Infectious Diseases Flashcards
What are important factors to consider in the presentation of a febrile child?
How has fever been identified e.g. electronic thermometer, tympanic
How old is the child
Any risk factors for infection e.g. illness in other family members, specific illness present in community, unimmunised, recent travel abroad
Contact with animals
Increased susceptibility from immunodeficiency e.g. post autosplenectomy in sickle cell, splenectomy, nephrotic syndrome - more at risk from encapsulated organisms e.g. strep pneumoniae, haemophilus
How ill is the child
Is there a rash
Is there a focus for infection
What are the red flag features suggesting urgent investigation in infection?
Fever >38 if <3 months
Fever > 39 if 3-6 months
Colour - pale, mottled, blue
Level of consciousness is reduced Neck stiffness Bulging fontanelle Status epilepticus Focal neurological signs or seizures Significant resp distress Bile stained vomiting Severe dehydration or shock
What is the management of the febrile child?
If significantly unwell, continue investigations, septic screen
Parental antibiotics given immediately, e.g. third generation cephalosporin e.g. ceftrixone or cefotaxime
Aciclovir if herpes simplex encephalitis suspected
What are some diagnostic clues to look out for when evaluating the febrile child?
URTI
Otitis media - examine tympanic membrane
Tonsilitis - any exudate or erythema on tonsils
Stridor - epiglottitis, croup, tracheitis
Pneumonia - fever, cough, raised RR, abnormal auscultation, CXR
Sepsis screen - tachycardia, tachypnoea, poor perfusion, start abx
Meningitis/encephalitis - lethargy, loss of interest, drowsy, seizure
In older children - headache, neck stiffness, photophobia, Kernig’s pain on straight leg
Abnormal posturing in raised ICP
Seizure - febrile convulsion, meningitis, encephalitis
Periorbital celllulitis - redness, swelling of eyes
Rash - viral exanthem, purpura from meningococcal
UTI
Abdominal pain - appendicitis, pyelonephritis, hepatitis
Diarrhoea - gastroenteritis
Blood in stool - shigella, salmonella, campylobacter
Prolonged fever Bacterial infection Kawasaki disease Drug reaction Malignant disease
What is the cause of bacterial meningitis?
Neisseria meningitidis
Strep pneumoniae
In neonates - Group B Strep GBS contracted during birth which live harmlessly in vagina
What is the presentation of meningitis?
Fever Neck stiffness Vomiting Headache Photophobia Altered consciousness Seizures
Meningococcal septicaemia presents with non blanching rash
Neonates - hypotonia, poor feeding, lethargy, hypothermia, bulging fontanelle
When is an LP in meningitis recommended?
Under 1 month with fever
1-3 months fever and unwell
<1 year with unexplained fever and other features of serious illness
What is Kernig’s test?
Lie patient on back, flex hip and knee to 90 then straighten leg with hip still flexed
Stretches meninges, causes pain or resistance
What is Brudzinski’s test?
Lie patient flat on back, use hands to lift head and neck off bed, flex chin to chest
Involuntary flexion of hips and knees if positive
What is the management of bacterial meningitis in the community?
In primary care and suspected and non blanching rash - urgent stat injection IM or IV of benzylpenicillin before transfer to hospital
In hospital - LP prior to starting antibiotics
Bloods for meningococcal PCR
<3 months cefotaxime plus amoxicillin (covers listeria contracted in pregnancy)
Above 3 months ceftriaxone
Vancomycin added if risk of penicillin resistant infection e.g. recent travel or prolonged antibiotic exposure
Steroids to reduce freq and severity of hearing loss and neuro damage
Dexomethasone 4x daily for 4 days to children over 3 months
Notifiable disease
What post exposure prophylaxis is required for meningococcal infections?
Single dose of ciprofloxacin ideally within 24 hours of the initial diagnosis
What are the most common causes of viral meningitis?
Herpes simplex
Enterovirus
Varicella zoster virus
Milder and needs supportive treatment
Aciclovir
What is seen on lumbar puncture in a bacterial infection?
Cloudy appearance
High protein and neutrophils
Bacterial culture present
Low glucose
Bacteria swimming in CSF will release protein and use up the glucose
Neutrophils released in response to bacterial infection
What is seen in CSF on lumbar puncture in a viral infection?
Clear appearance Mildly raised protein Lymphocytes released in viral infection so WCC high No culture Normal glucose
What are the complications of meningitis?
