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Paediatrics > Infection + immuno > Flashcards

Infection + immuno Flashcards

1
Q

Name some causes of fever in children

A
  • Infection: sepsis, meningitis, pneumonia, URTI eg. otitis media, UTI, appendicitis, TB, septic arthritis, viral infection
  • Malignancy
  • Inflammatory conditions: IBD, JIA, reactive arthritis
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2
Q

A 4 year old girl is brought to the GP by her mother. She says she has been poorly with a fever for the past two days, but this morning is very drowsy and there is an odd rash appearing. On examination, there is a widespread pin-point rash that does not blanch when pressed. What is the immediate management?

A
  • Call 999 for ambulance to take the child to A&E
  • Give IM benzylpenicillin after checking for allergies

(Also need to contact the health protection team and arrange ciprofloxacin prophylaxis treatment for contacts)

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3
Q

A 4 year old girl is brought to the GP by her mother. She says she has been poorly with a fever for the past two days, but this morning is very drowsy and there is an odd rash appearing. On examination, there is a widespread pin-point rash that does not blanch when pressed. The GP gives an IM injection of benzylpenicillin and calls an ambulance. What would be the next management in A&E?

A
  • Call a senior, A to E approach
  • Full history and examination including obs
  • Septic screen: bloods (FBC, CRP, U+Es, cultures, VBG), throat swab for PCR, LP, rapid antigen screen on blood
  • Sepsis 6: blood cultures and lactate, give high flow O2, IV fluids 10-20ml/kg over 5-10 mins, IV antibiotics (ceftriaxone), monitor urine output
  • Needs admission
  • Inform the health protection team
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4
Q

A 4 year old girl is treated in hospital for meningococcal meningitis. What is important to do on discharge?

A
  • Review by paeds in 4-6 weeks

- Arrange audiology assessment to assess for complications

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5
Q

Where should temperature be measured in children?

A
  • <4 weeks: axilla

- 4 weeks-5 years: axilla or tympanic

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6
Q

Describe the traffic light system of assessing children presenting with fever

A
  • Green (mild): normal colour + activity, no dehydration
  • Amber (moderate): pale, drowsy + lethargic, nasal flaring, mild tachypnoea, low sats, tachycardia, dehydration, high temp, rigors, joint swelling
  • Red (severe): mottled/cyanotic, extremely drowsy, grunting, significant tachypnoea, chest retractions, any neuro, bulging fontanelles, non-blanching rash
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7
Q

Define tachycardia in children

A

<12 months: >160
12-24 months: >150
2-5 years: >140
5-12 years: >120

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8
Q

A 7 year old boy is brought to the GP by his mum. He has had a fever for the past 2 days and is feeling generally unwell and eating less than usual. On examination, his temp is 37.9, other obs are within the normal range, there are no signs of dehydration or focal signs of infection, and urine dip is normal. What is the management of this child?

A

Because there are no amber or red features (using the traffic light system), and no focal symptoms/signs of infection, this is likely and viral infection and does not need immediate management.
The child can go home with advice for conservative management and safety-netting.
-Maintain good fluid intake, antipyretics can be used to relieve symptoms of fever, stay home from school while feverish
-Look for signs of dehydration and worsening illness eg. drowsiness, dryness, seizures, non-blanching rash, fever lasting >2 weeks

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9
Q

In which ages should a LP be done if the child presents with a fever?

A

<1 month with fever
1-3 months with fever + clinically unwell/WCC abnormal

Consider if:

  • Fever and any red features
  • <1 year with amber features
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10
Q

A 1 month old baby is brought to A&E by his mother with a fever of 38˚. There are no clear focal signs of infection. A urine dip is negative. Bloods are taken and a LP is done. While waiting for the results, what treatment should be given?

A

Start IV antibiotics, ceftriaxone + amoxicillin to cover Listeria

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11
Q

A 7 year old girl is brought to A&E by her dad because she has fever. What questions would you like to ask in the history?

