Infectious Disease

Question 1

Name 3 risk factors for oral candidiasis

Answer 1

1. Prematurity (systemic)
2. Broad-spectrum antibiotic treatment
3. Use of a soother
4. Inhaled glucocorticoids

Question 2

What age is safe to use clotrimazole troches (lozenges) for oral candidiasis?

Answer 2

≥3 years

Question 3

What is the recommended treatment for oral candidiasis?

Answer 3

Nystatin 100,000 units/mL 1-4 mL q6h x 7-14 days

Question 4

What is the most common superficial dermatophyte infection in paediatrics?

Answer 4

Tinea capitis

Question 5

Name 2 treatments for tinea capitis

Answer 5

• 1st line: Terbinafine PO x 4-6 wks
• 2nd line: Fluconazole
• PO Adjuncts:
  
  • Ketoconazole 2% or selenium sulfide 1% shampoo 2-3 times weekly to lower carriage of viable fungal elements

Question 6

What 2 situations should prompt an ID referral for tinea capitis?

Answer 6

1. Living in immigrant populations
2. Exposed to infected household pets/farm animals
3. Immunodeficiency or immune system compromise

Question 7

Name a risk factor for dermatophyte infections

Answer 7

1. Trisomy 21
2. Immune system compromise

Question 8

Name a complication seen with Azoles (fluconazole/itraconazole)

Answer 8

1. Hepatic toxicity
2. Drug interactions
   
   • Azithromycin: Prolonged QT
   • ↑toxicity w/ immunosuppressive agents, chemo, phenytoin, midazolam

Question 9

How should you treat pityriasis/tinea versicolor?

Answer 9

1. Topical antifungals:
   
   • 2% ketoconazole, 2.5% selenium sulfide lotion or 1% selenium sulfide shampoo
   • Apply for 15-30min to affected area nightly x 1-2wks, then q1mo x 3mo to avoid recurrence

Question 10

What is the most common etiology of tinea capitis in North America?

Answer 10

Trichophyton tonsurans

Question 11

Name 5 risk factors for community-acquired MRSA

Answer 11

1. Close skin-to-skin contact
2. Openings in skin, such as cuts or abrasions
3. Contaminated items and surfaces
4. Crowded living conditions (military recruits, prisoners)
5. Poor hygiene
6. Lower socioeconomic status
7. Limited access to health care
8. Participation in activities that result in abraded or compromised skin surfaces (IVDU, athletes, MSM)
9. Indigenous population

Question 12

Why are Indigenous people at increased risk of CA-MRSA?

Answer 12

1. Household crowding (hard to separate personal items, maintain clean environment and personal hygiene)
2. Lack of piped potable water (hard to maintain personal and environmental hygiene)

Question 13

List 3 complications of CA-MRSA

Answer 13

1. Osteomyelitis
2. Septic arthritis
3. Sepsis
4. Pneumonia
5. Necrotizing fasciitis

Question 14

What is the treatment for a <1mo for CA-MRSA?

Answer 14

1. Incision and Drainage
2. IV Vancomycin x 7d
3. If reliable, well with no fever, outpatient management with PO Clindamycin x 7d

Question 15

What is the treatment for 1-3mo for CA-MRSA?

Answer 15

1. Incision and Drainage
2. If well w/no fever:
   
   • TMP/SMX x 7d; otherwise
   • IV Vancomycin

Question 16

What is the treatment for ≥3mo for CA-MRSA?

Answer 16

1. Incision and Drainage
2. If well w/no fever: Observation
3. If no improvement or another pathogen on culture: Treat.
4. If significant surrounding cellulitis only (no fever/well):
   
   • PO TMP/SMX + Cephalexin
   • Systemic symptoms +/- fever:
     
     • IV Vancomycin

Question 17

List 5 recommendations to prevent spread of CA-MRSA.

Answer 17

1. Keep wound covered w/clean, dry bandage (if unable, exclude from contact sports or child care until drainage stops or healed)
2. Dispose of used dressings in plastic-lined garbage container with sealed lid immediately after removed
3. Use proper hand hygiene before and after changing dressings
4. Avoid sharing personal items, especially towels, bedding, clothing and bar soap
5. Bathing regularly and washing clothing and bedding often
6. Regular cleaning of contact surfaces in the home with standard household cleaner/detergent

Question 18

What causes Lyme disease and how is it transmitted?

Answer 18

• Caused by Borrelia burgdorferi.
• Transmitted by Ixodes scapularis (central/eastern Canada) and Ixodes pacificus (BC)

Question 19

What time frame is Lyme disease usually preventable?

Answer 19

If tick removed within 24-36h after starting to feed.

Question 20

When should post-exposure prophylaxis be provided for Lyme Disease? With what?

Answer 20

1. If tick is engorged and has been attached for ≥36h (within 72h of removal)
2. Known endemic areas:
   
   • Doxycycline 200mg (or 4.4mg/kg) x 1 dose

Question 21

How is erythema migrans diagnosed and treated?

Answer 21

• Clinical Diagnosis
• Treatment is either:
  
  • Doxycycline BID x 10 days
  • Amoxicillin TID x 14 days
  • If beta-lactam allergy: Cefuroxime BID x 14 days
    
    • If unable to take: Azithromycin OD x 7 days

Question 22

When does erythema migrans appear?

Answer 22

Usually 7-14 days after bite (3-30 days is possible)

Question 23

List 3 examples of Late Lyme Disease

Answer 23

1. Arthritis 2. Facial nerve palsy 3. Heart Block (carditis) 4. Meningitis 5. Peripheral neuropathy (rare) 6. CNS manifestations (rare)

Question 24

What is the most common late Lyme disease presentation?

Answer 24

Arthritis (pauciarticular, large joints [esp. knees])

Question 25

What testing should you order for Lyme disease with late presentation?

Answer 25

ELISA IgM/IgG followed by Western blot IgM/IgG If CSF: IgM/IgG antibodies

Question 26

False positives are seen with ELISA testing for Lyme disease in what populations?

Answer 26

1. Autoimmune disorders (SLE)
2. Viral infections
3. Spirochetes

Question 27

How long do you treat arthritis, facial nerve palsy, heart block and meningitis with Lyme Disease?

Answer 27

• Arthritis: 28d
• Facial nerve palsy, heart block + meningitis: 14d

Question 28

You just started treatment for Lyme disease. The patient suddenly develops a headache and myalgias. What is this called and how do you treat it?

Answer 28

Jarisch-Herxheimer reaction

Stop antibiotics.

Give NSAIDs

Question 29

6 months after treating Lyme Disease, your patient continues to have fatigue, myalgias and arthralgias.

What is this called?

Should you prescribe another course of antibiotics?

Answer 29

Post-treatment Lyme Disease Syndrome (PTLDS)

Can linger for ≥6mo.

Does not improve with antibiotics.

Question 30

List 3 ways to prevent Lyme Disease.

Answer 30

1. 20-30% DEET or icaridin repellant
2. “Full body” check for ticks everyday. Remove any found on yourself, children or pets.
3. Shower or bathe within 2h of being outdoors to wash off unattached ticks
4. Landscaping where play spaces adjoin wooded areas

Question 31

What causes scabies?

Answer 31

Sarcoptes scabiei

Question 32

List 5 risk factors for scabies infestation.

Answer 32

1. Young 2. Elderly 3. Immunocompromised 4. Developmentally delayed 5. Overcrowding/bed0sharing 6. Malnutrition 7. Reduced access to health care

Question 33

What is the treatment for scabies for children ≤3mo?

Answer 33

• Sulphur 8-10% precipitated in petroleum jelly.
• Applied daily x 3 days.
• Decontamination of all bedding/clothing worn next to skin (hot cycle washer + dryer).
  
  • If unable to wash, plastic bag x 5-7 days

Question 34

What is the treatment for scabies for children >3mo?

Answer 34

• Permethrin 5% lotion or cream.
  
  • Applied to skin from neck to toes overnight, wash off in the morning.
  • Repeat treatment in 7 days.
• Decontamination of all bedding/clothing worn next to skin (hot cycle washer + dryer).
  
  • If unable to wash, plastic bag x 5-7 days

Question 35

When can children return to day care/school after a scabies infestation diagnosis?

Answer 35

After their first treatment

Question 36

What is the first line treatment of lice infestation?

What is the mechanism of action?

Answer 36

Permethrin 1% or pyrethrins (≥2mo) Neurotoxic to lice Decontamination by washing items in close/prolonged contact with head (pillowcases, hats, brushes and combs) in hot water ≥66˚C or dry in hot dryer for 15min or store in sealed plastic bag x 2 weeks

Question 37

If 2 treatments of permethrin 1% is not effective for lice, what is recommended?

Answer 37

• Rule out misdiagnosis or overdiagnosis or reinfestation.
• Treat with different class, such as:
  
  • Resultz (≥4yo) (dissolves exoskeleton → dehydration and death) or
  • NYDA (≥2yo) (silicone oil flows into the breathing system to suffocate)
• Decontamination by washing items in close/prolonged contact with head (pillowcases, hats, brushes and combs) in hot water ≥66˚C or dry in hot dryer for 15min or store in sealed plastic bag x 2 weeks

Question 38

What is a management strategy for residual itch/burning after lice treatment?

Answer 38

Topical corticosteroid or antihistamines

Question 39

How long should children be kept home from school/day care after lice diagnosis?

Answer 39

• No exclusion required.
• Recommend full course of treatment and avoid head-to-head activities.

Question 40

Name 4 methods to practice antimicrobial stewardship.

Answer 40

1. Treat infection, not contamination
2. Narrow the spectrum of antimicrobials when causative organism is identified
3. Optimize the dosing of antimicrobials to obtain maximal benefit
4. Use shortest recommended course of therapy for uncomplicated infections
5. Take care not to change or prolong antimicrobial therapy unnecessarily
6. Promote vaccinations to reduce the likelihood of clinical disease
7. Laboratories should produce local, age-specific antibiograms to guide antibiotic choices for selected infections
8. Take a careful history of potential antibiotic side effects and, if possible, confirm an antimicrobial allergy

Question 41

Name 3 outcome goals for antimicrobial stewardship.

Answer 41

1. Optimize therapy
2. Minimize risk of adverse events
3. Optimizing patient outcomes

Question 42

What are the indications for VariZIG?

What is a contraindication?

Answer 42

Should be administered within 96 hours of most recent significant exposure to varicella disease (but can be given up to 10 days after)

1. Susceptible pregnant women
2. Newborn infants of mothers who develop varicella during 5 days before to 48h after delivery
3. Susceptible immunocompromised individuals (post-HSCT, HIV with CD4 <200 or <15%, high dose CS ≥2 weeks)
4. NICU exposure within the first few weeks of life: <28wks GA or <1000g

Contraindication: IgA deficiency

Incubation period is 21 days

Question 43

What is the rate of vertical transmission with no prophylaxis?

If treatment during pregnancy?

When does the majority of vertical transmission of HIV occur?

Answer 43

25%

<2%

Question 44

List 5 risk factors for HIV in pregnancy

Answer 44

1. IV drug use
2. Late or no prenatal care
3. Recent illness suggestive of HIV seroconversion
4. Regular unprotected sex with partner known to be living with HIV (or at significant risk for it)
5. Diagnosis of STI during pregnancy
6. Emigration from HIV-endemic area
7. Recent incarceration

Question 45

When should an infant be tested for HIV when born to an HIV positive mother? With what test?

