ID and Immunization Flashcards
Which is false about Hep C:
- 5% of preg F w/ chronic transmit to infant
- no specific intervention to decrease vertical transmission
- primary dx test performed at 6 mo
- approximately 25% infant clear virus spontaneously
Primary dx test is HCV serology and done at 6 months of age.
** HCV serology not reliable in infancy because mother’s antibodies. Test at 12-18 month; repeat at 18 month if (+).
Note: testing at any age negative= don’t need to repeat.
If sero-(+) at 18 month= infected with HCV.
Recurrent HSV mom with lesions on labia at delivery. Delivered via C/S. Asymptomatic. When do you do surface swab:
- after 24 h
- immediately at birth
- within first 4 h
- < 12 h of age
24 h or later
What are the congenital infections?
CHEAP:
- chicken pox
- Hep B, C, E
- Enterovirus
- AIDS
- Parovirus B19
TORCHES:
- Toxoplasmosis (Big Cat/ C’s)
- Other (Zika)
- Rubella (Blue eyes + ears + heart)
- CMV (Draw the face+ Crown)
- HSV
- Every other STD
- Syphilis (the S’s)
What is the most common congenital infection?
CMV
What % of kids with CMV who are asymptomatic get permanent sequelae later?
15%
T or F: Most congenital CMV is symptomatic.
False (85%= asymp)
Describe key congenital CMV features:
CMV Draw a face with a crown. - C= chorioretinitis - C= ears= Deafness - M= Crown= MR and microcephalic - V= periventricular Ca2+
T or F: Congenital CMV treated w/ valganciclovir associated with improved hearing and neurocognitive skill at 24 months.
True
When do you treat congenital CMV? Tx with what? Monitoring?
- symptomatic w/ CNS, B/L sensorineural hearing loss or Chorioretinitis
- Tx: valganciclovir x 6 months
- Monitor toxicity:
CBC (neutrophil), Cr - Stop therapy if ANC < 0.5
- Long term F/U hearing + neurocognitive
Maculopapular rash on palm + sole. Chorioretinitis. Bony changes?
- Toxo
- Rubella
- CMV
- Syphilis
- HIV
Syphilis
List Syphilis Findings:
Syphilis= S’s
- snuffles
- salt + pepper chorio
- soles + palm rash
- stupid bones
Early:
- Snuffles
- Chorioretinitis “salt and pepper”
- Maculopapular palsm + soles
- HSM
- Bones: pseudo paralysis, osteochondritis, diaphysial periostitis
Late:
- GDD
- hydrocephalus
- chorioretinitis, glaucoma
- hearing loss
- saddle nose, frontal bossing, high arched palate
- Hutchinson’s teeth
- mulberry molars
- Linear Scars
Syphilis Preg F. RPR 1:128. Given 1 dose IM pen after RPR drop 1:64. Drop to RPR 1:32. Management for BB who has normal p?E:
- no tx as mom tx good
- full W/U = LP + 10d IV pen irregardless
- full W/U = LP + 10d IV penicillin if abN W/U
- full W/U= LP + single dose IM pen if abnormal
Goal: 4X RPR preg F drop
If not= W/U= LP
+ 10 d IV penicillin
When do you consider tx for a pt for congenital syphilis?
- Mother not treated
- Tx with non-pen regiment
- Tx within 30 d of child’s birth
- < 4X drop in mother’s non-treponema titre
- Infant has signs + symp of congenital syphilis
= TX FOR SYPHILIS (pen x 10d)
What is your W/U for congenital syphilis?
- **P/E
- **BW: CBC, LFTs
- **Syphilis serology (non treponemal and treponemal)
- Direct detection (dark field microscopy)
- **Skeletal Survey
- ** LP (even if asymp; test treponemal and non treponemal serology; if + repeat in 6 mo.)
What do you do if you have an asymptomatic pt whose mother’s RPR fell 4X or greater in preg?
If material RPR Fall 4X
** Check infant RPR!
= Non reactive or infant RPR < mother and asymptomatic
= No Tx
= clinical + serology F/U to 18 months
IF Infant RPR 4 fold or higher than maternal or symptomatic= full evaluation + Tx
What is Tx for Congenital Syphilis
IV pen G 10-14d
Macrocephaly/ Hydrocephalus + Cerebral Calcification + Chorioretinitis. Which TORCH?
“BIG Cat/ C’s”
- Big Brain= Hydrocephalus/ macrocephaly
- Cerebral calcifications
- Chorioretinitis
Note: LP= lymphocytic pleocytosis + high protein
How do you dx and treat congenital Toxo?
Dx: PCR (CSF, Blood, urine, tissue)
Tx: pyrimethamine + sufladiazine + leucovorin x 12 months
Monitor: Neutrophil
List Congenital Rubella Features?
BLUE EYES + EARS + HEART + BONES
- Blueberry rash
- Cataracts (blue eyes)
- Bony lesions
- Hearing (SNHL)
- PDA
Name congenital VZV (Varicella) features?
Microcephaly
Scars
Limb hypoplasia
GERD
Name congenital Zika features?
Microcephaly
Brain malformations
Macular scar
Contracture
Which TORCH infection has MACROcephaly?
BIG CAT/ C’s
- big head= hydrocephalus + macrocephaly
- chorioretinitis
- parenchymal Ca2+
T or F: highest risk period is during T3 for zika virus.
False.
affect brain
= T1 + T2
W/U: zika serology and PCR on mother + baby
If (+)= imaging (US and MRI)
Which TORCH infection has cataracts?
Rubella
Blue eyes
Blue ears
Blue heart
Blue bones
Which TORCH infection has snuffles?
Syphilis
All the S’s-
- snuffles
- salt + pepper chorio
- soles + palm rash
- stupid bones
Which TORCH infection has IUGR?
All
Which TORCH infection has a PDA open?
Rubella
Blue eyes
Blue ears
Blue heart
Blue bones
What are indictions for intrapartum Abx prophylaxis for GBS?
(+) GBS screen (35-37 week GA)
Unknown GBS AND
- previous infant GBS dx
- GBS bacteriuria in current preg
- Delivery < 37 week GA
- ROM min. 18 h
- Intrapartum fever (>38)
Which Abx do you give for GBS preg F prophylaxis? Which are “adequate” coverage?
1= Penicillin
Goal: 4h min. pre birth
#3= Severe= Clinda or vanco ** these are not considered efficacious
T or F: you should still give GBS Abx prophylaxis if BB born via C/S before ROM.
False.
As does not reduce risk of late onset dx.
T or F: GBS preg F prophlyaxis has decreased the rate of late onset dx?
False.
RF for early onset sepsis in TERM neonate?
- maternal GBS
- GBS bacteriuria during current preg
- previous infant w/ invasive GBS dx
- ROM min. 18 h
- maternal temp (min. 38C)
+ GBS mom + no other RF + adequate Abx. BB Tx?
Routine care
+ GBS mom + no other RF + inadequate Abx
Close observation= observe 24-48h (VS q3-4h)
R/A
Counsel pre d/c
+ GBS mom + other RF (irregardless of IAP)
Min observe 24-48h VS q3-4h Consider CBC at 4h R/A Counsel pre d/c
(-) GBS and no RF
Routine Care
(-) GBS and 1 RF
Good Abx= Routine
Bad Abx= examine at birth, observe 1-2d, VS q 3-4 h, R/A and counsel pre d/c
(-) GBS and 2 RF
Min observe 24-48h VS q3-4h Consider CBC at 4h R/A Counsel pre d/c
When does CPS state you consider CBC at 4 hours for early onset sepsis?
GBS (+) and other RF
GBS (-) and two RF
Fever in 0-28d:
Full Septic W/U
Admit
Abx
Fever 29-90d
Well= Assess “Risk”
Low risk = past term = non toxic = no focal infection (except AOM) = WBC 5-15 = Absolute Band < 1.5 = Urine < 10 WBC per high field = Stool (if diarrhea) < 5 WBC per high field
Empiric Abx for Fever for without source:
0-28d
29-90d
3-36 month
< 1 mo= Amp + Gent
If meningitis= Cefotax
29-90d = Cefotax + Vanco (incase strep pneumoniae or staph aureus resistance)
+/- amp (listeria)
3-36 month= Ceftriaxone + Vanco
What is the most common HSV presentation in a neonate?
