Infections and immunity conditions Flashcards
Presentation Kawasaki disease
Conjunctivitis without discharge
Fever 39C+ and >5days
Strawberry tongue and cracked lips
Peeling skin on palms of hands and soles of feet
Macular erythematous rash on main part of body and genitals
What is a serious complication of Kawasaki?
Coronary artery aneurysm
Treatment kawasaki?
Ig and aspirin
When do measles symptoms come on in relation to exposure?
10-14 days post exposure
Measles presentation
- cough/coryza
- fever (can be as high as 40 and last a week)
- conjunctivitis
- Irritability
- Koplik’s spots
- Morbilliform rash starting behind ears and spreading down whole body to hands and feet last. Starts red and turns dark brown (‘staining’)
How long does measles take to resolve?
about 3w
Complication measles?
Encephalitis
Management measles?
Notifiable disease
Stay away from suscpetible- off work for at lest 4 days after rash onset, preferably until fully recovered
Supportive Rx
Safety net for uncontrollable fever, SOB, convulsions or reduced consciousness
Presentation infectious mononucleosis
Photophobia
Throat sore and red
Lymphadenopathy
Cough
Fatigue, malaise, loss appetite, headache
Tonsils red, swollen, white patches
Splenomegaly, abdo pain
Nausea and vomiting
Occasionally jaundice
Fever, chills, aches
infectious mononucleosis aka
Ebv
glandular fever
what blood cells are seen on a blood film in infectious mononucleosis?
Peripheral leucocytosis with atypical lymphocytes (large, irregular nuclei)
How do you diagnose infectious mononucleosis?
Serology (monospot test)
What treatment must you avoid in infectious mononucleosis? Why?
Amoxicillin causes mac pap rash
What pathogens cause periorbital cellulitis?
Staphs, strep pneumoniae, strep pyogenes, milleri
How is periorbital cellulitis caused?
Paranasal sinus infection
Eyelid injury/infection
Dental injury/infection
External ocular infection
Management periorbital cellulitis
Unless very mild, admit for:
CT
ENT and ophthal opinion
Antibiotics
±surgery
periorbital cellulitis presentation?
Inflammation around orbit
Decreased eye mobility
Fever
periorbital cellulitis complications
Spread to meninges or cavernous sinus, form abscess
Can = blindness due to pressure on the optic nerve/thrombosis of optic nerve vessels
In any irritable child with unexplained fever you should consider what?
Meningitis
When is meningitis most common?
Neonatal
which viruses can cause meningitis?
Mumps
Coxsackie
Echovirus
HSV
Poliomyelitis (if unvaccinated)
Viral meningitis is preceded by…?
Pharyngitis or gi upset
Are complications more common in viral or bacterial meningitis?
Bacterial
Is viral or bacterial meningitis generally better?
Viral is milder and self-resolving usually.
Treatment for viral meningitis?
Generally supportive. If severe HSV/EBV/VZV consider aciclovir
Bacterial causes of meningitis?
Neisseria meningitidis
Strep pneumoniae
H. influenza type B
Group B strep
E. coli and listeria
TB
Meningococcal meningitis is caused by what?
Neisseria meningitidis
Pneumococcal meningitis is caused by what?
Strep pneumoniae
Group B strep, E. coli and listeria are a more common cause of meningitis in which group?
Neonates
TB is a more common cause of meningitis in which group?
Immunocompromised
As well as the cardinal symptoms, how might a child with meningitis present?
drowsy, vacant
irritable
high pitched cry
occas. convulsions
What are early signs of bacterial meningitis?
Headache
Fever
Leg pains
Cold hands and feet
Abnormal skin colour
What are later signs of bacterial meningitis
Meningism
Reduced GCS, coma
Seizures ±focal CNS signs
Petechial rash (IF MENINGOCOCCAL)
Shock (cap refill, DIC, hypotension)
Bulging fontanelle in infants
Are Kernig’s and Brudzinski’s sign reliable in young infants?