When should prophylaxis be started?

What short term effects should be monitored?

Long-term?

Answer 45

Immediately (within 48h)

HIV DNA or RNA PCR

• No breastfeeding - contraindicated
• Consult paediatric ID with expertise in HIV

Immediately: Within 72h post-delivery (AZT or combination ART)

Short term: neutropenia, anemia

Long-term: Neurodevelopment, growth, general health

Question 46

What test should be conducted for all infants in foster care and adoptees whose birth mother’s HIV status is not known?

Question 47

When should you give tetanus prophylaxis for cuts?

Answer 47

• If fully immunized, do nothing
  
  • Unless >10y since last dose of vaccine or >5y if severe wound that’s not clean
  • Don’t need to give Ig ever
• If NOT fully immunized, then should always give booster
  
  • AND if unclean/severe wound, then also give Ig

Question 48

List 2 risk factors for invasive GAS.

Answer 48

1. Recent pharyngitis
2. Varicella
3. Recent soft tissue trauma
4. NSAID use

Question 49

List 4 infections that are considered invasive GAS.

List 4 non-severe GAS infections

Answer 49

Invasive GAS

1. ​Meningitis
2. Necrotizing fasciitis
3. Streptococcal Toxic Shock Syndrome
4. Pneumonia (if pleural fluid positive)
5. Any other life-threatening condition or infection resulting in death

Non-severe GAS

1. Osteomyelitis
2. Cellulitis
3. Bacteremia
4. Lymphadenitis
5. Septic arthritis
6. Soft tissue abscess

Question 50

What is the diagnostic criteria for Streptococcal Toxic Shock Syndrome?

Answer 50

Must have HYPOTENSION + ≥2 of:

Renal impairment (Cr 2X ULN or 2X baseline)

Coagulopathy (plt ≤100 or DIC)

Liver function abnormality (AST or ALT ≥2X ULN)

ARDS

Generalized erythematous macular rash (may later desquamate)

Question 51

Define Congenital varicella vs Neonatal varicella

Answer 51

Congenital varicella:

• If maternal infection in 1st or 2nd trimester:
  
  • Limb hypoplasia
  • CNS damage (microcephaly, seizures, dev delay)
  • Scarring of skin
  • Ophtho abnormalities (chorioretinitis, microphthalmia, cataracts)

Neonatal varicella:

• occurs if maternal infection within 5 days prior to or 2 days post delivery
• give VZIG
• if infant has lesions, treat with IV Acyclovir 10mg/kg q8h
• can be life-threatening

Question 52

When should you provide prophylaxis for Hib and with what drug?

Answer 52

Recommend for:

• All members in households:
  
  • With at least one contact < 4 years of age who is unimmunized or incompletely immunized
  • With a child < 12 months who has not received the primary series
  • Immunocompromised child, regardless of Hib immunization status
• Child care settings:
  
  • If one case of invasive Hib disease has occurred, then prophylax all incompletely or unimmunized children < 4 years
  • If 2+ cases of invasive Hib disease within 60 days and unimmunized or incompletely immunized children attend the facility, chemoprophylaxis for all attendees and childcare providers should be considered.

Use Rifampin:

• ASAP - most secondary occur during the first week of index hospitalized case
• Initiation of prophylaxis more than 7 days after hospitalization may still be beneficial

Question 53

What is the management for perianal abscess?

What are diseases associated with perianal abscess?

Answer 53

• Presentation:
  
  • Younger children → usually mild rectal pain & area of perianal cellulitis; abscess usually adjacent to involved crypt; these spontaneously drain & resolve w/o tx
  • Older patients with predisposing illnesses → abscesses tend to be deeper in the ischiorectal fossa or supralevator
• Tx:
  
  • Infants → usually self limited. Conservative management is advocated (even if there’s a fistula) as typically these self-resolve. Abscesses can be drained if there is local discomfort.
  • Older children with predisposing conditions → if little discomfort and no systemic sx, then can tx with abx. If unwell, then I&D and abx.

Predisposing conditions:

• Crohn’s
• TB
• Pilonidal disease
• Hidradenitis
• HIV
• Trauma/ foreign bodies
• Dermal cysts
• Sacrococcygeal teratoma
• Actinomycosis
• Lymphogranuloma venereum
• Radiotherapy

Question 54

Women in labor with genital herpes, list 4 risk factors for transmission to infant.

Answer 54

• first episode of herpes for mom (primary infection) - prolonged rupture of membranes - vaginal delivery - use of instrumentation in delivery (forceps, vacuum, fetal scalp electrode)

Question 55

Woman in labour with genital herpes. If you are going to do investigations, in what situation would that be and what tests would you do on the infant? (list 2)

Answer 55

Mom has active primary lesions, baby asymptomatic, born by C/S after ROM - mucous membrane swabs and start IV acyclovir on spec. If swabs positive, then do blood and CSF PCR *if infant symptomatic, admit, treat, swab and FSWU

Question 56

Mom is IVDU. Her blood work: HEB B + HepC +. Baby’s blood work at 6 mo, hep B and hep C ab negative. What to do: a) Repeat Hepc in 6 months b) No further investigations c) PCR

Answer 56

b) No further investigations -negative Hep C ab in child of any age indicates transmission did not occur

Question 57

Mom ivdu. Early latent syphilis. Titer from 6 months ago and now. They have dropped by 8 times. Baby is born. What do you do to for the baby: a) Observe b) Tryponemal screen and RPR c) CSF RPR d) Swab baby

Answer 57

b) Tryponemal screen and RPR

Question 58

Neonate with purpura and thrombocytopenia. Diagnosed with CMV. Give six other features of congenital CMV infection.

Answer 58

• hearing loss - microcephaly - SGA - chorioretinitis - jaundice - HSM

Question 59

You are seeing a full term newborn born to a 25 year old mother with a history of genital herpes diagnosed 5 years ago. She had no active lesions at the time of delivery and thus was untreated. The baby was born by SVD. a. What is your management of the newborn (1 line)?

Answer 59

• observe for signs of neonatal HSV and educate parents about what to look for. No swabs or other investigations indicated in this case

Question 60

A full term infant is born by vaginal delivery to a woman with a vaginal herpes lesion. In order to decrease infectivity you would: a) place baby and mother in same room with no breastfeeding b) place baby and mother in same room and allow breastfeeding c) place baby and mother in separate rooms d) discharge both immediately e) contact isolation from other patients

Answer 60

ANSWER: b) place baby and mother in same room and allow breastfeeding AND e) contact isolation from other patients - until lesions crusted over, 14d infectivity period passed or swabs negative d) discharge both immediately- no, await swabs

Question 61

An infant is born to a mother with a history of recurrent genital herpes which was not active at the time of vaginal delivery. For how long after delivery is it possible for this infant to develop herpes: a) 1-2 weeks b) 4-6 weeks c) 12-16 weeks d) 20-24 weeks e) up to 36 weeks

Answer 61

b) 4-6 weeks

Question 62

A baby is born by c-section at 6h since membranes ruptured. Mother has active HSV lesions. The baby is asymptomatic. When should cultures of the baby be done? a. Immediately and start Acyclovir b. After 48h c. When the baby is symptomatic d. Observe only

Answer 62

a. Immediately and start Acyclovir

Question 63

A women is diagnosed with chicken pox 10 days prior to delivery. The baby is normal at birth. You would: a) give VZIG immediately b) provide normal newborn care unless the infant develops varicella c) isolate the baby from the mother

Answer 63

ANSWER: b) provide normal newborn care unless the infant develops varicella a) give VZIG immediately- only if rash <5d prior to or 48h after delivery or prem c) isolate the baby from the mother (usually lesions crusted by 5d after)

Question 64

What is the most common sequela of congenital CMV: a) deafness b) petechiae c) cataracts d) splenomegaly e) jaundice f) microcephaly

Answer 64

a) deafness

Question 65

A mother is exposed to parvovirus B19 in her first trimester. Most common result: a) IUGR b) microcephaly c) limb abnormalities d) cardiac malformation e) non-immune hydrops fetalis

Answer 65

e) non-immune hydrops fetalis (from fetal anemia)

Question 66

Greatest risk of mortality with parvovirus B19 infection is associated with: a) prematurity b) sickle cell disease c) ALL on chemotherapy d) congenital heart disease e) fetus of a mother infected with parvovirus B19

Answer 66

e) fetus of a mother infected with parvovirus B19 ~5%

Question 67

A pregnant women comes into contact with a child with parvovirus during her twelfth week of pregnancy. You would recommend: a. isolate woman from child b. perform parvovirus serology on the woman c. IVIG d. Abortion

Answer 67

b. perform parvovirus serology on the woman - look for susceptibility (may have immunity) and evidence of acute infection

Question 68

Mother who is HBsAg positive. Management of newborn should consist of: a. Hep B vaccine only b. Hepatitis titres and if negative, Hep B vaccine in 1 week c. Hep Ig q monthly if breastfeeding d. Hep Ig within 12 hours and Hep B vaccine within 12 hours e. Hep Ig at birth and Hep B vaccine within 7 days

Answer 68

d. Hep Ig within 12 hours and Hep B vaccine within 12 hours

Question 69

Baby born to a Hep B positive mom. He gets immunoglobulin and vaccine at birth. At nine months he is asymptomatic. What would his blood tests show? 1. HbeAg+, HbcAg+, HbsAg+, HbsAb+ 2. HbeAg-, HbcAg-, HbsAg+, HbsAb+ 3. HbeAg-, HbcAg-, HbsAg-, HbsAb+ 4. HbeAg+, HbcAg-, HbsAg+, HbsAb- 5. HbeAg-, HbcAg+, HbsAg+, HbsAb

Answer 69

3. HbeAg-, HbcAg-, HbsAg-, HbsAb+ surface antigen should be negative (if it’s positive he has Hep B), and surface antibody should be positive (has immunity from vaccine)

Question 70

Complications of neonatal gonococcal eye infections include: a. retinal hemorrhage and blindness b. corneal perforation and blindness c. anterior uveitis and fixed pupil d. glaucoma

Answer 70

b. corneal perforation and blindness

Question 71

Infant born to mother with no prenatal care. Hepatosplenomegaly and copper rash especially on palms and soles. Rhinitis and cough. Diffuse consolidation on CXR. Appropriate investigation: a. urine CMV b. VDRL/FTA abs c. blood culture

Answer 71

b. VDRL/FTA abs

Question 72

A woman has recently immigrated from China to Canada and has just delivered a healthy term infant. She does not know her hepatitis B status, but the results will be available in 2 days. What will be your management: a) await results of HBsAg before treating infant b) give HBIG now, but await results of HBsAg before giving Hep B vaccine or allowing breastfeeding c) give Hep B vaccine now and allow breastfeeding d) give HBIG and Hep B vaccine now; do not allow breastfeeding e) give HBIG and Hep B vaccine now; allow breastfeeding

Answer 72

c) give Hep B vaccine now and allow breastfeeding - unknown status: Hep B vaccine at birth, if mom ultimately tests positive give HBIG within 1 week of life *if baby <2000g give Hep B vaccine and HBIG at birth

