ILA + lecs-infection + rhem Flashcards
Child develops fever, high pitched cry and lethargy over 8 hour period. Progressively less responsive. Then becomes hypotensive with a delayed capillary refill time, and develops tachycardia and a purpuric rash. Diagnosis?
meningitis
What is a septic screen, and what does each thing screen for?
BUFALO!!
blood culture for bacteria, FBC, CRP, urine sample (common due to UTIs being common, usually do a clean catch)
Check renal function, liver function and clotting function -U+Es, LFT, clotting screen??
Consider: CXR, LP, rapid antigen screen and PCR on CSF/blood/urine
PCR for viruses and meningococcal/pneumococcal
Do LP to identify organism and therefore correct abx and length of time
What is a contraindication to a LP and what indicates this CI?
Raised ICP- can see because: HR goes down and BP goes up and Possible focal neuro symptoms
Clotting problems eg APTT Contraindicates LP
If ventilated or on lots of fluid blouses – don’t want to put in position that will cause reap distress
What are possible complications of a LP?
Complications of LP can be CSF leak (cause headache), infection at site, bleeding
The microbiologist rings to confirm a CSF white cell count of 500 with no red cells. The cells are predominantly neutrophils. CSF glucose is low and CSF protein raised. Gram film shows gram negative diplococci. What is the likely diagnosis?
Meningitis – bacterial caused by N. Meningitisidis – meningococcal septicaemia
What would be the immediate management of a child with meningitis?
What would be the immediate management of a child with meningitis?
ABCD
IV abx
IV fluids to raise BP – give bolus, give 0.9 saline (crystalloid) 200 ml as do 20x10
What antibiotics would you prescribe in a child with meningitis?
Cefotaxime 100 as first dose
Give amanpicillin/ amoxicillin if less than three month as could have a listeria infection
What is the cause of the purpura in a meningitis rash?
Infection causes inflammatory toxins which causes capillary leakage causing DIC and microemboli in vasculature, tissues become necrotic
What measures may be used to stabilise and manage a patient with meningitis, after abx, if they contribute to deteriorate?
Ventilate for airway and breathing- reduces the metabolic demand and can be if gcs drops protects their airway
Fluids for circulation
Vasodilator in shock so reduce fluid as capillaries are already leaky
Check urine – catheter
Adrenaline – inotrope- improves heart function
Central access eg femoral or internal jugular line in young child
Broader abx eg merypenin or clindamycin
How is meningitis carried and passed on?
Nasopharyngeal carrying – airborne
What first-line treatment is recommended to reduce the risk of meningitis in “close contacts”? Are there any contraindications to this treatment?
Give prophylactic rifampicin or ciprofloxacin to eradicate nasopharyngeal carriage in household contacts. If pt has had group c meningitis then contacts should get this vaccine.
If have received rifampicin before may be less effective.
Rifampicin is CI in breast feeding or pregnancy
USUALLY use ciptoflaxacin as less contraindications and only need one dose
What might you warn any people receiving prophylactic medications for meningitis?
Red urine SE
Liver toxicity—hepatitis, liver failure in severe cases
Abdominal — nausea, vomiting, abdominal cramps, diarrhea
Flu-like symptoms—chills, fever, headache, arthralgia, and malaise.
Allergic reaction—rashes, itching, swelling of the tongue or throat, severe dizziness, and trouble breathing
How is a “close contact” defined in infectious diseases?
people living in the same house; university students sharing a hall of residence ; a boyfriend or girlfriend
Laura, a two year old, presents to her general practitioner with a two month long history of malaise, pallor and reduced appetite. She has occasional febrile episodes, associated with a pink rash, and with a persistent complaint of soreness in her left thigh. Despite walking at the age of 13 months, she is now reluctant to weight bear. Her birth and development history show no concerns and all her immunisations are up to date. On examination, she has a low grade fever (37.7°C) and generalised cervical lymphadenopathy. When made to walk, she limps, but does not seem to be in too much discomfort. She is reluctant to move her left leg. There is a full range of passive movement and no specific site of tenderness. The rest of her examination is essentially normal. What is the differential diagnosis?