Hearing loss - inflammatory damage to cochlear hair cells
Local vasculitis may lead to cranial nerve palsies
Local cerebral infarction - focal or multifocal seizures, may lead to epilepsy
Subdural effusion may require more antibiotics
Hydrocephalus from impaired resorption of CSF or blockage
Cerebral abscess
What are the investigations for meningitis/encephalitis?
FBC Blood glucose Blood gas - acidosis Coag screen, CRP U&Es, LFTs Blood culture Sepsis 6 Rapid antigen test LP If TB suspected - CXR, mantoux, gastric washings or sputum early morning urines
Consider CT/MRI brain scan, EEG
What are the contraindications to lumbar puncture?
Cardiorespiratory instability
Focal neurological signs
Signs of raised ICP - coma, high BP, low HR, papilloedema
Coagulopathy
Thrombocytopenia
Local infection at sight
If it causes delay in starting antibiotics
What are causes of encephalitis?
Direct invasion of the cerebrum by neurotoxic virus e.g. HSV
Delayed brain swelling following disordered neuroimmunological response to antigen e.g. virus e.g. post infectious encephalopathy e.g. chickenpox
Slow virus infection e.g. HIV
What are the features of encephalitis?
Altered consciousness Altered cognition Unusual behaviour Acute onset of focal neurological symptoms Acute onset of focal seizures Fever
What are the investigations for encephalitis?
LP, CSF for viral PCR CT scan if LP contraindicated MRI EEC Swabs HIV Septic screen
What is the management of encephalitis?
Aciclovir for HSV and varicella zoster
Ganciclovir for cytomegalovirus
Repeat LP to ensure successful treatment before stopping antivirals
Aciclovir usually started empirically
What are the complications of encephalitis?
Lasting fatigue, prolonged recovery Change in personality or mood Changes to memory and cognition Learning disabilities Headaches Chronic pain Movement disorders Sensory disturbance Seizures Hormonal imbalance
What is seen in toxic shock syndrome?
Caused by toxin producing staphlococcus aureus and group A streptococci
Fever <39, hypotension, diffuse erythematous rash
Organ dysfunction
Mucositis: conjunctivae, oral or genital mucosa
GI: vomiting, diarrhoea
Renal and liver impairment
Clotting abnormalities and thrombocytopaenia
CNS - altered consciousness
What is the management of septic shock?
Intensive care support
Antibiotics - cephalosporin e.g. ceftriaxone with clindamycin
IV fluids to improve BP and tissue perfusion
What are the signs of sepsis in a child?
Deranged physical obs Prolonged cap refill Fever or hypothermia Deranged behaviour Poor feeding Inconsolable or high pitched crying High pitched or weak cry Reduced consciousness Reduced body tone - floppy Skin colour changes - cyanosis, mottled pale or ashen
Shock involves circulatory collapse and hypoperfusion of organs
What is the immediate management of sepsis?
Give oxygen if evidence of shock or sats below 94 Obtain IV access Blood tests - including FBC U&Es, CRP, clotting, blood gas, acidosis Blood cultures Urine dipstick Cultures and sensitivities Antibiotics given within 1 hr IV fluids
CXR if pneumonia suspected Abdo and pelvic USS LP Meningococcal PCR Serum cortisol if adrenal crisis suspected
Continue abx for 5-7 days
What is candida?
Yeast like fungus normal commensal in human GI tract and vagina
What are the risk factors for oral candidiasis?
Hot humid weather Too much time between diaper changes Poor hygiene Immunocompromise Antibiotics promote growth
What are the complications of candidiasis?
Oral candidiasis can cause chronic pain, discomfort
Impaired speech
Impaired eating, chewing, limits to nutrition
Candidemia - presence of species in the blood
What is the management of oral candidiasis?
Admit if evidence of systemic illness, widespread infection e.g. oesophageal candidiasis
Exclude risk factors e.g. diabetes, haematinic deficiences, poor dental hygiene
Prescribe miconazole oral gel first line if 4 months and over
Advise good dental hygiene
Rinse mouth after inhalation of inhaled corticosteroid
If after 7 days some response to tx, continue miconazole gel or offer 7 day course nystatin suspension
What is cutaneous candidiasis?
Nappy rash - contact dermatitis, moist warm environment in the nappy can lead to added infection with candida
Discrete red spots around the perineum, worse in skin creases
Send swab to microbiology
What is the management of cutaneous candidiasis?
Miconazole cream twice daily for 10 days
What is the presentation of cellulitis?