Question 73

Contraindication to breastfeeding e. Hep B f. Bilateral mastitis g. Active TB

Answer 73

g. Active TB

Question 74

Picture of baby with rash: told cataracts, microcephaly, hepatosplenomegaly, bony changes a) Syphilis b) CMV c) Rubella d) toxoplasmosis

Answer 74

c) Rubella - hearing loss, cataracts, MR, IUGR, hepatitis, osseous changes, cardiac defects

Question 75

6 mo baby of IV drug user. Mom is Hep C-positive. Baby’s anti-HepBs positive and anti-HCV positive. What do you do? a. no further testing b. repeat anti-HCV in 6 months c. do HCV RNA PCR now d. P24 antigen

Answer 75

b. repeat anti-HCV in 6 months - HCV serology not reliable in infants because can reflect mom’s antibodies - test at 12-18 months; if positive repeat testing in 6 months (if seropositive after 18 months, they are infected)

Question 76

Mother has herpes labialis. What do you advise regarding her 4 day old infant? a) wear mask when breastfeeding b) apply topical acyclovir to lesion c) stop breastfeeding d) infant needs IV acyclovir

Answer 76

a) wear mask when breastfeeding

Question 77

A pregnant woman with syphilis and a RPA of 1:512 receives a full course of treatment and the titer falls to 1:256. Upon delivery of the child, the next appropriate step is: a) treat the child as the fall in the titer is inadequate b) test child’s serum for VDRL and anti-treponemal AB and treat if positive c) test child’s CSF for VDRL and anti-treponemal AB and treat if positive d) no treatment is necessary for syphilis but this child should be tested for HIV

Answer 77

a) treat the child as the fall in the titer is inadequate - full work up (blood, CSF, X-ray) and treat

Question 78

Baby born with rash, cataracts, bone lesions, big liver (photo of baby shown) most likely has: a. Congenital syphilis b. Congenital CMV c. Congenital rubella

Answer 78

c. Congenital rubella cataracts - rubella; chorioretinitis - CMV

Question 79

Which of the following maternal infections is a contraindication to breast feeding? a) Hep A b) Hep B c) CMV d) HIV

Answer 79

d) HIV

Question 80

Baby with tachypnea, afebrile, nontoxic, has eosinophilia. CXR shows bilateral interstitial markings, areas of atelectasis. What is the likely pathogen? a) GBS b) Chlamydia trachomatis c) Ureaplasma urealiticum d) RSV

Answer 80

b) Chlamydia trachomatis - onset of cough 1-3 months; no fever; staccato cough, eosinophilia - treat with erythromycin (can cause pyloric stenosis)

Question 81

Neonate born to mom who just revealed HIV positive status. a.) What treatment(s) would you start this baby on (1 line). How long would you treat for?

Answer 81

Zidovudine x 6 weeks + 3 doses of nevirapine during 1 st week of life (@ birth, 48h after first dose and 96h after 2nd dose)

Question 82

Neonate born to mom who just revealed HIV positive status. When would you start the treatment? (1 line)

Answer 82

Within 12 hours of birth

Question 83

What infection is the worst prognosis in HIV for an infant a) Lymphoid interstitial pneumonia b) Pneumocystis Carinii Pneumonia c) Cardiomyopathy d) Nephropathy e) Candida

Answer 83

b) Pneumocystis Carinii Pneumonia - PCP is an AIDS defining illness - if present in first 6 months of life is associated with poor prognosis

Question 84

Baby born to HIV-positive mother discovered during pregnancy and treatment initiated. How to test the baby to confirm diagnosis? a) ELISA b) Western blot c) HIV DNA PCR d) p24 Ag

Answer 84

c) HIV DNA PCR - preferred test for <18m *a) ELISA- screening in >18m b) Western blot - confirmatory test d) p24 not as sensitive - never recommended o Testing with HIV DNA or RNA assays at 14-21d o Repeat at 1-2m and 4-6m if negative then ELISA at 18m o Test <48h if in utero infection suspected

Question 85

The leading cause of HIV in women in Canada is due to: a. homosexual transmission b. heterosexual transmission c. IV drug use d. blood transfusion e. occupational exposure

Answer 85

b. heterosexual transmission

Question 86

All of the following are features of HIV infection EXCEPT: a) hypogammaglobulinemia b) CD4 leukopenia c) reverse CD4/CD8 ratio d) poor response to tetanus and diptheria vaccines e) poor response to TB skin test

Answer 86

d) poor response to tetanus and diptheria vaccines (can have a reduced response, but this is the most correct answer)

Question 87

A 1 year old child has a cough, and mom wants to know if she can use an over-the- counter cough preparation for him/her. What do you tell her?

Answer 87

OTC cough medications are not helpful in kids and can be harmful. Not recommended in kids under 6 years.

Question 88

Child develops rash on both cheeks. Then a reticulated lacy rash is seen on his body. His mother is pregnant. What infection does this child have (1) How would you manage the mother (1)?

Answer 88

Parvo B19 - serologies for mom

Question 89

One of your patients has mono like symptoms. Your blood work comes back. IgM negative; IgG positive; Early D antigen negative; Nuclear capsid antigen was positive. Interpret these results.

Answer 89

This patient had a previous (remote) infection, but this is not the explanation for current symptoms ● IgM = early rise and then drop off by 1-2 mo. ● IgG = early rise and stay elevated ● Early D antigen = peak week two then decreases by 4 mo. = (+) in acute or recent primary infection ● Nuclear capsid antigen= low then rise 6 mo. onwards

Question 90

4 year old boy presents with a pruritic rash over his chest and axilla. 2-5mm flesh coloured papules w/ central depression or umbilication. Provide most likely diagnosis.

Answer 90

Molluscum contagiosum

Question 91

8? Year old with vesicle on erythematous base on uvula, tonsils, soft palate. What is the diagnosis?

Answer 91

Herpangina (coxsackie virus)

Question 92

Winnipeg Doc..calls family concerned about west nile. 4 suggestions to help prevent west nile virus in his patients

Answer 92

o community-level mosquito control programs to reduce vector density o personal protective measures to decrease exposure of infected mosquitoes (e.g. long sleeved shirts, limit outdoor from dusk to dawn, mosquito repellent, using air conditioning, installing window screens) o screen of blood and organ donors

Question 93

A child is brought to see you with 3 days of high fever of 40.1 degrees and feeling unwell. The only thing you see on physical exam is clear rhinorrhea. A CBC shows the following : Hb 118, WBC 2.0 x 10^9 (2000/m3), platelets of 250. The differential shows neutrophils 2%, lymphocytes 70%, eosinophils 8%. What are TWO things that you will do in the management of this child?

Answer 93

Viral infection - ensure adequate fluid intake, analgesia and antipyretics for comfort

Question 94

Robert is a 6 year old boy with Varicella. In the last 24 hours he has become unwell. On exam, his temperature is 40, HR 140, BP 95/60, RR 24. He has obvious lesions consistent with chicken pox. He has a red, swollen left arm that is tender. a) Outline a prioritized differential diagnosis. b) Outline your initial investigations. c) Outline your management plan.

Answer 94

a) Ddx: ● infected rash = cellulitis, ● Cellulitis ddx: abscess, osteomyelitis ● Nec Fas b) Ix: - CBCD, CRP, blood culture c) mgmt: admit and IV cefazolin

Question 95

Varicella. With nec fash/or purpura fulminans. What is your management: a) vanc cefotax b) pen G and clinda c) amp gent

Answer 95

b) pen G and clinda

Question 96

You diagnosed a toddler with Chicken pox a few days ago. Now he is in your office. Mother tells you he’s refusing to weight bear since this morning. Photo of his foot is shown. Area of erythema over 3 rd -4 th metatarsals and phalanges, with black necrotic looking areas. What is the diagnosis? How will you treat him (4)?

Answer 96

1. Dx: necrotizing fasciitis 2. mgmt: - admit to hospital - blood future, CBCD, CRP - start pen G and clindamycin IV - surgical consult for debridement

Question 97

Child presents with ataxia and inability to sit up two weeks after having chicken pox. A) What is the diagnosis? B) How do you differentiate this from meningoencephalitis? List three.

Answer 97

A) acute cerebellar ataxia B) no fever, no nuchal rigidity, CSF normal or shows mild lymphocyte pleocytosis vs meningitis which shows PMN pleocytosis

Question 98

Name 4 indications for VZIG

Answer 98

PEP in high risk kids who are exposed: - immunocompromised without immunity (e.g. leukaemia, on steroids) - newborns of mom with varicella 5d before of 48h after delivery - pregnant women without immunity - hospitalized prems <28 weeks or <1000g

Question 99

Kid with exudative pharyngitis. 1y/o. What is most likely dx a) Viral pharyngitis b) MONO c) Strep

Answer 99

a) Viral pharyngitis

Question 100

31 week GA baby, now 3 mos old. It is October. Parents are non-smokers. Mother planning to stay at home with babe. A) What one intervention can you do to minimize risk of severe RSV bronchiolitis? B) How does paluvizumab decrease risk and by what mechanism does it work?

Answer 100

A) this baby does not qualify for paluvizumab - protective factors are: breastfeeding, hand hygiene and not smoking B) decreases rate of hospitalization in some groups of prem babies (if hospitalized, does not reduce severity or mortality); confers passive immunity (immunoglobulin)

Question 101

A 4 year old child comes to your Emergency department with a history of a fever for 3 days. You do a CBC and find that the WBC count is low at 3.2. a. What is the most common reason for this clinical scenario? b. On a differential, which cell line, if low, increases the risk of serious infection?

Answer 101

a. viral suppression b. neutropenia

Question 102

Hep A. When can return to school? a. 1 wk b. when no fever c. if washing hands well d. when no symptoms

Answer 102

a. 1 wk (red book, CPS)

Question 103

Girl returns from mexico and begins to have vomiting, diarrhea and jaundice. Her abdomen is tender. Her LFTS are elevated. When can she return to daycare? a) 7 days b) When symptoms stop c) When LFTs normal d) Now

Answer 103

a) 7 days - risk of transmission minimal 1 week after jaundice onset

Question 104

Biting incident at daycare, breaks skin superficially, both kids are previously healthy and have all their immunizations but no HepB shots. What do you do? a. screen them for HIV b. start Hep B vaccinations in both kids c. test Hep B serology only in the biter d. tetanus immunoglobulin

Answer 104

b. start Hep B vaccinations in both kids

Question 105

Which virus is associated with transient arthropathy: a) RSV b) rubella c) measles d) Hepatitis A

Answer 105

b) rubella

Question 106

Wheezing toddler with URTI symptoms. Which is a proven therapy? a. O2 b. racemic epi c. iv steroids d. bronchodilators

Answer 106

a. O2 (assuming bronchiolitis)

Question 107

Child admitted with known RSV bronchiolitis. On third day of his admission, develops a fever and CXR shows a small RML infiltrate. What is the most likely cause of his fever? a. Strep pneumo b. Chlamydia trichamotas c. RSV d. GBS

Answer 107

c. RSV

Question 108

A 13 y.o. boy with HIV is diagnosed with measles. The only proven treatment is: a) Acyclovir b) Vitamin A c) Inhaled amantadine d) Vitamin E

Answer 108

b) Vitamin A (more severe disease if vit A deficient) ● WHO recommends Vit A for treatment of all children with measles o Daily for 2d o 50 000 IU <6m o 100 000 IU 6-11m o 200 000 IU >12m

