infections Flashcards
Tommy is a 5-year-old boy who has been brought in to see you by his mother. She explains that Tommy has had a fever for 3 days and yesterday developed some ulcers in his mouth. Today, she noticed that there are red spots on Tommy’s hands and feet which have now started to concern her.
Which virus is most likely the causes of Tommy’s symptoms?
Coxsackie A16 virus
Hand, foot, and mouth disease (HFMD) is an acute viral illness characterized by vesicular eruptions in the mouth and papulovesicular lesions of the distal limbs.
what is the Mx of HFMD?
- symptomatic treatment only: general advice about hydration and analgesia
- reassurance no link to disease in cattle
- children do not need to be excluded from school
- the HPA recommends that children who are unwell should be kept off school until they feel better
- they also advise that you contact them if you suspect that there may be a large outbreak.
A 12-year-old girl presents with a two-day history of an itchy rash over her whole body associated with a low-grade pyrexia.
Dx and causative organism?
Chickenpox – varicella zoster virus
Shingles = reactivation of the dormant virus in dorsal root ganglion
how is chickenpox spread?
via the respiratory route
can be caught from someone with shingles
Chickenpox is highly infectious.
When is it infectious and what is its incubation period?
- infectivity = 4 days before rash, until 5 days after the rash first appeared*
- incubation period = 10-21 days
what are the clinical features of chickenpox?
(tend to be more severe in older children/adults)
- fever initially
- itchy, rash starting on head/trunk before spreading. Initially macular then papular then vesicular
- systemic upset is usually mild
what is the management of chickenpox?
Management is supportive
- keep cool, trim nails
- calamine lotion
- school exclusion: NICE Clinical Knowledge Summaries state the following: Advise that the most infectious period is 1–2 days before the rash appears, but infectivity continues until all the lesions are dry and have crusted over (usually about 5 days after the onset of the rash).
- immunocompromised patients and newborns with peripartum exposure should receive varicella zoster immunoglobulin (VZIG). If chickenpox develops then IV aciclovir should be considered
what is a common complication of chicken pox?
secondary bacterial infection of the lesions
- NSAIDs may increase this risk
- whilst this commonly may manifest as a single infected lesion/small area of cellulitis, in a small number of patients invasive group A streptococcal soft tissue infections may occur resulting in necrotizing fasciitis
A 5-year-old girl presents to the Emergency Department with a 10-day history of persistent coughing bouts. These are described to be worse at night and after eating. Her parents also notice a loud noise every time she breathes in. Her birth history is uncomplicated. Vaccination records are unknown. Auscultation of the chest is normal and the child appears generally well.
What is the most likely diagnosis and what is it caused by?
Whooping cough (pertussis)
caused by Gram-negative bacterium Bordetella pertussis
when are infants routinely immunised for whooping cough (pertussis)?
infants are routinely immunised at 2, 3, 4 months and 3-5 years.
neither infection nor immunisation results in lifelong protection - hence adolescents and adults may develop whooping cough despite having had their routine immunisations
what is the diagnostic criteria for whooping cough?
Whooping cough should be suspected if a person has an acute cough that has lasted for 14 days or more without another apparent cause, and has one or more of the following features:
- Paroxysmal cough.
- Inspiratory whoop.
- Post-tussive vomiting.
- Undiagnosed apnoeic attacks in young infants.
how is whooping cough (pertussis) mx?
- infants under 6 months with suspect pertussis should be admitted
- in the UK pertussis is a notifiable disease
- an oral macrolide (e.g. clarithromycin, azithromycin or erythromycin) is indicated if the onset of the cough is within the previous 21 days to eradicate the organism and reduce the spread
- household contacts should be offered antibiotic prophylaxis
- antibiotic therapy has not been shown to alter the course of the illness
- school exclusion: 48 hours after commencing antibiotics (or 21 days from onset of symptoms if no antibiotics )
what are the complications of whooping cough (pertussis)?
