Infections

Question 1

What are early compensated clinical signs of sepsis?

Answer 1

o	Tachypnoea
o	Tachycardia
o	Decreased skin turgor
o	Sunken eyes & fontanelle
o	Delayed capillary refill (>2s)
o	Mottled, pale, cold skin
o	Core-peripheral temperature gap (>4oC)
o	Decreased urinary output

Question 2

What are late compensated clinical signs of sepsis?

Answer 2

o	Acidotic (Kussmaul) breathing
o	Bradycardia
o	Confusion/depressed cerebral state
o	Blue peripheries
o	Absent urine output
o	Hypotension

Question 3

How does HIV/AIDS present?

Answer 3

o Mild immunosuppression: may have lymphadenopathy or parotitis
o Moderate immunosuppression: may have recurrent bacterial infections, candidiasis, chronic diarrhoea and lymphocytic interstitial pneumonitits (LIP)
o Severe AIDS: diagnoses include opportunistic infections (eg. Pneumocystis jiroveci – PCP), severe FTT, encephalopathy, malignancy

Question 4

What are the longterm features of HIV?

Answer 4

o	Compliance
o	Failure to thrive
o	Risk of transmission
o	HIV encephalopathy
o	Neuropathy and myelopathy
o	Cancers – Kaposi’s sarcoma, Non-Hodgkin’s lymphoma

Question 5

How is perinatal transmission of HIV been reduced?

Answer 5

o Use of maternal antenatal, perinatal and postnatal antiretroviral drugs to achieve an undetectable maternal viral load at the time of delivery
o Avoidance of breast-feeding
o Active management of labour and delivery, to avoid prolonged rupture of the membranes or unnecessary instrumentation
o Pre-labour Caesarean section if the mother’s viral load is detectable close to the time of delivery

Question 6

What is the management for HIV?

Answer 6

Prophylaxis against Pneumocystis jiroveci (carinii) pneumonia (PCP) with co-trimoxazole is prescribed for infants who are HIV-infected, and for older children with low CD4 counts
Immunisation (not BCG)
Regular follow up

Question 7

What are the other aspects of management for HIV?

Answer 7

Immunisation (not BCG)
MDT- family clinic HIV specialist
Regular follow up (weight/neurodevelopment)

Question 8

What else is EBV responsible for besides glandular fever?

Answer 8

Burkitt lymphoma, lymphproliferative disease in immunocompromised hosts and nasopharyngeal carcinoma

Question 9

What are the features of glandular fever?

Answer 9

o	Fever
o	Malaise
o	Tonsilopharyngitis- often severe, limiting oral ingestion of fluids/food- rarely, breathing may be compromised
o	Lymphadenopathy- prominent cervical lymph nodes , diffuse adenopathy
o	Petechiae of the soft palate
o	Splenomegaly (50%)  Hepatomegaly (10%)
o	A maculopapular rash (5%)
o	Jaundice

Question 10

How is glandular fever diagnosed?

Answer 10

o Atypical lymphocytes- numerous large T cells seen on blood film
o A positive Monospot test, the presence of heterophile antibodies i.e. antibodies that agglutinate sheep or horse erythrocytes but which are not absorbed by guinea pig kidney extracts – this test is often negative in young children with the disease
o Seroconversion with production of IgM and IgG to Epstein–Barr virus antigens.

Question 11

What is the management for glandular fever?

Answer 11

Symptomatic
If airway compromised consider steroids
If group A streptococcus grown from the tonsils this can be treated with penicillin

Question 12

What are the complications of glandular fever?

Answer 12

o	Hepatitis- 90%
o	Jaundice- 5%
o	Mild thrombocytopenia- 50%
o	Haemolytic anaemia- 0.5-3%
o	Upper airway obstruction due to tonsil hypertrophy- 0.1-1%
o	Splenic rupture- 0.1-0.2%
o	Neurological complications- 1%
o	Many neurological conditions including coma, meningitis, encephalitis, cranial nerve palsies etc
o	Myocarditis and pericarditis
o	Reye syndrome
o	Chronic fatigue syndrome

Question 13

What are the risk factors for Kawasaki disease?

Answer 13

6m-4yrs
Japanese/afro-caribbean
Polymorphism is ITPKC on chromosome 19

Question 14

What occurs in phase 1 of kawasaki disease (acute 1-2w)?

Answer 14

child’s symptoms will appear very suddenly and can often be severe
These are high fever, conjunctival injection, rash, changes in hands and feet, swollen lymph glands and changes to the lips, mouth and tongue (red, dry, cracked, peeling, swollen or bleeding)

Question 15

What occurs in phase 2 of kawasaki disease (subacute 3-4w)?

Answer 15

symptoms will become less severe but may last longer, fever should subside but there may be persistent irritability and considerable pain
peeling skin, abdominal pain, vomiting, diarrhoea, urine that contains puss, lethargy, headache, joint pain and jaundice
It is in this phase that complications such as coronary artery aneurism are likely to develop

Question 16

What occurs in phase 3 of kawasaki disease (covalescent 4-6w)?

Answer 16

• The child will begin to recover and all signs of illness should disappear, however the child may still lack energy and is easily worn out during this time
Occasionally complications can also occur in this phase

Question 17

What is the diagnostic criteria for Kawasaki disease?

Answer 17

Fevere >38 for >5 days with at least 4 of:
o Conjunctival injection in both eyes
o Change to the mouth or throat – such as dry cracked lips or a red swollen tongue
o Changes to the skin on the arms or legs such as swelling, redness or peeling skin
o A rash
o Swollen lymph nodes of the neck

Question 18

What is the management for Kawasaki disease?

Answer 18

intravenous immunoglobulin (IVIG) given within the first 10 days has been shown to lower the risk of coronary artery aneurysms
Aspirin to reduce risk of thrombosis, continued at low dose until 6 weeks, echocardiography shows absence or presence of aneurysms
antiplatelet aggregation agents may also be used to reduce the risk of coronary thrombosis
Children with giant coronary artery aneurysms may require long-term warfarin
Persistent inflammation and fever- infliximab, steroids or ciclosporin

Question 19

What are the long term complications of Kawasaki disease?

Answer 19

The coronary arteries are affected in about one-third of affected children within the first 6 weeks of the illness, this can lead to aneurysms which are best visualised on echocardiography
• Subsequent narrowing of the vessels from scar formation can result in myocardial ischaemia and sudden death mortality is 1–2%

Question 20

What are the features of typhoid fever?

Answer 20

worsening fever, headaches, cough, abdominal pain, anorexia, malaise and myalgia may be suffering from an infection with Salmonella typhi or paratyphi
Contaminated water or food
GI symptoms may not appear until the 2nd week- diarrhoea or constipation
Splenomegaly, bradycardia and rose-coloured spots on the trunk may be present
Multi-drug resistant strains: a 3rd generation cephalosporin or azithromycin is usually effective

Question 21

What are the complications of typhoid fever?

Answer 21

o Gastrointestinal perforation
o Myocarditis
o Hepatitis
o Nephritis