Fever Paeds Flashcards
A child presents with fever, cough and a runny nose. O/E = Unremarkable. What is the most likely Dx?
- Common Cold (Corzya)
Dx = Clinical
Tx = Symptomatic relief
Prognosis = Self-resolving with cough persisting for up to 4 weeks
A 6y/o presents with a Fever >38 degress and a sore throat but no cough. O/E you notice swollen and tender Anterior Cervical Lymph nodes and Tonsillar swelling. No rash is present. What is the most likely Dx and how should you Tx?
- Viral Throat infection
- Bacterial Throat Infection
- Scarlet fever
- Infectious Mononucleosis
- GABHS (Group- A Beta-Haemolytic Strep)
This patient has a Centor score of 5 making GABHS most likely.
- Centor score 0/1 suggest viral infection (Adeno, Entero, Rhino or EBV) with supportive therapy indicated
- Centor score 2/3 warrants further Ix with a Throat swab for culture. if positive, Tx as bacterial and if negative Tx as viral
- Centor score of 4 or more indicates antibiotic therapy with culture for sensitivity and confirmation of pathogen (GABHS = most common - others include HiB and Maroxella Catarrhalis)
Scarlet fever would present with a characteristic diffuse papular rash 1-2 days after onset of fever (Scarletiniform rash)
Tx for GABHS
1st line = Penicillin avoiding Amoxicillin due to risk of rash if Infectious Mononucleosis
2nd line = Macrolide
Fungal infections are typically only seen in the immunosuppressed.
1st line Tx = Nystatin
2nd line Tx = Fluconazole
8 month old baby presents with fever, anorexia and irritability. O/E the tympanic membrane is red, buldging and lacks the light reflection. What is the most likely Dx?
- Acute Otitis Media
- Otitis Media with effusion
- Acute Otitis Media
Viral = RSV, Adeno and Rhinovirus Bacteria = Pneumococcal, HiB and Maroxella
Otitis media with effusions is more common in those aged 2-7yrs and the tympanic membrane is typically retracted with a fluid level
How do you manage Acute Otitis Media?
1st line = Paracetamol or Ibuprofen for symptomatic relief
2nd line = Oral Amoxicillin
- Give straight away if <6 months
- Delay until follow-up if >6 months as most cases resolve spontaneously
3rd line = Tympanocentesis if severe pain or antibiotics fail
Complications of Otitis media?
- Mastoiditis and Meningitis = uncommon with Tx
- Hearing deficits can lead to speech and language development issues
How do you manage recurrent Otitis media/URIs
Grommet insertion
A 3y/o presents with fever, nasal congestion, cough and is complaining of pain under their eyes. What is the most likely Dx? O/E the throat appears normal.
- Rhinitis
- Sinusitis
- Common Cold
- Pharyngitis
- Sinusitis
This could be a common cold or Rhinitis but the pain/pressure under their eyes suggests Sinusitis.
Given the fever, this would suggest Viral Sinusitis which is more common in children of this age. Viral sinusitis typically lasts <10 days, is associated with fever, sore throat +/- cough and myalgia. This is managed with rest, hydration and symptomatic relief with Para/Ibu and decongestants such as oxymetazoline
Bacterial Sinusitis can superimpose upon viral sinusitis. Bacterial Sinusitis typically lasts more 10 days with the patient becoming acutely unwell or deteriorating after an initial period of recovery. In this case, a nasal endoscopy for culture should be conducted for MC&S.
1st line Tx = Ben-Pen (Co-Amox if acutely unwell, Clari or Doxy if penicillin allergy)
2nd line = Co-Amox
A 3 y/o presents with fever, anorexia + drooling and worsening breathing difficulty with a soft Stridor. A Hx reveals missing vaccinations. What is your most likely Dx and what is your management?
- Croup
- Epiglottitis
- Foreign body
- Tonsillitis
- Epiglottitis
In this case the child is missing the HiB vaccination which is the causative pathogen in the majority of cases. The Fever, breathing difficulty, soft stridor and drooling is also classical Epiglottitis.
Croup would present with a seal-like bark that is worse upon excitation and a harsh stridor.