Septic arthiritis Osteomyelitis Juvenile arthiritis Transient synovitis Malignancy eg osteosarcoma Reactive arthiritis SLE Systemic JIA
What is the diagnostic criteria for systematic JIA?
arthritis with at least two weeks of daily fever. The fever must be greater than 39ºC and return to less than 37ºC between peaks on at least three days (called a quotidian fever). There must be one or more of:
Rash - evanescent (quickly fading) non-fixed erythematous, salmon pink (classically) with fever
Lymph node enlargement.
Hepatomegaly and/or splenomegaly.
Serositis (pericarditis, pleuritis, peritonitis).
Progression:
Average age of onset before the age of 5 years.
Arthritis is only seen at disease onset in one third of children but commonly develops within a few months. It is usually symmetrical and affects several joints.
What investigations would help in child with limp, rash and fever?
XR, POSs Us hip Blood culture ANA FBC Synovial fluid culture Partial septic screen
The investigations are essentially normal apart from the ESR, which is significantly raised. What is the likely diagnosis?
Juvenile arthritis – systemic
What are the different types of juvenile arthiritis?
Other types other than systemic includes oligoarticular, polyarticular, enthesitis, psoriatic
What drug treatment might be considered in SJA?
1st line: NSAIDs
2nd line: corticosteroids;
Methotrexate, Leflunomideand sulfasazine - DMARDS(need to monitor for BM suppression and abnormal LFTs)
; Biological- tocilizmab, adalumab, Abatacept
tanercept is licensed for those patients with polyarticular JIA for whom methotrexate has been ineffective. It is the only anti-TNF licensed in the UK for JIA
joint injections for oligoarticular
Which professionals should be involved in JIA care?
Rheumatology Physiotherapy Occupational therapy Clinical psychology Play specialist support Ophthalmology Pain team
Jirou, a three year old boy presents with a seven day history of high fevers. He has now developed red eyes, a rash and is complaining of a sore mouth and throat. On examination he appears miserable and unwell with a diffuse maculopapular rash mainly on his torso. He has bilateral injected conjunctiva, red cracked lips and a strawberry tongue. He has a unilateral 3cm x 2cm cervical swelling, and swollen reddened palms. What is the differential diagnosis?
Kawacaski’s disease Scarlett fever Meningitis Sepsis Juvenile arthiritis Toxic shock syndrome Steven Johnson’s syndrome Tonsilitis Measles Rubella Parvovirus Enterovirus
How would you manage child with high fever, rash, lympadenopathy and dore throat?
full septic screen including a lumbar puncture, and has intravenous antibiotics started.
What may you see on blds for Kawasakis?
thrombocytosis and a high ESR.
What criteria are used to make Kawasakis diagnosis?
Kawasaki’s - assess in children where fever has lasted over 5 days at 39 degrees plus at least four of:
Acronym My HEART —->
My - mucosal involvement - strawberry tongue, swollen throat
H- hand and feet desquamation (peeling) + red and swollen
Eyes non purulent bilat conjunctivitis
Anopathy cervical unilat 1.5cm lymphadenopathy
Rash - truncal
T-Temperature for 5 days
Also other more generic sx:
Liver toxicity—hepatitis, liver failure in severe cases
Respiratory—SOB
Abdominal —N+V+D
Flu-like symptoms—chills, fever, headache, arthralgia, and malaise.
What is the management of Kawasakis?
Treat with IV immunoglobulins, aspirin, steroids, infliximab, cyclosporin, if have aneurysm may need long-term warfarin.
Give two possible complications with the first-line treatments used in Kawasakis.
