Infectious Disease Flashcards
What is the septic screen in children?
Blood vulture
FBC including WCC
Acute phase reactant
Urine sample
Consider a CXR
Lumbar puncture (unless contraindicated)
Rapid antigen screen on blood/ CSF/ urine
Meningococcal and pneumococcal PCR on blood/CSF samples
PCR for viruses in CSF(HSV and enteroviruses)
What risk factors for infection do you want to ask about in
Illness of other family members Specific illness prevalent in commuNity Lack of immunisations Recent travel abroad Contact with animals Immunodeficiency
What are red flag features you should consider when a child is ill/has a fever?
Fever over 38 degrees if they are less than 3 months, or over 39 degrees if they are 3 months to 6 months of age.
Colour- if they are pale, mottled or cyanosed
Level of consciousness being reduced, neck stiffness, bulging fontanelle, status epilepticus, focal neurological signs or seizures
Significant resp distress
Bile stained vomiting
Severe dehydration or shock
What would the classic rash be for meningitis?
Non blanching purpuric rash
When looking at the febrile child, how can you find the focus of the infection?
Do a head to toe approach
Check fontanelles- meningitis/encephalitis?
Look at ENT sources- peri orbital cellulitis, otitis
Media, tonsillitis, upper respiratory tract infection
Look for any rashes on the chest and listen to the chest for pneumonia
Do a urine dip for A UTI
Look for signs of septicaemia (tachycardia, tachypnoea, poor perfusion, need to start ABx in clinical suspicion without waiting for culture results).
Look for abdominal pain/tenderness (appendicitis/pyelonephritis/hepatitis), look at joints for osteomyelitis or septic arthritis
Is there any diarrhoea (gastroenteritis, or if there is fever with blood and mucus in the stool- shigella, salmonella, campylobacter).
How should you treat seriously unwell children with a fever?
Parenteral antibiotics should be given immediately to seriously unwell children eg: a third generation cephalosporin such as: cefotaxime (<1 month old who have been discharged from hospital) or ceftriaxone (>1 month old)
Remember that in children under 1 month ampicillin is also added to cover for listeria infection.
What treatment is given if herpes simplex encephalitis is suspected?
Aciclovir
What are the early (compensated) signs of shock?
Tachypnoea Tachycardia Reduced skin turgor Sunken eyes and fontanelle Delayed cap refill (>2seconds) Pale, cold, mottled Temperature gap (>4degrees) Decreased urinary output
What are the late (decompensated) signs of shock?
Acidotic (kussmaul) breathing- this is deep and laboured Bradycardia Confusion/depressed cerebral state Blue peripheries Absent urine output Hypotension
How do you rescucitate a child in shock?
Initially you would give 0.9% saline or blood (20ml/kg) and you can give that two times if necessary, if there is no improvement then you take them to intensive care, if there is improvement then you correct the hypovolaemia.
How do you calculate the maintenance IV fluid requirements in children?
First 10kg= 100mls
Second 10kg= 50mls
Subsequent kg = 20mls
What should you do if there is no improvement following the initial fluid resuscitation or if there is progression of shock and Resp failure?
Paediatric intensive care unit should be involved and transfer arranged, the child may need:
Tracheal intubation and mechanical ventilation
Invasive monitoring of blood pressure
Inotropic support
Correction of haematological, biochemical and metabolic derangements
Support for renal failure
What is shock?
Insufficient blood flow to the tissues of the body as a result of problems with the circulatory system
What are the four types of shock?
Low volume
Cardiogenic
Obstructive
Distributive shock (sepsis)
What is sepsis?
Sepsis is the overwhelming and life threateninf response to an indection leading to poor perfusion to the tissues/organs.
What are the clinical features of septicaemia in terms of history and examination?
History- fever, focal infection, poor feeding, miserable, irritable, lethargic, predisposinf immunodeficiency (like sickle cell disease)
Examination- fever, tachycardia, tachypnoea, low BP, purpuric rash, shock, multiorgan failure
What are the management options of shock?
Children with septic shock like having organ failure may need to be transferred to PICU.
Antibiotic therapy must be started without delay, the choice should be based on the childs age and any predisposition to infection
Fluids- Central venous pressure monitoring and urinary catheterisation may be required to guide fluid balance assessment.
