Infectious Disease 2 Flashcards
What is Kawasaki Disease?
- Type of systemic, medium sized vasculitis which is predominantly seen in children
- Affects young children- typically under 5
Who does Kawaksaki disease predominantly affect?
- Typically under 5
- More common in asian children: Japanese and Korean
- Boys
Key complication in Kawasaki Disease?
- Coronary artery aneurysm
Features of Kawasaki disease?
- Persistent high fever (> 39C) for more than 5 days- characteristically resistant to anti-pyretics
- Widespread erythematous maculopapular rash
- Desquamation (skin peeling) on palms and soles
- Conjuctical injection
- Bright red, cracked lips
- Strawberry tongue
- Cervical lymphadenopathy
Investigations for Kawasaki disease?
- Clinical diagnosis but the following can be helpful
- FBC: may show anaemia, leukocytosis and thrombocytosis
- LFTs: hypoalbuminaeamia and elevated liver enzymes
- Inflammatory markers: raised WBC w/o infection
- ECHO: coronary artery pathology
Phases to Kawasaki Disease?
- Acute phase: The child is most unwell with the fever, rash and lymphadenopathy. This lasts 1 – 2 weeks.
- Subacute phase: The acute symptoms settle, the desquamation and arthralgia occur and there is a risk of coronary artery aneurysms forming. This lasts 2 – 4 weeks.
- Convalescent stage: The remaining symptoms settle, the blood tests slowly return to normal and the coronary aneurysms may regress. This last 2 – 4 weeks.
Management of Kawasaki Disease?
- high dose aspirin- one of the cases it is indicated in children
- IV Immunoglobulin
- Echos + follow up for coronary artery aneurysms
What is Mumps?
- Viral infection
- Tends to occur winter and spring
- Spread by respiratory droplets
- Incubation period: 14-25 days
- Self limiting that lasts around 1 week
- MMR vaccine offers around 80% protection against mumps
What is essential to cover in a hx for someone with ?Mumps
- Vaccination hx
What causes Mumps?
- RNA paramyxovirus
Outline the spread of Mumps?
- By droplets
- Resp tract epithelial cells–> parotid glands–> other tissues
- Infective 7 days BEFORE and 9 days AFTER parotid swelling
Clinical features of Mumps?
Patients have a ‘prodrome’ which occurs a few days before the parotid swelling:
* Fever
* muscle aches
* lethargy
* Reduced appetite
* Headache
* Dry mouth
Then you get Parotitis:
* Earache
* Pain on eating
* Unilateral initally and then bilateral in 70 % of cases
Note: Some pts may present with symptoms of complications e.g.
* Abdo pain (pancreatitis)
* Testicular pain (orchitis)
* Confusion, neck stiffness, headache (meningitis or encephalitis)
* IF THE ABOVE WITH UNILATERAL/ BILATERAL PAROTID SWELLING–> could it be mumps?
Management for Mumps?
- Self limiting- treatment is supportive
- Rest
- Fluids
- Notifiable disease
Investigations for Mumps?
- PCR testing on a saliva swab
- Blood or saliva can be testing for antibodies for the mumps virus
Complications of Mumps?
- Orchitis- 25-35% of post-pubertal males, symptoms start 4-5 days after the start of parotitis
- hearing loss- usually unilateral or transient
- Meningoencephalitis
- Pancreatitis
Meningitis organisms in children neonatal- 3months?
- Group B Streptococcus: usually acquired from the mother at birth. More common in low birth weight babies and following prolonged rupture of the membranes
- E. coli and other Gram -ve organisms
- Listeria monocytogenes
Menigitis organisms in children 1 month to 6 years?
- Neisseria meningitidis (meningococcus)
- Streptococcus pneumoniae (pneumococcus)
- Haemophilus influenzae
Meningitis organisms in children older than 6 years?
- Neisseria meningitidis (meningococcus)
- Streptococcus pneumoniae (pneumococcus)
Differentiate between Meningitis vs Meningococcal septicaemia?
- Meningitis: Inflammation of the meninges
- Meningococcal septicaemia: meningococcus bacterial infection in the bloodstream- this is when you get the non-blanching rash
Presentation of Meningitis?
- Fever
- Neck stiffness
- Vomitting
- Headache
- Photophobia
- Altered consciouness
- Seizure
Neonates and babies:
Non specific signs: - hypotonia
- poor feeding
- lethargy
- hypothermia
- bulging fontanelle
What tests would you do on examination for Meningitis?