A
  • Fever: onset, timings, severity, tried anything
  • Localising symptoms: rashes, cough/runny nose/sore throat, headache/fits, urine symptoms, D+V, ear pain, joint pain/swelling
  • Consider malignancy if >2 weeks: weight, lumps, tiredness
  • Eating + drinking
  • RFs: around anyone else unwell (school/home), travel
  • Immunisations
  • Development screen
  • PMH
  • Social Hx: home, school
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12
Q

A 15 month old child comes to the GP with a fever of 38˚ and poor feeding. There are no localising symptoms. Describe your examination + first-line investigations.

A

Examination: inspect for rash, auscultate chest, palpate tummy, palpate lymph nodes, inspect throat, visualise tympanic membrane. Take HR, RR, temp, sats +/- BP

Investigations: urine dip. If needed bloods or further tests (CXR, LP), send to A&E.

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13
Q

What is the treatment of HSV encephalitis?

A

IV aciclovir

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14
Q

Which antibiotics should be given to any child presenting with fever and signs of severe/life-threatening infection?

A

-IV cefotaxime/ceftriaxone

+ amoxicillin if <3 months to cover for Listeria

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15
Q

What is a septic screen? What is the paediatric sepsis 6?

A
  • Bloods: FBC, CRP, U+Es, VBG, blood cultures
  • Urine dip + MC&S
  • CXR, LP as indicated
  • Rapid antigen screen for meningitis organisms (blood, CSF)

Management/sepsis 6:

  • High flow O2 (15L via non-rebreathe mask)
  • IV fluids (10-20ml/kg 0.9% NaCl over 5-10 mins)
  • BS antibiotics (usually IV ceftriaxone +amox if <3mos)
  • Monitor urine output
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16
Q

Describe the results on CSF analysis in bacterial, viral and TB meningitis.

A

Bacterial: turbid CSF, polymorphs++, protein +, glucose -0

Viral: clear CSF, lymphocytes++, protein –, glucose –

TB: clear/turbid CSF, lymphocytes+, protein ++, glucose –0

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17
Q

What is toxic shock syndrome?

A

A serious condition caused by severe immune response to toxin produced by bacteria, leading to multi-organ dysfunction.
Usually caused by toxin-producing S. aureus or Group A Streptococcus

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18
Q

How can toxic shock syndrome present?

A
  • High fever
  • Localised area of tenderness, erythema, oedema
  • Hypotension
  • Diffuse macular rash, may start on palms
  • N+V
  • Renal, hepatic impairment, clotting abnormalities
  • Altered consciousness/seizures
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19
Q

How is toxic shock syndrome managed?

A
  • Consider need for ICU admission if shocked
  • Give high flow O2, IV fluids
  • IV antibiotics: clindamycin + vancomycin
  • Surgical debridement of infected soft tissue
  • Consider IVIG treatment
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20
Q

How does necrotising fasciitis present? What is the management?

A

Presents with severely painful soft tissue area that may not appear inflamed at the time, with systemic illness.
Management:
-Consider ICU admission
-Surgical debridement is NECESSARY
-Broad spectrum IV antibiotics: eg. vancomycin, linezolid, meropenem etc.

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21
Q

Streptococcus pneumoniae can cause which infections? Which children are most at risk of invasive infection?

A

-Otitis media
-Pharyngitis
-Sinusitis
-Pneumonia
-Sepsis
-Meningitis
Children with poor immune functioning and hyposplenism (e.g sickle cell disease) are at highest risk and should receive daily penicillin prophylaxis.

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22
Q

How can staphylococcus and Group A streptococcus cause disease? Describe 4 ways and give examples.

A
  • They can cause disease by direct invasion into tissues eg. cellulitis
  • By dissemination eg. meningitis
  • Through the production of endotoxins that trigger severe immune response eg. TSS
  • By affecting the immune system and triggering immune-mediated organ damage eg. post-streptococcal GN, rheumatic heart disease
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23
Q

What is impetigo? What are the types?