Management
1. Refer to ITU/Theatre
2. 1st line = Emergency Laryngoscopy in theatre
- Dx = Inflammation of Supraglottic structures
(Seen as thumb-print sign on XR of the neck)
- Tx = Establish airway and give Oxygen (May require intubation or Surgical airway)
- Adjuncts = Corticosteroids and Racemic Adrenaline for compromised airway
3. 2nd line = FBC and Blood cultures once airway is secured
- Tx = IV Ceftriaxone for patient and Prophylactic Rifampicin for family if Haemophilus Infleunza
4. 3rd line = Vaccination if not previously
A child presents with fever, sore throat +/- cough, dysphagia and a hoarse voice. O/E there are enlarged, tender antterior cervical lymph nodes. What is the most likely Dx and how would you manage?
- Pharyngitis
- Tonsillitis
- Laryngitis
- Strep Throat
- Laryngitis
Hoarse voice alongside features of URTI suggests laryngitis.
Aetiology = Viral (Rhinovirus, Paninfluenza, Influenza and RSV), Bacterial (S.Aureus, HiB and Maroxella) or Fungal if immunocompromised
Risk factors
- URTI
- Travel to TB endemic areas
- Missing Diphtheria vaccination
- Immunosuppression
Ix
- If bacterial = Throat/nasal swab and sputum culture
- If Diphtheria suspected add blood sample for PCR
- Laryngoscopy if biopsy required
Tx
- Viral = supportive
- Bacterial = 1st line Phenoxymethylpenicillin and 2nd line Erythromycin
- If TB = Isolate and RIPE
- If Diphtheria = Osolate and Phenoxymethylpenicllin or Erythromycin + Diphtheria toxoid
- Adjuncts = Mucolytic (Guaifenisin) and cough suppressant (Codeine Phosphate)
A 12 month older baby was brought into the hospital by her mother with a fever and swollen neck/face. They have recently returned from visiting family in Pakistan and thus missed the child’s 12 month vaccinations. What Dx should you be most concerned about and what is the Ix?
- Mumps
The MMR vaccine is given at 12 months
Mumps presents with general viral symptoms, swollen Lymph nodes and Parotid glands giving the appearance described hear.
The test for Mumps is Salivary IgM/PCR
Other tests which can be conducted are a USS of the Parotids and local lymph nodes for Parotitis and DDX (Sialadenitis or URTI) and a CT head/LP if there are signs of Meningitis/Encephalitis
Tx is supportive with Vaccination of child
A child presents with abdominal pain, bloating and diarrhoea. They say that everything gets better after going to the toilet but they don’t ever feel like they go fully relieve themselves. O/E = Normal. What is the most likley Dx and what is your managemnt?
- IBD
- IBS
- Constipation
- Coeliac’s
- IBS
- Bloating, tenesmus and relief upon defaecation is characteristic of IBS. This patient presented with diarrhoea but they can also have constipation
- However, IBS is a Dx of exclusion and so CRP and Faecal Calprotectin for IBD and Serology (Anti-tTG/EMA) for Coaliac’s should be conducted before Dx made. If infection suspected, blood cultures and stool samples may be required.
- Tx = Diet modification (avoid fructose, lactose and caffeine + high fibre and hydration) + anti-diarrhoeals/laxatives depending on GI motility
What is the difference between UC and Crohn’s?
- Crohn’s = Crampy abdominal pain and diarrhoea that is rarely bloody +/- mucous. Children also tend to present with growth retardation. Erythema nodusum may be present.
- UC = Colicky abdominal pain with bloody diarrhoea and PR bleeding. Growth retardation is uncommon and Eryhtema Nodosum is not seen
Describe the Tx of Crohn’s?