Skin, eye, mouth= 45%
- usually at DOL 10-12
- encephalitis= 30%
Usually ppt 2 wk + - disseminated= 25%
Usually DOL 10-12
T or F: most neonates with disseminated HSV have neurologic sequelae?
True
T or F: most neonatal HSV infection ppt within 1st wk of life?
False.
Mainly= 1.5 wk-2 wk.
Skin, Eye, Mouth= DOL 10-12
Encephalitis= DOL 16-19
Disseminated= DOL 10-12
T or F: < 10% of kids with CNS dx have skin lesions.
False.
Yes 60% have skin
but 40%!!! have none.
T or F: you only do LP in suspected/ sympatomic HSV dx?
False.
Do LP even if well or only skin, eye, mouth.
What is the W/U for suspected HSV dx?
Culture/PCR
- vesicle fluid
- nasopharynx
- eyes
- urine
- stool
- blood
- CSF (must do LP)
Wha is the Tx for suspected HSV dx?
IV acyclovir
2 wk= SEM
3 wk= CNS, disseminated
Repeat LP at end point to ensure still (-).
+ 6 mon. suppressive PO if CNS dx to improve neuro outcome.
G1 recurrent HSV-2. Lesions at delivery. Well baby. Tx?
- surface swab, blood, CSF; start IV acyclovir
- surface was, no Tx until PCR return
- surface swab, IV acyclovir pending PCR
- no need for swab for recurrent dx; watch clinically
Surface swab
No treatment until PCR return
List RF for HSV transmission from mom?
- Type: First primary > 50% transmission
- Type: HSV-1
- Mode of Delivery: C/S reduce risk
- ROM: > 6h
- Instruments: fetal scalp monitor, forceps etc.
T or F: most women who have HSV-infected newborn have hx of genital herpes.
False.
Asymptomatic infant
+ active lesions at birth
TEST ALL
= Surface swab (mouth, nasopharynx, conjunctiva, anus)
recurrent= at ~24h of life
+/- blood
Tx: > 1st episode SVD or C/S after ROM = Empiric Acyclovir If (+) Test= W/u + Tx If (-)= complete 10 d
> 1st episode and C/S prior to ROM= no Tx
If (+) Test= W/U + Tx
> Recurrent episode
= No Tx
If swab/blood (+) then W/U and Tx.
What is the difference between 1st episode primary and 1st episode non primary maternal HSV infection?
1st primary
= no antibodies
1st non-primary
= new infection with one HSV in presence of antibodies to other type
Toxic appearing 4 y.o w/ pneumonia. O2 requirement. Tx?
- ceftriaxone
- ceftriax + vanco
- ceftriax + azithro
- amp
- amp + vanco
Ceftriaxone + Vanco
Description = rapidly progressing multi-lobar dx or pneumatocele
= Add Vanco for MRSA and extra strep-pneumoniae coverage!
Most common cause of acute bacterial pneumonia? Others?
Streptococcus pneumoniae
Other:
- staphylococcus aureus
- streptococcus pyogenes
- Haemophilus influenzae
- Mycoplasma pneumonia
- Chlamydia pneumoniae
- Mycobacterium TB
- Viral: RSV, Influenza, Adeno, Parainflu, hmpa, Coronavirus etc.
When is vanco recommended for pneumoniae?
rapidly progressive multi-lobar
OR
pneumatocele
List meningitis bugs for neonate vs. 1-3 mo. vs. > 3 mo.
Neonate
= GBS, E coli, Listeria
Amp + Cefotaxime
1-3 mo
= Above or Below
Vanco + Cefotax +/- Amp
> 3 month
= Strep pneumoniae, Neisseria meningitidis, Haemophilus influenzae type b
= Ceftriaxone + Vanco
(incase s. pneumoniae resistance)
What is treatment duration for meningitis:
- Neisseria
- H flu
- S pneumoniae
- GBS
- Ecoli
Neisseria= 5-7 d > H flu= 7-10d > S pneumoniae= 10-14d > GBS= 14-21 d > E coli= 21 days
When do you give dexamethasone in cases of meningitis?
H. flu or S. pneumoniae
> Reduces hearing loss + mortality
3 y.o. Abscess. No redness or fever. Similar had similar lesion recently. Tx?
- Keflex x 10d; I+D if fails
- Cotrimoxazole x 10 d; I+D if fail
- I+D; no Abx
- I+D; Keflex + Cotrimoxazole pending Cx
I+D
No Abx
unless red or fever.
If > 3 month and no other signs= Observe after I+D
If Abx
= Keflex (MSSA) + Septra (MRSA)
Varicella 1wk ago. New fever and refusal to wt bear with indurate and ++ painful foot? Dx? Tx?
Nec Fasc
Due to S. pyogenes (GAS)
= Cloxacillin
+ Clinda
+/- IVIG if GAS but no data for S. aureus
+ Sx consult
+/- MRI after consult if stable.
When do you give chemoprophylaxis for invasive GAS disease?
CLOSE contact to confirmed SEVERE case.
Close:
= household 4h/d or 20 h/week
= share bed, sex, direct MM
Severe dx
= Toxic shock, soft tissue necrosis, meningitis, pneumonia
List pathogens kids w/ asplenia at risk of:
- Strep pneumoniae
- Haemophilus influenzae type b
- Neisseria meningitidis
- Salmonella
What immunization and Abx prophylaxis is given to kids w/ no spleen?
Imm:
- Prevnar 13+23
- Quadrivalent Men + 4CMenB
- Hemophilus type B
- Influenza vaccine
- Typhoid if travel
- household immunized
Abx:
till 3month= Amox-Clav
> 3 month= Pen
Unilateral cervical node. Ipsilateral conjunctivitis. No fever. No lymphocyte. Likely cause:
- Staph
- Toxoplasma gondi
- bartonella
- EBV
- Mycobacterium TB
Bartonelle Henselae
Lick eye= primary and then neck too.
Tx: Azithro for lymphadenitis.
4 y.o. with chronic draining cervical node:
- S. aureus
- Atypical mycobacterium
- Bartonela henselase
- TB
- EBV
Atypical mycobacterium.
T or F: Bartonella henselae highest risk with kittens.
True
Most common neurologic manifestation of Lyme Dx?
Facial Nerve Palsy
Lyme dx= Borrelia Burgdorferi
Describe the early local versus early disseminated versus late lyme dx:
Early local
- > Erythema migran
- > Systemic (fever, myalgia, neck stiff)
Early disseminated
- > Many EM
- > Facial n. palsy
- > Meningitis
- > Carditis (rare)
Late:
- > Arthritis
- > Peripheral neuropathy
- > CNS
Most common manifestation of Lyme Disease?
Erythema migrans
When do you treat Lyme Dx with IV Abx?
SERIOUS Dx!
Carditis
Meningitis
Encephalitis
IV= ceftriaxone or Pen
Rest: Amox PO x 2-3 wk. (Or doxy if > 8 y.o.)
How can we prevent Lyme Disease?
Physical Barrier
- Screen
- Fine mesh for crib, stroller
- Long loose fitting clothes
- Hat w/ closed shoes
Repellent
- DEET (10% if < 12; 30% if > 12)
After Outside
- inspect skin daily
- shower w/in 2h
How do you remove a tick?
- tweezer
- grasp as close to skin as possible
- straight out; no squeezing
- don’t try to burn off
- don’t send to public health
What is the role for Abx prophylax is suspect lyme exposure?
Doxycycline x 1 if > 8 y.o.
If high risk exposure.
T or F: Most west nile virus are symptomatic.
False.
~80% asymp.