A

A superficial infection of the skin caused by Staphylococcus or group A streptococcus.
Can be non-bullous (more common) or bullous (only S aureus).

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24
Q

What does impetigo look like?

A
  • Can be bullous or non-bullous
  • Can present with thin, honey-coloured crust on an erythematous base, often on the face eg. peri-oral
  • Or with large bullae that quickly rupture
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25
Q

Explain the management of impetigo.

A

Depends on the age and the severity of infection as well as MRSA status.
In all, advise hygiene eg. 2x/day washing with soap and water, no sharing towels, stay home from school until lesions scab.
-Neonates: non-bullous- erythromycin, bullous clindamycin. MRSA vancomycin
-Superficial localised: hydrogen peroxide cream, fusidic acid 5 days.
-Widespread cutaneous OR any bullous: PO flucloxacillin or clindamycin for MRSA QDS 5 days.
-Deep soft tissue: IV clindamycin or vancomycin for MRSA

26
Q

The mother of a 18 month old child brings him into the GP. He has a temperature of 37.5 and marked erythema and swelling around the left eye. He is very irritable and does not tolerate an examination of the eye. What is the diagnosis, and what is the management?

A

Periorbital cellulitis

Refer to A&E as the child will need admission for IV antibiotics eg. ceftriaxone to prevent damage to the eye

27
Q

What is staphylococcal scalded skin syndrome? Which sign is it associated with? What is the management?

A

A painful blistering skin condition caused by production of exfoliative toxin by Staphylococcus aureus.
Nikolsky’s sign: gentle pressure on the skin causes separation of the epidermis
Manage with IV antibiotics eg. fluclox and analgesia

28
Q

How can HSV infection manifest? What is the treatment?

A

-Asymptomatic infection
-Gingivostomatitis: severe mucosal infection in younger children
-Cold sores
-Eczema herpeticum
-Conjunctivitis +/- corneal ulceration
-Disseminated infection eg. encephalitis
Treatment with aciclovir. Gels for cold sores, PO for complicated but not severe, IV if eye/disseminated.

29
Q

How is chickenpox spread? What is the incubation period and when does shedding occur?

A

By droplet transmission. Incubation is 10-23 days (avg 14), and shedding occurs 2 days before onset of rash to about 5-7 days after onset/when lesions scab over.

30
Q

Describe the presentation of chickenpox infection.

A
  • Prodrome phase of general illness
  • Child develops fever + pruritic papules about 2 weeks after exposure
  • Papules –> vesicles, which burst and crust over after several days
31
Q

The mother of a 6 year old boy phones the GP because she suspects her son has chickenpox. He has been feeling unwell for the past 4 days and has now developed a rash on his trunk and face after his classmates had chickenpox. He is feeling well besides the itching, and the mother is not worried. What advice would you give her?

A
  • Likely to be chickenpox. Can ask for a picture of the rash
  • Explain the course of infection (vesicles -> crust)
  • Advise good fluid intake, use paracetamol if needed, cut nails to prevent damage from itching, wear loose clothing, use cooling creams/gels, take cold baths
  • Stay away from pregnant women, young babies, or people with poor immune systems
  • Stay home from school until the blisters crust over (about 5 days)
  • Safety net: if new high fever, new blisters coming in 1 week after onset, dehydration, child becomes more unwell seek medical attention
32
Q

What are the potential complications of chickenpox?

A
  • Bacterial superinfection –> PO antibiotics eg. fluclox
  • Pneumonitis –> admission, IV aciclovir 7-10 days
  • Encephalitis –> admission, IV aciclovir
33
Q

How does EBV infection present?

A
  • Usually symptomatic in older children/adolescents
  • Triad: Pharyngitis/tonsillitis, lymphadenopathy, fever
  • Plus fatigue, splenomegaly, soft palate petechiae, rash
34
Q

How is EBV diagnosed?