Erythematous, hot tender rash
May be associated with swelling and systemic features
What are some of the differentials for cellulitis?
Allergic/contact dermatitis
Impetigo - crusting lesions
Staph scalded skin syndrome
Necrotising fasciitis
What are the investigations for cellulitis?
Dental/max fax review if facial or submandibular
Send skin swab for MC&S if skin broken
Complex cellulitis - FBC, CRP, blood culture
What are the features of complex cellulitis?
Severe infection
Significant immunosuppression
Associated with VZV
Post-burn
What is the management of cellulitis?
If mild/mod treat with antibiotics e.g. flucloxacilllin or if penicillin allergy clarithromycin for 5-7 days
What is periorbital cellulitis?
Inflammation and infection of the eyelid soft tissue superior and anterior to the orbital septum.
What is orbital cellulitis?
Post-septal
Infection in the muscles and fat of the orbit so the septum can be affected and can lead to ocular dysfunction
What is the difference in periorbital and orbital cellulitis in children?
Children may develop it secondary to an occult underlying bacterial sinusitis or due to spread from another primary infection e.g. pneumonia
Means peri-orbital infection can progress rapidly to orbital cellulitis
What is seen on examination in peri-orbital cellulitis?
Redness and swelling
Can open eye sufficiently to demonstrate normal light reflexes and move in all planes
What are the red flags suspicious of orbital cellulitis?
Eyelid swelling that the eye is not visible Toxic/systemically unwell CNS signs or symptoms Severe persistent headache Pain on pressing closed eyelid Pain on eye movement Diplopia Reduced visual acuity Absent light reflexes No improvement on abx
What is the management of periorbital/orbital cellulitis?
Mild - oral abx; 5-7 days
co-amoxiclav
Orbital cellulitis
IV cefotaxime or oral amoxicillin 10-14 days
NBM if need for surgery, seek ENT and opthamology advice
CT scan orbit, sinuses, brain
FBC, blood culture, LP
What is conjunctivitis?
Inflammation of the conjunctiva of the eye
What are the types of newborn conjunctivitis?
Chemical - irritation from eye drops given at birth, lasts 2-4 days, does not need treatment
Gonococcal - from neisseria gonorrhoea, can be picked up from vaginal birth
Inclusion conjunctivitis - from chlamydia trachomatis - swollen red eyelids, fluid leaking from eyelids
What are the causes of childhood conjunctivitis?
Bacteria - staph aureus, strep pneumonia, chlamydia
Viruses - HSV, adenoviruses
Allergies
What are the symptoms of conjunctivitis?
Itchy irritated eyes Swelling of eyelids Redness of conjunctiva Mild pain looking at light Eyelids stuck together in the morning Clear thin fluid leaking from eyes; virus or allergens Crusty lesion - herpes infection
What is ophthalmia neonatorum?
Conjunctivitis of the newborn
Occurs within first month of life
Bacterial, chlamydial or viral acquired during passage through infected birth canal
Redness
Profuse discharge
Swelling of lids
Bilateral symptoms
Mucopurulent conjunctivitis
Oedema
Cornea can be involved, may cause perforation
What is the management of conjunctivitis?
First line - bath/clean eyelids with cotton wall in sterile saline or boiled then cooled water to remove crusting
Treat only if severe as most cases viral, self-limiting
Second line - chloramphenicol eye drops, azithromycin eye drops
Third line - fusidic acid
Herpes simplex - same day eye casualty, <1 month give IV aciclovir, >1 month give oral aciclovir
For ophthalmia neonatorum - cefotaxime single dose IV immediately, plus chloramphenicol eye drops
What is acute epiglottitis?
Life threatening emergency
Caused by H influenzae B.
Intense swelling of epiglottis and surrounding tissues associated with septicaemia
What are the clinical features of epiglottitis?
High fever, ill toxic looking child
Intensely painful throat, prevents child from speaking or swallowing
Saliva drools down chin
Soft inspiratory stridor
Rapidly increasing respiratory difficulty
Immobile, upright with open mouth to optimise airway
Onset over hours
No cough
Not able to drive
Reluctant to speak
What should not happen in epiglottitis?
Attempts to examine throat or perform lateral neck x-ray must not occur
Can precipitate total airway obstruction and death
What is the management of epiglottitis?
Urgent admission Senior anaesthetist, paediatrician, ENT Intubation Secure airway, blood cultures, start IV antibiotics Ceftriaxone Oral stepdown - co-amoxiclav
Prophylactic antibiotics rifampicin offered to close household contacts
What is scalded skin syndrome?
