ID Flashcards
what are the congenital infections?
CHEAP TORCHES Chicken pox Hepatitis B, C, E Enterovirus Aids Parvovirus B19
Toxoplasmosis other (zika etc) Rubella CMV HSV every other STD Syphilis
what is the most common congenital infection?
CMV
what is the most common cause of acquired hearing loss in childhood?
CMV
what are the manifestations of CMV
KEY- IUGR, hepatosplenomegaly, thrombocytopenia, microcephaly, periventricular calcifications SNHL, chorioretinits
general- IUGR, prematurity
skin- petechia, purpura, ecchymoses, jaundice
hematopoietic- thrombocytopenia, anemia, splenomegaly
hepatobiliary- hyperbola, elevated ALT, hepatomegaly**
CNS- microcephaly, seizures, periventricular calcifications**
eye- Chorioretinitis, strabismus, optic atrophy, micropthlamia
ear- sensorineural hearing loss
more common presentation: thrombocytopenia, petechiae, may have hepatomegaly
severe end of the spectrum: microcephaly, Chorioretinitis, hearing loss, periventricular calcifications
what type of calcifications are seen with CMV? zika? toxo?
CMV- periventricular calcifications
Zika- subcortical calcifications
toxo- intraparenchymal calcifications
HIV- basal ganglia
what is the treatment for congenital CMV
moderate to severe (multiple manifestations or CNS involvement)- treat with oral Valganciclovir (within the first month) for 6 months
- monitor neutrophil count and ALT
newborn infant with microcephaly, club foot, dislocated hips, chorioretinal scars. what is the cause?
zika
what type of virus is zika
how do you get zika
flavivirus
mosquito- borne (aedes mosquitos)
clinical manifestations- 75-80% are asymptomatic
what are the features of congenital zika syndrome
KEY- microcephaly, brain malformations, subcortical calcifications, macular scars, contractures
microcephaly with partially collapsed skull
thin cerebral cortices with subcortical calcifications
macular scarring with focal pigmentary retinal mottling
congenital contractures (arthrogryposis, club foot, congenital hip dislocation)
early hypertonia
Neuroimaging: diffuse, subcortical calcifications ventriculomegaly hypoplasia of corpus callous decreased myelination cerebellar vermis hypoplasia
what is the congenital anomaly risk of zika in pregnancy?
5-10% overall
higher risk in first trimester versus 3rd
how do you make an antenatal diagnosis of zika?
serology (IgM, IgG, PRNT)
- PRNT is confirmatory test
have to do Dengue serology at the same time
PCR in blood and urine
- remains positive for 3-7d after symptom onset
what is the workup for zika in a newborn
serology
- IgM and IgG, dengue IgM and IgG
if positive then PRNT
(zika IgM on CSF)
PCR
- placental and umbilical cord tissue
- serum, urine, CSF (if LP done)
do not use cord blood due to possible contamination with maternal blood
how is congenital zika virus confirmed
zika PCR in any specimen from child
highly likely
- detection of zika by PCR from placenta
- zika IgM reactive in baby
positive IgG or PRNT may reflect transplacental maternal antibody
newborn with maculopapular rash (including soles), microcephaly, Chorioretinitis, hepatosplenomegaly, bony changes. what is the most likely diagnosis?