Inotropic support may be needed as inflammatory cytokines and circulating toxins may depress myocardial contractility
Disseminated intravascular coagulation
Abnormal blood clotting in sepsis leads to widespread microvascular thrombosis and consumption of clotting factors. If bleeding occurs then clotting derangement should be corrected with fresh frozen plasma, cryoprecipitate and platelet transfusions.
What are the signs and symptoms of candidiasis?
Wide range of symptoms
1) candidiasis of the skin- commonly occur in folds of the skin, lesions are usually rimmed with small, red based pustules
2) vulvovaginitis or vaginitis caused by candida
3) penis infected by candida
4) oral candidiasis (thrush)
Candida around nails, systemic candidas
What may discharge and a red eye be due to?
This may be due to a staphylococcal or streptococcal infection
How would you treat staphylococcal or streptococcal infections of the eye?
Can be treated with a topical antibiotic eye ointment- chloramphenicol or neomycin.
What may purulent discharge with conjunctival infection and swelling of the eyelids within the first 48 hours be due to?
Gonococcal infection
The discharge should be gram stained urgently, as well as cultured and treatment should be started immediately due to the loss of vision that can occur.
If gonococcal eye infection is present, how do you treat?
Due to penicillin resistance you would use a third generation cephalosporin given IV with frequent eye cleaning.
Chlamydia trachomatis can cause an eye infection, how does this usually present?
Usually presents with a purulent discharge, together with swelling of the eyelids at 1-2 weeks of age, but may also present shortly after birth.
The organism dan be identified with immunofluorescent staining
How do you treat chlamydia trachomatis eye infection?
Oral erythromycin for 2 weeks
Mother and partner also need to be checked and treated
What is the presentation of herpes simplex virus?
Presentation is any time up to 4 weeks of age
Localised herpetic lesions on the skin or eye, or with encephalitis or disseminated disease.
How can you treat HSV?
Aciclovir
If the woman has genital herpetic lesions at the time of delivery then an elective C section is indicated
If the woman has recurrent infections then vaginal delivery can be carried out as normaL.
What can H influenzae cause?
Important cause of systemic illness in children, including otitis media, pneumonia, epiglottitis, cellulitis, osteomyelitis and septic arthritis, was the second most common cause of meningitis in the UK. Immunizisation is highly effective and Hib now rarely causes systemic disease.
What is the presentation of periorbital cellulitis?
Erythema, tenderness, oedema of the eyelid or other skin adjacent to the eye
It is almost always unilateral
How do you get periorbital cellulitis?
It may follow local trauma to the skin.
In older children it may spread from a paranasal sinus infection or dental abscess
How do you treat periorbital cellulitis?
Should be treated promptly with IV abx such as high dose ceftriaxone to prevent posterior spread of the infection and causing orbital cellulitis
How would orbital cellulitis present?
Proptosis
Painful or limited ocular movement with or without reduced visual acuity
Orbital cellulitis may be complicated, what is it complicated with?
Abscess formation
Meningitis
Cavernous sinus thrombosis
What should be done if orbital cellulitis is suspected?
CT/MRI scan should be performed to assess the posterior spread of infection.
How does HSV enter the body?
HSV enters the body through the mucous membranes or skin and the primary infection may be associated with intense local mucosal damage.
There are eight known herpes viruses, what is HHV-8 associated with?
Kaposi sarcoma in HIV infected individuals.
What is the difference between HSV-1 and HSV-2 viruses?
HSV-1 is usually associated with lip and skin lesions
HSV-2 more commonly associated with genital lesions but both can cause both types
What is the most common form of primary HSV illness in children?
Gingivostomatitis
It usually occurs from ten months to 3 years of age
How does gingivostomatitis present?
Vesicular lesions on the lips, gums, anterior surfaces of the tongue and hard palate which often progress to extensive, painful ulceration with bleeding. There is high fever and the child is very miserable.
Dehydration may occur due to pain of eating and drinking
What is the treatment of gingivostomatitis?
Management is symptomatic but severe disease may need IV fluids and aciclovir.
Other than gingivostomatitis, what can herpes simplex virus cause?
Skin manifestations- mucocutaneous junctions eg: lips and damaged skin
Eczema herpeticum
Herpetic whitlows (painful pustules on the fingers)
Eye disease- blepharitis, conjunctivitis, corneal ulceration
CNS- aseptic meningitis, encephalitis
Pneumonia and disseminated infection in the immunocompromised
What is the pathophysiology of bacterial infection?