Exfoliative staphylococcal toxin which causes separation of the epidermal skin through the granular cell layers
Fever, malaise, purulent crusting localised infection around eyes nose mouth.
Areas of epidermis separate on gentle pressure.
IV antibiotics - flucloxacillin
Analgesia, monitoring fluid balance
What is the hallmark of herpesviruses?
After primary infection, latency is established
Long term persistence of virus within the host
After certain stimuli, reactivation of infection may occur
What is herpes simplex virus?
Enters body through mucus membranes or skin
Site of primary infection may be associated with intense local mucosal damage
HSV1 lip and skin lesions
HSV2 genital lesions
Treatment with aciclovir
What is gingivostomatitis?
Most common form of primary HSV in children
Vesicular lesions on lips, gums, anterior surfaces of tongue and hard palate.
Progress to extensive, painful ulceration and bleeding.
High fever, may persist up to 2 weeks.
Management symptomatic
Severe disease may need IV fluids and aciclovir
What are cold sores?
Recurrent HSV1 lesions on the gingival lip margin
What is eczema herpeticum?
Wide spread vesicular lesions develop on eczematous skin
May be complicated by secondary bacterial infection and result in sepsis
What are herpetic whitlows?
Painful erythematous oedematous white pustules on broken skin on fingers
Spread by auto-inoculation from gingivostomatitis and infected adults kissing children’s fingers
HSV2 may be cause in sexually active adolescents
What are the causes of a maculopapular rash?
Viral - roseola infantum Enteroviral rash Parvovirus slapped cheek Measles Rubella
Bacterial Scarlet fever - Group A strep Erythema marginatum - rheumatic fever Salmonella typhi Lyme disease
Other
Kawasaki disease
Juvenile idiopathic arthritis
What are the causes of vesicular bullous pustular rashes?
Viral
Chickenpox, shingles
Herpes simplex virus
Coxsackie - hand, footh, mouth
Bacterial Impetigo Boils Staphylococcal bullous impetigo Staphylococcal scalded skin Toxic epidermal necrolysis
Other
Erythema multiforme
Stevens-Johnson syndrome
What are the causes of a petechial purpuric rash?
Bacterial
Meningococcal, other bacterial sepsis
Infective endocarditis
Viral
Enterovirus
Other Henoch-Schonlein purpura Thrombocytopenia Vasculitis Malaria
What is influenza?
Respiratory infection caused by influenza virus
Spread because children touch noses, eyes, mouths, put things in mouth
Spread through droplets in the air, coughing, sneezing, touching surfaces
What are the features of flu in children?
Sudden fever, chills, shakes, headache, muscle aches
Extreme tiredness
Dry cough, sore throat
Loss of appetite
Newborns and infants with high fever that can’t be explained
Young children - temps over 39.5 and febrile seizures
Cause of croup, pneumonia, bronchiolitis
Stomach upset, vomiting, diarrhoea, abdominal pain, earaches, red eyes
What conditions are classed as an URTI?
Common cold
Sore throat - pharyngitis, tonsillitis
Acute otitis media
Sinusitis
What can URTIs commonly cause?
Difficulty in feeding in infants - blocked nose
Febrile convulsions
Acute exacerbation of asthma
What is tonsillitis?
Form of pharyngitis
Intense inflammation of tonsils, purulent exudate
What are common causes of tonsillitis?
Group A beta haemolytic strep
EBV - infectious mononucleosis
Not possible to distinguish between bacterial and viral
What are some of the other symptoms in tonsillitis?
Marked constitutional disturbance, headache, apathy and abdo pain
White tonsillar exudate
Cervical lymphadenopathy
What is the management of tonsillitis?
Paracetamol, ibuprofen for pain
> 3 years use FeverPAIN to assess symptoms
0-1 no antibiotics
2-3 back up
4-5 antibiotics
Phenoxymethylpenicillin for 5 days
Clarithromycin if allergy
What is the fever pain score?
Fever - during prev 24 hrs Purulence - pus on tonsils Attend rapidly - within 3 days Severely Inflamed tonsils No cough or coryza
What is acute otitis media?
Inflammation of tympanic membrane
Severe pain
Presents over course of days to weeks
What is the cause of acute otitis media?
Bacterial infection
Nasopharyngeal organisms migrating via eustachian tube
Infection more likely due to short straight wide tube
S pneumonia
H influenza
M catarrhalis
S pyogenes
Viral - respiratory syncytial virus, rhinovirus
What are the risk factors for AOM?