If symp= fever, neuro dx (ascetic meningitis, encephalitis, acute flaccid paralysis)
Varicella. later has difficulty breathing. LIKley cause:
- myocarditis
- PE
- VZV pneumoniae
- Sepsis
- S. aureus pneumonia
VZV pneumoniae
List 3 complication of chickenpox
- *- pneumonia
- hepatitis
- nephritis, orchitis
- low plt
- cellulitis, abscess
- *- nec fasc
- *- ataxia
- encephalitis
- *- reye syndrome
- stroke
How do you screen 16 y.o. F with sexual activity?
NAAT first catch urine
> C. trachomatis
> N. gonorrhoea
HIV serology
Syphilis serology
How do you screen for STI’s?
All F sexually active of victim of sexual assault.
M if RF (contact w/ STI, previous STI, new partner or > 2 partner in 1 year, IVDU, unsafe sex, sex worker, abuse)
How do you treat STI’s?
Ceftriaxone + Azithromycin (assume chlamydia if (+) Gon)
Untreated mom w/ gonorrhoea. For Well BB? Unwell BB?
Well
= Conjunctival Cx
IM Ceftriaxone x 1
Unwell
= Conjunctival, Blood, CSF
= Talk to ID
Untreated mom with chlamydia. Infant Management?
Just observe!
- conjunctivitis
- pneumonia
- no routine Cx
- no routine Tx
14 y.o. Labia minora lesions. H/A. Name 4 causes:
S- HSV (pain) vs. syphilis (painless)
- Bartholian gland cyst
- Chancroid
- Bechet disease
- Trauma
- Genital Warts
- Molluscum contagiosum
Treatment for Bell’s Palsy?
Steroids
+/- antiviral if vesicles in ear (i.e. Ramsay Hunt)
Mom has genital herpes hx with NO ACTIVE LESIONS. Well BB. Tx?
Observe.
No swab.
No Tx.
Note: any symptomatic BB= Full W/U and Tx.
Mom has ACTIVE genital herpes lesions (HSV) + well baby.
** ACTIVE= MM swab or blood PCR now! (recurrent= @24h)
C/S without ROM= D/C while pending
C/S + ROM or SVD
= IV ACV x 10 d
If HSV (+)= Admit
- CSF, Blood, LFT’s
min. 2 wk if rest (-)
3 week if (+).
Mom has RECURRENT genital herpes (HSV) lesions + well baby:
** RECURRENT= Swab at 24 h!!
D/C while pending.
If HSV (+)= Admit
- CSF, Blood, LFT’s
min. 2 wk if rest (-)
3 week if (+).
If BB found HSV (+). Min treatment duration?
2 weeks.
If blood or CSF (+)= 3 week min.
Mom with syphilis has adequate titre drop (4X or more). What do you do with BB?
monthly clinical assessment
Serology (RPR, TT) 0, 3, 6, 18 month.
List 6 features of congenital CMV:
CMV
- C= chorioretinitis
- C= ears= Deafness (sensorineural)
- M= Crown= MR and microcephalic
- V= periventricular Ca2+
Other:
- SGA
- Jaundice
- Low Plt= petechiae
- high ALT
25 y.o. mom with hx of genital herpes 5 years ago. No active lesions. Baby SVD. Well. Tx?
NO LESIONS.
Observe for signs.
No swab or tx.
T or F: you place pt + mom in contact isolation from other patients if vaginal herpes.
True.
Until lesions crusted over, 14d infectivity period gone, or swab (-).
Mom has recurrent genital herpes. No active lesions. How long after delivery possible for infant to develop herpes:
- 1-2 wk
- 4-6 wk
- 12-16 wk
- 20-24 wk
- up to 36 wk
4-6 wk
BB born C/S with ROM. Active herpes lesions. BB well. Next?
Immediate Cx
Start Acyclovir
Reminder:
** ACTIVE= MM swab or blood PCR now!
C/S without ROM= D/C while pending
C/S + ROM or SVD
= IV ACV x 10 d
If HSV (+)= Admit
- CSF, Blood, LFT’s
min. 2 wk if rest (-)
3 week if (+).
T or F: mom exposed to parvovirus B19 may have baby with fetal hydrops, IUGR or lung or heart effusion?
True.
BUT not cause a congenital anomalies or teratogenicity.
Greatest risk of mortality w/ parvo B19 linked with:
- prem
- sickle cell
- ALL on chemo
- congenital heart dx
- fetus of mom with parvo B19
Fetus w/ mom with Parvo (5% risk)
Mother Hep B positive. Newborn Management? When do you check if they got it?
Hep B IG < 12h ideal (up to 1 wk)
Vaccine at birth
Repeat vac @ 1 + 6 mo.
Post-immunization testing for HBsAG and anti-HBS 1 month after last vaccine to ensure surface (-) (not infected) but protected (anti-Hbs +)
If BB got Hep B immunoglobulin and vaccine at birth but NOT infected. What are best tests:
- HbsAg
- HbsAb
- HbeAg (inside)
- HbcAg (core)
Surface antigen (-) = HbsAg negative.
Antibody (+)
= HbsAb positive
HepcAg= anti-HbC
if positive= means had infection.
List two complications of neonatal gonococcal eye infection
- Corneal hemorrhage
- Globe perforation
- Blindness
T or F: there is a routine recommendation of erythromycin for eyes for ALL babies.
False (CPS).
Does not prevent chlamydia and increasing resistance.
Vary per institution.
T or F: the most common outcome of congenital CMV is sensorineural hearing loss.
True.
BB. HSM. Copper rash on palms + Soles. Rhinitis. Cough. Diffuse consolidation.
- urine CMV
- VDRL/FTA Ab
- BCX
VDRL/ FTA Abs
F dx with chicken pox 10d prior to delivery. BB normal at birth.
- give VZIG
- provide newborn care unless get varicella
- isolate BB from mother
Provide newborn care unless develop varicella.
VZIG: only give mom gets onset of rash < 5d prior or 48h after delivery. OR PREM.
Hep B Unknown Mom. Won’t have results for 2 d:
- await Tx
- HBIG now and await result before hep B vacc
- Vacc + BF
- HBIG + Hep B; no BF
- HBIG + Hep B; allow BF
Hep B vaccine now (ideally in < 12 h)
HBIG w/in 1 wk
(if mom + give with vac in < 12h; if mom status unknown and mom result will come back w/in 1 wk can wait)
4 mo. M. exposed to grandfather who dx cavity pulmonary TB. Clinically well. Tx?
- Tx rifampin
- Give BCG
- tx with isoniazid
- CXR
- asymptomatic; no W/U
Do CXR + TST
3 y.o. exposed to pulmonary TB in home. Clinically. well. TST negative. CXR normal. Next?
- No Tx
- No Tx; Repeat TST in 3 month, if positive then 9 mo. Isoniazid
- Start isoniazid now; d/c in 3 month if well and repeat TST negative.
- start 9 month isoniazid
AGE= 3 y.o.= at risk of developing dx so you start!
Start Isoniazid.
All kids < 4 y.o. or immunocompromised with close contact should get treated for Latent as long as active dx R/O by exam + CXR.
Note: Hamilton= Start Tx but D/C in 3 month if repeat TST neg.
What is (+) TST:
(+) IF:
=0-4mm: < 5 AND high risk for TB infection
High risk= infant, post-pubertal teen, recent infection (in last 2 yr), immunodeficiency.
= 5mm +:
well HIV, close contact with active case in last 2 yr, healed dx on CXR, organ transplant, TNF-alpha inhibitor, other immunosuppressive, ESRD
10 mm +: All others
including TST conversion (within 2 yr), DM, malnutrition, hematologic malignancy
List reasons for (+) TST:
- Mycobacterium tuberculosis infection**
- Non-TB mycobacteria infection **
- BCG in past **
- Incorrect technique
List reasons for a false (-) tuberculin skin test:
- Incorrect technique**
- Active TB dx**
- Immunodeficiency states**
- Corticosteroids**
- Young age**
- Malnutrition
- Viral (measles, varicella, influenza)
- Live attenuated vaccines (measles)
T or F: Interferon gamma release assay MORE specific for M. tuberculosis than TST.
True.
Does NOT cross react with BCG and most non-TB mycobacteria.
List Indication and two pros of the interferon gamma release assay in TB testing. Cons?
Indication: Latent TB in BCG folks.
