Infections Flashcards
What % of cases of meningitis occur in children under the age of 15?
75%
What is the most common causative organism of meningitis?
What organism do you suspect if child is unvaccinated and <4 years?
Neisseria Meningitides
Neisseria Meningitides and streptococcal pneumoniae should be suspected if <4 years and unvaccinated
Most common causes of meningitis in neonates?
○ Group B streptococci (gram +)
○ Listeria monocytogenes (gram +)
○ EColi (gram -)
How does infection of the meninges occur, and why is this more likely to occur in children?
Usually there is an infection of the nasopharyngeal mucosa first and then this infection gets into the blood. Because in children the blood brain barrier (BBB) is less developed these bugs are more likely to reach the meninges and cause infection
Infection of the meninges leads to leaking of proteins and cerebral oedema as well as inflammation of the blood vessels in the brain (cerebral vasculitis)
What symptoms are likely to be present in a child with meningitis and what might make diagnosis more difficult?
Photophobia, neck stiffness and headache are the classical distinguishing symptoms but the young child (infant) might not have these making diagnosis more difficult.
They might have NON-SPECIFIC SYMPTOMS OF INFECTION
- Fever, malaise, vomiting, anorexia
OTHER MENINGITIC SIGNS: Seizures irritability drowsiness disorientation altered mental state bulging fontanelle papilloedema focal neurological signs (tuberculous meningitis)
What investigations should be done in a child with meningitis?
What should you do if there is meningococcal septicaemia?
Do NOT let investigations delay treatment
EXAMINATION
- A to E assessment for shock (CRT, temp, HR BP)
- Kernigs and brudzinskis
BLOODS:
FBC
Us and Es (check if they have been affected)
Glucose (see if this is causing drowsiness and to compare)
CRP
Coagulation
MICROBIOLOGY Blood cultures Urine dip to look for infection Lumbar puncture PCR to look for specific causes (Nisseria meningitides or enterovirus/HSV/HIV/TB) -Western blot for borrelia burgdorferi -Thin blood smear for malaria
If suspecting meningococcal septicaemia give dose of benzylpenicillin IV or IM (or if no rash but cant get urgent hospital transfer)
It is not appropriate to do an LP in all children, in which ones is it contra-indicated?
Contraindications for lumbar puncture
- Raised ICP or bulging fontanelle
- Coagulopathy (bleeding disorder)
- Haemodynamic instability (low perfusion)
- Focal neurological signs or focal seizures (more -suggestive of TB meningitis)
- Infection of skin at LP site
- Respiratory insufficiency
What is the ultimate concern in children with meningitis and what signs are there of this?
SHOCK (that might be septic or neurogenic in origin but is ultimately distributive in type) -Incr HR -Decr BP (near fatal) -Increased RR -Poor CRT -Cold, mottles, clammy skin -Poor urine output -Cyanosis THESE CHILDREN NEED IMMEDIATE RESUSCITATION
What is the MANAGMENT of children with bacterial meningitis?
- ANTIBIOTICS
Wide spectrum cephalosporin penetrate CSF
-50mg CEFOTAXIME
-OR
-80mg CEFTRIAXONE
+ Amoxicillin in children under 3 months (or elderly) for listeria cover - STEROIDS (ASAP before/at same time as AB)
(reduce risk of neurological complications, particularly deafness and death. Within 12 hours if cant give immediately)
-although not if <3 months
-DEXAMETHASONE 0.15mg/kg QDS might reduce the neurological sequelae particularly deafness (need to confirm with LP and consult senior first) - FLUIDS if in shock
- 20ml/kg 0.9% NaCl fluid bolus (monitor response and monitor Ca and K) - PHE should be notified (contact prophylaxis might be required) and TREAT contacts prophylactically
- SAFTEY NET AND FOLLOW UP
- follow up with pads and hearing test
- safety net: come back if any hearing or developmental problems (memory)
What is meningococcal septicaemia?
This is a sepsis caused by a meningococcus (of any type). It can occur with or without meningitis (most common is Meningitides serogroup B)
What are some signs and symptoms of meningococcal septicaemia?