- Kernigs test: lie patient on their back, flex on hip and knee to 90 degrees and then slowly straighten knee whilst keeping hip flexed at 90 degrees- this causes slight stretch in the meninges- if meningitis present will produce spinal pain or resistance to movement
- Brudzinskis test: lie patient flat on their back and gently use your hands to lift their head and neck off the bed and flex chin to chest. In meningitis will cause the patient to involuntarily flex their hips and knees
When do you perform a lumbar puncture in children?
- Under 1 month presenting with fever
- 1 to 3 months with a fever and unwell
- Under 1 year with unexplained fever and other features of serious illness
- If you suspect meningitis
When is a lumbar puncture contraindicated?
Any signs of raised ICP
* Focal neurological signs
* papilloedema
* significant bulging of the fontanelle
* DIC / coagulopathy
* coma
* signs of cerebral herniation
* meningococcal septicaemia- blood cultures and PCR for meningococcus should be obtained
Examinations and investigations for Meningitis?
- Kernigs
- Brudzinskis
- Lumbar puncture for CSF unles contraindicated
- Blood test for meningococcal PCR and/or blood cultures
Outline how to perform a lumbar puncture
- Needle inserted into L3-L4 intervertebral space as spinal cord ends at L1-L2
- Sample is sent for bacterial culture, viral PCR, cell count, protein and glucose
- Blood glucose sample should be sent at the same time so it can be compared to CSF
Describe the makeup of CSF in bacterial meningitis
- Appearance: Cloudy
- Protein: High
- Glucose: Low
- WCC: High (neutrophils)
- Culture: Bacteria
Describe the make up of CSF in viral meningitis
- Appearance: Clear
- Protein: Low
- Glucose: Normal
- WCC: High (lymphocytes)
- Culture: Nothing
Management of ?meningitis for a child who presents to the GP
Suspected meningitis and non-blanching rash:
* Stat injection (IM or IV) Benzylpenicillin prior to transfer to hosp
* If penicillin allergic- priority is travel to hosp
Management of bacterial meningitis
- Antibiotics
* < 3 months IV amoxicillin (or ampicillin) + IV cefotaxime
* > 3 months IV cefotaxime (or ceftriaxone) - Steroids
* dexamethosone should be considered if lumbar puncture shows the following:
* frankly purulent CSF
* CSF white blood cell count greater than 1000/microlitre
* raised CSF white blood cell count with protein concentration greater than 1 g/litre
* bacteria on Gram stain - Fluids: treat any shock
- Cerebral monitoring: mechanical ventilation if resp impairment
- Public health notification and antibiotic prophylaxis of contacts
* ciprofloxacin (now preferred over rifampicin)- single dose ideally within 24 hours of the initial diagnosis
Common causes of viral meningitis?
- HSV
- Enterovirus
- Varicella zoster virus
Management of viral meningitis?
- Aciclovir can be used to treat suspected or confirmed HSV or VZV
What causes Influenza in children?
- Influenza type A and B: most common and sends people to hosp
- Influenza C: causes a very mild resp illness or no symptoms at all
Transmission of Influenza?
- Respiratory droplets e.g. Sneezing or coughing; Doorknobs, toys, pens or pencils etc; Sharing utensils
- People are contagious 24 hours before symptoms and while symptomatic until day 5-7
Complications of meningitis
- Sensorineural Hearing loss is a key complication
- Seizures and epilepsy
- Cognitive impairment and learning disability
- Memory loss
- Cerebral palsy, with focal neurological deficits such as limb weakness or spasticity
RF for influenza in children
- Are around people with flu
- Have not had the flu vaccine
- Do not wash hands after touching infected surfaces
- Underlying health conditions- more likely to have a complicated/severe infection
*
Symptoms of Influenza in child?
- Fever, which may be as high as 103°F (39.4°C) to 105°F (40.5°C)
- Body aches, which may be severe
- Headache
- Sore throat
- Cough that gets worse
- Tiredness
- Runny or stuffy nose
- Nausea
- Vomiting
- Diarrhea
How is flu diagnosed?
Clinical
How is Influenza managed
- Most children will recover in a week
- Supportive: paracetamol, fluids, lots of bed rest
- Antivirals e.g. Tamiflu in older children or at high risk of developing complications. Usually started within 2 days of starting symptoms
Complications of flu in children
- Pneumonia
- Ear infections
- Worsen current conditions e.g. asthma
When do children get the influenza vaccine?