Bacterial infection of the meninges usually follows bacteraemia. Much of the damage caused by meningeal infection results from the host response to infection and not from the organism itself
The release of inflammatory mediators, activated leucocytes together with endothelial damage leads to cerebral oedema, raised ICP and decreased cerebral blood flow
The inflammatory response below the meninges causes a vasculopathy which results in cerebral cortical infarction, and fibrin deposits may block the resorption of CSF by the arachnoid villi which results in hydrocephalus.
What are the organisms that cause bacterial meningitis?
Neonatal to 3 months= group B streptococcus
E coli
1 month to 6 years: neisseria meningitides, strep pneumoniae, haemophilus influenza
> 6 years strep pneumonia, neisseria meningitides
What are the investigations for meningitis/encephalitis?
FBC and differential count
Blood glucose and blood gas (for acidosis)
Coagulation screen, CRP, U&Es, LFTs
Culture of blood, throat swab, urine, stool for bacteria
Rapid antigen test can be done on blood, CSF or urine
Samples for viral PCRS
Lumbar puncture for CSF unless contraindicated
If TB suspected then CXR, mantoux, and/or onterferon gamma release assay, gastric aspirates or sputum for microscopy and culture
What are the contraindications to lumbar punctures
Cerebal oedema cardiorespiratory instability Focal neurological signs Thrombocytopenia Local infection at the site of LP If it causes delay in starting antibiotics
It can cause coning of the cerebellum through the foramen magnum in these circumstances.
What are the cerebral complications of bacterial meningitis?
Hearing impairment Local vasculitis Local cerebral infarction Subdural effusion Hydrocephalus Cerebral abscess
What causes viral meningitis?
Enteroviruses
EBV
Adenoviruses
Mumps (rare due to the MMR)
What are the clinical features of mumps?
Incubation period is 15 to 24 days
Onset of the illness is with fever, malaise and parotitis
Only one side of the face may be swollen initially, but bilateral parotid involvement nay occur over the next few days. Parotitis is uncomfortable and children may complain of earache or pain on eating or drinking.
What is a common fear of mumps?
Orchitis
When it occurs its unilateral
What is malaria?
Infectious disease caused by members of the plasmodium family of protozoan parasites.
What is the most severe and dangerous plasmodium member family?
Plasmodium falciparum
How is malaria spread?
Spread through bites from the female anopheles mosquitos
How does malaria lead to haemolytic anaemia?
Sporozoites mature in the liver into merozoites which enter the blood and infect red blood cells. In red blood cells, the merozoites reproduce 48 hours after which the red blood cells rupture releasing loads more merozoites into the blood and causing a haemolytic anaemia.
This is why people with malaria have high fever spikes every 48 hours.
What are the non specific symptoms and signs of malaria?
Non specific symptoms: . Fever, sweats, rigors . Malaise . Myalgia . Headache . Vomiting
Signs:
. Pallor due to anaemia
. Hepatosplenomegaly
. Jaundice as bilirubin is released during the rupture of red blood cells
How do you diagnose malaria?
Malaria blood film which is sent in an EDTA bottle, the red top bottle used for a FBC
The malaria blood film will show parasites, the concentration and what type they are
3 samples are sent over 3 consecutive days to exclude malaria being released into the blood from red blood cells
The sample may be negative on days where the parasite is not released but becomes positive a day or two later when they are released from the RBCS
What is the management of malaria?
Oral options in uncomplicated:
Quinine sulphate
Doxycycline
IV options in severe or complicated
Artesunate
Quinine dihydrochloride
What are the falciparum complications?
Cerebral malaria Seizures Reduced consciousness AKI Pulmonary oedema DIC Severe haemolytic anaemia Multi organ failure and death
Give an example of an antimalarial medication…
Doxycycline
What is an inactivated vaccine and give examples…
Inactivated vaccines involve giving a killed version of the pathogen they cannot cause an infection and are safe for immunocompromised patients . flu . Polio . Hep A . Rabies
What are live attenuated vaccines?
They contain a weakened version of the pathogen and are still capable of causing infection, particularly in immunocompromised patients. MMR BCG Chickenpox Nasal influenza Rotavirus
What are subunit and conjugate vaccines?
Pneumococcus Meningococcus Hep B Petussis HPV Hib Shingles
What is a toxin vaccine?