NON-BLANCHING PURPURIC RASH (this is very concerning) Increased HR Increase RR FEVER Poor urine output Increased CRT ...Start thinking SHOCK
What is the prophylactic meningitis treatment of contacts and who should be treated?
Prophylaxis (ciprofloxacin, although check guidelines) against meningococcal disease and also H influenza
- people close contact in household setting 7 days prior to onset
- transient contact only if large exposure to droplets (kissing)
- side room for 24hr after AB
REGARDLESS OF VACCINATION STATUS
How should a suspected case of meningococcal septicaemia be managed?
A to E assessment
80mg CEFTRIAXONE or 50mg CEFOTAXIME
Resuscitation - 20ml/kg 0.9% NaCl fluid bolus (monitor response and monitor Ca and K)
If child is less than 3/12 give amoxicillin to cover for listeria
PHE alert - treat contacts prophylactically
How should non-blanching rash lesions be referred to occurring to their size?
<3mm = petechial 3-10mm = purpura >10mm = ecchymosis
Why do non-blanching rashes occur?
Vascular disorders (immune complex vasculitis) Platelet disorders Endotoxin release from bacteria (meningococcal)
What are some common differentials in a child with a non-blanching rash?
MENINGOCOCCAL SEPTICAEMIA - always work to rule this out
HENOCH-SCHONLEIN PURPURA (HSP) - is another key differential
Where is the rash usually located in children with HSP?
Over the legs and buttocks
Who normally gets HSP and what seems to trigger it?
- Usually occurs in boys between the ages of 3-10
- Usually occurs after an upper respiratory tract infection -(winter more common)
What other systemic problems can HSP cause?
- It is a type of IgA complex disease - these complexes being deposited in the skin capillaries is what causes the rash
- They can also be deposited in the NEPHRONS (one of the most common causes of IgA Glomerulonephritis)
Asides from the rash what other signs might there be of HSP?
square of symptoms
- Flitting joint pain (lower limb more)
- GI symptoms (nausea/vomiting/bloody stools/can get necrotic bowel and intussusception due to vasculitis)
- Pupruric macula rash (symmetrical, buttocks/legs)
- Renal involvement (blood in urine)-nephritis 40%
What treatment options are there for HSP?
-Usually treatment is supportive and the disease will be self limiting
-Monitor for kidney function
CORTICOSTEROIDS sometimes given but therapeutic value is unclear
-FOLLOW UP FOR 6 MONTHS (to check for renal impairment)
How do we prevent meningitis?
REVENTION OF MENINGITIS
• 2 months-MenB (booster at 4 months and 1 year)
• 2 months -Pneumococcus (strep pneumonia) (booster at 4 months and 1 year)
• 6in1 against H. Influenza type B
• 1 year-MenC
• Teenagers aged 13-15 years (and uni): quadrivalent vaccine (meningococcus groups A, C, W, Y)
• 65+ pneumococcal vaccination
Intrapartum screening for group B strep and AB prophylaxis
Which agent causes chicken pox?
How would you investigate chicken pox in GP?
Varicella Zoster Virus (VZV)
- normally chicken pox is clinical diagnosis however can do PCR of skin scrapings
- make sure to check for complications (breathing, walking, speach, skin)
What is the classical clinical presentation of chicken pox?
Order of events:
- FEVER (couple days before_
- MACULOPAPULAR RASH
- VESICULAR RASH
- PUSTULES AND RUPTURE
- CRUST OVER (takes about a week-longer may mean impaired immunity)
○Rash starting on head/trunk, then spread all over
○ Can also include mucosal membranes
○ SYSTEMIC UNWELLNESS
- Some children will be playing/running around
- Some children will be wheezy, fatigued and very lethargic, low appetite, headache, abdominal pain
- Females might get unpleasant vulval lesions
What is the incubation period and how long for chicken pox?
Incubation period (time taken from exposure to symptoms) is 10-21 days
How long will children be infective for with chicken pox?