No
What signs could you find that the meningitis is caused by HZV?
Shingles or chicken pox
What signs could you find that the meningitis is caused by HSV
Cold sore
What signs could you find that the meningitis is caused by HIV
lymphadenopathy, dermatitis, candidiasis, uveitis
What signs could you find that the meningitis is caused by leptospirosis
Bleeding ± red eye
What signs could you find that the meningitis is caused by mumps
parotid swelling
What signs could you find that the meningitis is caused by glandular fever
sore throat
jaundice
nodes
What signs could you find that the meningitis is caused by immune deficiency
Splenectomy scar
Differentials for meningitis?
Malaria
Encephalitis
Septicaemia
SAH
Dengue
Tetanus
Tonsillitis and otitis media may mimic neck stiffness
In primary care if you come across a non-blanching rash and suspect meningitis what could you do?
Give benzylpenicillin IV, or IM if no vein- as proximally as possible into a warm limb. Before admitting to secondary care.
Don’t do if there is no rash, unless urgent transfer to secondary care not possible.
If someone is penicillin allergic should you still give BenPen in susp meningitis in primary care?
If the allergy is just a rash yes, if anaphylactic no
What does of benpen should you give for susp meningitis in primary care?
<1y- 300mg
1-9y- 600mg
> 10y- 1200mg
When does meningitis become septicaemia?
When features of shock
What should initial management of bac meningitis (without features of shock or raised ICP) be?
ABC- fluids, glucose
Blood cultures
Senior help
LP <1hr (as long as no shock, no rash and no raised ICP)
Abx IV after LP (unless LP delayed by >1hr)
Dex 10mg IV
What should initial management of bac meningitis (without features of shock but with signs of raised ICP) be?
ICU help
ABx IV (often ceftriaxone 2g/12h)
Dex 10mg/6h IV
Support airway, fluids
Nurse at 30 degrees
Delay LP until stable
What should initial management of bac meningitis with signs of shock be?
ICU help
Blood cultures
IV ABx
Airway support, maybe pre-emptive intubation
Fluid resus/inotropes/vasopressors. Aim for MAP >70mmHg, urine output >30ml/h
Delay LP until stable
What is later management for bacterial meningitis (±shock, raised ICP)
Careful monitoring
Adjust abx based on sensitivities
Fluid resus/maintenance
Inform PHE
Kissing contacts prophylaxis
What is used for bac meningitis contacts prophylaxis?
Rifampicin/ciprofloxacin
Why is dex given in bac meningitis?
helps meningism
Should you do LP before antibiotics?
Only if:
- no signs of shock
- no rash
- no raised ICP
- can get within 1h
What other investigations can you do in bac meningitis
U&E, FBC (decreased WCC could = immunocompromised), LFT, glucose, coag
Throat swabs for bacteria and virology
CXR
HIV/TB test?
How common are meningitis complications
1/3 to 1/2 survivors are left with at least one permanent problem. More common in bac.
What are the complications of meningitis?
Total/partial hearing loss (usually get hearing test after a few weeks)
Recurrent seizures (epilepsy)
Problems with memory and concentration
Co-ord/movement/balance problems
Vision loss (total or partial)
Learning dfficulties and behav probs.
Loss of limbs
Bone and joint probs- e.g. arthritis
Kidney probs
How often is bac meningitis fatal?
10%
What is waterhouse-friderichsen syndrome?
A complication of meningococcal meningitis
Endotoxins –> coagulopathy –> haemorrhagic necrosis of the adrenal glands.
DIC
Acute adrenal gland failure
Resp failure
> 40% mortality
How do you treat waterhouse-friderichsen syndrome?
Abx
Fluid and electrolyte management
Coagulopathy treatment
CSF opening pressure is seen initially on the LP, and the CSF should then be sent for?