Contain a toxin produced by a pathogen, they cause immunity to the toxin and not to the pathogen itself- diphtheria and tetanus.
What does the HPV vaccine protect against?
HPV strains 6,11,16,18
The intention is to prevent them contracting and spreading HPV once they become sexually active
What is disseminated intravascular coagulopathy and why do you get it in sepsis?
This is when activation of the coagulation system leads to a deposition of fibrin throughout the circulation, which further compromises organ and tissue perfusion. It also leads to consumption of platelets and clotting factors as they are being used up to form blood clots,
Why does blood lactate rise with sepsis?
It rises as a result of anaerobic respiration in the hypo perfused tissues with an inadequate oxygen. A waste product of anaerobic respiration is lactate.
How can you treat septic shock?
Should be treated aggresively with IV fluids to improve blood pressure and tissue perfusion. If fluid boluses fail to improve the blood pressure and lactate levels then children should be escalated to high dependency unit or ICU and given inotropes (noradrenalin).
What signs would indicate sepsis?
Sometimes the signs can be unspecific and not obvious. Hard signs that indicate sepsis are... deranged physical observations Prolonged capillary refill time Fever or hypothermia Deranged behaviour Poor feeding Inconsolable/ high pitched crying Floppy (reduced body tone) Weak Skin colour changes (cyanosis, mottled, pale, ashen)
When should you urgently treat a baby for sepsis?
All infants under 3 months with a temperature of 38 degrees or above need to be treated urgently for sepsis until proven otherwise.
What is the management of sepsis?
Give oxygen if the patient has evidence of shock or the sats are below 94%
Obtain IV access
Blood tests- FBC, CRP, U and E, clotting screen (INR), blood gas for lactate and acidosis
Blood cultures before giving abx
Urine dipstick and lab testing for culture and sensitivities
Abx according to local guidelines- GOLDEN HOUR give within one hour
IV fluids 20ml/kg IV bolus of normal saline is lactate above 2mmol/l or there is shock
What are differentials for sepsis?
adrenal crisis
Why is it you get a purpuric non blanching rash in meningococcal septicaemia (other causes of bacterial meningitis do not usually cause the non blanching rash).
It is due to DIC and subcutaneous haemorrhage.
What is the most common cause of bacterial meningitis?
In children and adults= Neisseria meningitides and strep pneumoniae
In neonates= group B strep (usually from mothers vagina).
What is the presentation of meningitis?
Neck stiffness Fever Photophobia Headache Vomiting Altered consciousness
Neonates and babies can present with very non specific signs- hypotonia, poor feeding, lethargy, hypothermia, bulging fontanelle.
How should you manage meningitis?
If bacterial and in the community- give an immediate STAT dose of IV/IM benzylpenicllin before transfer to hospital
If in hospital then ideally LP and blood cultures would be taken, however if the patient is acutely unwell give Abx first.
Send bloods for meningococcal PCR if meningococcal disease is suspected
Under 3 months- cefotaxime plus amoxicillin (this covers listeria)
Above 3 months- ceftriaxone
Vancomycin should be added to these antibiotics if there is a risk of penicillin resistant pneumococcal infection, for example a recent foreign travel or prolonged abx exposure
Steroids used to reduce frequency and severity of hearing loss and neurological damage
You need to inform public health
What would you give to someone who has been exposed to meningitis?
Ciprofloxacin single dose
What causes viral meningitis and what treatment can be given for it?
Usually varicella zoster, hsv, enterovirus.
Sample of CSF should be sent of for PCR testing
Aciclovir can be used to treat it
What are the complications of meningitis?
Hearing loss is a key complication Seizures and epilepsy Learning disability Memory loss Cerebral palsy
What is encephalitis?
Inflammation of the brain
Mostly caused by infective sources but can also be non infective (autoimmune) meaning antibodies are created that target brain tissue.
What causes encephalitis
Mostly caused by viruses- HSV, vZV, CMV, EBV
Polio, mumps, rubella and measles viruses can cause encephalitis as well.
What is the presentation of encephalitis?
Altered consciousness Altered cognition Unusual behaviour Acute onset of focal neurological symptoms Acute onset of focal seizures Fever
How do you diagnose encephalitis?
Lumbar puncture sending CSF for viral PCR testing
CT scan if lumbar puncture is indicated
MRI scan after the lumbar puncture allows visualisation of the brain in detail
EEG recording
Swabs can help establish the causative organism
HIV testing is recommended to all patients with encephalitis
When would a lumbar puncture be contraindicated?