Pro:
- more specific
- doesn’t cross react with BCG or MOST non-TB mycobacteria
- no F/U in 48-72 h required
Con:
- cross react to SOME non-TB mycobacteria
- can’t tell latent from active (so limited specificity and sensitivity for active TB)
Which population are considered at increased risk of TB disease:
- Infant
- Post pubertal adolescent
- Recent infection (in last 2 yr)
- Immunodeficiency state (HIV, Ca, transplant, med, malnutrition, primary immunodeficiency)
T or F: most kids with TB are asymptomatic.
True.
T or F: TST and IGRA Rule out pul TB
False.
Also do not distinguish latent from active dx.
How do you dx pulmonary TB?
CXR
Gastric aspirate (3 consecutive early morning aspirate)
- Acid fast staining, PCR
+/- Bronchoalveolar lavage
Note: TST, IGRA do NOT R/O pul dx.
What’s the difference between TB exposure vs. infection vs. disease?
Exposure: significant contact.
- All testing negative.
Infection: No symptom. Normal CXR but (+) TST.
Disease: signs and symptom or CXR (+).
How do you treat latent TB infection?
Latent Dx= + TST or IGRA but no dx.
Tx= Isoniazid x 9 months
How do you treat TB disease?
Reminder dx= signs + symp, or CXR (+).
**- 4 drugs (INH, RIF, PYR, ETH)
- Step down to 3 drugs if fully sensitive strain
**3-4 drugs x 2 months
**Then= INH + RIF course.
Total duration= depend on dx.
What can you do to prevent vertical transmission of HIV if mom (+)?
- Triple ART in T2
- IV zidovudine in labour
- Zidovudine to infant x 6 wk
Note: If mom viral load ++ combo ART to infant may be warranted. - C/S if viral load > 1000
- Avoid BF (contraindicated)
BB born to mom with HIV. Min Tx? Testing?
Yes, zidovudine x 6 wk min.
ALL offered prophylaxis regardless of any factors (incld if C/S).
If mom viral load ++ (>1000) or no ART in preg= 3 drug combo x 2 wk then zidovudine till 6 wk
No BF
HIV PCR at birth, 1 month, 3-4 month.
HIV R/O if PCR (-) at > 1 mon and > 2 month age.
HIV infection confirmed via (+) PCR x 2 < 18 month or reactive serology after 18 month.
Still get routine immunization.
List AE for isoniazid, rifampin and pyrazindamide.
All= hepatotoxicity
Isoniazid: peripheral neuropathy
Rifampin: hypersensitive, memory issue, orange bodily fluid
Pyrazinamide: uric acid up
List two AE of zidovudine
Anemia
Elevated lactate.
T or F: kid with HIV are treated the same way as other kids for acute illnesses.
True.
Assuming tx adherent and normal CD4 count.
Kid comes into ER with HIV for typical kid infection. What do you want to now about their HIV?
- clinical status
- immune status (CD4 count, CD4 %)
- viral load
- ART tx and adherence
T or F: kids with HIV should be given all childhood vaccines.
True
* Including live virus vaccine (MMR, VZV) unless severe immune compromise.
Other vaccine:
- flu vaccine
- polysacc pneumnococcal
- meningococcal (4CMenB)
Born to mom with active recurrent genital herpes. What is done to minimize spread?
- “room in”; no BF
- BB “room in”; BF ok
- Isolate BB from mom; no BF
- contact + resp isolation for mom and BB; allow BF
BB to “room in” w/ mom; allow BF
- Contact precautions during labour, delivery, postpartum
- Hand hygiene
- BF okay if no lesions on breast and active lesions covered
T or F: Mom with herpes labials should wear Sx mask while touching BB (aka BF)
True.
- If BB <6 wk= Mask until lesions crusted and dried
- No kiss or nuzzle until lesions cleared.
- Can still BF; BB does not need acyclovir for this.
BB tachypnea, afebrile, non toxic, (+) eosinophilia. CXR show b/l interstitial markings. Likely pathogen:
- GBS
- Chlamydia trachomatis
- Ureaplasma Urealiticum
- RSV
Chlamydia trachomatis
Pneumoniae onset: 1-3 month No fever Peripheral Eosinophilia Interstitial infiltrate on XR.
BB born to mother with unknown HIV status. What do you do?
Mom: rapid HIV antibody test.
If (+) confirm with standard serology test.
If mother consent not available then newborn HIV serology.
No BF while waiting.
Controversy whether you start on prophylaxis (since most effective if started in first 3d)
T or F: if you are starting HIV prophylaxis meds you want to start in less than 12 h.
True
Predictors of poor outcome in kids with HIV:
- high viral load
- CD4 < 15%
- Opportunistic infections: Pneumocystis Jirovecii pneumoniae
- Encephalopathy and develop regression
- Severe wasting
Best test to confirm dx of HIV in BB:
- ELISA
- Western Blot
- HIV DNA PCR
DNA PCR (preferred if < 18 mon.)
Screen if > 18 mon= ELISA
Confirm= Western Blot
T or F: leading cause of HIV in F in canada due to IV drug use.
False.
Due to heterosexual transmission.
Pregnant mother has child with reticulated lacy rash on body and rash on both cheeks. What do you tell mother?
Parvovirus B19
Fetus risk: non immune fetal hypdrops from anemia + high CO
Mother: Serology testing
- if (+) = serial U/S
Interpret EBV IgG (+). IgM negative. Early D antigen negative. Nuclear capsid antigen (+).
Remote infection.
IgG (+)= had infection
IgM= drop off by 1-2 mo.
Early D antigen= (-)= not primary as peak week 2 and lower by 4 month. Only + if acute or recent primary infection.
Flesh coloured warts in school age. Central umbilication. Dx?
Molluscum Contagiosum
- Poxvirus
- School age
- NOT on palm, sole, scalp
- months to years
- Tx: reassurance
- Local destruction: Cantharidin, CryoSx, Curettage
- Wash hand, ensure not sharing towel, cover bumps if not covered by clothing
Vesicle with red base on uvula, tonsil, soft palate. Dx?
Herpangia.
- Coxsackie virus
- Summer + Fall
- Supportive (Pain, magic mouthwash if older)
List suggestions to prevent West Nile Virus:
- Community level mosquitos control program
- Personal protective measure (long sleeve shirt, limit outdoor during dusk to dawn, mosquito repellent, use AC, install window screen)
- screen blood + organ donors
Varicella. 2 wk later = ataxia and instability to sit up. DX?
Acute Cerebellar ataxia
- often 2-3 wk after: varicella, coxsackie, echovirus
- sudden
- NO FEVER, NUCHAL rigidity, CSF NORMAL
- improve in few weeks; full recovery
4 Reasons for post exposure VZIG prophylaxis:
- pregnant F without evidence of immunity
- newborn of mom who had onset of symp 5d before or 48h after delivery
- Prem babies
> 28+ but mom hx or BW doesn’t show protection from
OR < 28GA or < 1kg regardless of mom’s history - immunocompromised kids (w/out hx of varicella or immunization)
1 y.o. exudative pharyngitis. Likely: Viral, mono, strep?
Viral
T or F: prem without CLD or CHD born after 30+ qualify for palivizumab.
False. DO NOT.
Child with fever, diarrhea, vomit, jaundice after coming from Mexico. LFT high. When can they return to school:
- 1 wk
- when afebrile
- if wash hand
- when no symptom
Hep A
= Return to school in 1 wk
Note: Hep A < 6 y.o.= non specific. Most infectious 1-2 wk before jaundice, LFT.
Risk of transmission minimal at 1 wk after jaundice onset.
Child dx with hep A 10 d ago. Still symptomatic. What to do with otherwise healthy family member?
- hep A immune globulin
- hep A vac
- No tx; prophylactic window passed
- both hep A vac + Immune globulin
Answer: Vaccine for all.
Hep A post-exposure prophylaxis:
**min. 6 month old:
Hep A vacc w/in 2 wk of exposure.