1st line = Induce remission
• Enteral nutrition with whole protein modular feeds if concerned about growth defects/side-effects of drugs
• Drugs
o Oral prednisolone or IV Hydro (ONLY Tx FOR EXACERBATIONS OR SEVERE PRESENTATIONS)
Budesonide if traditional steroids refused/contraindicated or distal ileum, ileo-caecal or right sided disease
• Explain there are fewer side-effects but is less effective
• DO NOT OFFER FOR SEVERE PRESENTATIONS OR EXACERBATIONS
o ASA if steroids refused/contraindicated
Explain they are less effective
DO NOT OFFER FOR SEVERE PRESENTATIONS OR EXACERBATIONS
o Add Azathioprine or 6-Mercaptopurine if:
2 or more exacerbations in previous 12 months or steroids cannot be tapered
ASSESS TMPT ACTIVITY BEFORE ADMINISTRATION
o Biologics (Infliximab or Adalimumab) if above fails to induce remission
• Surgery
o Consider if disease limited to distal ileum and have growth retardation or refractory disease
- 2nd line = Maintain
• Follow-up if maintenance refused
• Azathioprine or mercaptopurine monotherapy following drug therapy
o Methotrexate if TMPT deficient or intolerant to above
o Add metronidazole if surgical remission
o PACES Counselling
- Explain the diagnosis (a disease with an unknown cause that causes inflammation of the digestive system leading to malabsorption and bloody diarrhoea)
- Explain that it is a life-long condition and there is always a risk of relapse
- Reassure that there are many medications that can be used to settle down the inflammation any time it flares up (and explain that they will be seen by a gastroenterologist)
- Explain complications (malabsorption and bowel cancer)
- There is no special diet but you may find that certain foods will make it worse
- Support: Crohn’s and Colitis UK
What is the management of UC?
o UC (Induce remission and then maintain)
- Assess severity using PUCAI (Paediatric Ulcerative Colitis Activity Index)
• Severe >65
• Mild-moderate 10-64
- Mild-moderate proctitis/proctosigmoiditis
• Induce
o 1st line = Topical Aminosalicylates (Mesalazine)
Oral if they decline 1st line but explain this is less effective
o If no response after 4 weeks, add Oral Aminosalicylates
o If further Tx, add Oral or topical corticosteroid
o Consider adding Tacrolimus if still no response
• Maintain
o Topical +/- oral ASA
Oral inferior to topical as stand-alone
o Oral Azathioprine or mercaptopurine if:
2 or more exacerbations within a year requiring steroids
ASA remission failure - Mild-moderate left-sided
• Induce
o 1st line = Topical Aminosalicylate
Oral if they decline 1st line but explain this is less effective
o If no response after 4 weeks + high-dose oral Aminosalicylates or switch to high-dose oral Aminosalicylates + Oral Corticosteroid
o Consider adding Tacrolimus if still no response
• Maintain
o Oral ASA
o Oral Azathioprine or mercaptopurine if:
2 or more exacerbations within a year requiring steroids
ASA remission failure - Mild-Moderate Extensive
• Induce
o 1st line = Topical and Oral Aminosalycylate
o If no response after 4 weeks
Stop Topical
Continue oral and add oral Corticosteroid
o Consider adding Tacrolimus if still no response
• Maintain
o Oral ASA
o Oral Azathioprine or mercaptopurine if:
2 or more exacerbations within a year requiring steroids
ASA remission failure - Further Treatments
• Biologics if azathioprine fails
o Infliximab, Adalimumab an Golimumab (Anti-TNF α) - Severe - EMERGENCY
• MDT assessment including Paeds gastro
• Asses likelihood of surgery and give IV steroids
o IV Ciclosporin or Surgery if steroids declined or contraindicated
o Add IV Ciclosporin to steroids if no improvement after 72hrs or worsening
o Use infliximab if Ciclosporin contraindicated
• Factors increasing likelihood of surgery
o >8 stools per day
o Pyrexia
o Tachycardia
o Dilation on AXR
o Low albumin or Hb
o High Plt or CRP
• Maintenance
o Oral Azathioprine or Mercaptopurine
ASA if above contraindicated or intolerable
- PACES Counselling
- Explain the diagnosis (condition with unknown cause that leads to inflammation of the bowel, which leads to symptoms)
- Explain that it isn’t common but is a well-known disease
- Explain that there is no cure and it is a condition that tends to come and go in flare-ups every so often
- Reassure that there are medications that can be used to reduce the likelihood of flare-ups and to treat flare-ups when they happen
- Explain the complications (growth issues, bowel cancer and surgery)
- Explain that they will be seen by a gastroenterologist
- Support: Crohn’s and Colitis UK
A 1 y/o girl presents with fever, reduced appetite and lethargy. Temperature = 38.5, HR 160 and RR 45. She scores an orange on the NICE traffic light system and so is admitted. O/E normal cap refill, Tachypnoea and Tachycardia, genitalia normal. You perform the following tests: FBC, CRP, U&E, LFT, Blood cultures and Urine for dip and MC&S. CRP is raised the urine dip is positive for nitrates but negative for leukocyte esterase. Blood cultures and Urine MC&S are not yet available. What is your most likely diagnosis and what is your management?