GCS less than 9
Haemodynamically unstable
Active seizures
Post ictal
What is the management of encephalitis?
Aciclovir- treats herpes simplex virus and VZV
Gangiclovir treats CMV
Repeat LP is usually performed to ensure successful treatment prior to stopping antivirals
Follow up, support and rehabilitation is required after encephalitis, with help managing the complications
What are the complications of encephalitis?
Changes to mood Lasting fatigue and prolonged recovery Learning disability Headaches Chronic pain Movement disorders Sensory distrubance Seizures Hormonal imbalance
What should you be thinking about in an exam question if it states an adolescent with a sore throat has developed an itchy rash after taking amoxicillin?
Mononucleosis!
Mononucleosis causes an intensely itchy maculopapular rash in response to amoxicillin or cefalosporins
What are the features of infectious mononucleosis?
Sore throat Fever Splenomegaly Lymphadenopathy Tonsillar enlargement Fatigue
What investigations can you do for EBV?
You can test for heterophile antibodies, however they take 6 weeks to be produced and are not always produced (specific not sensitive)
Either test for them by doing the MONOSPOT gest
Or paul bunnell
You can also test specific antibodies
IgM will be high un early infection, IgG suggests immunity
How do you manage EbV?
Acute illness lasts 2-3 weeks however it can leave the patient with fatigue once infection is cleared
Patients are advised to avoid alcohol as EBV impacts the ability of the liver to process alcohol, patients are also advised to avoid contact sports due to the risk of splenic rupture.
What are the complications of EBV?
Splenic rupture Glomerulonephritis Haemolytic anaemia Thrombocytopenia Chronic fatigue EBV is associated with burkitts lymphoma
How do you manage mumps?
Self limiting however it is a notifiable disease
Diagnosis can be confirmed using PCR testing on a saliva swab, blood or saliva can also be tested for antibodies to the mumps virus
What is the pathophysiology behind HIV?
HIV is a RNA retrovirus. It attacks CD4T helper cells. There is an initial seroconversion flu like illness occurring within a few weeks of infection. The infection is then asymptomatic until it progresses and the patient becomes immunocompromised and begins developing AIDS defining illnesses, potentially years later.
How is HIV spread?
Unprotected anal, vaginal or oral sexual activity
Mother to child at any stage of pregnancy, birth, breastfeeding (vertical transmission)
Mucous membrane, blood or open wound exposure to infected blood or bodily fluids, this could be through sharing needles, needle stick injuries or blood splashed in the eye.
What prophylactic treatment can be given to the baby if the mother has HIV?
Low risk babies where mothers viral load is <50 should be given zidovudine for 4 weeks
High risk babies where mums viral lode is >50 copies should be given zidovudine, lamivudine and nevirapine for 4 weeks
How can you test for HIV?
HIV antibody screen tests whether the immune system has created antibodies due to exposure to the HIV virus, this is the standard screening test but it can give false positive in babies of HIV positive mums due to maternal antibodies that cross the placenta. It can take up to 3 months for antibodies to develop after exposure to the virus.
HIV viral load will never be falsely positive however can be undetectable in patients on antivirals
How do you test HIV in children with positive parents?
HIV viral load at 3 months
HIV antibody test at 24 months
How should you manage HIV in children?
Antiretroviral therapy (ART) to suppress the HIV infection
Normal childhood vaccines, avoiding or delaying live vaccines if severely immunosuppressed.
Prophylactic co-trimoxazole (Septrin) for children with low CD4 counts, to protect against pneumocystis jirovecii pneumonia (PCP)
Treatment of opportunistic infections
What is hepatitis B and how is it spread?
DNA virus
Spread through blood or bodily fluids- sexual intercourse, sharing needles, even through contaminated household products like toothbrushes or contact between minor cuts or abrasions.
What is chronic hepatitis B?
So most children will fully recover from the infection, however a portion to on to become chronic hepatitis carriers, in these patients the virus DNA integrates into their own DNA and continues to produce viral proteins.
The risk of developing chronic hepatitis B after exposure is…
. 90% for neonates
. 30% for children under 5
. Under 10% for adolescents
What can chronic hepatitis B cause?