Question 109

Child sucks on finger. Lesions on finger for 10 days. Finger hurts when mom touches it – picture of a finger with vesicles but also a central area of ulceration, some diffuse erythema of finger. What is your management? 1. po cephalexin 2. I & D 3. po acyclovir 4. flamazine dressing

Answer 109

3. po acyclovir Herpetic whitlow - treat with acyclovir if immunocompromised or severely infected; otherwise can do nothing

Question 110

Mom wants to know where her 18 month old daughter acquired perineal warts. You tell her from: a. perinatal acquisition b. sexual abuse c. day care d. from bathing with her older sister e. from dad changing diapers

Answer 110

a. perinatal acquisition

Question 111

What is the best test for HSV encephalitis? a) PCR on CSF b) Viral culture of CSF c) HSV IG in CSF d) Differential on CBC

Answer 111

a) PCR on CSF

Question 112

Mom concerned about possibility of west nile in her child. What is the most common presentation of west nile in children? a. Asymptomatic b. Mild fever c. Encephalitis

Answer 112

a. Asymptomatic (70-80% of WNV infections are asymptomatic) - if symptomatic: febrile illness with myalgia, arthralgia, headache, GI upset, maculopapular rash

Question 113

3 year old with a history of fevers. Occur every 4 to 12 weeks for 1-4 days. Growing well. Treated for numerous otitis and pharyngitis. A) multiple viral infections B) familial med fever C) CVID

Answer 113

A) multiple viral infections

Question 114

11 year old girl with vague abdominal pain, vomiting, and jaundice. Her labs show ALT 1000, total bilirubin 100. What test will likely confirm the diagnosis? a) Hep A IgM b) CMV urine c) Heb B serology d) monospot

Answer 114

a) Hep A IgM - Hep A accounts for 50% of all clinically apparent acute viral hepatitis - clinical presentation of hep A - fever, malaise, jaundice, anorexia, nausea, vomiting

Question 115

6 year old girl has recent history of gastroenteritis. She develops bilateral decreased sensation in her feet. Her respirations are normal. What is her diagnosis (1)? What test or procedure would you do and what are your expected findings? What is the likely organism that caused her gastroenteritis (1)?

Answer 115

1. guillain-barre syndrome 2. LP - elevated protein (>2x ULN), glucose normal, no CSF pleocytosis, cultures negative - can also do MRI: thickening of cauda equina and intrathecal nerve roots with gad enhancement 3. campyobacter jejuni

Question 116

Native girl, received BCG in past, PPD 13mm. a.) How do you interpret this? b.) What is your approach to treatment? (1 line)

Answer 116

a) positive test - in kids who are vaccinated, if they have been exposed to TB or are at high risk for disease the cutoffs for a positive test are the same as if they hadn’t been vaccinated b) 9 months of isoniazid for LTBI

Question 117

Child gets a puncture wound of the foot through the sneaker. He is Limping. Bone scan confirms osteomyelitis. What is the likely causative organism? List 2 treatment modalities.

Answer 117

1. pseudomonas 2. - irrigation and debridement under GA, abx x14 days (pip-tazo, cefuroxime, cipro gent all antipseudomonal)

Question 118

Name 4 drugs with pseudomonas coverage

Answer 118

• pip-tazo - cefuroxime - aminoglycosides (gent, tobra) - cipro

Question 119

Child has worsening swelling around an eye. List 2 signs that would make you worried about orbital cellulitis.

Answer 119

• proptosis - pain with extraoccular movements - decreased visual acuity

Question 120

A child has bacterial meningitis. Soon after starting his vancomycin infusion, he breaks out in a red rash. Blood pressure is normal. What is your IMMEDIATE management? What are TWO things that can be done so this doesnʼt happen the next time?

Answer 120

1. stop infusion; give benadryl and ranitidine 2. premedicate with diphenydrydramine +/- ranitidine - run infusion at slower rate Red man syndrome - not true allergy; is a rate dependent infusion reaction

Question 121

Description of a mom who presents with her child who has otitis media. What are 4 risk factors for otitis media?

Answer 121

• pacifier use - exposure to cigarette smoke - certain syndromes (e.g. T21 - flatter angle of ear canals) - orofacial abnormalities (e.g. cleft palate) - over crowded housing - shorter duration of breast feeding

Question 122

Kid with pain with movement both directions. Supple neck, slight red throat otherwise normal oral pharynx. Drooling. a) Peritonsilar abcess b) Retropharyngeal abcess c) Mono d) URTI

Answer 122

b) Retropharyngeal abscess

Question 123

Teen can’t open mouth. Has fever. Dx? a. Retropharyngeal abscess b. Peritonsillar abscess

Answer 123

b. Peritonsillar abscess

Question 124

Bite in daycare Q. What to do: a) Reassure mom of low risk of hiv infection b) HIV serologies for both kids c) initiate HIV prophylaxis for both kids d) HIV prophylaxis for kid who was bitten only

Answer 124

a) Reassure mom of low risk of hiv infection - PEP after a bite by a child known to be infected with HIV is rarely indicated and should only be given in consult with ID

Question 125

3 year old with a bite on his cheek. List 4 characteristics of the bite that would have an impact on the management of this patient.

Answer 125

• depth - signs of infection - what bit him - animal versus human (puncture wound vs graze) - infective/immune status of biter if known - tetanus status - duration since bite (do not close if >24 hours)

Question 126

3 week old with RSV, day 2 of admission. Fever of 39. RML infiltrate that was new. a) cefotax b) amp and gent c) supportive management

Answer 126

b) amp and gent - because fever in <1 month

Question 127

Inuit grandmother diagnosed with active TB. His child has a TB skin test which shows 8 mm of induration. What are two possible reasons for this test result (2)

Answer 127

• latent TB infection (in otherwise asymptomatic) - indicative of previous BCG vaccine Positive test is >5mm in a child with close contact with persons with active TB

Question 128

2 year old with fever and right ear pain. She was treated with clarithrymycin a few weeks ago for a respiratory infection. ON exam has an otitis media. What are three possible antibiotics for her (3)

Answer 128

• amoxicillin - amoxicillin-clavulanic acid - cefuroxime

Question 129

Family comes to you from an area endemic for Lyme disease – What is the organism and vector causing it (2)?

Answer 129

• borrelia burgdoferi; from black-legged ticks

Question 130

What are two antibiotics that are effective against lyme disease (2)? When is IV and treatment indicated?

Answer 130

1. • doxycycline (kids 8+ years) - amoxicillin - cefuroxime 2. ceftriaxone/pen G for endocarditis, meningitis, encephalitis

Question 131

What are three things to do for prevention if you live in a lyme endemic area (3)

Answer 131

• use landscaping to separate play spaces from wooded areas - 20-30% DEET bug spray - full body check for ticks after coming inside and promptly remove any that are found - showed within 2 hours of coming inside to wash off unattached ticks

Question 132

List 4 clinical signs to distinguish orbital from periorbital cellulitis.

Answer 132

• pain with EOM - rapid afferent pupillary defect - proptosis - decreased visual acuity - chemosis

Question 133

18 month old child with URTI. He develops higher fever 3 days later, pulling at ear and has erythematous right tympanic membrane, not bulging. Do you treat for AOM? Explain why or why not?

Answer 133

No treatment. No bulge suggests there is no middle ear effusion, and erythematous TMs are common in viral infections. Since patient is over 6 months watchful waiting x24-48 hours is appropriate

Question 134

What are the five major criteria for rheumatic fever?

Answer 134

Joints: migratory polyarthritis Carditis: new murmur/valve disease on echo Subcutaneous nodules Erythema marginatum Sydenham’s chorea

Question 135

Child presents with bloody diarrhea, anemia and thrombocytopenia. What is the diagnosis?

Answer 135

Hemolytic uremic syndrome - triad: microangiopathic hemolytic anemia, TCP, renal insufficiency

Question 136

Which of the following is TRUE as regards TB in children: a) tine test and PPD are equally specific and sensitive b) 10% of children with active disease are PPD negative c) prior vaccination with BCG is a contraindication to PPD testing

Answer 136

b) 10% of children with active disease are PPD negative

Question 137

4 y.o. with chronically draining cervical node. Most likely bug: a. Staph Aureus b. Atypical mycobacterium c. Cat scratch d. Tuberculosis

Answer 137

b. Atypical mycobacterium

Question 138

Child with a supraclavicular lymph node 1.5 by 2 cm, firm, nontender, mobile no surrounding erythema . what is best management a. skin testing for atypical mycobacteria b. PPD (TB skin test) c. excision biopsy

Answer 138

c. excision biopsy

Question 139

Greek 6 y/o girl with fever to 40 degrees. WBC 38. Pain in the right hypochondrium. Tender in right hypogastrium but no guarding or rebound. What is the diagnosis: 1. Pleurodynia 2. Bacterial pneumonia 3. First presentation of Familial Mediterranean Fever 4. Fitz-Hugh-Curtis 5. Cholecystitis

Answer 139

2. Bacterial pneumonia

Question 140

Adolescent male whose partner is positive for gonorrhea. Your management would be a. Amoxil b. tetracycline c. ceftriaxone d. doxycycline e. erythromycin

Answer 140

c. ceftriaxone 250mg IM x1 - same treatment for partners as for confirmed cases - also give one dose of azithro 1g PO (or 7d doxy)

Question 141

12 month old who is toxic with a lobar infiltrate. Which antibiotic do you use: 1. IV Cefuroxime and IV Erythromycin 2. IV Vancomycin 3. IV Ampicillin 4. PO Amoxicillin 5. PO Clarithromycin

Answer 141

3. IV Ampicillin - ceftriaxone for life threatening infection/shock - if rapidly progressing multi lobar pneumonia add vance for MRSA

Question 142

First line for treatment for sinusitis: 1. Amoxicillin 2. Azithromycin 3. Clarithromycin 4. TMP/SMX

Answer 142

1. Amoxicillin

Question 143

6 y/o boy with 2 weeks of sudden onset of OCD behaviours. Which infectious agent would you be concerned about: 1. Strep pneumonia 2. Group A Strep 3. E. Coli 4. H. Flu 5. Echovirus

Answer 143

2. Group A Strep (PANDAS)

Question 144

A child eats at a picnic and develops vomiting and diarrhea four hours later. What is the likely causative organism: 1. E Coli 2. S Aureus 3. Shigella 4. Campylobacter 5. Salmonella

Answer 144

2. S Aureus (onset 1-6 hours after exposure)

Question 145

An epileptic who has been on carbamazepine for the past year presents with otitis media. You prescribe Ceclor for the otitis. Two days later he returns with an urticarial rash. The otitis is still present. What would be the next drug of choice: a) amoxicillin b) erythromycin-sulfa c) clarithromycin d) TMP-sulfa e) cefixime

Answer 145

a) amoxicillin- 1 st line for AOM; if you have a cephalosporin allergy it is usually to the side chain, not the beta lactam, so don’t tend to have penicillin allergy cefixime is also a cephalosporin so not a good idea (though is a good choice for kids with pen allergies because does not cross react with penicillins eryrtho, clarithro and septa all have interaction with carbamazepine (could induce toxicity)