A
  • Usually just a clinical diagnosis
  • Do an FBC (lymphocytosis with atypical lymphocytes) and Monospot eg. agglutination test for heterophile antibodies after 1 week of illness
  • EBV viral serology is used in younger children (Viral Capsid Antigen- VCA and EBV nuclear antigen- EBNA)
35
Q

A 14 year old girl comes to the GP because she has been unwell for a week and has needed to take time of from school. She describes feeling extremely fatigued, and has a sore throat and fever. On examination, she has a temperature of 37.8, there is cervical lymphadenopathy and the pharynx is erythematous and swollen. What would you advise?

A

This is very likely infective mononucleosis, due to the triad of fever, pharyngitis and lymphadenopathy, also supported by the fatigue.

  • Explain the diagnosis and course (usually 1-3 weeks but some people have fatigue lasting for 1-3 months)
  • Rest and drink lots of fluids
  • Take paracetamol and ibuprofen as needed to feel better
  • No need to take time off from school, do as needed
  • Avoid contact sports until recovered (splenic rupture)
36
Q

What must you never do in patients with suspected infectious mononucleosis?

A

Give amoxicillin/ampicillin. This will cause a florid widespread maculopapular rash.

37
Q

How can CMV infection present? What is the management?

A
  • CMV is usually mild or subclinical, or can present similarly to EBV but less pharyngitis
  • Worse if immunosuppressed eg. transplant recipients
  • Conservative management, IV ganciclovir/PO valganciclovir if needed
38
Q

Roseola infantum is caused by ___

A

HHV 6+7

39
Q

Describe the presentation of roseola infantum. What is the management?

A
  • Viraemic phase: very high fever, malaise, irritability
  • Followed by generalised maculopapular rash after several days
  • Conservative management. Warn of febrile seizure possibility
40
Q

Erythema infectiosum is also known as ___. It is caused by ___

A

Slapped cheek syndrome. Caused by parvovirus B19

41
Q

How does erythema infectiosum present? What is the management?

A
  • Viraemic phase: fever, malaise, myalgia
  • Rash after 1 week: ‘slapped cheek’ followed by lace-like rash on trunk and limbs
  • Conservative management. Avoid pregnant women
42
Q

Name some types of enteroviruses and clinical syndromes

A
  • Poliovirus, coxsackie virus, echovirus
  • Many can cause exanthems, usually fine petechiae
  • Hand, foot and mouth: Coxsackie virus A. Mild systemic features with painful vesicular rash on palms, soles and mouth
  • Herpangina: painful sores in mouth
  • Meningitis, myocarditis + pericarditis
43
Q

What type of virus is measles? How is it transmitted?

A

Paramyxovirus. Droplet transmission

44
Q

Describe the presentation of measles.

A
  • Incubation period of 7-18 days
  • Viraemic phase: fever, cough, runny nose, conjunctivitis
  • Koplik’s spots on buccal mucosa
  • 3-4 days later an erythematous maculopapular rash starting on the face
45
Q

What are the complications of measles?

A

Worse in developing countries where malnutrition -> poor immunity

  • Pneumonia
  • Encephalitis
  • SSPE (subacute sclerosing panencephalitis) after several years
46
Q

A 6 year old boy is brought to the GP by his mother who is worried about a rash that appeared this morning. She reports her son has been poorly for the past several days with a runny nose, cough and fever. On examination the child appears mildly unwell, with normal observations. There is a maculopapular rash on his face and trunk. The child has not received any routine immunisations. What is your management?

A

This is likely to be measles due to the viral prodrome followed by maculopapular rash on the face and trunk.

  • Notify the local health protection team as measles is a notifiable disease
  • Advise to rest and drink fluids, take paracetamol and ibuprofen as needed to feel better
  • Stay home from school for the next 4-5 days
  • Safety net: seek medical attention if short of breath, very high fever, fits, or something changes
47
Q

Describe the presentation of mumps

A
  • Fever, malaise, parotitis (uni or bilateral)
  • Parotitis may present with ear pain or pain when eating/chewing
  • Lasts for 7-10 days
48
Q

What are the complications of mumps?