syphilis
what are the manifestations of congenital syphilis
Main ones- snuffles (often bloody), pseudo paralysis, rash involving palms and soles, body changes
general- prematurity, IUGR FTT
mucocutaneous- snuffles **, maculopapular rash followed by desquamation, blistering and crusting, condyloma late
rediculoendothelial- hepatosplenomagly, lymphadenopathy
hematologic- Coombs negative hemolytic anemia, thrombocytopenia
skeletal- pseudo paralysis, oseochonritis diaphysial periostitis, demineralization.destruction of proximal tibia metaphysis, osteitis
neurologic- aseptic meningitis, hydrocephalus, cranial nerve palsies
eyes- salt and pepper chorioretinitis
late onset manifestations of syphilis
prob not that impt
saddle nose deformity hutchinson's teeth mulberry molars ragades(linear scars( saber shins global developmental delay hydrocephalus seizures cranial nerve palsies sensorineural hearing loss
when should you evaluate for syphilis (6) * impt to know
- signs and symptoms of congenital syphilis
- mother not treated or treatment not adequately documented
- mother treated with non-penicillin regimen
- mother treated within 30 days of child’s birth
- less than 4 fold drop in mother’s non-treponema titre or not assessed or documented
- mother had relapse or reinfection after treatment
what is the evaluation for a child with suspected congenital syphilis (7)
physical exam (must have audiologic testing and an eye exam)
CBC
LFTs
serology
lumbar puncture- to see if there is CNS disease (if so must be repeated in 6 months)
skeletal survey (primarily looking at long bones)
direct detection- dark field microscopy/direct fluorescent Ab
what is the treatment of congenital syphilis
10-14 days of IV Pen G
asymptomatic, mother adequately treated- close clinical follow-up
two month old term infant, asymptomatic at birth. Now hypotonic and macrocephalic. what is the cause?
toxoplasmosis
what are 3 investigations to confirm toxoplasmosis?
serology- IgM/IgG/ IgA
PCR on CSF, serum, urine
placental pathology
what is seen on LP with toxoplasmosis?
lymphocytic pleocytosis
elevated CSF protein (often very high)**
what is the classic triad for toxoplasmosis?
HCC
hydrocephalus
cerebral calcifications (intraparenchymal calcifications)
chorioretinitis
toxoplasmosis in 3rd trimester- how do they present?
untreated the majority will go on to develop disease
Chorioretinitis most common manifestation
what is the treatment of confirmed congenital toxoplasmosis?
pyrimethamine+ sulfadiazine+ leucovorin x 12 months
- frequent monitoring of neutrophil count
- steroids for eye disease and passively hydrocephalus
- VP shunt for hydrocephalus
how do you diagnose toxoplasmosis:
serology- IgM and IgA can be falsely negative in early infancy
PCR- CSF, blood, urine or tissue samples
cicatrical scars/limb hypoplasia in seen with what congenital infection?
congenital varicella
what are the clinical manifestations of congenital varicella?
KEY- microcephaly, cicatrical scars, limb hypoplasia, Microphthalmia, GERD
skin- cicatrical scars, skin loss, contractors
MSK- limb hypoplasia, equinovarus, abnormal/absent digits
eye- Microphthalmia, cataract, Chorioretinitis
CNS- mental retardation, seizures, microcephaly, bulbar palsy
GI- GERD, duodenal stenosis, microcolon, barret’s esopahgus
GU- poor or absent bladder sphincter function
IUGR
what is the risk of congenital varicella syndrome if maternal VZV during first 20 weeks of gestation?
1%
infant disease by timing of maternal infection with varicella:
first and second trimester
third trimester
perinatal (5d before or 2 d after)
first and second trimester- congenital varicella syndrome
third trimester- herpes zoster in infancy or childhood
perinatal- disseminated neonatal varicella
what is given to mother with exposure to varicella in pregnancy if IgG negative
VZIG within 10 days of exposure
if develops chicken pox= acyclovir
what is the classic triad for congenital rubella syndrome?
“CPS”
cataract
PDA
SNHL
what are the clinical features for congenital rubella syndrome
KEU- IUGR, blueberry muffin rash, hepatosplenomegaly, cataract, bony lucencies, PDA, SNHL
early manifestations: low birth weight hepatosplenomegaly, lymphadenopathy blueberry muffin rash ** hemolytic anemia thrombocytopenia bony lucencies ** (celery stalk appearance)
permanent: SNHL cataract, sal and pepper retinitis, microphthalmia PDA GDD, seizures
what infection is associated wth blueberry muffin rash?
congenital rubella
when do we screen for GBS in mom?
