ID SAQ

Question 1

1. You see a child that you suspect has measles.

A. What 3 lab tests would you do to confirm the diagnosis? (1)

B. What are 3 complications of measles?

C. What type of isolation should this patient have? (1)

Answer 1

A.

1. Measles serology - IgM usually appears 1-2d afer the onset of the rash and remains detectable for 1mo
2. Measles viral PCR
3. Viral isolation from blood, urine, or resp secretions by culture
4. 4-fold increase in IgG Ab in acute + convalescent specimens collected 2-4 weeks apart
5. Decreased WBC (lymph > neut), normal ESR/CRP

B.

1. Encephalitis
2. Subacute sclerosing panencephalitis
3. Acute otitis media (most common complication)
4. Pneumonia
5. Death
6. Diarrhea
7. Hospitalization

C. Airborne

3Cs: cough, coryza, conjunctivitis + RASH (hairlind down, palms + soles; lasts 7d then desquamation)

Question 2

2. A. Name 4 methods to practice antimicrobial stewardship (4)

B. Name 3 outcome goals for antimicrobial stewardship (3)

Answer 2

A.

1. Use clinical judgement: accurate diagnose with judicial investigations
2. Document rationale and pt’s vital signs + status for all ABx choices
3. Document any suspected drug adverse events that occur to better determine if true allergy or not
4. Narrow the spectrum of antimicrobials when a causative organism is identified
5. Optimize the dosing for maximal benefit
6. Take the shortest recommended course of therapy for uncomplicated infections
7. Promote vaccination to reduce likelyhood of clinical disease

B.

1. Optimize therapy
2. Decrease adverse events and superinfections related to antimicrobial use
3. Prevent resistance
4. Cost saving

Question 3

3. Name 4 high risk groups for a severe influenza infection

Answer 3

1. 6mo-5yo
2. Pregnant
3. Chronic illnesses
   
   • Cardiovascular, liver, renal, metabolic disease
   • Neuro or neurodevelopmental conditions
   • Anemia or hemoglobinopathy
   • Malignancy + other immune compromising conditions
4. Chronic ASA
5. Indigenous
6. People in chronic care facilities

Question 4

4. Name the organism that most commonly causes severe infections in children with asplenia (1). Name 2 others (2).

Answer 4

1. Strep pneumo
2. Hemophilus influenzae
3. Neisseria meningitidis
4. E coli
5. Salmonella

Question 5

5. Mom with HIV, SVD, CD4 =600, on Zidovudine IV.

A. What TWO things do we test for in the infant and when?

B. What are the chances of transmission?

C. What’s the status with breastfeeding in Canada?

Answer 5

A. Tests

1. HIV PCR at birth, 1-2mo, then 4-6mo
   
   • Can also do HIV culture + p24 antigen within the first 12-24H. If positive, repeat. If negative, repeat at 1-2mo of age
2. HIV serology at 18mo

• R/o HIV if 2 neg PCRs at >=1mo AND >=2mo
• Dx HIV if 2 pos PCRs <=18mo OR positive serologies >18mo

B. 1%

C. Don’t breastfeed

Question 6

6. Travelling kid with fever and vomiting coming back from rural Nigeria.

A. What two tests would you do to look for what can cause this presentation?
B. What are THREE vaccine preventable conditions from this area?

Answer 6

A.

1. Malaria thick and thin smears
2. Blood culture lookign for salmonella typhi + N meningitidis

B.

1. Hep A
2. Typhoid fever
3. Yellow fever
4. Meningococcal disease
5. Hep B

Question 7

7.This 2 year old boy has had recurrent unexplained fevers. He does not look ill. (This was exactly the picture on the exam… they clearly googled it

A) What is the diagnosis?

B) What is the mechanism of his fevers?

Answer 7

A. Hypohidrotic Ectodermal dysplasia

1. Partial or complete absence of sweat glands
2. Abnormal teeth
3. Hypotrichosis

• Dx: scalp biopsy

B. No sweat glands, cannot regulate body temperature. Mistakenly considered FUO

Question 8

8. Description of child with fevers every few months with abdominal pain. Also has pharyngitis, apthous ulcer and cervical adenopathy.

A) What is the diagnosis?

B) How do we treat it?

C) What are two other things on your differential?