Age - peak 6-15 months Gender - more in boys Passive - parenteral smoking Bottle feeding Craniofacial abnormalities
What are the risk factors for recurrent AOM?
Use of pacifiers
Those fed supine
first episode of AOM occurred <6 months
AOM most common in winter season
What are the clinical features of AOM?
Pain, malaise, fever
Coryzal symptoms
Last few days
May tug or cradle ear that hurts
Disinterested in food
Have vomiting
What is seen on examination of AOM?
Tympanic membrane erythematous, bulging on otoscopy
Perforation may lead to small tear and purulent discharge
Test and document function of facial nerve, check for any intracranial complications, cervical lymphadenopathy.
What are the main differentials for acute otitis media?
Chronic suppurative otitis media
Otitis media with effusion
Otitis externa
What are the investigations for AOM?
Most can be diagnosed clinically
Blood tests, FBC, CRP
Fluid sent for MC&S
Blood cultures
What is the management of AOM?
Most will resolve spontaneously 24 hrs - 3 days
Simple analgesia
Antibiotics should be avoided, watch and wait
Oral abx considered if
Systemically unwell
RFs e.g. congenital heart disease, immunosuppression
Unwell 4 days or more
Discharge from ear
Children younger than 2 with bilateral infections
Systemically unwell adults
When should inpatient admission be considered for AOM?
All children under 3 months with temp of >38
3-6 months with temp >39
Consider for those with evidence of AOM complication or systemically unwell
Those with cochlear implant
What are the complications of AOM?
Mastoiditis Meningitis Facial nerve paresis Intracranial abscess Sigmoid sinus thrombosis Chronic otitis media
What is otitis media with effusion?
Glue ear
Viscous inflammatory fluid within the middle ear, causing a conductive hearing impairment
What are the risk factors for otitis media with effusion?
Bottle fed Parental smoking Atopy Genetic disorders - mucociliary e.g. CF or primary ciliary dyskinesia Craniofacial disorders e.g. Down's
What are the clinical features of otitis media with effusion?
Difficulty hearing - in young children may be difficulty in attention, poor speech and language development
Sensation of pressure
Popping and crackling
On examination
Tympanic membrane dull
Light reflex lost - fluid, bubble behind TM
External ear normal
What is seen on audiometry in otitis media with effusion?
Pure tone audiometry and tympanometry - conductive hearing loss
Reduced membrane compliance
What is the management of otitis media with effusion?
Active surveillance, 50% cases resolve in 3 months
If no resolution - hearing aid insertion, or myringotomy and grommet insertion
Persistent disease and multiple grommit insertion consider adenoidectomy
What is otitis externa?
Inflammation of the external ear canal, acute or chronic
Acute < 3 weeks
Chronic > 3 months
Malignant is when the infection spreads to the mastoid and temporal bones causing osteomyelitis
What is the cause of otitis externa?
Infection of skin in external auditory canal
Bacterial infection - pseudomonas aeruginosa, staph aureus
Bacteria enter due to blockage, absence of cerumen due to excess cleaning, trauma, alteration of pH
Fungal infection
What are the risk factors of otitis externa?
Hot and humid Swimming Older age Diabetes Narrowing of ear canal Excessive cleaning Wax build up Eczema Trauma Radiotherapy to the ear
What are the clinical features of otitis externa?
Pain, itching, discharge, hearing loss Oedema Erythema Exudate Mobile tympanic membrane
Pain on moving tragus
Pre-auricular lymphadenopathy
What is the management of otitis externa?
Avoid getting ear wet
Remove discharge
Remove hearing aids, earrings
Use painkillers
Topical acetic acid or topical antibiotic
If cellullitis or extends out of ear canal - fluclox
If perforation ciprofloxacin
Topical neomycin sulphate
What is mastoiditis?
Intratemporal complication of otitis media, spreads to mastoid air cells
Air filled spaces in the mastoid process of the temporal bone, communicate with middle ear
What are the risk factors for mastoiditis?
More common in young children
Immunocompromised patients
Pre-existence of cholesteatoma
What is seen on examination of a child with mastoiditis?
Unwell child, lethargic Red bulging eardrum Ear discharge, perforation Oedema Tenderness behind pinna Pinna can be pushed forwards
Advanced disease - abnormal findings in abducens nerve or facial nerve
What are the investigations for mastoiditis?