Liver cirrhosis and hepatocellular carcinoma, however less than 5% develop liver cirrhosis and less than 0.05% will develop hepatocellular carcinoma before adulthood. The risks increase once they enter adulthood.
Ŵhat should you test for in hepatitis B?
When screening for Hep B, test for HepB cAb and HBsAg once confirmed the diagnosis then you can do HepeAg and HBV DNA for viral load.
What are the roles of HBsAb and HBcAb in terms of hep B testing?
HBsAb tells you whether or not they have had the infection OR VACCINATION
HBcAb can help distinguish between acute, chronic and past infection, IgM and IgG versions of the HbcAb can be measured, IgM indicated current infection and will give a high titre with an active infection and a low titre with a past infection.
Who would you test for hepatitis B?
Children from hep B positive mothers
Migrants from endemic areas
Close contact of patients with Hep B.
What treatment can be given to babies with Hep B positive mothers?
Neonates with Hep B mothers should be given the Hep B vaccination and also hepatitis B immunoglobulin infusion.
Infants are given Hep B vaccination at 1 month and 12 months and also at 8, 12 and 16 weeks.
How does the Hep B vaccine work?
Vaccination involves injecting the hepatitis B surface antigen, this is why the HbsAb does not distinguish between vaccination and previous infection.
How would you manage a child with chronic Hep B?
Most are asymptomatic and do not require treatment, however they require regular specialist follow up to monitor their serum ALT, viral load (HbeAg, HBV DNA), physical examination and liver ultrasound.
When there is evidence of cirrhosis or hepatitis then treatment with antivirals can be considered.
How do you screen for hepatitis C in children?
Hepatitis C antibody testing is the screening test
Hepatitis C RNA testing is used to confirm the diagnosis of Hep C, calculate the viral load and identify the genotype
They are tested at 18 months.
Can mothers with Hepatitis B breastfeed?
Yes they can breastfeed as it has not been found to spread Hep C, if nipples become cracked or bleed then breastfeeding should be temporarily stopped whilst they heal.
Medical treatment may be considered in children over 3 years- pegylated interferon and ribavirin.
What is tonsilitis?
Inflammation of the tonsils, most common cause is viral however you can get bacterial tonsilitis (group A streptococcus- strep pyogenes).
How can you treat bacterial tonsilitis?
Penicillin V
What tonsils are affected in tonsilitis?
Typically the palatine
How does tonsilitis present?
Child with fever, sore throat and painful swallowing
They can present with non specific symptoms- fever, poor oral intake, headache, vomiting, abdominal pain
What would you examination reveal in tonsilitis?
Red, inflamed and enlarged tonsils with or without exudates.
Remember to always palpate for cervical lymphadenopathy and look in the ears (otoscopy)
What is the centor criteria?
This can be used to estimate the probability that tonsilitis is due to a bacterial infection and will benefit from antibiotics
A score of 3 or more gives a 40-60% probability of bacterial tonsilitis and is appropriate to offer Abx, a point is given for the following…
. Fever
. Absence of cough
. Tonsillar Exudates
. Tender anterior cervical lymphadenopathy
What is the fever pain score?
This is an alternative to the centor criteria
. Fever during previous 24 hours
. Purulence (pus on tonsils)
. Attended within 3 days of the onset of symptoms
. Inflamed tonsils
. No cough or coryza
How would you manage tonsilitis?
Viral- safety net and advice about supportive treatment (paracetamol and ibuprofen)
Give Abx if the Centor score is > or equal to 3 or FeverPAIN is > or equal to 4 or if they are at risk of more serious infections (immunocompromised/ significant co morbidity or hx of rheumatic fever).
What antibiotics are given for tonsilitis?
Penicillin V for ten days is first line
The trouble is it tastes bad and children dont like it if they require syrups
If children have true penicillin allergy then they can take clarithromycin
What are the complications of tonsilitis?
Chronic tonsilitis Peritonsillar abscess- quinsy Otitis media Scarlet fever Rheumatic fever Post streptococcul glomerulonephritiis/ post streptococcal reactive arthritis
What is quinsy?
Also known as peritonsillar abscess, this arises when there is a bacterial infection with trapped pus, forming an abscess in the region of the tonsils.
How do patients with quinsy present?
Sore throat, painful swallowing, fever, neck pain, referred ear pain, swollen tender lymph nodes
Additional signs:
1) trismus- patient unable to open their mouth
2) change in voice- this is due to the pharyngeal swelling, ‘hot potato voice’
3) swelling and erythema in the area behind the tonsils
What causes quinsy?