Answer 8

A. Periodic fever, aphthous stomatitis (painless), pharyngitis (Cx neg), cervical adenopathy = PFAPA syndrome

• Regular fever 4-6d, 3-6wk cycles
• Asymptomatic in between episodes, normal growth

B. Tx

• Low dose prednisone x 1 when fever starts. Can repeat in 12-24H
• Colchicine for ppx therapy
• Tonsillectomy for potentially curative Tx

C.

1. FMF
2. TRAP
3. Cyclic neutropenia
4. Malignancy
5. SLE

Question 9

9. Child presents with 3 weeks of cough and you suspect pertussis. Mom wants antibiotics.

A. What do you do and what do you tell her.

B. What are FOUR nation wide strategies that we can use to prevent pertussis.

Answer 9

A.

• Treatment of the child indicated to reduce the spread, won’t impact the duration of the cough.
• Household contacts should also get antibiotics
• Vaccinate

B.

1. Universal vaccination of children
2. Universal vaccination of teenagers + adults
3. Do not go to daycare until 5d of treatment, or 3 wks after if not treated
4. Post-exposure immunization
5. Education of the public
   6.

Question 10

10. Kid traveling to the developing countries, what are the most 3 important causes to consider of fever?

[Nelson’s fever in returning traveler

5 DDx for

A. Systemic febrile illness

B. Acute diarreha

C. Dermatological manifestations]

Answer 10

1. Malaria
2. Typhoid fever
3. Dengue fever

[A. Systemic Febrile Illness

1. Malaria
2. Typhoid
3. Dengue
4. Rickettsial infections (tick-borne spotted fever)
5. Chikungunya

B. Acute diarrhea

1. Giardiasis
2. Amebiasis
3. Campylobacter, Shigella, Salmonella, E coli
4. Presumed viral

C. Dermatologic

1. Insect bites
2. Abscess
3. Cutaneous larva migrans
4. Leishmaniasis
5. Impetigo

Question 11

11. 3 years old kid with splenectomy

A. What 3 bugs is this child susceptible to?

B. Name 2 preventive strategies

Answer 11

A.

1. Strep pneumonia
2. Hemophilus influenza
3. Neisseria meningitidis

B.

• Prophylactic antibiotics until 5yo (<=3mo amox clav, >3mo pen) and/or at least 2 years post-splenectomy
• Immunize. Ideally vaccinate at least 2wks before splenectomy
  
  • Pneumoccal 13V conjugate + 23V polysaccharide vaccines
  • Meningococcal
  • Hib
  • Inflyenza

Question 12

12. A baby with intracranial calcifications, chorioretinitis, hepatosplenomegaly, purple nodules which is consistent with toxoplasmosis.

A. What 3 investigations would you do to confirm?

B. What two findings on CSF?

Answer 12

A.

1. Toxoplasmosis PCR on CSF, blood, +/ urine
2. Toxoplasmosis serology in serum of infant
3. Placental pathology

B. CSF findings

1. Lymphocytic pleocytosis
2. Elevated CSF protein (often very high)

Question 13

13. Mom has varicella and a rash for 9 days prior to the delivery; baby just born 30 wks gestational age

A. 2 things would you do for the baby

B. 3 things you would do for infection control

Answer 13

A.

1. Give VZIG
2. Test for presence of IgG (serology)
3. Treat with acyclovir IV if develops chickenpox

B.

1. Mother should be in negative pressure room under airborne precautions if she still has active lesions
2. Baby should be isolated with mother (incubation period 7-21d post-exposure)
3. Non-immune family members should not come to the hospital (incubation period)

Question 14

14. Name 3 reasons for RSV prophylaxis

Answer 14

1. If at beginning of RSV seasons is <6mo and <30wk GA
2. <6mo and <36wk GA living in remote area
3. <6mo and term if Inuit and living in remote area that requires air transport out and high rates of RSV
4. <12mo and hemodynamically significant CHD still requiring O2, diuretics, steroids
5. <12mo and CLD
6. Consider in <24mo
   
   • Still on home O2 (or in past 3mo)
   • Had prolonged hospitalization for severe resp illness
   • T21
   • CF
   • Severe immunocompromised

• Do not continue palivizumab if hospitalized for breakthrough RSV infection

Question 15

15. A 15 y/o immunocompromised male likes to swim in the family hot tub. He presents with a pruritic follicular rash, malaise and lymphadenopathy. What is the likely etiologic pathogen?