35-37 weeks gestation
what are the indications for intrapartum antibiotic prophylaxis
mom GBS +
GBS status unknown and any of the following:
- previous infant with GBS disease
- intrapartum fever
- membranes ruptured >18 hours
- delivery <37 weeks
- GBS bacteriuria during current pregnancy
what is the appropriate antibiotic for mom for GBS prophylaxis?
penicillin or ampicillin
if mild penicillin allergy: cefazolin (considered adequate prophylaxis for baby)
severe: clindamycin or vancomycin (NOT adequate prophylaxis for baby)
does not prevent late onset GBS disease
what are the risk factors for early onset sepsis in term neonates? (5)
- previous infant with GBS disease
- intrapartum fever
- membranes ruptured >18 hours
- maternal intrapartum GBS colonization during current pregnancy
- GBS bacteriuria during current pregnancy
what are the most common bacterial pathogens in infants
0-28d
29-90d
3-36mo
0-28d: GBS, E.coli
29-90: GBS, E.coli
3-36 mo: Strep pneumo
empiric antibiotics for toxic appearing infants age
0-28
29-90
3-36mo
0-28: Amp + gent or cefotaxime
29-90: ceftriaxone+ Vanco +/- ampicillin
3-36: ceftriaxone + vanco
what is the treatment for suspected HSV disease
isolated mucocutaneous disease
disseminated, CNS
IV acyclovir 60mg/kg/day
isolated mucocutaneous: 2 weeks
disseminated: 3 weeks + 6 months of suppressive oral acyclovir (improves neurologic outcome for those with CNS disease)
do an LP before completion of treatment to show it is negative
what is the workup for suspected HSV?
full septic workup
PCR of vesicle fluids, blood, CSF
LP
what infection should you think of for axillary lymph node?
bartonella henselae
what infection is associated with parinaud oculoglandular syndrome? what is that?
bartonella henselae
swollen cervical lymph node and ipsilateral conjunctivitis
4 year old with a chronically draining cervical lymph node. what is the most likely bug?
atypical mycobacterium
what is on your differential for chronic unilateral adenitis
non-tuberculosis mycobacteria
bartonella
mycobacterium tuberculosis
what is on your differential for acute unilateral adeninitis
staph aureus
strep pyogenes
what is on your differential for acute bilateral adenitis? chronic?
EBV CMV respiratory viruses enteroviruses adenovirus
chronic: EBV HIV Toxoplasmosis CMV
what is the treatment for cat scratch disease (B.henselae)
azithromycin for lymphadenitis (shorten disease)
doxycycline + rifampin for neuroretinitis/CNS disease
* risk highest with kittens
when can a teenager with infectious mono return to sports?
after 3 weeks
highest risk during first 3 weeks of illness
what is the treatment for acute otitis media in a child <2? >2?
<2 years old: amoxicillin x 10 days
>2 years old: 5 days
what are the common pathogens for acute otitis media?
bacteria:
strep pneumonia
hemophilus influenza
moraxella catarrhalis
viruses
what are the antibiotic options for AOM?
amoxil
if mild allergy to amoxil- cefuroxime, ceftriaxone
severe amoxil allergy- azithro, clarithro, clinda
treatment failure- amox-clav or ceftriaxone for 3 doses
what pathogens cause acute bacterial pneumonia
strep pneumo staph aureus strep pyogenies hemophilus influenza mycobacterium tuberculosis
mycoplasma pneumonia
legionella
coxiella= Q fever
when should you consider adding vancomycin for pneumonia?
rapidly progressing multi lobar disease or pneumatoceles
what is the empiric therapy for hospitalized children with uncomplicated pneumonia?
ampicillin
respiratory failure or septic shock- ceftriaxone +/- Vancomycin
what is the treatment for chlamydia pneumonia?
erythromycin
* see eosinophilia
typically presents at 3- 6 weeks
why is antibiotic prophylaxis not recommended for chlamydia trachomatis? what should you do? when do you treat?
due to risk of pyloric stenosis
recommend close clinical follow-up
PCR testing if symptoms
treat if PCR testing is positive
what is empiric therapy for meningitis:
neonate
1-3 mo
>3 mo
neonate: amp+ cefotax
1-3 mo: ceftriaxone + vancomycin +/- ampicillin
ceftriaxone and vancomycin
what bugs do we worry about for meningitis:
neonate
>3 mo
neonate: GBS, e.coli, listeria
>3 mo: strep pneumo, Neisseria meningitidis, hemophilus influenza type b
why do we consider dexamethasone for meningitis?