MC&S
Protein
Lactate
Glucose
Virology/PCR
What is the appearance of CSF in:
Normal
Bacterial
Viral
Fungal
TB
Normal clear and colourless
Bac cloudy and turbid
Viral clear
Fungal clear or cloudy
TB opaque, fibrin web if left
What is the opening pressure in different types of meningitis
Always raised, might be normal in viral
What is the WCC in CSF in the different types of meningitis?
Always raised, but to different degrees. Polymorphs are seen in bacterial or early viral/TB
Normal 0-5
Bac: >100
Viral 50-1000
Fungal 10-500
TB 10-1000
What is glucose content of CSF in the different types of meningitis?
Low, apart from in viral where it is normal
What is protein content of CSF in the different types of meningitis?
Always high
what would signs of raised ICP be in meningitis?
papilloedema, FND, seizures, GCS =12
Meningococcal septicaemia with meningitis is when…?
Purpuric non-blanching rash with neck stiffness
What is the treatment of infectious mononucleosis?
Supportive
What does infectious mononucleosis put you at risk of in future?
Lymphoma, gastric and nasopharyngeal cancer
Causes of purpura can be divided into which two groups?
Non thrombocytopenic and thrombocytopenic
What are the non thrombocytopenic causes of purpura?
HSP
Sepsis (meningococcal or viral)
Trauma
Scurvy
What are the thrombocytopenic causes of purpura?
ITP
Leukaemia
DIC
Aplastic anaemia
HUS
TTP (rare in children)
Purpura <3mm is called ?
Petechiae
Purpura >1cm is called ?
eccymosis
What is HSP (pathophysiologically)
Small vessel vasculitis of unknown cause
Key features of HSP?
Often follows viral illness
Purpuric rash to buttocks and legs, symmetrical
±arthritis
±abdo pain (GI vasculitis) and possibly N&V, diarrhoea
±nephritis (haematuria, proteinuria, HTN, rarely renal failure)
May get bilateral scrotal swelling in boys
33% have some sort of gastric haemorrhage
Does HSP need treatment?
Generally self limiting (resolves in a few weeks) so supportive only
Steroids may help abdo pain
What are complications of HSP?
Intusussception
Gastric haemorrhage
1% irreversible kidney damage- CKD
1/3 relapse a few months afterwards
Does HSP need follow up?
Yes renal
HSP investigations?
No specific tests but these all may be elevated:
- creat
- urea
- IgA
- platelets
- CRP
- ESR
What sort of age gets HSP?
Preschool
ITP stands for?
Immune thrombocytopenic purpura
ITP age group?
2-10y
What is the commonest cause of thrombocytopenia in children?
ITP
ITP cause?
Often preceded by viral infection 1-2w earlier.
Destruction of circulating platelets by IgG autoantibodies.
ITP presentation
Widespread purpura and superficial bruising. May have problematic bleeding e.g. epistaxis or menstrual.
How is ITP diagnosed?
Dx of exclusion. Must distinguish from acute leukamia and aplastic anaemia via:
- clinical features- hepatosplenomegaly or marked lymphadenoathy should prompt BM investigation.
- FBC- anaemia or neutropenia should prompt BM investigation.
- Blood film- ITP will show mostly normal and some large platelets.
If no worrying clinical features, only low platelets on FBC and no intention to treat then do not need to examine BM.
Does ITP need treatment?
Benign and self limiting in 80%. 6-8w course.
Treatment not usually required unless bleeding present. If major bleeding (intracranial or GI) or persistent minor bleeding that is problematic (e.g. nosebleeds, menstrual) then can treat
How do you treat problematic bleeding in ITP?
Prednisolone PO (NB must do BM sample before as giving it could mask diagnosis of ALL and compromise outcome)
IV anti D
IV Ig
NB all significant SEs
Life threatening haemorrage= platelet transfusion
What advice should be given to ITP patients?
Avoid trauma and contact sports while plt count still low and parents should have access to 24h hospital
Complications ITP?
IC haemorrhage if plt vv low (headache, blurred vision, LOC, HTN, bradycardia)
Chronic ITP 20%- plt low after 6m. Mainly supportive Rx.