4 days before the appearance of the rash and until lesions have crusted over (usually 5 days after the rash first appeared)
What are some complications of chicken pox?
USUALLY VERY UNCOMPLICATED
- Infection of the lesions with group A staph - can lead to toxic shock or necrotising fasciitis. safety net: return if new onset higher fever/persistantly high after couple days
- Encephalitis - commonly of the cerebellum (cerebellitis) - the prognosis for this is actually quite good
- Purpura fulminans - widespread vasculitis and necrosis
- Pneumonia
How should children with chicken pox be managed?
SUPPORTIVE
- Fluids and oral intake
- Paracetamol (avoid ibo-may increase risk of complications)
- Short nails/wear mittens
- Keep them cool to help comfort with fever
- Avoid pregnant mums/immuncompromised/newborns
- Calamine lotion can soothe itching
- SCHOOL EXCLUSION from 5 days after onset of rash/when lesions crusted over (most infectious period is 1/2 days before rash
MEDICATION
Immunocompromised patients can be given VZIG prophylactically or IV acyclovir for treatment (and those with complications)
When does conjunctivitis usually occur in a child’s life?
It is a common infection and can occur at any time. There is a notable peak in the neonatal period due to infections obtained from the birth canal
What are some symptoms of conjunctivitis?
Red, irritated, itchy, weeping eye
What features might make you consider a bacterial cause of conjunctivitis and what are some common agents?
If the weeping is purulent and sticky (rather than serous as in viral)
If the conjunctivitis is particularly red/irritant looking how could you consider treating it?
Chloramphenicol drops or neomycin topical ointment (could be staphylococcal)
What is general management for all infective conjunctivitis?
Cleaning with saline or water regularly is recommended and this will usually lead to the infection clearing up in 3 or 4 days
If conjunctivitis occurs in the first 48 hours after birth what should you consider?
That it might be caused by gonococcus from the mother’s genital tract
How should conjunctivitis caused by gonococcus be treated?
- Gonorrhoea is common penicillin resistant in the UK so treatment with third gen cephalosporin is advised (CEFOTAXIME)
- Sample to lab
- Really important because can cause blindness
If a baby presents with conjunctivitis 1-2 weeks after birth what organism should you consider?
Chlamydia trachomatis
How should conjunctivitis caused by chlamydia be investigated and how should it be treated?
- Can be investigated using immunofluorescence screening
- Should be treated with oral erythromycin
What is the cause of infectious mononucleosis?
EBV
What affect does EBV have and what malignancy is it associated with?
- It affects the pharyngeal epithelial cells and B cell lymphocytes
- It’s effect on B lymphocytes also causes its link with Burkitt’s Lymphoma (bucket list to kiss harry Barr)
Which age of children does infectious mononucleosis most commonly occur in?
Peak in adolescence due to its common route of spread (kissing)
- AKA the kissing disease
What are some common clinical features of infectious mononucleosis?
- fever
- extremely tired (think about ptn who couldn’t snpachat)
- swollen tounsils (extremely painful, affecting breathing, eating and voice changes)
- swollen lymph nodes in neck (b cells accumulate)
- red dots back of throat (petechiae)
- maculopapular rash
- hepatosplenomagally (good diagnostic clue)-NO SPORT or ALCOHOL
- jaundice
What investigations should you do in a child who you suspect to have infectious mononucleosis?
- normally clinical diagnosis
- Atypical lymphocytes (numerous BIG T killer cells seen on blood film aiming to kill weird B cells)
- Positive monospot test
- IgG and IgM responding to EBV antigens in blood
How long does infectious mononucleosis last?
Symptoms usually last 1-3 months then resolve
ADVISE NO CONTACT SPORT
How should we manage infectious mononucleosis?
SYMPTOMATIC/SUPPORTIVE TREATMENT (symptoms caused by your body to virus)
- Fluids
- Temp control
- Consider corticosteroids if airway obstruction
- Treat concurrent bacterial infection of tonsils with penicillin
- ADVISE NO CONTACT SPORT
What should you never give someone who has infectious mononucleosis?