Ear swab
Bloods - WCC, CRP
CT head and mastoid with contrast
MRI head
What is the management of mastoiditis?
IV abx inpatient acute
Co-amoxiclav or ceftriaxone
What is EBV?
Infectious mononucleosis
Most common in teenagers and young adults, 18-22
Most common transmission route is exchange of saliva by kissing
Incubation period 6 weeks
Sore throat Head and neck complaints General systemic upset Swollen neck Snoring, sleep apnoea
Feverish, headaches, nausea and vomiting, TATT
Cervical lymphadenopathy
Abdo tenderness, splenomegaly, hepatomegaly
What are the investigations for EBV?
FBCs
LFTs
Monospot for IgM
ELISA immunoassays
What is the management of EBV?
Benzylpenicillin if bacterial superinfection present
Hospital admission if stridor, dehydration severe, complication e.g. splenic rupture
What are some complications of EBV?
Post-viral fatigue Malignancy - lymphomas Guillain Barre syndrome Encephalitis Splenic rupture
What are the red flags for a child presenting with foreign body?
Any signs of airway compromise; stridor, dysphonia, drooling
Any signs of oesophageal perforation e.g. chest pain, features of sepsis, surgical emphysema
Any history of button battery ingestion
Mediastinal widening
What is kawasaki disease?
Systemic vasculitis
Mainly affect 6 months to 4 years old
Young children more commonly affected, incomplete cases - not all symptoms
What are the causes of a prolonged fever?
Infective -
localised infection, bacterial infections, IE, TB, virus e.g. EBV, CMV, HIV
Parasites e.g. malaria
Non infective - SLE, Kawasaki IBD Sarcoidosis Malignancy Drug fever Fabricated
What is the cause of kawasaki disease?
Unknown
Likely to be immune hyperreactivity to variety of triggers in genetically susceptible host
How is a diagnosis of Kawasaki disease made?
Made on clinical findings
Irritable children
High fever hard to control
High inflammatory markers
Platelet count rises after 2nd week of illness
Coronary arteries can be affected, can lead to aneurysms
What is the treatment of kawasaki disease?
Prompt treatment with IV immunoglobulin in first 10 days to reduce risk of coronary artery aneurysms
Aspirin reduces risk of thrombosis
High dose until inflammatory markers are normal, then at antiplatelet dose until echo reveals present or absent aneurysms
Persistent inflammation and fever may require treatment with infliximab, steroids of ciclosporin.
What are the features of kawasaki syndrome?
High grade fever lasts for >5 days, resistent to antipyretics
Conjunctival infection
Bright red, cracked lips
Strawberry tongue
Cervical lymphadenopathy
Red palms of the hands and soles of feet, later peel
Why is aspirin usually contraindicated in children?
Risk of Reye’s syndrome - severe progressive encephalopathy
accompanied by fatty infiltration of liver, kidneys and pancreas
What are the four species of malaria?
Plasmodium falciparum
Vivax
Ovale
Malariae
What are protective factors of malaria?
Sickle-cell
G6PD deficiency
HLA-B53
Absence of Duffy antigens
What are the features of malaria?
Fever, headache, splenomegaly
malariae associated with nephrotic syndrome
Diarrhoea, vomiting, flu like symptoms, jaundice, anaemia, thrombocytopenia
Children particularly vulnerable to severe anaemia and cerebral malaria - seizures, coma
Falciparum, severe malaria - Schizonts on blood film Parasitaemia Hypoglycaemia Acidosis Temp >39
What is the management of falciparum malaria?
Observation in hospital for at least 24 hours due to possibility of rapid progression
Artemisinin combination therapy first line
Oral quinine alternative, can add doxycycline or clindamycin
Who should doxycycline not be prescribed to?
Children under 12 years
Due to risk of dental hypoplasia and permanent discolouration of teeth
What is the management of non-falciparum malaria?
Artemisinin combination therapy or chloroquine
Primaquine can be given with chloroquine for radical cure, but screen for G6PD deficiency
What is measles?
Rarely seen in developed world
RNA paramyxovirus
Infective from prodrome until 4 days after rash starts
What are the features of measles?
Prodrome - irritable, conjunctivitis, fever
Koplik spots - before rash, white spots on buccal mucosa
Rash starts behind ears, then whole body, discrete maculopapular rash becomes blotchy and confluent
May desquamate in second week
Diarrhoea
Encephalitis - headache, lethargy, irritability, convulsions, coma
Subacute sclerosing panencephalitis - loss of neurological function
What are some of the complications of measles?