Question 146

A mother brings her 3 children to your office because she thinks they all have strep throat. The 18-month-old and 2½ -year-old both have exudative tonsillitis. The 4-year-old has a red pharynx and mild anterior cervical lymphadenopathy. a) no treatment is necessary now; reassess in a few days b) treat all 3 children with penicillin V tid x 10 days c ) take throat swabs and await the results before treating d) take throat swabs and treat empirically with penicillin V e) take throat swabs and do CBCs; if increased WBC then start penicillin V

Answer 146

c ) take throat swabs and await the results before treating

Question 147

A child has Campylobacter cultured from his stool. He is toxic. Which antibiotic: a) PO Erythromycin b) PO Septra c) PO Flagyl d) IV Ampicillin e) no antibiotics

Answer 147

a) PO Erythromycin - gram negative bacilli - leading cause of acute diarrhea worldwide

Question 148

A 10-year-old child has completed a 2-week course of oral erythromycin as treatment for pertussis. His mother complains that her child is still coughing. You advise: a) chest x-ray b) ventolin c) oral prednisone d) another 14 days of erythromycin e) reassure that nothing further needs to be done

Answer 148

e) reassure that nothing further needs to be done - 100 day cough

Question 149

A 7 year old with CP, severe GERD and frequent choking spells while eating is admitted to the hospital with fever and increased RR. On CXR there is an air bubble in the LLL with surrounding consolidation and pleural effusion. What is the most likely organism that is causative: a. Staphylococcus b. Haemophilus c. Anaerobes d. Mycoplasma

Answer 149

a. Staphylococcus - causes necrotizing pneumonitis - pneumatocele

Question 150

A 13 year old boy has had a 3 week history of fever, malaise and a weight loss of ten pounds. On examination he has diffuse lymphadenopathy including a right supraclavicular node and his spleen tip is palpable. His WBCs are 10, Hgb is 120 and Plts are 150. HIV and mono testing are negative. Which of the following tests is the next step in your investigations: a. CT abd b. BM aspirate c. ANA d. CXR

Answer 150

d. CXR - mediastinal mass for cancer; hilar adenopathy for TB

Question 151

12 month old girl is seen with fever, tachypnea and vomiting. She appears unwell but her vitals are stable. On CXR there is a lobar consolidation. What antibiotics do you start: a. IV cefuroxime b. IV cefuroxime and IV azythromycin c. IV vancomycin and cefotaxime d. IV ampicillin

Answer 151

d. IV ampicillin

Question 152

A 3 year presents to your office with 3 days of low grade temperature, rhinorrhea, and occasional cough. On exam he looks well and has green crusted nasal discharge. A culture of his nasal secretions is growing small amounts of H. influenzae. What is your treatment: a. no treatment b. amoxicillin c. trimethoprim-sulfmethoxazole d. ENT consult

Answer 152

a. no treatment - h flu is normal part of respiratory flora in 60-90% of children

Question 153

A 7 year old boy visited a farm recently. He now presents with a cough, hepatomegaly and a slight elevation of his AST and ALT. What is the likely diagnosis? what is the treatment? a. Psittacosis b. Legionella c. Q fever

Answer 153

c. Q fever - coxsiella burnetti (rickettsial infection) - supportive only; can treat with doxycycline if diagnosed within 3 days of onset (otherwise abx ineffective)

Question 154

You see a 4 year old child with a history of an enlarged left axillary lymph node for the past 14 days which is slowly enlarging in size. He has not been traveling outside the country. On examination the node is soft, mobile and mildly tender but there is no overlying redness. He is afebrile and there is no obvious skin infection over the left arm. What investigation is most likely to confirm the diagnosis: a. Bartonella hensellae serology b. PPD testing c. Excisional biopsy

Answer 154

a. Bartonella hensellae serology - self limited - axillary lymph node common

Question 155

Otitis media → complications of “watch and wait” approach a. Bacteremia b. Mastoiditis c. Prolonged fever d. Prolonged pain

Answer 155

c. Prolonged fever

Question 156

12 month girl is diagnosed with otitis media by her family doctor. She is started on amoxil 80 mg/kg/day and returns to you three days later still febrile. Her tympanic membrane is red and bulging. She appears well. What antibiotics should you give her: a. Amoxil/clavulinic acid- b. Cefuroxime c. Ceftriaxone d. Clarithromycin

Answer 156

a. Amoxil/clavulinic acid-

Question 157

3 yo F with 1 wk of yellow discharge on panties. On exam inside of labia majora red and yellow secretions pooled in posterior fourchette and around urethra. Most likely diagnosis. a. Candida b. Foreign body c. GAS d. Pinworms

Answer 157

c. GAS

Question 158

A 10-year-old boy has painful swelling behind his right mandible. He has torticollis on the same side and a red pharynx. Remainder of the exam is normal. Most important diagnostic test: a) lateral neck x-ray b) blood culture c) monospot d) amylase

Answer 158

a) lateral neck x-ray - consider amylase - mumps

Question 159

A 3-month-old child has had tender swelling over the mandible bilaterally for 1 week, along with fever and irritability. There is hyperostosis on x-ray. Most likely diagnosis: a) Caffey’s b) parotitis c) cherubism d) osteomyelitis e) hypervitaminosis A

Answer 159

a) Caffey’s (infantile hyperostosis of jaw, scapula, clavicles, diaphysis of long bones, can have fever and irritability)- resolves by 2y ● Cortical hyperostosis (bone thickening) with inflammation of fascia and muscle ● Avg onset 10 weeks (can be prenatal and severe- hydrops) ● Most commonly involves mandible

Question 160

Why do you treat Salmonella bacteremia in a 2 month old child? a) To eliminate the carrier state b) To decrease the duration of symptoms c) To prevent meningitis d) To eliminate shedding from the GI tract

Answer 160

c) To prevent meningitis

Question 161

Child with symptoms consistent with orbital cellulitis. What should be done? a) IV Ceftriaxone b) surgical drainage c) PO clindamycin

Answer 161

a) IV Ceftriaxone

Question 162

Child appears toxic and has lobar pneumonia. What antibiotics should be used? a) PO Amoxil b) Cefuroxime IV c) Cefuroxime IV and Azithromycin PO d) Vanco and ampicillin

Answer 162

b) Cefuroxime IV - best of available; really IV amp is best

Question 163

4nmo infant. Grandfather, who lives in child’s home has been diagnosed with cavitating TB. How should the infant be managed? a) Treat with rifampin b) give BCG c) Treat with INH d) Do CXR

Answer 163

d) Do CXR - should have TST or IGRA, physical exam and CXR - at minimum will be treated for LTBI with INH BUT need CXR to rule out active disease which will change management

Question 164

15 yo male with severe retropharyngeal abscess, requiring surgical decompression. On day 3, he has new onset headache. What is the most likely cause? a) meningitis b) jugular thrombosis c) migraine

Answer 164

b) jugular thrombosis - thrombophlebitis of internal jugular vein ultimately causing central venous sinus thrombosis

Question 165

Child was bitten on the hand by a cat 24 hours ago. He has been taking Clavulin, but the hand has become very erythematous and swollen. What do you do? a) IV Ticarcillin/clavulanate b) IV Cefuroxime c) IV Cloxacillin d) Call Ortho to do Surgical Debridement and irrigation

Answer 165

a) IV Ticarcillin/clavulanate (pip-tazo would also work)

Question 166

A young boy is walking in the street. Suddenly a stray dog, unprovoked, bites him. What do you do with regard to rabies? a. Prophylaxis b. Prophylaxis if dog shows signs of rabies c. No prophylaxis

Answer 166

a) treat child prophylactically - if dog healthy and could be quarantined, could delay prophylaxis and only start if animal became symptomatic

Question 167

A 3 year with 5 days low grade temperature, rhinorrhea, occasional cough. On exam he looks well, has green crusted nasal discharge. Mom has been giving acetaminophen 6 to 7x/day. Next test: a) Sinus x-rays and treat if fluid level present b) treat with amoxil c) consult with ENT d. counsel on Tylenol dosing and risk of too much acetaminophen

Answer 167

d. counsel on Tylenol dosing and risk of too much acetaminophen

Question 168

15 year old with h. pylori. You should treat with: A) h2 blocker B) amox, clarithro and proton pump inhibitor C) clarithro and h2 blocker D) amox and proton pump inhibitor

Answer 168

B) amox, clarithro and proton pump inhibitor

Question 169

Photo shown of antecubital fossa demonstrating Pastia’s lines. Etiology: a) staph b) strep c) roseola d) rubeola e) rubella

Answer 169

b) strep

Question 170

Strep throat in children aged 1 to 3 years may present with all of the following EXCEPT: a) low grade temperature b) prolonged fever c) decreased appetite d) exudative tonsillopharyngitis e) seromucoid rhinorrhea

Answer 170

d) exudative tonsillopharyngitis - kids under 3 rarely have strep but when they do they present atypically

Question 171

A 13-year-old aboriginal female who lives on a reserve presents with tender erythematous induration of her shins bilaterally. What should you investigate for: a) sarcoidosis b) tuberculosis c) Cat-scratch disease d) inflammatory bowel disease e) drug hypersensitivity

Answer 171

tuberculosis - erythema nodosum can be caused by TB, cat scratch, sarcoid, IBD - so multiple answers could be correct but given Aboriginal on reserve has increased risk of TB

Question 172

12 m with crusty yellow discharge from Left eye and conjunctivitis. Normal visual acuity, no proptosis, no periorbital swelling, normal EOM. You prescribe cipro topical drops. At 36 h exam, unchanged. What is your next step? a. Refer to ophto b. Prescribe IV antibiotic c. Continue and return in 48 h d. Prescribe fucidic acid drops

Answer 172

c. Continue and return in 48 h

Question 173

3 months old with seromucoid discharge from one eye, and occasional yellow crusting from the other eye. What do you do? a. refer to an ophthalmologist b. reassure c. give daily antimicrobial eye drops

Answer 173

b. reassure

Question 174

Child with fever, purulent nasal drainage x 14 days. What to treat him/her with? a. amoxicillin b. Keflex

Answer 174

a. amoxicillin

Question 175

What would be an indication to do radiological studies in sinusitis? a . orbital cellulitus b. adolescent with no fever and mucopurulent discharge

Answer 175

a. orbital cellulitus

Question 176

What are 3 complications of sinusitis?