Answer 15

Pseudomonas aeruginosa

Question 16

16. 8 yo girl previously healthy, has been visiting South Saharan Africa for 8 weeks. 2 days after she returns, she presents with 40 degrees fever and rigors. List 3 DDx.

Answer 16

1. Malaria
2. Typhoic fever
3. Dengue fever

Question 17

17. 2 weeks old baby with new onset seizures. CT of head showing what looked like diffuse calcifications. What is the diagnosis?

Answer 17

• Toxoplasmosis: parenchymal
• CMV: periventricular
• Zika: subcortical
• HIV: basal ganglia, brain atropy

Question 18

18. List 3 or 4 indications to give the tetravalent meningococcal vaccine

Answer 18

1. Adolescent booster in all prov + territories (except Manitoba, QB, Nunavut)
2. HIgh risk groups of invasive meningococcal disease
   
   • 2-3 doses starting at 2mo of age
   • booster at 12-23mo
   • Q3-5Y until 7y
   • then Q5y
3. Recommend for individuals >=2mo of age travelling to countries with a high risk of invasive meningoccoal disease
   
   • 2-3 dose if <12mo old
   • 2 doses if 12-23mo
   • 1 dose if >=24mo

• Menveo (Men-C-ACYW-CRM) is currently recommended quadrivalent for <2yo
• Pts at risk for invasive meningococcal disease
  • Underlying medical condition
    
    1. Asplenia or functional asplenia
    2. Properdin, factor D or complement deficiency (incl’g acquired complement deficiencyf rom eculizumab (Soliris))
    3. HIV
  • Potential for exposure
    
    1. Lab workers who work with meningococcus
    2. Military personnel living in close quarters
    3. Travellers to endemic areas (sub-Saharn Africa, Hajj pilgrims)
    4. Close contacts of a case of IMD

Question 19

19. A child who sustained a nail injury through his running shoe 3 days ago. Now presenting with a red heel that is swollen and tender. What one organism MUST you think of when prescribing treatment?

Answer 19

Pseudomonas aeruginosa

Common organism responsible for osteomyelits secondary to puncture wounds

Question 20

20. What are three high risk groups for invasive pneumococcal disease?

Answer 20

1. Asplenia or hypospenia
2. Primary immunodeficiency - CGD
3. HIV

Question 21

21. Child with perianal cellulitis not responding to corticosteroids or antifungal treatment. (picture) Diagnosis?

Answer 21

?GAS perianal dermatitis

• Do culture
• 7days of cefuroxime + topical mupirocin

Question 22

22.

A. For what population is Gardasil vaccine recommended for?

B. A mother’s 10 year daughter recently had the vaccination. She wants to know how this changes her daughter’s need for pap smear. What would you tell her?

[What 4 entities does HPV vaccine prevent?]

Answer 22

A.

• HPV-9 routinely to females and males 9-13yo, ideally before sexual activity
• Catch up schedule with full HPV-9 series on age-appropriate schedule for all unimmunized >=13yo or individuals who wish to be re-immunized with HPV-9 (even if fully vaccinated with HPV-2 or HPV-4)
  
  • 9-26yo
  • Consider for woemn >=27yo at ongoing risk AND MSM
• Can give simultaneously with all other vaccines for adolescents
• 2 doses for 9-14yo, given at least 6mo apart
• 3 doses for immunocompromised, HIV, and >=15yo

B. It does not change need for pap smear

[Prevention

1. Genital condylomas
2. Cervical cancer
3. Penile cancer
4. Cancer of vulva, vagina, anus, mouth + oropharynx
5. Asymptomatic persistent infection

Question 23

23. A mother has a TB skin test of 13 mm and a negative chest X-ray. She is to start INH therapy. What would you tell her about breastfeeding her newborn baby.

Answer 23

• Continue breastfeeding
• If active TB
  • No breastfeeding until 2wks of treatment
  • Can give EBM during that time

Question 24

24. 10 yo teen with fever, sore throat and vesicles on an erythematous base on tonsillar pillars, posterior pharynx and soft palate. Cause?