What is HUS?
Progressive renal failure
Microangiopathic haemolytic anaemia (RBC fragmentation)
Thrombocytopenia
Microthrombi
What is the most common cause of AKI in children?
HUS
What are the two categories of HUS?
Typical and atypical
What is typical HUS?
Caused by shiga-like toxin (from shigella dysenteriae or E coli) 70% E coli 0157:H7
Children 2-3y
Diarrhoea precedes
Fairly good prognosis
What is atypical HUS?
5-10%
Adults
No prodromal diarrhoea
Poor prognosis
Not associated with shiga-like toxin
Various triggers: nonenteric infection, virus, drugs, malignancy, pregnancy, transplant
40% strep pneumoniae
Investigations in HUS
Urinalysis- proteinuria, RBC, RBC cast
Bloods- blood urea nitrogen, creatininte, U&E, FBC, lactate
Blood film
Complement serology testing
Stool culture
Management HUS
supportive
Only give Abx if septic
Renal transplant if progress to end stage renal disease
Atypical- plasma exchange and eculizumab
Complications of HUS
Chronic renal failure
Encephalopathy
Colitis
What is the most common malignancy in children?
Leukaemia
What happens in leukaemia?
Malignant proliferation of WC precursors in BM. Blast cells –> circulation, may be deposited in lymphoid and other tissue
What is the commonest type of leukaemia in childhood?
ALL
Peak incidence leukaemia in children?
2-5y
When is the prognosis of leukaemia worse?
<2y and >10y
Presentation leukaemia
Malaise
Anorexia
Pallor
Bruising
Bleeding
Lymphadenopathy
Splenomegaly
Bone pain
Investigations of leukaemia
FBC (anaemia, thrombocytopenia, raised WCC. Higher WCC = worse prognosis)
Blood film- blast cells
Bone marrow aspirate to diagnose- blast cell infiltration.
Management leukaemia?
Chemo to induce remission, then chemo to maintain remission
What is the general prognosis for leukaemia?
Generally good
What is the pathophysiology of DIC?
Systemic activation of coag –> fibrin generation and deposition –> microvascular thrombi various organs –> multiple organ dysf –> consumption of clotting factors and platelets –> haemorrhage
DIC is always ____?
secondary to an underlying disorder
How do you diagnose DIC
Thrombocytopenia
aPTT and PT (prolonged or normal)
Clotting factors reduced
Inhibitors e.g. antithrombin
D-dimer
Treatment DIC
Underlying disorder
Consider plt transfusion if bleeding
could give tranexamic acid + heparin
What is aplastic anaemia?
Damage to BM and the stem cells within due to:
drugs/irradiation/infection/immune disease/50% idiopathic
Causes pancytopenia
How do you confirm the diagnosis of aplastic anaemia?
BM sample
Treatment aplastic anaemia
Immunosuppressants
Stem cell transplant
Is it important to treat aplastic anaemia?
yes risk of death if not.
How does chicken pox present?
Red papule on chest becomes vesicular, then crops of vesicles follow.
These progress: macule, papule, vesicle, crust.
Itchy
Viral prodrome
Incubation period of chicken pox
10-21 days
How long do chicken pox lesions last?
6-10 days
If the child was in nursery a few days before the rash developed, do they need to tell them? What should a pregnant nursery nurse do?
Yes as it is infectious a few days before
If the pregnant person hasn’t had chicken pox or can’t remember then they should get a blood test
When can the child with chicken pox return to nursery
When lesions scabbed over
Complications chicken pox
Scars
Secondary infection
Encephalitis (cerebellar signs and ataxia a couple of weeks later)
Thrombocytopenia with haemorrhage into skin
Management chicken pox
Cool baths and calamine lotion
Promethazine syrup (1st gen antihistamine) if v distressed
Keep fingernails short and clean to reduce infection risk
What if an immunocompromised child is exposed to chicken pox?
Consider prophylactic zoster Ig. If disease develops admit for IV aciclovir.