Answer 176

• orbital/periorbital cellulities - epidural abscess - meningitis - cerebral venosinous thrombosis - brain abscess - Pott’s puffy tumour (osteomyelitis of frontal bone)

Question 177

PANDAS would be suspected in a child with a. recurrent Sydenham’s chorea b. new onset of tics after a group A strep infection c. pancreatitis and depression after strep A infection

Answer 177

b. new onset of tics after a group A strep infection

Question 178

Picture of lateral neck xray (++ prevertebral soft tissue swelling), febrile with difficulty opening the mouth. Presents with neck pain, what is the dx? a. bacterial trachieitis b. peritonsillar abscess c. retropharyngeal abscess d. epiglottis

Answer 178

c. retropharyngeal abscess

Question 179

Child with CP, has a fluid-filled thing in his lung surrounded by an area of consolidation. History of recurrent aspiration. What is this? a. CLE (congenital lobar emphysema) b. pulmonary abscess c. pulmonary sequestration

Answer 179

b. pulmonary abscess

Question 180

Toxic child with high fever, respiratory distress. White-out on 1 side of the lung on CXR. What to do? a. decubitus x-ray b. chest ultrasound c. consult surgery d. bronch

Answer 180

b. chest ultrasound – fluid vs consolidation/atelectasis/tumor *a. decubitus x-ray – can show shift in fluid (tells you if effusion versus consolidation

Question 181

Child with pulmonary findings, eosinophilia, slightly elevated calcium (2.8) a. miliary TB b. sarcoidosis c. cryptococcus d. blastomycosis

Answer 181

ANSWER: b. sarcoidosis = lung (non-caseating granulomas) + hypercalcemia + eosinophilia - non infectious a. miliary TB lung + hypercalcemia c. cryptococcus lung + eosinophilia + hypercalcemia? (but often in immunocompromised) d. blastomycosis lung +eosinophilia (+ hypercalcemia in dogs)

Question 182

A 6y M has always lived on a farm. For the last 3 months he has had intermittent fever, vomiting, diarrhea and weight loss. A test shows narrowing of distal ileum. Which is the causative agent? a. Entameoba histolytica b. Yersinia c. Salmonella d. Giardia

Answer 182

b. Yersinia- ileitis - mesenteric adenitis causes abdo pain and fever (mimics appendicitis) - terminal ileitis and diarrhea (mimics IBD)

Question 183

Kid with bloody diarrhea 1 month ago which has now resolved. Now has weight loss and abdominal pain. Which was the most likely organism? a. Yersinia b. Campylobacter c. E Coli d. Shigella

Answer 183

Yersinia – can be cause of chronic abdominal pain/weight loss (not in nelsons)- crohns mimicker- can last months (Toronto notes)

Question 184

Chlid with 4+ proteinuria, distended abdo, fever. Most likely organism causing acute abdomen? a. Ecoli b. Strep pneumo

Answer 184

b. Strep pneumo - nephrotic syndrome complicated by spontaneous bacterial peritonitis

Question 185

Teenage male treated for Chlamydia with azithromycin. When can he resume sexual activity? a) once he has completed his medication b) once his partner is treated c) after seven days after completing treatment d) once his symptoms appear to have resolved

Answer 185

c) after seven days after completing treatment (if same partner, then also after 7 days after partner completes treatment)

Question 186

Treatment of Lyme disease in a 6 year old: a. clarithromycin b. amoxicillin c. doxycycline d. erythromycin

Answer 186

b. amoxicillin

Question 187

Head lice - which one is least likely to increase resistance? a. permethrin 1% b. R&C c. lindane d. Resultz shampoo

Answer 187

d. Resultz shampoo (isopropyl myristate) - R&C = pyrethrin - same resistance to permethrin and pyrethrin - lindane - high failure rate and potentially neurotoxic - per CPS, increasing resistance to pyrethrin, permethrin and lindane

Question 188

Child presents with pinworms. How do you treat?

Answer 188

Albendazole - single dose repeated 2 weeks later to kill any worms that have hatched from eggs in the meantime

Question 189

Asymptomatic child with Giardia spores in stool. Stool sent after another child in daycare diagnosed with giardiasis. Do you treat this child and explain why yes or no? If you would treat, what would you prescribe?

Answer 189

1. No because do not need to treat asymptomatic carriers, unless they share a household with a child with CF/hypogammaglobulinemia. 2. metronidazole x5-10 day course *not recommended to test asymptomatic children

Question 190

You are seeing a child with a very itchy rash. The older sibling has (or had?) a similar itchy rash. Photo shown of child’s ankle. (scabies) What is the diagnosis and how do you treat?

Answer 190

1. scabies 2. 5% permethrin cream from neck down; leave on for 12 hours, then rinse; repeat in 7 days

Question 191

A child with marked eosinophilia is suspected of having visceral larva migrans (toxocariasis). Physical examination would likely reveal: a) splenomegaly and lymphadenopathy b) hepatomegaly c) serpiginous rash d) arthralgias e) myalgias

Answer 191

b) hepatomegaly

Question 192

Which of the following infections causes eosinophilia? a. Giardia lamblia b. Entamoeba fragilis c. Ascaris lumbricoides d. cryptosporidium e. pinworms

Answer 192

c. Ascaris lumbricoides - giardia and cryptosporidium are protozoa not helminths - hallmark of helminths is eosinophilia

Question 193

A child with marked eosinophilia is suspected of having visceral larva migrans (toxocariasis). Physical examination would likely reveal: a) splenomegaly and lymphadenopathy b) hepatomegaly c) serpiginous rash d) arthralgias e) myalgias

Answer 193

b) hepatomegaly Toxocariasis o Roundworms of dogs/cats especially puppies/kittens o Visceral ▪ Fever, leukocytosis, eosinophilia, hypergammaglobulinemia, wheezing, abdominal pain, hepatomegaly ▪ Malaise, anemia, cough, pneumonia, myocarditis, encephalitis, hemorrhagic rash, seizures

Question 194

What are THREE indications for giving the conjugated quadrivalent vaccine for meningococcus?

Answer 194

• functional or anatomic asplenia - persistent complement deficiencies - travel to country where meningococcal disease is hyper endemic or epidemic - as part of routine vaccine schedule

Question 195

3 yr old boy with confirmed pertussis. Lives with 3 sibs, all of whom are immunized. What treatment, if any, do you recommend?

Answer 195

• patient should be treated - post-exposure prophylaxis for immunized household contacts (azithro x5 days)

Question 196

Apnea and pneumonia are common complications of pertussis in infants. This is not true of adults and adolescents. List 2 presentations of pertussis in adults and adolescents. What is the main reason for instituting a generalized immunization program for pertussis in adolescents?

Answer 196

1. mild URTI symptoms followed by prolonged cough (paroxysms of coughing with inspiratory whoop) 2. immunity from primary series wanes in adolescents so booster protects herd immunity and infants who have not yet been vaccinated

Question 197

You are planning to institute a universal vaccination program in your community. List 4 considerations in planning this program.

Answer 197

• which diseases to target (pick diseases which are a priority for that community, consider disease burden) - consider if other control measures could be more effective than vaccination for a given disease - effectiveness of vaccine - availability of supply of vaccine - cost of vaccine - ability of the community to adopt and implement a universal program given available resources

Question 198

A mother has come in with her 12 month old, and is concerned by the “number of shots” that is getting today. She has read in the paper about how is it bad to expose a child to a large number of “antigens” all at once, and is worried about overwhelming his immune system. What advice can you give to help alleviate this motherʼs worries?

Answer 198

• rigorous vaccine safety system (premarket studies and post market active and passive surveillance looking for rare complications) - children are exposed to many more antigens on a daily basis than they will get from the vaccines (food, bacteria, etc) - important for safety of child to stay on track with vaccine schedule (highest risk of severe disease when younger)

Question 199

Rotavirus question: what do you tell her regarding vaccine: a) Protects 95 against rotavirus b) 75% against all diarrhea c) Significantly Decreased hospitalizations d) Decreased virus shedding

Answer 199

c) Significantly Decreased hospitalizations - 85% efficacy in kids under age 2 years - decreased incidence of rotavirus hospitalization in areas with immunization programs - 79% decrease in rota hospitalizations for kids under 1 and 73% decrease for kids 12-23 months in Ontario after vaccine introduced

Question 200

A newborn baby comes in for a routine care visit. In terms of the 13 valent pneumoccocal vaccine, what is the routine schedule for it? (1) - question used to be about 7 valent which is no longer used

Answer 200

Schedule across Canada is 2, 4, 12 months almost everywhere (different in territories)

Question 201

Pregnant woman in contact with meningococcal meningitis. Tx: a. Cipro b. Rifampin c. Ceftriaxone d. Penicillin

Answer 201

c. Ceftriaxone - cipro and rifampin would treat it but should not be given to pregnant women - close contacts should get prophylaxis regardless of immunization status

Question 202

Which of the following is the most common side effect of the varicella vaccine? a. chickenpox b. flu-like symptoms c. herpes zoster d. fever

Answer 202

d. fever - pain, redness and swelling at injection site are actual most common side effects - rash and fever may not appear until up to 2 weeks after the injection

Question 203

Which vaccine is contraindicated in egg allergic patients? a. Pertussis b. Influenza c. Varicella d. Polio e. MMR f. Hib g. yellow fever

Answer 203

g. yellow fever (not to egg or chicken allergic patients) *b. Influenza (yes egg but new CPS statement says fine) - trace amounts of egg protein in flu, MMR, MMRV, rabies vaccines - intranasal influenza vaccine should not be given to egg allergic patients because there is no safety data

Question 204

All are excluded from day care except: 1. 3 y/o suspect of having scabies 2. pertussis treatment for 2 days 3. shigella day 2 4. campylobacter day 2 5. Hepatitis A after 10 days

Answer 204

5. Hepatitis A after 10 days - exclude for 7 days after onset - scabies: back once treatment completed - pertussis: back after 5d antibiotics or 21d from cough if not treated - shigella: 24h after diarrhea stopped - campy: if in diapers, no daycare until diarrhea done

Question 205

Which of the following infections would not prevent a child from attending daycare: a. Chicken pox b. Impetigo c. Hepatitis A d. Hepatitis B e. Pertussis

Answer 205

d. Hepatitis B - impetigo exclude until 24h after treatment started

Question 206

Give 2 examples of patients who should get pneumovax (pneumococcal polysaccharide 23 talent vaccine)

Answer 206

• cyanotic heart disease/CHF - CLD, including asthma with chronic high dose oral corticosteroids - DM - CSF leak, cochlear implant - functional/anatomic asplenia - immunocompromise: HIV, chronic renal failure, immunosupp drugs for cancer/AI disease, primary immune deficiency

Question 207

A four year child presents with pertussis. His 3 month old sibling has had her first immunization. What would you do regarding the sibling: a. treat with erythromycin if she becomes symptomatic b. isolate from her brother for 5 days c. treat her with erythromycin for 2 weeks

Answer 207

c. treat her with erythromycin for 2 weeks (is one option; azithro x5d, claritho x7d, TMP-SMX x14d also options) - continue pertussis vaccination according to routine schedule

Question 208

An 11-month-old child develops nephrotic syndrome and is going to be on prednisone. He has completed his 2, 4, and 6 month immunizations. Which is true regarding subsequent immunizations: a) he should continue his regular immunization schedule b) he should not receive any further immunizations until he has been off prednisone for 2 years c) he should not receive live-virus vaccines while on prednisone

Answer 208

c) he should not receive live-virus vaccines while on prednisone - inactivated vaccines can be given during immunosuppressive treatment, but need to be repeated once off as will not mount sufficient immune response - live vaccines cannot be given as are dangerous to the patient - common live vaccines: flu, rotavirus, MMR, varicella, BCG

Question 209

An infant born at 31 weeks gestation is now 2 months old, but has never left the hospital. What should be done about the immunizations: a) delay immunizations until discharge b) start routine immunization schedule at 8 weeks corrected age c) give DTaP, hemophilus influenza conjugate, and IPV now d) give DtaP, hemophilus influenza conjugate, and OPV now e) give half dose of DTaP and IVP now and repeat in one month

Answer 209

c) give DTaP, hemophilus influenza conjugate, and IPV now

Question 210

A 2 year old child sustains a laceration on the playground. She has not received any immunizations and is otherwise healthy. You clean and suture her laceration. What further management do you offer: a. Start tetanus immunization series b. Tetanus immunization and tetanus immunoglobulin c. Tetanus immunoglobulin and tetanus anti-toxin

Answer 210

b. Tetanus immunization and tetanus immunoglobulin

Question 211

Pre-splenectomy immunization a) polysacc meng A+E, polysacc pneumo and hep B b) hep B, conjugated mening, conjugated pneumo c) Hep A + B, mening

Answer 211

b) hep B, conjugated mening, conjugated pneumo - at least 2 weeks prior to surgery

Question 212

You are trying to set up an infection control program in your hospital. Which intervention will result in the best form of infection control for RSV? a) Hand wash with soap and water b) Gown and glove c) Hand wash with alcohol d) Isolate everyone with respiratory symptoms

Answer 212

c) Hand wash with alcohol waterless hand hygiene products save time and improve compliance and are therefore the recommended method of hand hygiene if hands are not visibly soiled

Question 213

List 3 common causes of neutropenia

Answer 213

• transient viral suppression of bone marrow - drug induced marrow suppression (antipsychotics, antidepressants, some antimicrobials) - secondary autoimmune (SLE, Crohn’s, RA) - destruction by autoantibodies - chronic benign neutropenia of childhood

Question 214

Neutropenic child with central line site red. Which antibiotic?