Answer 24

Coxackie A or enterovirus

Herpangina

• Sudden onset fever, sore throat, dysphagia, lesions in posterior pharynx
• Characteristic lesions on anterior tonsillar pillars, soft palate, uvula, tonsils, posterior pharyngeal walls, ocassionally posterior vuccal surfaces
• Discrete 1-2mm vesicles + ulcers that enlarge over 2-3d
• Surrounded by erythematous rings that vary up to 10mm in size
• Fever lasts 1-4d, Sx lasts 3-7d

Question 25

25. Regarding genital herpes: a) In a pregnant woman with genital herpes, list 3 risk factors for transmission of HSV to her baby b) You are consulted following a precipitous vaginal delivery at term, because mom was found to have a lesion that looks like genital herpes on her vulva. If the child remains well, list 2 indicated tests to detect HSV c) If choosing conservative treatment (observation), at what time should these tests be done?

Answer 25

a) 1. ROM \> 6H 2. Vaginal delivery 3. Scalp electrode 4. First episode primary infection 5. Active lesions at time fo delviery b) 1. Swab of conjunctival, nares, mouth, anus for HSV PCR 2. HSV PCR in blood (Ab to HSV-1 or 2 take approx 3wks to develop following an infection) c) * Do at least 24H after delivery

Question 26

26. 15 y.o. homosexual adolescent male complaining of dysuria. On questioning, he reports a history of urethral discharge in the mornings. On examination, genitalia are normal, but when the glans are compressed there is yellow discharge. a) What is the most likely diagnosis? b) List 4 other causes of urethritis in this patient:

Answer 26

a) 1. Gonorrhea (more common, copious discharge, more purulent) * CFTX 250mg IM x1 OR * Cefixime 800mg PO x1 + azithromycin 1g PO once b) 1. Chlamydia (more likely symptomatic, more watery urethral discahrge) * Azithromycin 1g PO x1 OR doxycycline 100mg PO BID x7d 2. Mycoplasma genitalium 3. Trichomonas vaginalis 4. HSV-1, HSV-2 5. EBV 6. Non-infectious: FB, trauma * **Mandatory reporting** * **Test + treat sexual partners** * **No sex for at least 7d** * **Retest 3mo after Tx**

Question 27

27. 4 year-old boy, recently immigrated from Sudan, presents to ER with T 39, drooling, toxic-looking. Lateral neck x-ray given (?epiglottitis). a) What is the diagnosis: b) What is the most likely causative organism: c) What is your immediate management priority (list 1)

Answer 27

A. Epiglottitis B. Hemophilus influenzae C. Secure artifical airway in a controlled environment (OR or PICU)

Question 28

28. Mother in Winnipeg with twin 2-year old boys, concerned about risks of West Nile Virus. List 5 strategies for avoidance of West Nile Virus.

Answer 28

1. Avoid times when mosquitoes are most active (between dusk + dawn, in shady places, near standing water) 2. Wear long, loose fitting clothes that cover arms + legs and tuck shirts into pants + pants into socks. Hat and closed shoes. 3. Use insect repellent * DEET: 10% for \<=12yo, 30% for \>12yo * Icaridin for 6mo-12yo 4. Use mesh screens for windows + doors at home and while camping 5. Limit mosquito breeding by minimizing containers or other objects with standing water

Question 29

29. Four indications for VZIG after significant Varicella exposure.

Answer 29

1. Pregnant 2. Immunocompromised with no previous varicella or unknown immune status 3. Infant of mother with varicella within 5d before and 2d after birth 4. \>=28wk GA if mother's varicella status unknown 5. \<28wk regardless of mother's varicella status * Give within 10d of exposure

Question 30

30. 9 month old infant with S. aureus septic arthritis. History of Strep pneumo meningitis and chronic oral thrush. What tests would you do?

Answer 30

1. CBC + diff 2. Nitrogen oxidative burst test 3. Immunoglobulins 4. Flow cytometry for B + T cell lymphocytes subsets 5. Vaccine titres

Question 31

31. 10 year old girl, recent immigrant from Sudan presents with fever, headache and pharyngitis with tonsillar exudates. List 3 possible causes.