Usually due to a bacterial infection- this is usually group A strep, streptococcus pyogenes
Also commonly caused by staph aureus and haemophilus influenzae
How do you manage a patient with quinsy?
Patients should be referred into hospital under the care of the ENT team for incision and drainage of the abscess under general anaesthetic
Broad spec antibiotics like co amoxiclav are appropriate for use before and after surgery but use local guidelines
Some ENT surgeons give steroids like dexamethasone which settle inflammation and help recovery, this is not universal.
What are the complications of a tonsillectomy?
Post tonsillectomy bleeding Pain Damage to teeth Infection Risks of general anaesthetic
What causes otitis media?
Most common cause of otitis media as well as other ENT infections like rhino sinusitis and tonsillitis is streptococcus pneumoniae.
Other causes: haemophilus influenzae, moraxella cattarhalis, staph aureus.
How does otitis media present?
Ear pain, reduced hearing in the affected ear and general symptoms of upper airway infection- fever, cough, coryzal symptoms, sore throat, feeling generally unwell.
Usually after an URTI
If it affects the vestibular system it can then lead to balance issues and vertigo.
Can be very unspecific in young children and therefore ears are always worth examining.
What will you see on otoscopy of a normal childs ear and a child with otitis media?
In a normal child- tympanic membrane should be ‘pearl grey’, translucent and slightly shiny.
In a child with otitis media- red, bulging tympanic membrane
How do you manage otitis media?
Most cases will resolve without antibiotics within 3 days, therefore you tend not to give antibiotics.
You would consider Abx if they are immunocompromised, have significant co morbidities or are systemically unwell.
What are the complications of otitis media?
Otitis media with effusion Mastoiditis (rare) Abscesses (rare) Perforated eardrum Hearing loss (temporary) Recurrent infection
What would you see on otoscopy of a patient with otitis media with effusion and how would you manage it?
Otoscopy can show a dull tympanic membrane with air bubbles or a visible fluid level. It can look normal
Referral for audiometry to establish diagnosis and extent of hearing loss
Usually treated conservatively and resolves without treatment within 3 months
What can cause haring loss in children?
Congenital- maternal rubella or CMV infection during pregnancy
Genetic deafness
Downs syndrome
Perinatal- prematurity, hypoxia during or after birth
After birth- jaundice, meningitis and encephalitis, otitis media or glue ear, chemo
How can children with hearing difficulties present?
Ignoring calls/sounds
Frustration or bad behaviour
Poor speech and language development
Poor school performance
What is in place to test for hearing?
Newborn hearing screening programme
What is cleft lip?
Congenital condition where there is a split or open section of the upper lip, the opening can extend as high as the nose.
What is cleft palate?
This is where a defect exists in the hard or soft palate at the roof of the mouth, this leaves an opening between the mouth and the nasal cavity
How do you manage cleft lip?
The priority is that the baby can drink
MDT should be involved- psychologists, dentists, speech and language therapists, GP, plastic, maxillofacial and ENT surgeons.
Definitive management is with surgery
What is a thyroglossal cyst?
During fetal development, the thyroid gland starts at the base of the tongue and then travels down in front of the trachea and beneath the larynx. When the thyroid does this it leaves a track behind called the THYROGLOSSAL duct cyst which then disappears, if part of this persists then it can give rise to a fluid filled cyst.
What is a key differential of Thyroglossal cyst and also what is the main complication?
Key differential= ectopic thyroid tissue
Main complication is infection causing a hot, tender and painful lump.
What are the features of a thyroglossal cyst?
Mobile Non tender Soft Fluctuant They move with the tongue!!
What is the management of thyroglossal cysts?
US/CT can confirm diagnosis
They are usually surgically removed
What is the presentation of a branchial cyst?
A round, soft, cystic swelling between the angle of jaw and SCM in anterior compartment of the neck
The swelling will transluminate
Usually occurs in young adulthood, after ten years old
When should you think of primary immunodeficency?
SPUR Serious Persistent Unusual Recurrent
What should you ask if you are suspecting Primary immunodeficiency?
Infection Hx- site, frequency, need for admission/IV abx, microbiology
Immunisation status
FH- infections, autoimmunity, consanguinity, neonatal deaths