Answer 214

Piptazo (for febrile neutropenia) + Vancomycin (for central line infection)

Question 215

Kid has had several infections. What other 4 findings would suggest immunodeficiency?

Answer 215

• persistent thrush - recurrent abscesses - failure to thrive - needing prolonged courses of antibiotics (2 months with little effect) - family history of immune deficiency

Question 216

Name two organ systems and two organisms that are typically affected by granulocyte defects

Answer 216

1. skin (abscesses, cellulitis), LNs (suppurative adenitis), internal organ abscesses, osteomyelitis 2. staphylococcus, klebsiella, pseudomonas, salmonella, fungi and parasites

Question 217

Description of a child who is having multiple episodes of otitis media and pneumonia. Lab results given are IgG 8 (normal), IgM normal and IgA 0.01 (decreased). What important piece of advice would you warn this child about?

Answer 217

Selective IgA deficiency - at risk of anaphylactic reactions to transfusion of blood products

Question 218

15 year old male immunocompromised in a hot tub afterwards develops folliculitis and enlarged lymph nodes. Name the organism.

Answer 218

hot tub folliculitis - pseudomonas

Question 219

Child post bone marrow transplant. Significant exposure to varicella. A) What therapy do you give him? B) What is the time frame for this therapy to be effective? C) How long do you isolate this patient from other immunocompromised patients?

Answer 219

A) VZIG B) as soon as possible - ideally within 96 hours but can give up to 10 days after exposure C) isolate for 28 days after VZIG given

Question 220

A 6-year-old boy with acute lymphocytic leukemia completed a course of chemotherapy 1 month ago. He has a household contact with chickenpox, and he has never had it before. Management: a) isolate the patient and observe for symptoms b) IM VZIG c) IM VZIG + oral acyclovir d) Admit + IV acyclovir e) Admit + IM VZIG + IV acyclovir

Answer 220

b) IM VZIG - no evidence that acyclovir works for immune compromised children (is given prophylactically to immune competent children 7 days after exposure) - vaccine within 3 days ideally but up to 5 days after exposure for immune COMPETENT people, 12+ months who do not have varicella immunity (no varicella vaccine for immune suppressed people)

Question 221

Teenager with Sickle cell disease presents with cough and fever. CXR shows pneumonia. She looks toxic. What do you treat her with a) Cefuroxime and eryhtromycin b) Ceftriaxone and erythromycin c) Amoxicillin

Answer 221

a) Cefuroxime and eryhtromycin - cefuroxime better than ceftriaxone because ceftriaxone can increase hemolysis in sickle cell patients

Question 222

Child with eczema and recurrent pneumonia. Hepatomegaly, petechiae, otitis media and low platelets. What do you expect? a. elevated IgA and IgE b. immune response to polysaccharide vaccine c. oral Candida d. abnormal mitogen proliferation

Answer 222

a. elevated IgA and IgE - poor response to polysaccharide vaccines (important they get conjugate) - Wiscott-Aldrich

Question 223

Which of the following is not associated with recurrent candida infection: a. complement deficiency b. prolonged antibiotic therapy c. hypoparathyroidism d. Addison’s disease

Answer 223

a. complement deficiency - autoimmune polyendocrinopathy type I - presents with chronic mucocutaneous candidiasis, hypopara, adrenocortical insufficiency (Addison’s) - other primary immune deficiencies that present with candida are congenital neutropenia, CGD, leukocyte adhesion deficiency

Question 224

The most common bug in febrile neutropenia: a. Pseudomonas b. PCP c. gram positive organisms d. candida

Answer 224

c. gram positive organisms

Question 225

Asplenic child, febrile, what organisms do you need to cover with your abx? a. staph aureus, strep pyogenes, group a strep b. strep pneumo, h flu, n. meningitides c. nocardia, aspergillus, etc

Answer 225

b. strep pneumo, h flu, n. meningitides *nocardia, aspergillus, etc (cause opportunistic infections in immunocompromised patients)

Question 226

teen girl with sickle cell anemia with evidence of pneumonia, what do you do a. discharge home on po antibiotic b. treat with cefuroxime and erythro IV c. treat with ceftriaxone IV

Answer 226

b. treat with cefuroxime and erythro IV - need macrolide since atypicals are common cause of chest crisis

Question 227

Child has Neisseria meningitidis arthritis. Prior history of Neisseria meningitidis meningitis. Which of the following tests could be positive. a) C3, C4, CH 50 b) CBC diff c) IgG, IgA, IgM, IgE

Answer 227

a) C3, C4, CH 50 - people with complement deficiency have 1000X increased risk of acquiring meningococcal disease

Question 228

Management of a child with asplenia: a) pneumococcal vaccine at 6 months b) meningococcal vaccine at 2 years c) antibiotic prophylaxis with daily Septra d) antibiotic prophylaxis until pneumococcal vaccine given

Answer 228

a) pneumococcal vaccine at 6 months - PCV13 (prevnar-13) at 2, 4, 6, 12-15 months - quadrivalent meningococcal conjugate vaccine (MCV4 - menveo) at 2, 4, 6, 12-15 months - antibiotic prophylaxis (with pen V) until age 5 and 2 years post splenectomy

Question 229

Kid with 1.5X2cm LN in the supraclavicular fossa for a few days. NO overlying erythema. P/E otherwise normal. Most helpful test? a. Excise LN b. Bartonealla Henselae serology c. Monospot/EBV serology d. TB skin test

Answer 229

a. Excise LN - LN biopsy is contraindicated if there is evidence of overlying infection - rule out leukemia/lymphoma

Question 230

Child with inguinal adenopathy found 1 week ago by parent while bathing. Give 4 indications for biopsy.

Answer 230

• weight loss - night sweats - unexplained fevers - no decrease in size over 4-6 weeks - increase in size over 2 weeks - hard or non mobile node

Question 231

Kid with kawasaki disease. Received IVIG and ASA. Now has massive hematuria. Low haptoglobin. GN picture. High bili and LDH and liver enzymes 1) renal vein thrombosis from thrombocytosis 2) hemolysis from iVIG 3) ASA mediated platelet dysfunction 4)Kawasaki mediated Gn

Answer 231

2) hemolysis from iVIG - passive transfer of antiA or antiB antibodies in IVIG is a known phenomenon and can cause hemolytic anemia

Question 232

An 8mo old Caucasian child presents to the ER with a 24h history of fever. His temperature is 39.2 degrees. His immunizations are up to date. He has no travel history. He is otherwise asymptomatic. On exam, he is a happy, smiling child with appropriate vital signs aside from the temperature. What is the next best step? A) Admit for IV antibiotics B) Do a CBC and blood culture C) Give a dose of ceftriaxone and discharge home D) Discharge home with follow-up the next morning

Answer 232

D) Discharge home with follow-up the next morning - should check a urine culture - if not immunized need to be more conservative (CBC and culture, abs if WBC >15)

Question 233

A 2 year old presents with a fever for 5 days and soft stools. Urine culture, urinalysis and blood tests are negative. What would be your next investigation? a) CXR b) ECHO c) serology for hep A d) stool cultures

Answer 233

d) stool cultures - 2 year old unlikely to be symptomatic with Hep A

Question 234

12 yo girl presents with >5 days of fever, unwell. Hepatomegaly. HR 85 despite the temperature of 39.5, BP normal. CBC und urine tests normal. Blood culture shows gram negative bacilli. What is the cause? a) pyelonephritis b) ovarian torsion c) typhoid fever

Answer 234

c) typhoid fever - salmonella typhi

Question 235

A 3 year old girl with fever, arthralgia and lethargy for 10 days has lymphadenopathy, moderate hepatosplenomegaly, no obvious arthritis but screams in pain with minimal examination. WBC 9.5 Hgb 98 Plts 140, smear Normal. Next test: a) bone marrow aspirate b) EBV titers c) follow

Answer 235

a) bone marrow aspirate

Question 236

Family comes to you from an area endemic for Lyme disease – What is the organism and vector causing it (2)? What are two antibiotics that are effective against it (2) What are three things to do for prevention if you live in an endemic area (3)

Answer 236

1. borrelia burgdorferi; black legged tick 2. doxycycline, amoxicillin (kids under 8), cefuroxime 3. 20-30% deet to clothes and skin - shower within 2 hours of coming inside - full body tick check daily - landscape to create barriers where play areas adjoin wooded areas

Question 237

Child camping in New Brunswick. Had an expanding skin lesion with central clearing in axilla. Now he has fever, myalgia, malaise and chills but no other symptoms. What is the likely diagnosis. Name 3 systems involved and their specific involvement.

Answer 237

1. lyme disease 2. skin - erythema migrans - CNS - facial nerve palsy, meningitis, peripheral neuropathy - heart - lyme carditis, heart block - rheumatologic - oligoarticular arthritis

Question 238

9 yo immigrated to Canada. NO previous immunizations. What 2 immunizations would you give on first visit?

Answer 238

Tdap-IPV and Men-C (kids 7-17)

Question 239

7 month old child has recently been adopted from another country. All immunizations are up to date. Should you vaccinate against meningitis? (1) If so, what would you use and what schedule (2 lines)

Answer 239

1. Yes should vaccinate 2. give Meningococcal conjugate vaccine for serotype C at 12 months of age (some recommend to not trust vaccine documentation and start from scratch using catch-up vaccine schedule)

Question 240

A 7 year old child has just returned to Canada from sub-Saharan Africa. She has fever and chills. List 3 common causes of her symptoms.