** < 6 month old or vaccine contraindicated: Immune Globulin
** Immunocompromised:
Vaccine + Immune Globulin
Child bitten in daycare with another child. HBV status unknown. Bitten child bleeding. Management:
- Don’t test kids; vac both
- Test both; IG to bitten and vac if biter (+)
- Test both; vac for bitten child
- Test biting child; no IG; initiate vac if biter (+)
Don’t test either kid.
Initiate HBV vaccination for both.
How do you manage daycare bite wounds?
- Wound Care > allow to bleed freely > soap and water > mild antiseptic > inform both parents > notify public health
- Abx > Prophylactic Abx ONLY if: = severe tissue damage = deep puncture wound = ORmore than superficial to face, hand, foot, genitalia = OR immunocompromised OR cat or dog > If Give= Amox-Clav
- Prevention
> Tetanus when appropriate
> Hep B: Never test kids. Unknown status= vaccinate both. If one is HBV carrier than IG and vaccinate the other.
> HIV only if one child HIV (+) and exchanged blood in bite
> Hep C: if significant blood exposure to known (+) serology at 6 month
Maternal HBsAg unknown. Just born. What do you do?
Stat HBsAg on mother
If can get result within 12 hour= wait for mom. Then if (+) HBV vac + HBIG now (vac 1 and 6 month too). Then test 4wk after that.
If can’t get results = seriously consider Vaccine + HBIG. Err on side of giving both.
Mother has Hepatitis C. What do you recommend:
- 5% transmission risk
- no evidence to support C/S
- avoid invasive stuff (scalp electrodes)
- can BF
- Test infant at 12 to 18 month
- RNA after 2 month done if +++ parental anxiety. If negative then = R/O. If positive still have to re-test.
Which maternal infections are contraindications to BF?
HIV
HTLV-1 and HTLV-2
- TB: delay until 2 wk of tx (can EBM though)
- Mastitis: continue unless pus -> pump + discard
- HSV: avoid if lesion on breast (until crusted)
List indications for palivizumab:
** < 6 mon. at start of season + < 30 week GA.
**<6 on. at start of season + Live in remote community and born at < 36 wk
** < 6 month at start of season + Inuit full term from community w/ high rate of RSV hosp
** < 12 month of age at start of season:
+ CLD who need ongoing med tx
OR + hemodynamic signif CHD
- Consider: < 2 y.o. IF:
- home O2
- prolonged hospitaliztion for severe pulmonary dx
- T21
- CF
- severe immune compromised.
T or F: if an animal is not available after bite manage them as rabid and consider rabies prophylaxis if appropriate.
True
Most common: dog, cat, racoon, skunk, bat.
T or F: domestic animals can be observed for 10 d for signs of rabies when deciding on prophylaxis after animal bite.
True.
T or F: you do not need to notify public health if you are treating for providing prophylaxis for rabies.
False.
Must notify public health.
What is the post-exposure prophylaxis for suspected rabies?
Immune globulin
* as much infiltrated into wound and rest IM
+ series of Rabies vaccine
Which conditions need N95 mask infection control precaution?
N95= Airborne
- Varicella
- Measles
- Tuberculosis
- Small pox
Describe the 5 hand hygiene moments:
- before touch pt
- after touching pt
- after touching pt surrounding
- before aseptic procedure
- after body fluid exposure/ risk
List three antibiotic stewardship principles:
- Clinical judgement (accurate dx with appropriate investigate i.e. CXR for pneumonia)
- Treat infection not contamination or colonization (i.e urine, surface swab)
- Assess for Abx allergy (rash versus anaphylaxis)
- Select narrow spectrum Abx with appropriate duration.
- Promote vaccines to reduce chance of dx.
All should be excluded from day care EXCEPT:
- 3 y.o. scabies
- Pertussis 3d after erythro
- E coli O157:H7 after diarrhea resolution
- Campylobacter d4 of illness
- Hep A 10 day after jaundice
Answer: Hep A 10 d after jaundice.
Hep A: until 1 wk after jaundice or onset.
Scabies: until after tx given.
Pertussis: 5 full day after tx start.
E coli O157: diarrhea resolved AND stool Cx negative x 2
C diff= until diarrhea resolve.
3 y.o. Day 3 chickenpox. Afebrile. Few lesion but not all crusted over. Can he return to daycare?
Yes as per CPS.
Reebok: wait until all lesions crusted over.
How do you manage mild C diff:
Mild= < 4 abN stool/day.
** D/C precipitating Abx + F/U
If no change= metronidazole PO x 2 wk
How do you manage Severe 1st episode C diff?
Severe= systemic toxicity (fever, rigors)
= PO Vanco
If severe+ complicated (colitis like low BP, shock) = PO vanco + IV metronidazole
What are infection control actions for C diff?
Hand hygiene
Contact precaution while symptom
Private room.
ID and clean environment (*CHLORINE based!!; EtOH does not kill spore)
T or F: you can use alcohol based hygiene product to clean surfaces in pt with C. diff.
False!!
Need chlorine-based for spores!
List bacterial causes of AOM:
- Streptococcus pneumoniae
- Non tapeable Haemophilus influenzae
- Moraxella catarrhalis
- Other: GAS, S. aureus (rare)
Note: viruses= 20% of cases
T or F: Bag specimens are appropriate for UTI Dx.
False.
Good rule out but high false positive rate.
Dx= sterile
-transurethral cauterization, clean catch, suprapubic aspiration.
T or F: most kids > 2 month can be managed with PO Abx for UTI
True. PO x 7-10 d
IV (amp + gent) IF:
- toxic
- can’t keep down PO
- immunocompromised
T or F: Renal and bladder US recommended for 1st febrile UTI in all kids < 3.
False.
< 2 y.o.
VCUG depend on US results or if recurrence of febrile UTI.
T or F: VUR grade 1 -3 should NOT get prophylactic Abx for UTI.
True.
Grade 4 and 5 only!
1st choice= TMP SMX, nitrofurantoin
R/A prophylaxis after 3-6 month.
T or F: if child has UTI organism resistant to TMP SMX and nitrofurantoin, and grade 5 VUR, your prophylactic Abx for future UTI should be stopped.
True.
do NOT give broader spectrum agents.
Risk of resistance!
BB born to mom with hep B surface antigen reactive. Given HBIG and Vaccine at birth. + Vaccine at 1 month + 6 month. At 9 month serology show what for:
- HBsAg
- HBcAg
- HBeAg
- HBsAb
- HBcAb
Surface Antigens= (-) >HBsAg (-) - protein on surface; (+) = INFECTION. >HBcAg (-) (core= infected acutely) > HBeAg (-) (acute or chronic infection)
Antibodies=
> HBsAb (+)= surface antibody
- RECOVERY OR IMMUNITY from hep B infection.
> HBcAb (+)
- core antibody = indicate previous infection or ongoing INFECTION
HBsAg (+) HBcAG (+) HBeAg (+). HBsAb (-). HBcAb (+). IgM HBcAb (+). HBeAb (-).
- immunized
- acute infection
- past infection
Acute infection
Surface antigen= infection.
Core antigen= previous or ongoing infection.
IgM to core antigen= recent infection (< 6 mo.)
Vs. Past infection would have negative antigen but positive antibodies!
Vs. Immunization all negative except HBsAb.
How can you remember Hep B serologies:
Surface antigen (+) = Infection Any antigen (+)= some type of infection
Surface antibody= immunity or recovery
Core Antibody (+) = Infection IgM= recent (< 6 mo.)
List RF for severe influenza.
- < 5 y.o.
- chronic health condition (CVS, liver, renal, metabolic, neuro, anemia, CA, immune deficiency)
- on ASA therapy
- Aboriginal people
- Pregnancy
If child has mild illness and not hospitalized but between 1-4 y.o. what would you do? What is they are > 5 still with no RF?
Oseltamivir can be considered if illness < 48h.
No routine antiviral if mild and > 5 y.o.
If child with influenza and either (+) RF or hospitalization… what do you do?
Antiviral therapy!
- Oseltamivir
- No response or already got it= Zanamavir
EBV testing: All test (mono spot, VCA IgM, EA IgG, VCA IgG) positive except EBNA IgG.