reduces mortality and hearing loss in meningitis due to hemophilus type and possibly strep pneumonia
* has to be administered before or within 30 minutes of antibiotics
what is the treatment of toxic shock?
cloxacillin + clindamycin
staph aureus, GAS
what is the treatment for skin abscess?
incision and drainage
what is the treatment for skin abscess pending culture results? <1mo 1-3 mo >3 mo with low grade fever or no fever >3 mo significant cellulitis
<1 mo: IV antibiotics (Vanco +/- other agents)
1-3 mo: Septra
>3mo: observe without antibiotics
>3 mo: Septra + cephalexin
what is the treatment for Necrotizing Fasciitis
IV penicillin + clindamycin + surgery consult
associated with GAS and chicken pox
what bugs cause impetigo? tx?
staph aureus
GAS
tx: cloxacillin, cephalexin
when do we do chemoprophylaxis for contacts of invasive GAS disease?
only for CLOSE contacts of CONFIRMED case of SEVERE disease
close contact: >4h per day or >20h per week
share bed, sexual relations, direct mucous membrane contact with oral/nasal secretions
severe disease: toxic shock syndrome, soft tissue necrosis, meningitis, pneumonia, other life threatening conditions
what are some complications of chicken pox?
pneumonia
hepatitis, pancreatitis nephritis, orchitis
thrombocytopenia
Bacterial infections:
cellulitis
soft tissue abscess
necrotizing fasciitis
Neurologic: cerebellar ataxia encephalitis reye syndrome stroke zoster (Ramsay hunt syndrome)
what are some complications of influenza? (5)
otitis media secondary bacterial penumonia myositis encephalopathy/encephalitis reye syndrome
what are some complications of enterovirus?
meningitis encephalitis acute flaccid myelitis myocarditis hepatitis
when should you consider a renal and bladder ultrasound for febrile UTI
recommended for first febrile UTI <2 years of age
VCUG is not indicated after first febrile UTI
what are the indications for VCUG (3)
hydronephrosis on ultrasound
renal scarring
recurrent febrile UTI
when would you consider prophylaxis for UTI?
grade IV-V VUR
if given should be reassessed after 3-6 months
what are the first line agents for UTI prophylaxis?
Septra
nitrofurantoin
if a child has a UTI resistant to prophylactic antibiotics septra and nitrofurantoin what should you do?
STOP prophylaxis
broader spectrum agents not recommended due to risk of infection with highly resistant organisms
what is the treatment for dog bite or human bite? puncture wound of foot with sneakers? no sneakers
PO amox-clav
IV cloxacillin + penicillin
with sneakers (pseudomonas): piperacillin or ciprofloxacin +/- gentamicin
no sneakers (staph aureus): po cloxacillin or keflex
what is the most important organism that causes severe invasive disease in patients with asplenia? other organisms of concern?
strep pneumonia
Neisseria meningitidis
hemophilus influenza
salmonella
capnocytophaga ( if they own dogs*)
What is the organism and vector causing lyme disease? what are 2 antibiotics for the treatment of Lyme disease?
Organism = Borrelia burgdorferi
Vector = black-legged ticks: Ixodes scapularis
Tx: amoxicillin, doxycycline, cefuroxime, IV ceftriaxone
highest rate of baby getting HSV is when mom has what type of lesion
first episode primary (first time getting a lesion)
when should you swab a baby when you are worried about HSV
at 24 hours
if you swab too soon it may just be transient colonization from mom
Mom has first episode of HSV. Babe is born vaginally or by c section after rupture of membranes. What do you do?
treat with acyclovir
if swabs positive- full workup and treatment
if swabs negative- treat for 10 days with IV acyclovir
Mom has first episode of HSV. Babe is born by c section PRIOR to rupture of membranes. What do you do?
do not need to treat empirically with acyclovir
if swabs positive- full workup and treatment
Mom has recurrent HSV. What do you do?
do not need to treat empirically with acyclovir
if swabs positive- full workup and treatment
if mom has herpes labialis what precautions (4)
avoid kissing the baby until lesions are crusted
wear a mask
avoid breastfeeding from breast with active lesions until crusted
skin lesions should be covered in the presence of newborn
Mother has recurrent HSV. There were no active lesion at delivery. For how long after delivery is the infant at risk for PERINATAL transmission?