Answer 31

1. GAS pharyngitis 2. EBV 3. Adenovirus

Question 32

32. Major criteria for rheumatic fever.

Answer 32

* Major 1. Joints - migratory polyarthritis, ++painful, responds even to a small dose of NSAIDs 2. Carditis 3. Subcutaneous nodules - firm nodules ~1cm diameter along extensor surfaces of tendons near bony prominences 4. Erythema marginatum - serpiginous, macular with pale centres, NOT pruitic. Trunk + extremities, NOT face 5. Sydenham chorea: 1) chaotic movements, 2) hypotonia, 3) emotional lability. Phenobarb. * Minor * Arthralgias * Prolonged PR interval * Fever \>T38 * Elevated ESR \>30 + CRP \>30 * ARF = evidence of GAS AND * 2 major * 1 major + 2minor * 3 cirumstances not fulfilling Jones' 1. Sydenham chorea is only major manifestation 2. Indolent carditis is only manifestation in pt seeking attention months after apparent onset of ARF 3. Recurrent ARF in particularly high risk populations

Question 33

33. Child with inguinal adenopathy found 1 week ago by parent while bathing. Give 4 indications for biopsy.

Answer 33

1. Matted. Fixed, nontender nodes, no other Sx. 2. \>2cm in diabeter or increasing from baseline 3. Contitutional symptoms (fever \>1wk, night sweats, wt loss \>10% of body wt) 4. Supraclavicular node 5. Abnormal CXR (mediastinal mass or hilar adenopathy) 6. Abnormal CBC 7. Persistently elevated ESR/CRP or rising despite ABx

Question 34

34. Child presents with ataxia and inability to sit up two weeks after having chicken pox. a) What is the diagnosis? b) How do you differentiate this from meningoencephalitis? List three.

Answer 34

A. Acute cerebella ataxia B. In acute cerebellar ataxia, there is no fever, no nuchal rigidity + no decreased LOC

Question 35

35. Child previously treated with pinworms, presents with reinfection. a) How do you treat? b) What other interventions are needed. List two.

Answer 35

A. Mebendazole 100mg PO to affected individuals + family members. Repat in 2wks B. OTher interventions 1. Morning bathing removes a large portion of eggs 2. Frequent changing of underclohtes, bedding 3. Repeat Tx Q3-4mo may be needed in circumstances of repeated exposure 4. Good hand hygiene is most effective method of prevention

Question 36

36. 31 week GA baby, now 3 mos old. It is October. Parents are non-smokers. Mother planning to stay at home with babe. A) What one intervention can you do to minimize risk of severe RSV bronchiolitis? B) How does this intervention minimize risk and by what mechanism does it work?

Answer 36

Doesn't actually meet criteira but likely an old question A. Palivizumab B. Monoclonal immunoglobulin against an epitope on the F glycoprotein on RSV. When above a certain trough level (max 3-5 doses), level is therapeutic

Question 37

37. Neonate with purpura and thrombocytopenia. Diagnosed with CMV. Give six other features of congenital CMV infection.

Answer 37

1. Microcephaly 2. Periventricular calcifications 3. Chorioretinitis 4. SNHL (usually unilateral) 5. HSM 6. Thrombocytopenia

Question 38

38. Child post bone marrow transplant. Significant exposure to varicella. a) What therapy do you give him? b) What is the time frame for this therapy to be effective? c) How long do you isolate this patient from other immunocompromised patients?

Answer 38

a) VZIG b) Within 10d to exposure c) * Airbone isolation * Starting from 8d from first d of exposure * Until 21 d after last day of exposure * OR until 28d after last day of exposure, if given VZIG

Question 39

39. Child presents with abdominal pain and arthritis. Picture of purpura on buttocks. (looked like HSP) a) What is the diagnosis? b) What is the MOST likely cause of long-term morbidity?

Answer 39

a) HSP b) Chronic renal disease

Question 40

40. Asymptomatic child with Giardia spores in stool. Stool sent after another child in daycare diagnosed with giardiasis. A. Do you treat this child and explain why yes or no? B. If you would treat, what would you prescribe?

Answer 40

Giardia lamblia If asymptomatic, no treatment required If symptomatic, treat with metronidazole PO x7d

Question 41

41. List 4 clinical signs to distinguish orbital from periorbital cellulitis.

Answer 41

Orbital cellulitis 1. Proptosis 2. Pain with extraocular eye movements 3. Opthalmoplegia 4. Visual impairment

Question 42

42. 18 month old child with URTI. He develops higher fever 3 days later, pulling at ear and has erythematous right tympanic membrane, not bulging. Do you treat for AOM? Explain why or why not?

Answer 42

No, because likely viral Has acute onset with fever and otlagia, has middle ear inflammation (though bulging would be more SN/SP sign) but no presence of effusion Practically however, given his 3 day history of higher fever and otalgia, would reassess in 24-48H and if his symptoms don’t improve or are worsening, would consider treating