UTI (Most likely pyelonephritis given the fever as Cystitis tends not to have one)
Epi
- 3-7% of girls and 1-2% of men have a UTI by age 6yrs (10-30% have reoccurrent)
- Up to 50% of cases have a congenital malformation
- Risk factors include defective barrier function (trauma), impaired voiding (congenital malformations) and reduced voiding (dehydration)
Path
o E.Coli accounts for 85-90% of paediatric UTI cases
o Proteus Mirabilis = 2nd most common and up to 30% of cases in boys
- Boys > Girls
Pathogens associated with abnormal structures
- Klebsiella aerogenes
- Enterococcus Faecalis
- Pseudomonas
S.Saprophyticus common among young women with normal structure
Presentation
- Younger children present with Fever + non-specific symptoms associated will illness.
- You may also find the parents complain of foul smelling urine
- Older children with present with classical symptoms of Fever, loin/groin pain, increased frequency, Dysuria and Dysparunia (if sexually active) and potentially resent onset incontinence
Lower UTI = May be afebrile (Cystitis) + Urinary symptoms due to irritation of the epithelium = FUND (Small amounts of haematuria may be present)
Upper UTI = Fever and rigors (rigors are associated with gram -Ve bacteraemia)
+ Often have lower urinary symptoms = FUND (These can precede fever)
Management
- Full Hx and exam (NICE traffic light approach)
- FBC and CRP
<3 months = Immediate referral to paediatrician with MC&S and Empirical Tx
3 months – 3 years = Dipstick
o Both Nitrite and Leucocyte -ve = do not treat and send MC&S
o 1 or both +Ve = Tx empirically and send urine for MC&S
>3yrs = Dip-stick
o Nitrate +Ve = Tx empirically as UTI, send urine for MC&S and adjust once MC&S back
o Esterase +Ve, Nitrite -Ve = Tx empirically if good clinical evidence, send urine for MC&S and adjust once MC&S back
o Both -Ve = UTI unlikely AND DO NOT MC&S (Blood and protein +Ve = suspect other Dx)
For all
- Blood culture if sepsis/bacteraemia
- USS if structural abnormality suspected (atypical or recurrent UTI)
Lower UTI (Cystitis) < 3 months o IV Ceftriaxone + Amoxicillin as sepsis cover until tests results are back
Lower UTI 3 months – 15yrs
o Trimethoprim if low resistance risk or Nitrofurantoin if eGFR>45 or Penicillin allergy
2nd line if no improvement within 48hrs or 1st line unsuitable = Nitrofurantoin if no previously used or Amoxicillin if culture and sensitivity back or Cefalexin (1st line in areas of trimethoprim resistance)
Pregnant = Same as 3months - 15yrs but no Trimethoprim
Upper UTI (Pyelonephritis) 3-15yrs o 1st line = Cefalexin or Co-Amox (if culture and sensitivity) or IV Beta lactamase stable Beta-lactam if oral administration unavailable o 2nd line = Consult local microbiologist
Upper UTI 16+ yrs
o 1st line = Cefalexin or Co-Amox (if culture and sensitivity) or IV Cefuroxime if oral unavailable
o 2nd line = Consult Microbiologist
Duration of Tx
- Uncomplicated and Women = short course (3 days)
- Complicated or >7 days of symptoms = long course (7 days)
Catheter associated
• IV Aminoglycoside before removal of catheter
• Refer to specialist
• Do not recatheterise unless there is a good indication
Recurrent = Prophylaxis (essentially with Cystitis regime)
PACES Counselling o Explain what the issue is and Tx o Explain ways to reduce risk - Good hygiene - Hydration - Regular and full voiding o Explain some red flags
Urinary Tract Abnormalities
- Vesicoureteric Reflux
o Aetiology
- Developmental anomaly whereby the ureters enter the bladder more laterally and at less of an angle with a shorter or absent intramural (within the bladder wall) course
o Path
- Reflux of urine back up the ureter during voiding
- In severe cases, this causes dilation of the ureter and renal pelvis, clubbed calysces and intrarenal reflux (reflux of urine from the collecting ducts into renal tubules)
o Presentation
- Recurrent or atypical UTIs
- Incomplete voiding
- Signs of CKD in more advanced disease due to renal scarring secondary to the reflux