Answer 240

• malaria - typhoid fever - dengue fever - viral illness

Question 241

A teenage girl presents with a one week history of periumbilical pain, fever of 39.2 degrees. She has just returned from a trip to Pakistan. She looks unwell and a blood C&S shows gram negative rods. Despite her fever and condition her HR is only 85. Which antibiotic will you treat her with: a. Ciprofloxacin b. Gentamicin c. Metronidazole d. Penicillin

Answer 241

a. Ciprofloxacin - treat empirically with ceftriaxone or fluoroquinolone - IV antibiotics x minimum 14 days for uncomplicated typhoid fever

Question 242

Child recently visited farm, presents with high fever, hepatosplenomegaly and pneumonia a. legionella b . Q fever c . cat scratch d. Psittacosis

Answer 242

ANSWER: b . Q fever (goat, sheep, cattle) - coxsiella burnetti (gram negative) - treatment decreases duration and severity a. legionella (usually contaminated water) c . cat scratch (cat bite/scratch, kittens, HSM can occur) d. Psittacosis (usually caged birds)

Question 243

8 year old girl with fever, nausea, vomiting, diarrhea, malaise and mild jaundice upon returning from Mexico. Labs show AST >1,000. Which of the following is true regarding her return to school/day care? a. she can’t return for 1 week b. she can’t return until she’s feeling better c. she can return if everyone is toilet trained d. as long as they wash their hands there, she can go back immediately

Answer 243

a. she can’t return for 1 week Hep A - out of school for 7 days

Question 244

A 6 year old presents with an erythematous lesion on the back and arthritis. He has been camping with his family recently in the U.S. You diagnose Lyme disease. What should he be treated with? a) PO doxycycline b) IV ceftriaxone c) PO amoxicillin

Answer 244

c) PO amoxicillin - under 8 - amox, 8+ - doxycycline - IV treatment for heart block, carditis, meningitis or encephalitis

Question 245

Newborn to a mum who has recently come from Vietnam. Her Hepatitis B status is unknown however her serology results will be back in two days. What do you do with infant? a) immunize with Hep B vaccine and if results from mum are positive, give Hep B IG at that time b) Immunize with hep B vaccine and hep B IG now c) Hep B IG now d) HBIG now and Hep B vaccine later if mum positive

Answer 245

a) immunize with Hep B vaccine and if results from mum are positive, give Hep B IG at that time - Hep B vaccine should be given within 12 hours of birth - HBIG ideally within 12 hours, but within 7 days acceptable if waiting for mom’s results

Question 246

List 4 other signs of endocarditis in a child with a fever, murmur, tachycardia and hepatospenomegaly.

Answer 246

• conjunctival hemorrhage - janeway lesions (non tender macules on fingers and soles) - osler nodes (painful lesions on hands and feet) - glomerulonephritis - splinter hemorrhages

Question 247

GBS positive mom.11 days old. On TPN from peripheral line. Three attempts at obtaining central access failed.In a tertiary care center. Now is septic. Culture shows gram positive cocci in clusters. What is the bug? What is the treatment

Answer 247

1. staph aureus (or coagulase negative staph) 2. vancomycin

Question 248

What are four clinical signs that would be considered a contraindication for a lumbar puncture?

Answer 248

• infection of skin over intended LP site - spinal deformities - bulging fontanelle - focal neurologic deficit - cardioresp instability - signs of bleeding diathesis (e.g. petechiae)

Question 249

Child previously treated with course of Amox for otitis media. Then presents signs of meningismus irritability and lethargy. LP high protein low sugar high WBC count. No organisms on gram stain. Gave one dose of ceftriaxone. Defervesced after dose. Doc calls you because culture has come back negative. What is the likely diagnosis. How would you tell the Doc to proceed

Answer 249

1. culture negative bacterial meningitis 2. will need treatment with IV antibiotics (ceftrixone empiric usage, depends on local susceptibilities, may need vanco also - strep pneumo resistance) for 2-3 weeks 3. recommend consult ID

Question 250

5 year old immigrant from Pakistan. Drooling with SOB and dysphagia. Lateral Neck. (thumb sign) What organism is the likely cause? How would you manage this patient?

Answer 250

1. hemophilus influenza B (epiglottitis) 2. keep patient as calm as possible, call ENT and anesthesia to intubate, needs IV antibiotics but if kid is going to freak out with IV insertion wait until airway secured - abx: ceftriaxone and vanco (for staph coverage)

Question 251

Description of child with Necrotizing fasciitis lower leg- some respiratory distress. Already started IV fluids and oxygen. 5 additional things in the management.

Answer 251

• abx: piptazo + vanco (MRSA) + clinda (antitoxin effect) - consult surgery - exploration and debridement - pain control (morphine) - anticipate multiorgan failure (watch U/O, BP, may need pressors) - blood cultures - consult ID, consider IVIG

Question 252

Nephrotic syndrome has peritonitis what is most likely org: a) Strep pneumo b) Ecoli c) Enterococus d) B fragilis

Answer 252

a) Strep pneumo - increased risk of infection with encapsulated bacteria (since lose complement and immunoglobulins)

Question 253

What are three high risk groups for invasive pneumococcal disease (3)

Answer 253

• functional asplenia - structural asplenia - humoral immune deficiency - HIV - DM - chronic renal failure - cochlear implants, CSF leak

Question 254

How do you confirm the diagnosis of endocarditis?

Answer 254

• positive blood culture and vegetations on echo (these are the 2 major criteria - if have both can make diagnosis) - also, 1 major and 3 minor OR 5 minor (Duke criteria)

Question 255

A 4-month-old septic child. CSF gram stain shows GPC. Initial antibiotic therapy: a) Ampicillin + Gentamycin b) Ampicillin + Cefotaxime c) Ceftriaxone d) Ceftriaxone + Dexamethazone e) Cefotaxime + Vancomycin

Answer 255

e) Cefotaxime + Vancomycin - third generation cephalosporin + vanco for resistant strep pneumo (which is a gram positive coccus)

Question 256

3 week child with suspected meningitis. Initial antibiotics?

Answer 256

Ampicillin and cefotaxime (amp for gram positive coverage, cefotax for gram negative coverage - gent does not have good CNS penetration)

Question 257

With respect to steroid use in bacterial meningitis: a) little is know about its effect b) needs to be given within 30 minutes of first dose of antibiotics c) helps the antibiotics penetrate the brain d) reduces incidence of hearing loss following infection

Answer 257

d) reduces incidence of hearing loss following infection - should be given before first dose of antibiotics, at same time or within 30 minutes - decreases hearing loss with Hib, and maybe strep pneumo - continue if culture positive for Hib or s pneumo

Question 258

What is true regarding the spread of meningococcal disease: a) household contacts are at greater risk than school contacts b) penicillin is the drug of choice for prophylaxis c) Neisseria meningitidis type B vaccine is use to prophylax against school outbreaks d) healthcare workers should be routinely immunized against Neisseria meningitides e) a negative NP swab will determine whether or not to treat exposed individuals

Answer 258

ANSWER: a) household contacts are at greater risk than school contacts - prophylaxis with rifampin, ceftriaxone or cipro - mening B vaccine used for lab and military personnel, not routine for school outbreaks - decision to treat exposed individuals is based on risk of exposure, not cultures

Question 259

A child is brought to ER very unwell. She has a preceding sore throat, headache and fever. She is beginning to have a purple rash that doesn’t blanche. How do you prophylaxis her family? a. Penicillin b. Ceftiaxone c. Rifampin

Answer 259

c. Rifampin - can also use ceftriaxone and cipro

Question 260

A child has been receiving IV Penicillin for meningococcemia for the past 7 days. He has now developed a warm swollen right knee. What should be done: a) provide NSAIDs b) add a second antibiotic c) change to a different antibiotic d) aspirate and culture e) bone scan

Answer 260

a) provide NSAIDs - allergic immune complex mediated arthritis (also vasculitis, pericarditis, episcleritis) - self limiting, occurs in first 10 days of disease onset - good response to NSAIDs - child with menigococcal disease who develops fever after 5 days on antibiotics - investigate for immune complex medicated disease

Question 261

A 10-year-old who underwent recent dental surgery now presents with fever, arthralgias, splenomegaly, and lesions on the hands and feet. a) septic emboli b) subacute endocarditis c) acute rheumatic fever d) juvenile rheumatoid arthritis e) coxsackie virus

Answer 261

b) subacute endocarditis

Question 262

3 year old child, 2-3 day history of viral prodrome, sudden onset this morning of stridor, temperature of 40 degrees. In your ED is anxious but not drooling and very stridorous. There is no significant change with one dose of neb racemic epinephrine. What is the most likely diagnosis: a. Croup b. Bacterial tracheitis c. Retropharyngeal abscess

Answer 262

b. Bacterial tracheitis - high fever, toxic appearance, poor response to nebulized epi

Question 263

Kid with varicella, now has a deep bluish lesion to his leg, very painful, looks unwell, high fever. What antibiotics do you start? a. penicillin, clindamycin b. pipercillin, tazobactam c. ampicillin, cefotaxime d. vanco, cefotaxime

Answer 263

a. penicillin, clindamycin - good if documented GAS - varicella gangrenosa (necrotic lesions)/necrotizing fasciitis - other abs regimens: vanco + pip/tazo or ceftriaxone + flagella

Question 264

Adolescent with ascending leg weakness and areflexia. Which of the following infectious agents would you worry about: 1. Campylobacter jejuni 2. E Coli 3. Yersinia 4. Cryptosporidium 5. Shigella

Answer 264

1. Campylobacter jejuni - GBS

Question 265

2 mo baby comes in with meningitis and focal seizure. Symptoms of shock described. GCS 6. What is the FIRST step in management? a) Culture and antibiotics b) Intubation c) CT d) LP

Answer 265

b) Intubation

Question 266

What are 3 major criteria for staph toxic shock?

Answer 266

• fever (T>38.8) - hypotension - eryrthroderma rash

Question 267

Premature baby. You are counseling mom about the risks of Transfusion. Which infection is the highest risk: a) HIV b) HEPB c) CMV d) HepC

Answer 267

b) HEPB - HIV 1/8-12 million - Hep C 1/5-7 million - Hep B 1/1.1-1.7million - should request CMV negative blood for premature baby

Question 268

A child diagnosed 14 days ago with Hepatitis A and is currently symptomatic. What to do with family members? 1. Hyperimmume immune globulin against Hepatitis A 2. Hepatitis A vaccine 3. No treatment 4. Antibiotic prophylaxis

Answer 268

2. Hepatitis A vaccine - hep A vaccine for pre-exposure protection (e.g. travelling to endemic area) - hep A vaccine equal effectiveness to Ig within 2 weeks of exposure; serologic testing not recommended

Question 269

Young child with periorbital edema and diarrhea. His albumin is 12. What is your differential diagnosis (4)?

Answer 269

• infectious diarrhea (parasitic infection) - cow’s milk protein intolerance - food protein induced enterocolitis syndrome - IBD - HUS

Question 270

Child had a URTI a week ago. He now presents with bloody diarrhea, abdominal pain and a petechial rash . What is his diagnosis?

Answer 270

HUS

Question 271

Teenage girl with a history of ulcerative colitis, status post total colectomy. Had a “J- pouch” and an anal pull-through ostomy that was later removed. Did have an ileostomy, but that was closed following an end-to-end anastomosis. Now she presents with a 5-day history of bloody diarrhea 8 times per day. Stool cultures are all negative. What is the diagnosis? What 1 treatment would be the best?

Answer 271

1. pouchitis - chronic inflammatory reaction in pouch leading to bloody diarrhea, abdo pain, and sometimes low grade fever 2. PO metronidazole or Ciprofloxacin X 14 days