- Yearly
- Age 2-8
Immunisations: Which vaccines do children get from birth- 4 months?
Birth
* BCG- IF RISK FACTORS
2 months
* 6-1 vaccine (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B): 1st dose
* Oral rotavirus vaccine: 1st dose
* Men B
3 months
* 6-1 vaccine: 2nd dose
* Oral rotavirus vaccine: 2nd dose
* Pneumococcal vaccine
4 months
* 6-1 vaccine: 3rd dose
* Men B: 2nd dose
What is in the 6-1 vaccine?
- Diptheria
- Tetanus
- Whooping cough
- Polio
- Hib
- Hep B
Immunisations: What vaccinations are given at 1 year old?
12-13 months
- Hib/Men C: Single jab containing Hib 4th dose and Men C
- MMR: 1st dose
- Pneumococcal vaccine: 2nd dose
- Men B: 3rd dose
Immunisations: What vaccines do children get aged 3-4 yrs old?
3 year 4 months
- 4 in 1 pre-school booster (diptheria, tetanus, whooping cough and polio): 4th dose
- MMR: 2nd dose
*
Immunisations: What vaccinations do children have aged 12y/o
- HPV: 2 jabs given 6-24 months apart
Immunisations: what vaccines do you give between 13-18years?
- 3 in 1 teenage booster (tetanus, diptheria and polio)
- Men ACWY
What is an ‘at risk’ baby for TB?
- TB in the family in the past 6 months
What causes worms in children?
- Enterobius vermicularis
- sometimes called pinworms
How are threadworms spread?
- Occurs after swalloing eggs that are present in the environment
Presentation of threadworm infection?
- asymptomatic in 90%
- Perianal itching, particularly at night
- girls may have vulval symptoms
- White threads on face
How to make a diagnosis of thread worms?
- Diagnosis is mostly empirical
- Can apply Sellotape to the perianal area and sending to microscopy to see the eggs
Treatment of threadworms?
- Single dose mebendazole > 6 months old and hygiene measures for ALL MEMEBERS OF THE HOUSEHOLD
Risk factors for Candidiasis in children?
- hot and humid weather
- too much time between nappy changes
- poor hygiene
- taking abx or steroids
- health conditions that weaken the immnue system e.g. diabetes, cancer or HIV
How does candidiasis present: skin folds/naval
- Rash
- Patches that ooze clear fluid
- Pimples
- Itching or burning
How does candidiasis present: Vagina
- Usually in teenage girls
- White/yellow discharge from the vagina
- Itching
- Redness in the external area of the vagina
- Burning
How does candidiasis present: Penis
- Redness on the penis
- Scaling on the penis
- Painful rash on the penis
How does candidiasis present: Mouth
- White patches on the tongue, top of the mouth and inside cheeks
- Pain
- Corners of the mouth: cracks or tiny cuts at the corners of the mouth
How does candidiasis present: Nail beds
- Swelling
- Pain
- Pus
- White or yellow nail that seperated from nail bed
How is candidiasis diagnosed in a child?
- Hx and exam
- May scrape skin sample off to check for candida in a lab
How is candidiasis treated in children?
- Candidasis on skin: treated with creams e.g. topical clotrimazole
- Oral thrush: Nystatin
- Genital thrush: topical clotrimazole or oral fluconazole or pessary
Complications of candidiasis?
- Can enter blood stream
- Can get candida in the brain, heart, kidney, liver etc
How does BACTERIAL conjuctivitis present?
- purulent discharge
- eyes may be ‘stuck together’ in the morning
How does viral conjunctivitis present?
- Serous discharge
- Recent URTI
- Preauricular lymph nodes
Common causes of bacterial conjunctivitis?
- Staphylococcus aureus
- Haemophilus influenza
- Streptococcus pneumoniae
- Neisseria gonorrhea
- Chlamydia trachomatis
Common causes viral conjunctivitis?
- Adenovirus
- Herpes virus
Management of conjunctivitis?
- Usually self-limiting withint 1-2 weeks
- Topical antibiotic therapy offered to pts: Chloramphernicol- drops given 2-3 hourly initially whereas ointment given qds
- Advise not to share towels
- School exclusion NOT necessary
Conjunctivitis symptoms in children?