- Acute or past infection?
Acute infection
EBV testing: All test (mono spot, VCA IgM, EA IgG) negative except VCA IgG and EBNA IgG (+).
- Acute or past infection?
Past infection.
Describe the comparison of peritonsillar abscess or lateral pharyngeal abscess or retropharyngeal abscess:
RPA:
- infancy or SMALL kid
- neck STIFF, TORTICOLLIS
- fever, sore throat, muffled voice
- bulge of pharyngeal wall
Peritonsillar abscess:
- preteen or TEEN
- fever, sore throat, muffled voice
- saliva pooling, TRISMUS, bulging TONSIL, UVULA deviated to contralateral side
Lateral pharyngeal Abscess:
- preteen or TEEN
- fever, neck pain
- TRISMUS, tonsil fine, HEAD TILT twd lesion, tender under mandible
When do you cover osteo or septic arthritis with clox and tobra?
Neonate
Bug: Staph, GBS, Gram negative.
Versus:
- 1-3 mon- Cefotax + Clox
- Child: Cefazolin
Abx for dog or cat bite
Amox-Clav
Bug: Pasteurella multocida, Streptococci species, Anaerobes
Abx of human bite if needed
Amox Clav
Bugs: streptococci, staph
Bug if puncture wound of foot w/ sneakers. Abx?
Pseudomonas aerugenosa
Tx: ciprofloxacin
+/- gentamicin
Which virus is associated with transient arthropathy:
- RSV
- Rubella
- Measles
- Hep A
Rubella
Child with RSV bronchiolitis. On Day 3 fever + infiltrate on XR. Most likely cause?
Viral
- Rarely RSV followed by bacterial pneumoniae superinfection.
13 y.o. w/ HIV dx with measles. only proven Tx:
- acyclovir
- vit A
- inhaled amantadine
- Vit E
Vitamin A!! (A= Answer)
- No antiviral therapy.
- Vit A decrease morbidity and mortality
Sucks on finger. Lesions on finger x 10 d. Vesicles and red. Painful. Tx?
Herpetic Whitlow
- Single or multiple vesicles merged on distal finger
- Swelling, red, tender
- heal 2-3 wk; self-limited
- if severely infected or immunocompromised
= PO acyclovir - high dose PO acyclovir on first sing help abort and reduce duration
- do NOT LANCE
T or F: anogenital warts in kids < 4 typically no sexual
perinatal, auto-inoculation
True.
If > 4 consider CAS call.
Best test for HSV encephalitis:
- CSF PCR
- CSF viral culture
- CSF HSV IG
- CBC + diff
CSF PCR
11 y.o. Vague abdo pain, vomiting, jaundice. ALT and bill high. Test to confirm dx?
- Hep A IgM
- CMV urine
- Hep B serology
- Monospot
Hep A IgM
CC: fever, jaundice, N/V
IgM (+)= infection.
Recent hx of gastroenteritis. Reduce sensation to feet bilaterally. Likely dx? Procedure and finding? Likely organism of gastro?
Guillain Barre Syndrome
Procedure: LP
- can be N in first 48 but rise in 1st week and persist
- elevated CSF protein
- no pleocytosis (WBC), normal glucose
Tx: IVIG to neutralize myelin antibodies; full recovery within months in most
Likely Gastro bug: Campylobacter (risk 1:1000 GBS)
How should you interpret TST in BCG vaccine recipient?
- If known contact of person with TB or high risk of Dx
= Interpret the same as person who never got vaccine
Native F. Got BCG vac in past. PPD (purified protein derivative; TST) 13 mm. Interpretation and tx?
(+) Test.
- If known contact of person with TB or high risk of Dx
= Interpret the same as person who never got vaccine
Treatment: Assuming latent
Latent Dx= + TST or IGRA but no dx.
Tx= Isoniazid x 9 months
If disease (symp or /CXR)= - 4 drugs (INH, RIF, PYR, ETH) x 2 months Then= INH + RIF course. Total duration= depend on dx.
Two treatment modalities for kid with puncture wound in foot through sneaker:
Pseudomonas
Tx:
Systemic ABX x 10-14 d
+/- Irrigation + Debridement
Abx options: (cipro, gent, tobra, ceftazidime, piptazo)
Red man syndrome. Immediate management and what to do next time?
Immediate:
- stop infusion
- benadryl +/- ranitidine (itch, uncomfortable)
- if low BP- IVF
- once symptoms gone restart over 4 hour (think restart at 1/2 the rate)
Prevention:
- premeditate antihistamine (benadryl; diphenhydramine)
- run at slower rate
T or F: there is a low risk of HIV from a bite in daycare.
True
List traits of a bite that would impact my management:
> Prophylactic Abx ONLY : = severe tissue damage = deep puncture wound = OR more than superficial to face, hand, foot, genitalia = ORimmunocompromised OR cat or dog > If Give= Amox-Clav
Lyme disease organism
Borrelia burgdorferi
T or F: 10% of kids with active dx are PPD (Purified protein derivative= Mantoux= TST) are negative.
True.
Male being treated for Gonorrhea. Treatment? Do you have to show proof it worked?
Ceftriaxone IMx1 PLUS azithro PO x 1
- combo as diff mechanism to improve tx efficacy and delay emergence and spread
- Gonorrhea you treat with both. Chlamydia you can do single treatment (Azithro or Doxy 7d course)
- don’t have to show cure
First line Abx for sinusitis:
Amox BID x min. 7d
Amox-Clav when Abx resistance likely (e.g. amox use within last 30d)
Child eats at picnic and 4h later gets V+D. Likely organism:
- E coli
- S aureus
- Shigella
- Campylobacter
- Salmonella
Staph Aureus= Sudden
Last 1-2d
E coli usually 1-3 d later
- water or food contaminated w/ human feces
Salmonella w/in 2d
- egg, chicken, unpasteurized milk or cheese
Campylobacter 5d
- raw meat, unpasteurized milk
Shigella 1 wk later
- raw, uncontaminated
Campylobacter Cx from stool. Toxic. Which Abx:
- Erythro PO
- Septra PO
- flagyl PO
- Amp IV
- None
Erythro PO
- gram (-) bacilli
- rehydrate
- Abx if bloody stool, fever, severe course, immunosuppressed
- azithro/erythro x 5d (shorten duration, and prevent relapse)
- Cipro can be used (high resistance)
- Sepsis= IV amino glycoside, meropenem, imipenem
T or F: cough can persist for several months after pertussis.
True
- 2wk of URTI > 2 wk paroxysm cough/ whoop > convalescent
- Azithro 10mg/kg x 1 and then 5mg/kg x 2-5d (5d if < 6 month)
- shorten duration but does not affect infectious-ness
- isolate 5d after Abx or until 3wk after onset of paroxysmal stage
- Prophylaxis for house (same as tx)
Most likely bug if air bubble w/ surrounding consolidation and effusion in child with high risk aspiration.
- Staph
- Haemophilus
- Anaerobes
- Mycoplasma
Staphylococcus
= necrotizing pneumonia (empyema, pneumatocele, pyopneumothorax, lung abscess)
= unwell
7 y.o. visited farm recently. Cough, big liver. Dx?
- Psittacosis
- Legionella
- Q fever
Q fever.
= Lamb, goat, dogs etc. = flu-like w/ interstitial pneumonitis = high fever, hepatitis ** cough, hepatomeg ** high LFT - Serology - Tx self limited If within 3d of onset= doxy.
Complication of “watch and wait” approach with AOM:
- bacteremia
- mastoiditis
- prolonged fever
- prolonged pain
Prolonged Fever
3 month old with swelling over mandible b/l x 1 week. Fever. Hyperostosis on XR.
- Caffey’s
- Parotitis
- Cherubim
- Osteo
- Hypervitaminosis A
Caffey
- infantile hyperostosis of jaw, can have fever and irritable. Resolve by 2y .o.
Salmonella Gastro. Who gets Abx?
<3 month
OR immunocompromised
Goal: prevent bacteremia and meningitis.
Retropharyngeal abscess post Sx. New headache:
Internal jugular thrombosis.