A

Meningitis in 10%

  • Pancreatitis (amylase can be raised in parotitis)
  • Epididymo-orchitis with infertility rarely
49
Q

Describe the management of mumps

A
  • Notify the local health protection team
  • Conservative: rest, fluids, paracetamol, ibuprofen
  • Avoid school for 5 days from onset of parotitis
  • Safety net: seek medical attention if very drowsy, fits, severe headache, etc.
50
Q

Describe the presentation of rubella. How is it managed?

A
  • Viral prodrome of mild fever/illness
  • Maculopapular rash starting on the face
  • Prominent suboccipital and postauricular lymphadenopathy

Conservative management, notify local HPT
-Stay home for 5 days from onset of rash, avoid pregnant women

51
Q

What is Kawasaki disease? When does it present?

A

An acute, systemic vasculitis

Affects children 6mos-4years usually

52
Q

What are the presenting features of Kawasaki disease? How is it diagnosed?

A 
CRASH and burn
Conjunctivitis
Rash- 
Adenopathy (unilateral cervical)
Strawberry tongue
Hand- swelling +/- erythema
Burn- fever

Clinical diagnosis. +/- bloods showing raised inflammatory markers (CRP, WCC, ESR)
-Echo can be used if the diagnosis is unclear, and should be done in all patients at diagnosis + later

53
Q

Describe the management of Kawasaki disease. What are the worrisome complications?

A
  • Admit for IVIG and monitoring
  • One dose IVIG + few days aspirin
  • 2nd line: steroids, infliximab, plasma exchange
  • Complications: 20-25% untreated have coronary artery aneurysms -> stenosis -> sudden death
54
Q

How does TB infection present in children?

A
  • Usually asymptomatic, but can present with non-specific features
  • Fever, cough, fatigue, anorexia, weight loss
55
Q

How is TB diagnosed in children?

A

-Difficult to diagnose via sputum sample in young children -> 3 consecutive morning gastric washings for Ziehl-Neeson/auramine stain/culture

TST and IGRA cannot differentiate latent vs active TB

  • TST: inject protein purified derivative into the skin, measure induration after 48-72 hours. >5mm =TB infection
  • Interferon gamma release assay (IGRA)
56
Q

Describe the management of TB in children

A
  • Admit if unwell
  • Notify the HPT for contact-tracing etc
  • Refer to TB team
  • RIPE: rifampicin, isoniazid, pyrazinamide, ethambutol
  • Active TB: RIPE x2 mos ->RI 4mos
  • Latent TB (eg +ve TST asymptom): RI x3mos/ Ix6mos

*If a child <2 years is exposed to active TB adult -> prophylactic isoniazid until 6 week TST/IGRA

57
Q

How should HIV be diagnosed in children?

A

<18 months: viral RNA PCR because maternal antibodies may be present
>18 months: HIV antibodies

58
Q

Describe the general management of HIV in children.

A
  • MDT approach with HIV specialist
  • Focus on preventing complications + ensuring good growth and development
  • Immunisations important
  • PCP prophylaxis w/ co-trimoxazole
  • ART should be started in infants because of high progression risk
59
Q

Erythema migrans is characteristic of which infection?

A

Lyme disease - infection with Borrelia burgdorferi

60
Q

What is the treatment for Lyme disease?

A

-Doxycycline -> amox -> azithro

61
Q

Describe the immunisation schedule

A 
8 weeks: 6 in 1, pneomococcal, Men B, rotavirus
12 weeks: 6 in 1, rotavirus
16 weeks: 6 in 1, pneumococcal, Men B
1 year: HiB, Men C, MMR, pneumococcal, Men B
2 + 3 years: flu
3 years 4 months: DTPP, MMR
4-8 years: flu 
13-18 years: DTP, Men ACWY, HPV
62
Q

What is in the 6 in 1 vaccine?

A 
Diphtheria
Pertussis
Polio
Tetanus
HiB
HBV

Paediatrics (13 decks)

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