AMOXICILLIN or AMPICILLIN
It will cause a florid maculopapular rash when there is an EBV infection
If a child has a prolonged fever what should you always suspect?
Kawasaki’s disease
What is Kawasaki’s disease?
It is a VASCULITIS with mucocutaneous lymph node involvement
Who does Kawasaki’s disease usually affect?
- Children between 6 months and 4 years of age
- Most common in male japanese toddlers
What clinical features must be present to make a diagnosis of Kawasaki’s disease?
A fever that has been present for 5 days + 4/5 of:
- Conjunctivitis
- Irritation around the mouth and lips (inc. strawb tongue)
- Desquamation / redness of the hands and feet
- Cervical lymphadenopathy
- Polymorphous rash
What investigations should you do if you suspect a child has Kawasaki’s disease?
There is no specific diagnostic test for Kawasaki’s disease but you should always do an ECHOCARDIOGRAM to check for Coronary artery aneurysms (30% of children and most common cause of MI)
What are differentials of Kawasakis?
- Measles (although measles normally have cough- LOOK AT IMMUNISATIONS)
- Scarlet fever (temp should respond to antipyretics whereas Kawasaki won’t)
What treatments should be given for Kawasaki’s disease?
TREATMENT FOR KAWASAKIS
- Intravenous immunoglobulin high dose (IVIG)
- High dose aspirin until fever gone, then low dose until the coronary aneurysms confirm/absent at 6 weeks
- Echo monitoring
If aneurism found then child will need long term warfarin therapy
Why is aspirin not normally given in children?
Risk of REYE’S SYNDROME
- Encephalopathy and liver swelling in children
***Should still give aspirin in Kawasaki’s
In what way will otitis media present?
It will either be acute or recurrent - important to get an idea of which one because recurrent OM is more at risk of glue ear and hearing loss
What age are children more susceptible to acute OM and why?
6-12 months because they have short eustachian tubes that don’t flush out contents as effectively. also downs syndrome
When should you consider examining the ears in a child?
Examine in every child with a fever
Ear infections are really common and fairly easy to treat
What symptoms will children with OM present with?
Ear pain (otalgia) Coryzal symptoms - current or preceding Fever Irritation Tugging of the ears Hearing loss Discharge from the ear (if membrane has ruptured)
When should you consider treatment for OM?
AMOXIXILLIN 5 days if:
- if the symptoms persist for 4 days or longer or don’t improve
- if there is purulent discharge from ear
- If child is immunocompromised
Otherwise it is probably self limiting (analgesia)
What is the concern if the child keeps having recurrent ear infections? treatment?
That this will lead to ear infection with effusion (OME)
Also known as glue ear or serous otitis media
-resolve spontaneously normally, grometts might be needed
What are the symptoms of periorbital (preseptal) cellulitis?
Fever + Redness + Tenderness + Oedema of the eyelid
UNILATERAL … if it is bilateral then consider other causes
What is the likely causative organism for orbital cellulitis?
what should you ask in history of swollen eye?
DEPENDS ON AGE OF CHILD
- if young and un-immunised consider HiB
-In older children it is more likely to be caused by spread from paranasal sinuses (so staph or strep infections) or dental abscesses
History:
- have you had vaccinations
- have you been unwell prior?
- have you got any problems with teeth?
What are signs of a worrying orbital involvement? What is management?
Involvement of the orbit is worrying:
- Proptosis / exophthalmos
- Painful / limited ocular movement
- Reduced visual acuity
- If orbital cellulitis is suspected then should do a CT scan to assess the spread
What investigations should you do in someone who has preseptal cellulitis?
Bloods:
- Inflammatory markers CRP and ESR
- Consider blood cultures
- Swabs of the site for specific organism
- Consider CT in orbital
How should preseptal and orbital cellulitis be managed?
ABX
- Preseptal cellulitis can be managed with oral co-amoxiclav
- Orbital cellulitis will require admission and IV abx
What is the causative agent of impetigo?
Where do you get scabs?
Managment?