Is conjunctivitis normally viral, bacterial, allergic, parasitic or chemical?
Viral
Most common viral cause of conjunctivitis?
adenovirus
Is it easy to clinically differentiate bacterial and viral conjunctivitis?
No
What pathogen causes hyperacute conjunctivitis?
Neisseria gonorrhoeae
Conjunctivitis in the first four weeks of life is called?
Ophthalmia neonatorum
Is ophthalmia neonatorum always infectious?
No but can be
Is ophthalmia neonatorum bad?
Usually mild but untreated infection (e.g. gonococcus, chlamydia, pseudomonas or herpes) can lead to serious complications e.g. sight loss and mortality
Are sticky eyes in first few weeks of life common? How can you manage?
Yes
Cleaning and treat with topical antibiotics e.g. neomycin
How does chlamydial ophthalmia neonatorum present?
Watery/mucopurulent discharge about 5-14 days after birth.
Is there a test for chlamydial ophthalmia neonatorum?
Monoclonal antibody test on secretions
Chlamydial ophthalmia neonatorum treatment?
2w oral erythro or topical tetracycline ointment
How does gonococcal ophthalmia neonatorum present?
First 5 days of life but can be up to 3w after delivery. Copious purulent discharge and eyelid swelling which may be severe.
Gonococcal ophthalmia neonatorum Rx?
IV Abx- cephalosporin
How does viral ophthalmia neonatorum present?
Petechial/large subconj haemorrhages and lymphadenopathy
What are serious things to r/o in susp conjunctivitis?
Acute glaucoma
Keratitis
Iritis
Corneal ulcer
Anterior uveitis
Scleritis
Trauma
What is pharyngoconjunctival fever?
Due to adenovirus
Conjunctivitis + URTI and pre-auricular lymphadenopathy
Things to ask in conjunctivitis history
Uni or bilat?
Discharge
Itch
Vision
Eyelid changes
Infectious contact
Pain (incl headache and photophobia)
Hx trauma
Contact lens use
Assoc sx
PMH atopy, similar episodes, immuno-compromise, eye surgery
What do you examine in susp conjunctivitis?
Look at the conjunctiva, follicles, cornea, sclera, eyelids and peri-orbital area
Assess pupil shape, size, reactivity
Visual acuity and fields
Lymph nodes
Could do fluorescein staining for keratitis and corneal ulcer
Do you need to swab in conjunctivitis?
Not routinely but may be indicated if fail to respond to initial treatment and doesn’t need ophthal referral
Conjunctivitis advice to pt
Reassure that usually self limiting (about a week)
Advise contagious (hand washing, use separate towels etc)
If bacterial/severe/require rapid resolution- topical antibiotics. Could do delayed prescription.
Self care: bathe eyelid with cotton wool soaked in saline or boiled and then cooled water. Cool compresses. Lubricating eye drops.
Return if persists beyond 7 days or if red flags
What Abx given in bacterial conjunctivitis?
Chloramphenicol drops- 1 drop 3-4x daily (depends on severity…could be every 2hrs) and reduce freq as infection controlled. Continue 48hrs after healing
Fusidic acid
Red flags of conjunctivitis?
Reduced visual acuity
Marked eye pain/headache/photophobia
Red sticky eye in neonate
Hx trauma/foreign body possible
Copious rapidly progressing discharge
HSV infection
Soft contact lens use with corneal Sx (photophobia, watering)
Complication conjunctivitis?
Periorbital cellulitis
HIV usually presents by age ___
3
5 ways HIV presents
FTT
Diarrhoea
Hepato/splenomegaly
Recurrent oral candidiasis
Severe bacterial infections
How do you diagnose HIV?
Detect HIV antibody or viral load via PCR
Vertical transmission HIV ___% without intervention?
20-30
What is in the 6 in 1 vaccine?
Dipth
Tetanus
Pertussis
Polio
Hib
Hep B
When is 6 in 1 given?