- subconjunctival haemorrhage
- pneumonia
- bronchiectasis
- seizures
A 4-year-old girl presents to the GP due to a persistent fever for the last 7 days that has not settled with regular paracetamol and ibuprofen. The mother describes that the child has been irritable and not eating or drinking as well as she usually does. On examination, a polymorphous blanching rash is seen on her abdomen. Her tongue is erythematous with a white coating and enlarged papillae. Tender cervical lymphadenopathy is palpated and her eyes are bilaterally erythematous but without discharge.
What is the diagnosis and Rx?
Kawasaki disease, high dose aspirin
Note that usually, aspirin is contraindicated in children due to the risk of Reye’s syndrome.
Kawasaki’s disease is uncommon but important to recognise. Why?
coronary artery aneurysms
echocardiogram (rather than angiography) is used as the initial screening test
what are the features of Kawasaki’s disease?
- high-grade fever which lasts for > 5 days. Fever is characteristically resistant to antipyretics
- conjunctival injection
- bright red, cracked lips
- strawberry tongue
- cervical lymphadenopathy
- red palms of the hands and the soles of the feet which later peel
A 3-year-old boy is brought into the emergency department with cough and noisy breathing following a 3-day history of coryzal symptoms. On examination, he is afebrile but has harsh vibrating noise on inspiration, intercostal recession and a cough. He is systemically well.
What is the Dx and the most likely causative organism?
Croup, Parainfluenza virus
what are the contraindications to an LP?
(any signs of raised ICP)
- focal neurological signs
- papilloedema
- significant bulging of the fontanelle
- disseminated intravascular coagulation
- signs of cerebral herniation
For patients with meningococcal septicaemia a lumbar puncture is contraindicated - blood cultures and PCR for meningococcus should be obtained.
how is meningitis in children managed?
- Antibiotics
- < 3 months: IV amoxicillin (or ampicillin) + IV cefotaxime
- > 3 months: IV cefotaxime (or ceftriaxone)
- Steroids
- NICE advise against giving corticosteroids in children younger than 3 months
-
dexamethsone should be considered if the lumbar puncture reveals any of the following:
- frankly purulent CSF
- CSF white blood cell count greater than 1000/microlitre
- raised CSF white blood cell count with protein concentration greater than 1 g/litre
- bacteria on Gram stain
- Fluids
* treat any shock, e.g. with colloid - Cerebral monitoring
* mechanical ventilation if respiratory impairment - Public health notification and antibiotic prophylaxis of contacts
* ciprofloxacin is now preferred over rifampicin
A 4-year-old boy presents with fever and a sore throat. Examination reveals tonsillitis and a furred tongue with enlarged papillae. There is a blanching punctate rash sparing the face
Dx?
Scarlet fever
A 3-year-old girl with a two day history of fever and malaise. Developed a pink maculopapular rash initially on the face before spreading. Suboccipital lymph nodes are also noted.
Dx?
Rubella
A 4-year-old boy presents with fever, malaise and a ‘slapped-cheek’ appearance.
Dx?
Parvovirus B19
A 6-month-old baby who was born in Bangladesh is brought to surgery. Around one week ago he started with coryzal symptoms. His mother reports he has not been feeding well for the past two days and has started to vomit today. Her main concern is a cough which occurs in bouts and is so severe he often turns red. No inspiratory or expiratory noises are noted. Clinical examination reveals an apyrexial child with a clear chest.
What is the most likely diagnosis?
Pertussis
The inspiratory ‘whoop’ is uncommon in patients this young.
what is the most common cause of gastroenteritis in children in the UK?
rotavirus
how long does diarrhoea and vomiting usually last for?
diarrhoea usually lasts for 5-7 days and stops within 2 weeks
vomiting usually lasts for 1-2 days and stops within 3 days
how to manage GE in children with no evidence of dehydration?
- continue breastfeeding and other milk feeds
- encourage fluid intake
- discourage fruit juices and carbonated drinks
what is the rash in scarlet fever like?
- fine punctate erythema (‘pinhead’) which generally appears first on the torso and spares the palms and soles
- rash often more obvious in flexures
- children often have flushed appearance with circumoral pallor
- rough ‘sandpaper’ texture
- desquamation occurs later in the course of illness, particularly around fingers and toes