- Staphylococcus aureus
- Honeycomb scabs on neck hands and face
How do we treat impetigo?
How long off school for?
HYGIENE
- advise on good hand washing
- not towel sharing or sharing any personal care products
- avoid scratching
- consider washing toys
SCHOOL
-Stay off school for 48hours after starting abx
MEDICINE
Usually topical FUSCIDIC acid (three time a day for 5 days) is enough. If the rash is more widespread then consider oral FLUCLOXACILLIN
What are some long term complications of meningitis?
- hearing loss (with the child or young person having undergone an urgent assessment for cochlear implants as soon as they are fit)
- orthopaedic complications (damage to bones and joints)
- skin complications (including scarring from necrosis)
- psychosocial problems
- neurological and developmental problems
- renal failure
long term complications of measles?
MEASELS
- Recurrent ottitis media MOST COMMON COMPLICATION (can cause deafness)
- pnuemonia MOST COMMON CAUSE OF DEATH
- encephalitis 1-2 weeks after (brain swelling leading to deafness/LD)
- Subacute sclerosing panencephalitis (SSP) is a rare but devastating long term potential complication of measles (can be up to 7 years later)
- DEATH
Bacterial meningitis levels of neutrophils, lymphocytes, protein and glucose ratio?
BACTERIAL LP
neutrophils: 100-10,000 (may be normal-0)
lymphocytes: usually <100
protein: usually >1g/L
glucose CSF:blood <0.4 (less than 50% serum) (may be normal)
**more pressure on LP
Viral meningitis levels of neutrophils, lymphocytes, protein and glucose ratio?
VIRAL LP neutrophils: usually <100 lymphocytes: 10-1000 (may be normal) protein: usually <1g/L glucose CSF:blood: normal (>0.6) (>60% serum glucose)
how does a tuberculosis meningitis LP look?
- VERY high protein
- Low glucose (like other bacteria)
- Protein >1g/L (like other bacteria)
- WCC moderate to elevated-predominantly lymphocytes (which is unexpected-normally viral)
Before giving vaccine what should you do
- Explain the purpose
- Explain side effects: redness around site, slight fever, achy bones, slightly irritable-straight away or delayed (Calpol)
- However if swelling lips/breathing problems happen soon after-call 999
- Check allergies
- PMH:bleeding disorders-if so do Subcut/immunocompromised (bone transplant, high dose steroids)
- advise to breastfeed during and after as pain relief
- Gain consent
What vaccines are live?
LIVE VACCINES
- Influenza (cant have if egg anaphylaxis)
- MMR
- rotavirus (liquid)
shingles BCG typhoid yellow fever varicella vaccine
Which injections cant be given in egg anaphylaxis?
influenza and yellow fever cant be given in egg anaphylaxis
What is the viris in measels?
How is measles spread?
WHAT CAUSES MEASLES
- RNA Morbillivirus causes measles
- Measels is spread by coughing/sneezes (including contaminated surfaces)
- One of the most contagious infection diseases
what is the incubation period of measles?
When is the infect ability period of measles?
Measles incubation period is 10-12 days
Measles infectivity is 4 days before, 4 days after rash
What are the clinical features of measles?
Clinical features of measles
PRODROME 2-4 DAYS BEFORE:
-fever (may be >40 degrees, steadily climbs, peak at day 5)
-koplick spots (will go after rash dissapears)
-cough (non productive)
-conjunctivitis and coryzal symptoms
-diarrhea
THEN GET MORBILLIFORM RASH (lasts 3-4 days)
- starts behind the ears (hairline) and slowly spread down body
- generally unwell and might have photophobia
- when rash goes they should feel better
Investigations for measles?
- check vaccination history
- blood or saliva virology to look for Measles specific immunoglobulin IgM
complications of measels?