6 weeks
what is required to consider watchful waiting for acute otitis media
- non-severe illness (mild otalgia, fever <39, responding to antipyretics, mild-moderate TM bulge)
- no underlying conditions of concern
- parents capable of recognizing signs of worsening disease
what is a common complication after chicken pox, especially if older than 12 or pregnant
VZV pneumonia
what is the most common cause of acute flaccid paralysis
enterovirus
also caused by west nile virus
what is the presentation of acute flaccid paralysis
acute focal limb weakness and MRI findings of mainly grey matter lesions involving one or more spinal cord segments
what is the most common presentation of west nile virus
asymptomatic
what is considered mild c. diff? moderate?severe
mild: <4 episodes of diarrhea
moderate: >4 episodes
severe: evidence of systemic toxicity (high grade fevers, rigors)
what is the treatment for mild, moderate, severe c diff
mild: stop antibiotic
moderate: PO metronidazole 10-14 d
Severe uncomplicated: PO vancomycin x 10-14d
Severe complicated: PO vanco + IV metronidazole
what type of hand cleaning is required for c diff
sporicidal agents (chlorine-based) alcohol based hand hygiene will not work for c diff!
what is the treatment for gonorrhea
Ceftriaxone 250 mg IM in a single dose PLUS azithromycin 1 g PO in a single dose
Three year old boy exposed to a suspected case of pulmonary TB in the home. Clinically well, TST negative, CXR normal. How do you treat him?
Start isoniazid now; discontinue in 3 months if still clinically well and repeat TST negative
What is the difference between TB infection and TB disease
TB infection- positive TST
TB disease- clinical symptoms or abnormal CXR
who should be screened for LTBI
contacts of infectious case immigrants from high burden countries children who travelled/resided endemic areas for 3 or more months HIV pre-transplant pre- TNF alpha inhibitors
**testing for TB should not be routine
what is considered a positive TST if less than 5 AND high risk of TB infection
0-4mm
Positive TST >5mm if what conditions
- HIV infection (well)
- Close contact with active contagious case (past 2 years)
- Presence of fibronodulardisease on CXR(healed TB)
- Organ transplant
- TNF-αinhibitors
- Other immunosuppressive medications (e.g. corticosteroids –equivalent of ≥15 mg/day for ≥1 month)
- End stage renal disease
what are 4 reasons for a reactive TB skin test
Mycobacterium tuberculosis infection
Non-tuberculous mycobacteria infection
BCG in past
Incorrect technique (measurement)
what are some causes of a false negative TB test (8)
Incorrect technique Active TB disease Immunodeficiency states Corticosteroids Young age Malnutrition Viral infections (measles, varicella, influenza) Live attenuated vaccines (measles)
what is the treatment for latent TB
Isoniazid for 9 months
OR rifampin for 4 months
OR isoniazid and rifampin for 3 months
what is the treatment for TB disease
Isoniazid
Rifmapin
Pyrazinamide
Ethambutol
which TB medication requires ophthalmology assessment
ethambutol
associated with optic neuropathy (decreased visual acuity, decreased visual fields, color blindness)
what is a common side effect of isoniazid, rifampin and pyrazinamide
hepatotoxicty
- pyrazinamide the most likely to give you hepatotxocity
What is the risk of transmission of HIV in a blood transfusion?