Child was bitten by a stray dog. Which is true re: rabies prevention:
- Tx child prophylactically
- Tx child if dog acting rabies like
Treat prophylactically= Rabies IG (into wound and rest IM)
Remember: if an animal is not available after bite manage them as rabid and consider rabies prophylaxis if appropriate.
If animal dosmetic available can observe for 10day and treat if signs of rabies.
15 y.o. H. Pylori. Treat with:
Triple therapy!
Amox
+ Claritho
+ PPI
Red line through antecubital fossa. Name and etiology?
Pastia’s line red
Etiology= Strep
Aboriginal teen with red induration on shins. Test for:
- Sarcoid
- TB
- Cat-Scratch
- IBD
- Drug hypersensitivity
TB (given RF)
CC: erythema nodosum (inflam of fat cells under skin)
Other causes: IBD, Behcet, Strep, Primary TB, Histioplasma, Cat-Scratch, Sarcoid etc.
If Q about child on carbamazepine. Rx Ceclor for otitis. Urticarial rash. AOM still there. Next Abx?
Choose another cephalosporin!
i.e. Cefixime
Low grade fever. URTI symptom. Well with green d/c x 3 d. Cx show H. influ. Next?
- No treat
- Amox
- TMP-Sx
- ENT
No treatment
H. influ part of flora.
Nasal swab only helpful for GAS or pertussis.
Dx sinusitis:
Persistent nasal congestion/d/c or cough x 10 d
OR
fever > 39 + purulent nasal d/c or facial pain > 3d
OR worsening symptom after initial improvement
XR correlate poorly; CT if suspect complication.
Amox x 7d after resolution dos symptom.
Amox-Clav if amox in last month.
Child w/ pul findings, Eosinophilia, calcium slightly high. Cause:
- miliary TB
- sarcoidosis
- cryptococcus
- blastomycosis
Sarcoidosis
Lung
Eosinophilia
Hypercalcemia
6 y.o. M. From farm. 3 month fever, vomit, diarrhea, wt loss. Narrowing of distal ileum. Cause:
- Entamoeba Histolytica
- Yersinia
- Salmonella
- Giardia
Yersinia= Ileitis
Crohn’s mimicker!
3 y.o. with 1 wk history of yellow d/c on panties. Labia major red and yellow secretion in posterior fourchette around urethra. Most likely dx:
- Candida
- FB
- GAS
- Pin worms
GAS
= beefy red labia, bloody +/- green
Pre puberty= DO NOT GET CANDIDA VAGINITIS
Other: S pneumo Neisseria meningitis (green) Shigella (bloody) FB (foul, green)
Young child bit by chat. Started on amox/clav PO. Increasing red and pain. Next?
- Vanco + Amp IV
- Ticarcillin/ Clavulin IV
- Cloxacillin IV
- Ortho
Ticarcillin/Clav IV
Cat= Pasturella Dog= S. aureus, Pasturella
Amox/Clav
IF allergy: Septra/Clav
Tic/Clav IV
Sx if deep, hands, face, bone, joint, infection needing drainage
Asymptomatic giardia in stool. Do you treat? If you would- Rx?
Tx carrier in household of pt with hypogammaglobinemia or CF.
Asymptomatic otherwise= DO NOT TREAT.
Rx: Metronidazole x 5-10d
How do you treat scabies?
5% permethrin cream
Neck to toes
x several hours
Retreat in 1 d
Treat all household (even if asymptomatic). Wash needing and clothes in hot water. If none, sealed plastic bags.
Do helminths (worms) have eosinophilia?
Yes.
- Round worms= Ascaris** (most common), Toxocariasis, Hookworm
- Tape worms= Taenia solium, Echinococcus
- Fluke worms: Fasciola and others
Ascaris - have eosinophilia?
Yes - Most common worm - most asymptomatic - GI: GI obstruction, Pulmonary dx - Loeffler's: pneumonitis, fever, eosinophil +++ Tx: Albendazole
Which has eosinophilia?
- Ascaris
- Giardia
- Cryptosporidium
- Pinworm
Ascaris!
Worm= Yes
except pinworm
Rest= other protozoa
++ Eosinophil. Suspected of visceral larva migran (toxocariasis). P/E:
- spleen ++ and lymphadenopathy
- liver ++
- serpiginous rash
- arthralgia
- myalgia
Hepatomegaly
Serpinginous= creeping looking rash= pinworm
Who gets conjugated quadrivalent vaccine for meningococcus?
People at risk of meningococcal dx
= meninogococcal conjugate quadrivalent (A, C, W-135, Y= Menactra) @ 2 mon.
> Functional or anatomic asplenia
* @ 2, 4, 6, 12-15 mon
+ re-vaccinate at 5 y.o.
> Complement deficiency (C5-C9)
> Community outbreak due to vaccine serogroup (thus at risk)
> Travel to country where meningococcal dx epidemic
Pertussis. Siblings all immunized. Any tx for them?
YES!
If close contact unimmunized or under immunized = start pertussis immunization
Post-exposure Abx for all household contacts regardless of imm status.
= Azithro x5
OR Erythro x 2 wk
Main reason for generalized immunization program for pertussis in teens?
Waning immunity in teens/adult so booster provide herd immunity and protect infant who haven’t complete primary series.
Mother worried about all the antigens bb gets at once. Advice?
- exposed to many foreign antigens everyday (i.e. food)
- limited # in vaccine does not add more burden or suppress sys
- EBM that show no adverse outcome to normal childhood immune sys
- early vaccine given to help protect baby (given risk of complication at this age)
- CPS: rigour of vaccine system
- CPS: addressing pain of vaccine
Rotavirus.
- protect against 95% against rotavirus
- protect against 75% of all diarrhea
- significant decreased hospitalization
- decreased viral shedding
Less hospitalization
When do we give pneumococcal vaccine?
13-valent conjugate
= 2, 4, months
12 months
Except north where given 2, 4, 6, 18
Close contact w/ meningococcal meningitis. What do you give if they are pregnant?
Regardless of imm= any close contact= get post-exposure prophylaxis. No Cx.
High risk if: household, childcare contact 1wk before illness, exposure to secretion (kiss) 1 wk before illness, slept in same place 1 wk before illness
Tx: rifampin x 2 d
Pregnant= Ceftiraxone
Other= Cipro
+ Vaccine if type was vac preventable.
Most common AE of varicella vaccine: Fever or chickenpox.
FEVER!
20%= pain, red, swollen 10%= fever 5%= rash around site, 5% over body
T or F: hepatitis B child- don’t attend daycare.
False.
If no behavioural or medical RF (e.g. not unusual aggressive or bleeding dx) can do daycare without restriction!
Who gets 23-valent pneumoccal polysacc vaccine?
High Risk= get min. 8 wk after last dose of pneumo-C; and 2nd min. 5 year after first
- *Chronic Dx
- CHD (esp cyanotic and HF)
- CLD (esp asthma on high dose steroid)
- DM
- CSF leak
- Cochlear impact (pre + post)
- *Functional or anatomic asplenia
- Sickle cell, Asplenia or splenic dysfunction
- Immunocompromised
- HIV
- Chronic RF
- chemo
- primary immunodeficiency (any)
T or F: kid with nephrotic syn who is about to be on pred should not get any further immunization until off x 2 years.
False.
No LIVE virus vaccine while on pred as affect cell-mediated immunity.
Prior to Tx: vaccine + booster
Inactive > 2 wk before
Live vaccine > 4 wk before.
During Therapy: inactivated if urgent needed (outbreak or PEP). NO LIVE (MMR, Varicella, Flu nasal, Rotavirus, Yellow fever, BCG)
After therapy:
- wait 3 mon. with either
Note: short term < 2 wk or physiologic dosing not contraindication to vaccine!
2 y.o. UNimmunized. Lac on playground. Clean and sutured. Tetanus?
- vac
- vac + Immunoglobulin
- immunoglobulin + anti-toxin
Clean: Vacc only
Dirty: Vaccine + Immunoglobulin
For all dirty wounds with people with inadequate vaccine.
Dirty= dirt, feces, soil, animal bite, massive crush or burn.