RESPIRITORY
- Bronchopnumonia (5%) MOST COMMON CAUSE OF DEATH
- Normally staph aureas /viral
- Otitis media-MOST COMMON COMPLICATION
- Giant cell pneumonitis
NEUROLOGICAL
Encephalitits
-headache/deafness/irritability/lethargy/seizures/coma
-Normally around 1-2 weeks after illness. Can be up to 7 years later (subacute sclerosing panencephalitis (SSPE)
• Other complications - Diarrhea - Children with vitamin A deficiency are at greater risk of developing blindness from measles ○ Corneal ulceration ○ Keratoconjunctivitis - Immunodeficiency (causes lymphopenia) - Myocarditis Pregnancy: Increased risk of miscarriage, prematurity and low birth weight
managment of measles?
MANAGEMENT OF MEASLES
- symptomatic only (fluids, analgesia, temp)
- vitamine A reduces risk of blindness
- isolation in hospital and inform PUBLIC HEALTH
- give MMR vaccine to post-exposure contacts (unless <1 year, immunocompromised of pregnant-seek advice)
SAFETY NET
-come back in if any new symptoms (breathing problems, colvulsions/drowsiness)
FOLLOW UP
What investigations should be done in suspected food allergy?
- skin prick test for specific IgE antibodies
- blood test: measure serum allergen-specific IgE
Whats an example of a non-IgE-mediated food allergy and how would you investigate?
-Cows milk protein allergy is non IgE mediated
Management:
-Trial elimination diet (normally for between 2-6 weeks)
- Reintroduction of cows’ milk to prove that it is the cause of symptoms
Whats the management of confirmed cows milk protein allergy?
-Once confirmed with elimination and re-introducing, advise the following until 1 year of age (or for 6 months)
A. Breastfed: mum excludes milk and milk products, take calcium and vitamine D to supplement
B. Formulafed: hypoallergenic infant formulas (extensively hydrolysed formulas or amino acid formulas)
C. Weened: exclude cows milk and products
FOLLOW UP: every 6 months to assess weight and see if we can introduce (milk ladder)
DIETITION: advise on food lables and to ensure child is growing appropriately
Describe features of rubella
Test?
Rash is the first sign here.
- It is pink, maculopapular and starts on theFACE before spreading to whole body over a course of 3-5 days
- Children will also often have a bizarre pattern of lymphadenopathy: post-auricular and sub-occipital
- Red forschheimer spots on soft palate
-Serology ± PCR testing of saliva – gold standard, detect IgM +ve
What causes scarlett fever? What are the symptoms?
THINK ABOUT S
- Scarlet Fever is caused by infection with group A strep that produces erythrogenic toxins
- Rash (spares the mouth, sandpaper-fine punctate)
- Strawberry tounge
- Children get fever, malaise and tonsillitis
What causes Erythema Infectiosum? What are symptoms?
Erythema Infectiosum
- This is also know as FIFTH disease or SLAPPED CHEEK SYNDROME. It is caused by parvovirus B19
- Children have lethargy, fever and a headache
- Rash: very red, might spread to proximal arms
What causes Hand, Foot and Mouth disease
- Hand, Foot and Mouth disease is caused by coxsackie A16 (vesicles)
- Systemic upset is only mild with sore throat and fever
what causes Roseola Infantum? What are symptoms?
- Roseola infants is caused by HHV-6 (sixth disease)
- Very high temp and then rash when child is getting better
- younge kids 6m-3 years
How can we prevent mothers with HIV passing it on to baby?
- No breastfeeding
- C section (avoid birth canal)
- Use of antenatal, perinatal and postnatal anti-retroviral drugs
clinical features of HIV in a child?
- May remain asymptomatic for months or years - LYMPHADENOPATHY or PAROTITIS might be two common presentations
- They might also have recurrent bacterial infections as well as candidiasis, chronic diarrhoea and lymphocytic interstitial pneumonitis (this is infiltration of the lungs by lymphocytes)
- Severe failure to thrive
- Encephalopathy
- Malignancy
- Any unusual constellation of symptoms ALWAYS CONSIDER HIV
Long term complications of mumps?
Mumps
- infertility in boys (post puberty)
- unilateral deafness
Long term complications of rubella?
Rubella (congenital syndrome-if mum has it)
- cateracts (vision problems)
- heart problems