1 in 10 million
The leading cause of HIV infection in women in Canada is?
heterosexual transmission
what is used for chemoprophylaxis after close contact diagnosed with n. meningitidis
rifampin
who should get the HPV vaccine
all boys and girls older than 9 years of age
regardless of sexual activity
who can get 2 doses of HPV vaccine instead of 3
9-14 years of age
children >/= 15 years of age or immunocompromised should get 3 doses!
what are 4 things that HPV vaccine prevents
anal cancer penile cancer vulvar cancer genital warts vaginal cancer oral cancer cervical cancer
HPV 6 and 11 are associated with what
genital warts
When should rotavirus vaccine be given
series needs to be completed prior to 8 months of age
first dose no later than 15 weeks!
up to what age should children get 2 doses of influenza vaccine
2 doses 4 weeks apart
up to 9 years of age, first year getting the vaccine
what age child can receive intranasal influenza vaccine
> 2 y of age
when should Hep A post exposure vaccine be given
HepA vaccine recommended as post exposure prophylaxis (>6 months) and should be given within 2 weeks of exposure
if <6 months of age or vaccine contraindications then give Hep A immunoglobulin
when do you testing on a baby for hep c
between 12-18 months
infant of HCV infected mother, what is the mode of delivery
doesn’t matter! avoid invasive procedures (scalp probe)
no evidence to recommend elective c section
what is the management for rabies exposure
notify public health
domestic animal- can be observed for 10 days to see if there are signs of rabies
wild animal- euthanize and test for rabies
rabies immune globulin into the wound
rabies vaccine series (4-5 doses)
what are the indications of palivizumab?
Children < 12 months of age with CLD of prematurity who require ongoing medical therapy at the start of the RSV season
Children < 12 months of age with hemodynamically significant heart disease
Consider in infants < 30 weeks and < 6 months of age at the start of the RSV season
Consider in infants who live in remote communities and born at < 36 weeks at the start of RSV season
is palivizumab recommended for children hospitalized with RSV?
No, do not need to continue palivizumab
what are the 3 main contraindications to breastfeeding
HIV
Human T-Lymphotropic Virus Type 1/2
what type of mask is required for measles?
N95 mask
it is airborne
what 3 viruses are airborne
measles
tuberculosis
varicella
what is the treatment for cutaneous larva migrans
albendazole
what is the oral rash seen with measles
koplik spots
how do we prevent influenza in infants <6 months of age?
to prevent influenza in infants <6 months of age, the best evidence-based strategy is to administer influenza vaccines during pregnancy.
Pregnant woman in contact with meningococcal meningitis. Tx:
Ceftriaxone
HBe Ag what does it tell you about the person
active viral replication
A child eats at a picnic and develops vomiting and diarrhea four hours later. What is the likely causative organism:
staph aureus
- onset between 1-6h (toxin)
what causes q fever
farm animals
- hepatitis, pneumonia
when can live vaccines be given after high dose steroids
1 month after stopping high dose steroids
gram positive rod in a baby suggests what bug
Listeria
4 indications for VZIG
1) Immunocompromised child with no evidence of immunity or history of varicella or herpes with exposure
2) Immunocompromised child with lesions suggestive of varicella
3) Pregnant with no evidence of infection or immunity
4) Baby born to a mum who gets CP 5 days prior or 2 days post delivery
5) Hospitalized preterm <28 weeks or <1000g who is exposed (regardless of maternal history)
6) Hospitalized preterm >=28 weeks who is exposed, with no maternal immunity
A 10 year old girl presents to your office having arrived in Canada from the Sudan 1 week ago. She complains of fever, headache and sore throat of 48 hours duration.
Name 3 diagnoses on your differential
Malaria
Typhoid
Meningococcemia
What is the antibiotic treatment for acute chest syndrome
3rd generation cephalosporin + macrolide
The most common bug in febrile neutropenia
gram positive organisms
What is pertussis close contact exposure prophylaxis
azithromycin x 5 days or erythromycin x 14 days
What are three high-risk groups for invasive pneumococcal disease?
sickle cell disease
asplenia/hyposplenia
immunocompromised
Child with inguinal adenopathy found 1 week ago by parent while bathing
Give 4 indications for biopsy
- hard
- matted
- > 2cm
- increasing in size over 2 weeks
- no resolution by 4 weeks
- associated with fever, weight loss, hepatosplenomegaly
- if supraclavicular node
what is the treatment for head lice
permethrin 1%, repeat in 7-10 days
they can return to school
- An infant is born to a mother with a history of recurrent genital herpes which was not active at the time of vaginal delivery. For how long after delivery is it possible for this infant to develop herpes:
Most NHSV will present in the first 4 weeks