Pre-splenectomy vaccine:
Min. 2 wk prior Sx…
**S. pneumo= Conjugated PCV 13 + Polysacc 23
**N. meningitides= Conjugated quadrivalent
**Hib
S. typhi if travel
Best control of RSV:
- wash w/ soap + water
- gown + glove
- wash w/ alcohol
- isolate anyone w/ resp symptoms
Hand wash w/ alcohol.
= save time= more compliance
Red central line in neutropenic patient. Abx?
Piptazo + Vanco
Name two organism affected by granulocyte defect in PID.
Granulocyte type of phagocyte.
Phagocyte= Staphylococcal + KEEPS (Klebsiella)
System= Skin abscess, suppurative adenitis, oral ulcers, osteo or abscess
15 y.o. immunocompromised. Hot tub and get folliculitis. Enlarged lymph nodes. Name organism.
Pseudomonas aeruginosa
= Hot Tub Folliculitis.
- contact w/ contaminated water due to inadequate chlorine, pH etc.
- self-limit
- skin hygiene
- avoid contaminated water
- PO cipro if severe or immunocompromised
- immunocompromised should be told to avoid hot tub.
Post bone marrow transplant. Varicella exposure. Therapy? Time frame for therapy to be effective? How long you isolate from other immunocompromised pt?
Therapy:
- VZIG
- Give asap but within 10d of exposure
- VZIG given: isolate 4 week
- No VZIG: isolate 3 wk
Acute chest crisis in sickle cell. Tx:
Ceftriaxone + macrolide
= Ceftri + Erythro
Feb neutropenia. most common bugs?
- pseudomonas
- PCP
- gram (+)
- candida
Gram (+)
= Coag. Neg Staph
Viridian’s strep
Staph Aureus
Rest= gram (-)
6 y.o. ALL. Completed course of chemo 1 month ago. Household chickenpox. Tx:
- isolate and watch
- IM VZIG
- IM VZIG + PO acyclovir
- admit + IV acyclovir
- admit + IM VZIG + IV acyclovir
IM VZIG
Ideally within 10 d of exposure.
Isolate: 3-4 weeks from exposure.
Asplenia vac:
- pneumo at 6 mon
- mening at 2 y.o.
- Abx prophylaxis with daily septra
- Abx prophylaxis till pneumo vac given
Standard immunization schedule
2, 4,6, 12-15 months
= PVC 13
+ PPV 23 after 2 years and booster 5 yr after 1st dose
= Quadrivalent Meningococcal (MCV4-Menveo)
= Re-vaccinate mening every 5 years
= Hib 2, 4, 6, 18
= Yearly influenza
= Salmonella typhoid if travel
= Abx (Pen V) if < 5 y.o. and < 2 yr post splenectomy.
Inguinal adenopathy. 4 reasons for bx:
B symptoms
- persistent unexplained fever
- wt loss
- night sweats
Node itself:
- hard node
- increase in size over 2 wk
- no regression in 3 months
Other: supraclavicular, mediastinal mass
Fever > 5 d, big liver. HR 85 with temp 39.5. CBC + urine normal. Cx: Gram (-) bacilli. Dx?
Typhoid fever.
Admit to Hosp
Min. 14 IV Abx (ceftriaxone)
Or Cipro
9 y.o. new to Canada. No immunization. First two you give?
Tdap-IPV (Tetanus Toxcoid, Diphtheria Toxoid and Acellular pertussis + inactivated polio)
AND
MenC (Meningococcal conjugate)
7 month old newly adopted. Stated UTD. do you vaccinate against meningitis. If so- what schedule?
Start on schedule appropriate for age:
- at 12 months (regardless of prior given doses somewhere else)
- if RF (i.e. asplenia or cochlear implant)= high risk schedule for CMV-4
Fever in returning traveler. Three conditions:
Malaria
= P falciparum= rapid! versus rest= subacute
- up to 1 month after
- persistent fever
- Thick + Thin Smear x 3 12 hours apart
- CBC down, low BG, LFTs, UA (R/O hemoglobinuria), ECG (QRS)
- Severe= 5% parasitemia on smear, or CNS, or, low plt or low BG= PICU for IV quinidine.
If mild= PO option
Typhoid = Salmonella typhi - gram neg. bacilli - South Central Asia - up to 3 wk after - fever + relative low HR - Rose spot - Dx: BCX Tx: ceftriaxone, cipro
Dengue = viral, mosquitos - S. American, SE Asia, Africa +/- middle east - 1 wk after - Epistaxis, HSM - hemorrhagic fever: fever, bruise bleed, vomit - Dx: Acute + Convalescent Titres - Self-limiting; support
8 y.o. Fever, N/V, diarrhea, mild jaundice upon returning from Mexico. LFT +++. When to return to day care:
- 1 week
- till asymp
- return if everyone toilet trained
- go back now if wash hands
1 week
= Hep A
4 y.o. Lyme dx. Red lesion on back + arthritis. Camping in US. Tx and duration?
Answer: Amox x 4 wk
Amox; If > 8= Doxycycline.
Duration:
All 2-3 week except arthritis (4 wk).
Signs of endocarditis:
Duke criteria:
Major: Organism x 2 Cx, or definitive Echo
Minor: RF (heart dx) Fever Vascular: - conjunctival hemm - intracranial hemm - arterial emboli - septic pul infarct - mycotic aneurysm - janeway lesion (no pain)
Immunologic:
- roth spot
- osler (painful)
- glomerulonephritis
- (+) RF
BCX atypical
Other common not in Duke: PE, splinter hmm, new murmur, HF
Gram positive cocci in clusters in late onset sepsis in NICU w/ central line. Likely bug. Tx?
MSSA
Coagulase negative Staph (epidermis, Sapraophyticus)
Tx:Vanco
Usually without Cx you start with Clox (or vanco) + gent.
4 contraindication to LP:
- brain mass
- SC mass
- ICP
- cardioresp instable
- infection over skin
- bleeding dx (plt < 20, DIC, hemophilia)
Child with prior course of amox. Everything fits meningitis except CSF Cx (-). Ceftriaxone given. Fever gone. Likely dx and next step?
Cx (-) bacterial meningitis (likely to due prior Abx)
Clinical course and investigation support.
= Ceftraixone x 2-3 week after consultation with ID.
New immigrant. Drooling. SOB. Dysphagia. Lateral neck (thumb sign). Likely cause?
H. influenzae type B
= Epiglottitis
Tx= ENT + Airway management + IV Abx (ceftriaxone)
Necrotizing fasciitis management:
- Admit
- ABC (fluids)
- Cx skin + Blood
- Abx broad (Piptazo, Vanco + Clinda)
- Consult Sx (exploration and debridement)
- Monitor (pain, multi organ failure)
- Consider IVIG (toxic shock or very ill)
Most common bug of spontaneous bacterial peritonitis (i.e. pt with nephrotic syn, ascites, sick):
Strep pneumococcus
T or F: steroids help decrease hearing loss when given before or with initial Abx in bacterial meningitis.
Controversial EXCEPT HIB or Strep!
If bacterial meningitis suspected recommend dex 0.6 mg/kg/d divided q6h before or within 30 min. of 1st dose.
Continue 2d if Hib or strep pneumonia identified
D/C if other etiology.
Child get IV pen for meningococcemia x 7d. Now arm swollen right knee:
- NSAID
- 2nd Abx
- Change Abx
- Aspirate + Cx
- Bone Scan
NSAID
Allergic immune complex= arthritis, pericarditis etc.
Self-limiting
Arthritis= NSAID
US post-colectomy. J pouch. Now 5 d bloody stool. Cx negative. Dx and Tx?
Pouchitis
Tx: PO metronidazole or cipro
x 2 weeks
Child with periorbital edema + diarrhea. Albumin 12. DDX?
Edema with low Albumin:
- Not making= Liver failure
- Losing= Renal (nephrotic), GI (protein losing enteropathy, malnutrition)
- Infectious Colitis (i.e. parasitic, post-infectious)
- Food induced protein enteropathy
- IBD
- Celiac disease