Otitis media Pneumonia - most common cause of death Febrile convulsions SSPE, encephalitis Hepatitis Appendicitis Corneal ulceration Myocarditis
What is the management of measles?
Mainly supportive
Admission if immunocompromised or pregnant
Notifiable disease
If immunocompromised, ribavirin may be used - antiviral
Vitamin A may modulate immune response, given in developing countries
What is mumps?
Viral infection spread by respiratory droplets
Incubation period 14-25 days
Self limiting, lasts 1 week
What is the presentation of mumps?
Flu like symptoms prodrome, before parotid swelling
Fever Muscle aches Lethargy Reduced appetite Headache Dry mouth
Parotid gland swelling is unilateral or bilateral, pain
Abdominal pain - pancreatitis
Testicular pain and swelling - orchitis
Confusion, neck stiffness, headache - meningitis, encephalitis
What is the management of mumps?
Diagnosis confirmed with PCR
Blood or salvia for antibodies to mumps virus
Notifiable disease
Management supportive
Rest, fluids, analgesia
What are the complications of mumps?
Pancreatitis
Orchitis
Meningitis
Sensorineural hearing loss
What is rubella?
German measles
Can cause damage to fetus
Incubation period 15-20 days
Spread by respiratory route
What are the features of rubella?
Prodrome of low grade fever
Maculopapular rash
Initially covers face, then spreads across body
Rash not itchy in kids
Lymphadenopathy - suboccipital and postauricular
What are the complications of rubella?
Arthritis
Thrombocytopenia
Encephalitis
Myocarditis
What is congenital rubella syndrome?
If contracted in pregnancy, is a risk
Sensorineural deafness Congenital cataracts Congenital heart disease Growth retardation Hepatosplenomegaly Purpuric skin lesions Microphthalmia Cerebral palsy
What type of TB is more likely to progress in children?
TB infection - latent TB compared to disease
Children usually acquire TB from an infected adult in the household
What is TB?
Due to mycobacterium tuberculosis
Chronic granulomatous disease
Spread by inhalation of infected droplets
First encounter - host macrophages engulf and carry to hilar lymph nodes
Small granulomas form containing mycobacteria
Miliary TB - primary not well controlled, invades bloodstream
What are the clinical features of TB in children?
More non-specific than adults Prolonged fever Malaise Anorexia Weight loss Focal signs of infection
Nearly half of infants and older children show minimal signs
Disease remains latent, may develop into active disease at later time
CXR changes
Cough
Post primary TB upon reactivation
Miliary TB to bones, joints, kidneys, pericardium, CNS
What are the investigations of TB?
Sputum sample generally hard as swallow sputum
Gastric washings on three consecutive mornings to culture acid-fast bacilli
NG into stomach, rinsed with saline before food
urine, lymph node excision, CSF, radiology if appropriate
If suspected - mantoux test but could be positive if past infection
Interferon gamma release assay blood test
What is the management of TB?
RIfampicin, isoniazid, ethambutol, pyrazinamide
Rifampicin and isoniazid after 2 months
After puberty, pyridoxine given weekly to prevent peripheral neuropathy associated with isoniazid therapy
Tuberculous meningitis - dexamethasone given for first month at least
Asymptomatic children who are mantoux positive and therefore latently infected treated
e.g. rifampicin and isoniazid for 3 months
What is the concept of vaccinations?
Weakened (attenuated) or inactive version of pathogen
Stimulates immune response and leads to immunity
What are examples of inactivated vaccines?
Killed version of infection
Safe for immunocompromised
Polio
Flu vaccine
Hepatitis
Rabies
What are examples of subunit and conjugate vaccines?
Contain part of the organism, which is needed to stimulate an immune response
Also safe for immunocompromised
Pneumococcus Meningococcus Hepatitis B Pertussis - whooping cough Haemophilus influenza type B HPV Shingles - HZV
What are examples of live attenuated vaccines?
Measles, mumps, rubella BCG Chickenpox Nasal influenza Rotavirus
What are examples of toxin vaccines?
Contain a toxin normally produced by the pathogen, not the pathogen itself
Diphtheria and tetanus
What vaccinations are given at 8 weeks?
6 in 1
Diphtheria, tetanus, pertussis, polio, Hib, Hep B
Meningococcal type B
Rotavirus - oral vaccine
What vaccinations are given at 12 weeks?
6 in 1 - again
Pneumococcal
Rotavirus - again
What vaccinations are given at 16 weeks?
