minor criteria for rheumatic fever
- h/o rheumatic fever or rheumatic heart disease
- polyarthralgia
- fever
- elevated ESR,CRP, leukocytosis
- s/s strep throat infection
diagnostic criteria/scoring to dx rheumatic fever
Two major or one major and two minor manifestations are needed for the diagnosis
tx for rheumatic fever
- PCN G IM
- ASA or Naproxen (better)
- Sydenham Chorea - self-limited
secondary prevention of rheumatic fever
- Continuous abx prophylaxis until 21 y/o / 10 years from initial acute attack with no recurrence
- PCN G x 21-28 d
- macrolides if penicillin allergy
- monitor closely - Treat sore throats early
An acute, multisystem vasculitis of infancy and early childhood characterized by high fever, rash, conjunctivitis, inflammation of mucous membranes, erythematous induration of the hands and feet, and cervical adenopathy
Peak age is 2nd yr of life
Kawasaki Disease
- Main cause of acquired heart disease in children in US
- No established cause, clinical features suggest an infectious process
Kawasaki Disease
dx criteria for Kawasaki
4 of 5 characteristics have to be present to make dx:
- Fever >5 d - fever always must be included
- Lip or oral cavity changes (lip cracking and fissuring, strawberry tongue, and inflammation of oral mucosa)
- BL, painless, nonexudative conjunctivitis
- unilateral cervical LAD ≥ 1.5cm
- Polymorphous exanthema (maculopapular, erythema multiforme like, and scarlatiniform) - Begins on extremities and moves centrally
- Extremity changes - Redness and swelling of the hands and feet with subsequent desquamation
complications of kawasaki dz
- Myocarditis, pericarditis, valvular heart disease (usually mitral or aortic regurgitation), coronary arteritis, MI, arrhythmias
- Can develop coronary aneurysms
tx for kawasaki dz
- Baseline Echo if suspected
- Initial tx: IVIG infusion x 8-12 hrs
- High-dose ASA divided 4x daily reduces length and severity
- Reduce dose when fever subsides so platelet count can return to normal
- Continue ASA if aneurysms - IVIG 2 g/kg x1 and ASA can prevent coronary artery lesions
- Steroids if ASA and IVIG both fail
kawasaki dz LT mgmt based on levels?
- Level 1 - PCP
- Level 2 - Ped. Cardiologist q 1-2 yrs w/ stress test
- Level 3 - daily lose dose ASA and annual echo
- Level 4 - low dose ASA and warfarin, angiography after disease subsides, modify physical activities
- Level 5 - ASA, warfarin, and possible bypass graft surgery, modify physical activities