IV immunogloblins- MI, haemolsis, aseptic meningitis, PE
Aspirin- Reye’s syndrome (encephalopathy and liver toxicity) and upper GI bleed
What further investigations are indicated in Kawasakis, and why?
urinalysis, FHC, inflamm markers, LFTs may show elevation of the transaminases and bilirubin, ECHO once stable to check for complications – no diagnostic tests
Will need long term cardio follow up if have a cardio issue
What is the long-term prognosis in Kawasakis?
Prognosis depends upon the degree of cardiac involvement. Most (50-70%) coronary artery aneurysms regress after a period of 1-2 years, although giant aneurysms never resolve entirely and have a worse prognosis.
What is the common causitive agent of:
epiglottitis
whooping cough
croup
Haemophilus influenza b
pertussis
Parainfluenza
Is Varicella Zoster (VSZ) serious? How does it present?
self-limiting but can result in death if subsequent encephalitis, secondary staph/strep infection, purpura fulminans (vasculitis skin and tissues )
VESICULAR lesions that starts at HEAD and TRUNK and spreads to the peripheries
Become papules then vesicles (fluid filled) with erythema and then pustules (scan over - no longer contagious)
Itching, fever and scratching
If lesions continue beond 10 days suggests poor immunity
dangerous to non-immune pregnant women
How does HSV present?
stomatitis, cold sore, occasional encephalitis
What are the phases of presentation of Kawasakis from week 1-3?
fever over 5 days, red eyes (NON exudative conjunctivitis), stomatis, raised platelets, cracked red lips, rash, red and oedematous palms and soles, strawberry tongue, cervical lymphadenopathy. In second week get peeling of fingers and toes. Third week onwards get CVS.
What are differentials of a prolonged fever?
kawasakis, deep abscess, osteomyelitis, TB, IE, EBV/HIV, malaria, SLE, vasculitis, IBD, sarcoidosis, malignancy, juvenile arthritis
What are the CSF findings for bacterial vs viral meningitis?
bacterial: Raised cell count
Raised protein
Low glucose
Bacteria identified in blood or CSF culture or PCR
viral: Raised cell count Normal protein Normal glucose Virus identified in CSF, stool, throat or blood commonly HSV encephalitis
What are the causes of meningitis is a:
a) <3 month old
b) >3 month old
c) >6 yr old
<3 months: e coli, listeria, GpB strep: give cefotaxime plus amoxicillin
>3 months: N. meningococcus, strep pneumococcus, haemophilus influenza: give just cefotaxime
>6 yrs: N. meningoccocus, strep pneumonia
How is encephalitis treated?
give acyclovir and treat as HSV
What are symptoms of meningitis?
Older children report: headache, photophobia, neck stiff, kernig’s sign positive
Drowsy/ irritable/ coma/ seizures
Vomit
What is Kernigs sign?
Kernigs= child lies supine with hip and knee flexed. Back pain on extension of knee.
What are early vs late signs of raised ICP?
Early sign of raised ICP – reduced consciousness, abnormal pupils, abnormal posturing, bradycardia, htn
Full fontanelle, papilledema (late sign raised ICP)
What are complications of meningitis?
hearing loss, hydrocephalus, local vasculitis or infarction
What is septicaemia presentation?
Red/purple non-blanching rash.
Cold hands and feet.
Tachypnoea.
Flu like symptoms
What is necrotising fasciitis?
Typically group A strep
Severe S/c infection
Debridgement required – emergency
What is toxic shock syndrome?
Fever, hypotension, erythema/macula rash
Toxin released from S.areus and group A strep
Go into shock, multile organ involvement
What are congenital infections?
HIV, Hep B, rubella, HSV, VSV, syphilis, TB, GpB strep, CMV
What is Epstein Barr virus linked to?
Burkitt’s lymphoma, nasopharyngeal carcinoma, autoimmune conditions eg MS
How does EBV present and what is the treatment?
May present with fever, tonsillitis, lymphadenopathy (known as mono or glandular fever)
Treat symptomatically, steroids in airways comprimised
Amoxicillin and ampicillin should avoided as can cause a rash.
