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