2m, 3m, 4m
What does diphtheria cause?
throat infection
pharyngeal exudate
membranes form that can obstruct airway
Exotoxin may cause myocarditis and paralysis
Is polio caused by a virus or bac?
Virus (poliomyelitis)
How does polio present?
Mild febrile illness progresses to meningitis in some children. Damage to anterior horn SC–> paralysis, pain, tenderness. May also cause resp failure and bulbar paralysis. Residual paralysis common in survivors
Hib used to be the main cause of _____ before the vaccine
Meningitis
Haemophilus influenza meningitis tends to cause what?
Severe neuro sequelae- deafness, cerebral palsy and epilepsy in 10-15% and death 3%
90% babies affected with hep b go on to get what?
Chronic liver disease. Can –> cirrhosis or liver cancer.
Pneumococcal disease is caused by what pathogen?
Strep. pneumoniae
Pneumococcal disease can cause what?
septicaemia, meningitis and pneumonia
The pneumococcal vaccine is against how many strains?
13 serotypes
Meningococcal group B vaccine is associated with what?
Febrile convulsions
What does Rota virus cause?
D&V, abdo pain, fever
can = dehydration and death in small baby
How is rotavirus vaccine given?
Oral
Which vaccines are live?
Rotavirus
MMR
Influenza nasal spray
BCG
chicken pox
What do immunocompromised parents need to be aware of if baby just had rotavirus vaccine?
Take care with personal hygiene when changing nappy for 2w following
When is MenC given?
12-13m and with the other mening. at 13-18y
Meningitis C causes what?
Purulent meningitis with purpuric rash and septiaemic shock
Mortality as high as 10% and morb can= hearing loss, seizures, brain damage, organ failure, tissue necrosis
When is MMR given?
1y and 3y4m
Who doesn’t get MMR?
Immunocomp- high dose steroids, chemotherapy, low CD4, HIV
Complications of mumps
aseptic meningitis, sensorineural deafness and orchitis. Subfertility in men
Why do we want to reduce incidence of Rubella given that it is mild infection in itself?
If infected in early pregnancy can = congenital defects such as cataracts, deafness and congenital HD
What 3 things do you need to check before giving the MMR?
Immunocomp
Egg allergy status
Pregnant in girls
What SE is common from the MMR?
rash and fever 5-10 days later/mild mumps 2w later
Who gets influenza vaccine and how?
Annual nasal spray in Sept/Oct for all children 2-9 years
Also if at risk: injection 6m-2y or nasal spray 9-17y
HPV is against which strains? Which cause cancer/warts?
16 and 18- cancer
and
6 and 11- warts
When is HPV given?
two doses 6-24m apart in girls aged 12-13
Men ACWY is recommended in who?
adolescents and students
14y (13-18y)
When do children get their first vaccines and which are given?
2m
D, T, Polio, pertussis, Hib, Hep B (6in1)
Pneumococcal
Men B
Rotavirus
When is the final dose of DTP?
14y (13-18y)
Which vaccines are given at 3y 4m?
DTPP (dose 4)
MMR (dose 2)
Which other vaccines are also available in some cases?
Chicken pox (sibs have suppressed immune system. From 1y+, two doses 4-8 weeks apart. Live vaccine)
BCG if TB risk (intradermal, live. Birth-16y)
Extra flu vaccine (diff ages)
Extra Hep B if at risk- additional doses at birth, 4w, 1y. May also get Igs at birth if mother particularly infectious. Babies of infected mothers should also be tested at 1y
BCG vaccine is less effective in what age group, and against what type of TB?
> 35y
Respiratory TB (most common form in adults). Is 70-80% effective against the most severe forms such as TB meningitis in children
Do premature babies get vaccines according to their chronological or corrected age?
Chronological as mother’s protection wears off after birth
Unless they are too sick
DRAW OUT THE VACCINE SCHEDULE
see notes
What is the injection site before 1y and after 1y?
Before 1y is thigh
After 1y upper arm
AT 1y is either (but men B is L thigh)