6 in 1 again
Meningococcal B again
What vaccinations are given at 1 year?
2 in 1 - haemophilus and meningococcal type C
Pneumococcal - again
MMR
Meningococcal type B again
What vaccination is given yearly from ages 2-8?
Influenza - nasal vaccine
What vaccinations are given at 3 years 4 months?
4 in 1
Diphtheria, tetanus, pertussis and polio
MMR - again
What vaccination is given aged 12-13?
HPV vaccine
2 doses given 6 to 24 months apart
What vaccination is given at 14 years?
3 in 1 - tetanus, diphtheria, polio
Meningococcal ACWY
What is the HPV vaccine?
Given before sexually active
Gardasil
Protects against strains 6 and 11 - genital warts, strains 16 and 18 - cervical cancer
What are the complications of chickenpox?
Secondary bacterial infection with staphylococci, group A strep
Encephalitis
Purpura fulminans - consequence of vasculitis in the skin
Fever from chickenpox which settles and then recurs is likely due to secondary bacterial infection
CNS - cerebellitis, encephalitis, aseptic meningitis
Immunocompromised - haemorrhagic lesions, pneumonitis, DIC
What are the clinical features of chickenpox?
Papules, become vesicles, becomes pustules, becomes crusty rash
Rash comes in crops for 3-5 days
200-500 lesions start on head and trunk, progress to peripheries
What is the treatment for chickenpox?
Symptomatic
Valaciclovir if immunocompromised
Human varicella zoster immunoglobulin given for immunocompromised high risk patients
What does recurrent or multidermatomal shingles suggest?
A T cell immune defect
More common in those who had chickenpox primary infection in first year of life
Due to reactivation of varicella zoster virus
How is CMV transmitted?
Saliva, genital secretions, breast milk
More rarely blood products, organ transplants
What are the features of CMV and how is it treated?
Atypical lymphocytes
Most common cause of non-genetic hearing loss at birth
Pneumonia, hepatitis, rash
Tiredness, muscle aches, headache, fever, mono symptoms
IV ganciclovir
What are the classic childhood exanthems?
First disease - measles
Second disease - Scarlet fever - streptococcus
third disease - Rubella - rubella virus
Fifth disease - erythema infectiosum - parvovirus B19
Sixth disease - roseola - human herpes 6B or 7
What are enanthems?
Eruptive lesions of the mucous membranes occurring as a symptom of disease
What is scarlet fever?
Group A beta haemolytic strep
Sore throat, headache, fever, tender cervical lymphadenopathy, malaise
Erythematous rash
Strawberry tongue
Pharyngitis
Do strep antibody test, throat swab
Notifiable disease, treat with penicillin V or erythromycin or cephalosporin
What is erythema infectiosum/parvovirus B19?
Slapped cheek
Asymptomatic
Infectiosum - fever, malaise, headache, slapped cheek rash one week later
Aplastic crisis - serious consequence in those with chronic haemolytic anaemias or immunodeficient
Fetal disease - transmission of maternal infection could lead to fetal hydrops
Treatment largely symptomatic
What is roseola?
Sixth disease
Herpesvirus 6 or 7
HHV-6 common benign illness, common cause of fever and febrile seizures
Palpebral oedema Uvulopalatal junction ulcers Erythematous papules on soft palate - Nagayama's spots Diarrhoea Cough
What is the cause of viral gastroenteritis?
Infection of the gastrointestinal tract, usually by rotavirus
Usually self limiting
If untreated can result in morbidity and mortality secondary to dehydration, electrolyte imbalance, metabolic acidosis
What are the key diagnostic factors for viral gastroenteritis?
Vomiting Non-bloody diarrhoea Hyperactive bowel sounds Abdominal pain Low grade fever Evidence of dehydration Decreased body weight
What are the risk factors fo viral gastroenteritis?
Age <5 years Poor personal hygiene Exposure to those with it Day-care attendance Winter months Poverty Lack of immunisation against rotavirus Lack of breastfeeding Immunodeficiency
What are the investigations for viral gastroenteritis?
Clinical examination Serum electrolytes, urea, creatinine FBC Stool microscopy Stool culture
What is the treatment of viral gastroenteritis?
No dehydration - fluids, age appropriate diet, ondansetron for vomiting
If mod dehydration - 100ml/kg oral rehydration therapy over 4 hours, or may need NG tube
If severe dehydration - Ringer’s lactate over 1 hour or 20ml/kg IV normal saline over 1 hour