- Itchy, irritated eyes
- Swelling of the eyelids
- Redness of the conjunctiva
- Mild pain when the child looks at a light
- Burning in the eyes
- Eyelids that are stuck together in the morning
- Clear, thin fluid leaking from the eyes, most often from a virus or allergies
- Sneezing and runny nose, most often from allergies
- Stringy discharge from the eyes, most often from allergies
- Thick, green drainage, most often from a bacterial infection
- Ear infection, most often from a bacterial infection
- Lesion on eyelids with a crusty appearance, most often from a herpes infection
How does a neonate contract herpes?
- Can occur during delivery when the baby comes into contact with the primary vesicles in the maternal genital tract
- Neonate most at risk if mother has had herpes for the first time in the last 6 weeks
- Transmission is low with recurrent herpes infection
Features of herpes in the neonate?
- Local or disseminated infection
- Local features incl:
Vesicular lesions on the skin, eye or oral mucosa w/o internal organ involvement - Disseminated features incl:
seizures, encephalitis, hepatitis, sepsis
Symptoms commonly appear in the first week of birth but manifestation ca
Managment of herpes in neonates?
- Parenteral acyclovir along with intensive supportive therapy for severe cases
- elective caesarean section or intrapartum IV acyclovir may be advised if active primary herpes lesions are present on the mother at term or there has been a primary outbreak within 6 weeks of labour.
What disease can be caused by Herpes virus?
- Meningitis
- Encephalitis
- Conjunctivitis
What is cellulitis?
- soft tissue infection of the dermis and subcut tissue
Risk factors for cellulitis in children?
- Skin injury e.g. bite, scrape or cut
- Skin inflammation e.g. radiation therapy or eczema
- Skin infection: impetigo and ringworm
- Immune system problems: HIV/AIDS, or chemotherapy
Symptoms of cellulitis in children?
- Skin that is swollen, painful, or warm
- Skin that looks red, bruised, dimpled, or blistered
- Swollen lymph glands (nodes) nearby
- Swollen lymph vessels nearby, appearing as red streaks on the skin
- Fever and chills
- High heart rate
- Low blood pressure
How is cellulitis investigated?
- Blood culture
- Skin swab for culture
- A-E assessment for sepsis
Management of cellulitis?
- Mark area to aid detection of rapidly spreading cellulitis
- Elevate if possible
- Oral abx
IV abx indicated in the following situations:
* Oral abx is not working
* Worsening infection
* moderate to severe cellulitis.
* Sepsis
* In neonates
Complications of cellulitis?
- Abscess
- Necrosis
- Infection spreading to other areas
What is the oral rotavirus vaccine?
- Oral live attenuated virus
- given at 2 and 3 month of age
Cause of malaria?
Blood protozoan (single celled organism) parasite - Plasmodium species. Spread via bites from female Anopheles mosquito carrying the disease.
Presentation of malaria?
NON SPECIFIC
Abrupt onset rigors
High fever
Sweats
Severe headache
Myalgia
Malaise
Nausea
Vomiting
Investigations for Malaria?
- Malaria blood film- need 3 to diagnose malaria
Once done:
* Rapid antigen test
* FBC - haemolysis, low HB, low platelets, thrombocytopenia
* U&Es - AKI. high creatinine.
* LFTs - ALT, jaundice (pre hepatic)
* Glucose - reduced
* Coagulation screen
* Head CT if CNS symptoms - confusion - can see bleeding or signs of cerebral malaria
* CXR - see ARDS
Complications from malaria by Plasmodium falciparum?
- Cerebral malaria
- Seizures
- Reduced consciousness
- AKI —> renal failure
- Pulm oedema
- DIC - disseminated intravascular coagulopathy
- Severe haemolytic anaemia
- Death
Management for uncomplicated malaria?
- Admit P falciparum pts for treatment
- Discuss with local ID unit
Oral options as follows:
1 Artemether with lumefantrine (called Riamet)
2 Proguanil and atovaquone (Malarone)
3 Quinine sulphate
4 Doxycycline
Management for complicated or severe malaria?
- Admit
- Has to be IV:
Artesunate (most effective, but not licensed)
Quinine dihydrochloride
Malaria prophylaxis advice to give pts?
Know where is high risk
Mosquito spray
Mosquito nets and barriers when sleeping
Antimalarial medication.
Types of Plasmodium species causing malaria?
Plasmodium falciparum- the worst
Plasmodium vivax
Plasmodium ovale
Plasmodium malariae
