Infectious diseases Flashcards
Give the various definition of fever
- fever: a practical definition is >38ºC/100.4ºF oral or rectal
- fever without a source/focus: acute febrile illness (typically <10 d duration) with no cause of fever even after a careful history and physical
- fever of unknown origin: daily or intermittent fevers for at least 2 consecutive wk of uncertain cause after careful history and physical, and initial laboratory assessment
What is fever protocol for babies less than 28 days and those 28-90 days and 3months -3 years?
- Age: <28 d Admit, Full SWU
- Age: 28-90 d NON-TOXIC and Reliable follow-up and Low-risk criteria
- Do Partial SWU+Abx
- May consider treating as outpatient or
- Consider observation without antibiotics
- All others: Admit, Full SWU, empiric antibiotic
- Age: 3 mo-3 yr
- TOXIC: Admit, Full SWU, empiric antibiotic
- NON-TOXIC and NO FOCUS
- T >39ºC Urine R&M,CBC
- WBC >15 :Blood C&S
- if NO source of infection can be identified, then empirical treatment can be used(i.e. amoxicillin or ceftriaxone 50 mg/kg IM should be started)Urine C&S Acetaminophen
- WBC <15:Blood C&S
- Observation Acetaminophen follow-up in 24 h
- 2.T <39ºC: Urine R&M observation
Fever management steps
Management of fever
• admit to the hospital if appropriate
• treat the source if known
• replace fluid losses (e.g. from vomiting, diarrhea); maintenance fluid needs are higher in a febrile child
• REASSUREparents that most fevers are benign and self-limited
• antipyretics (acetaminophen and/or ibuprofen) may be given if the child is uncomfortable
Describe the Rochester criteria
Rochester Criteria – Developed to Identify Infants ≤60 d of Age with Fever at Low-risk of Serious Bacterial Infection
Clinically Well
WBC Count 5-15 x 109/L
Bands <1.5 x 109/L
Urinalysis <10 WBC/high-power field
Stool
(if diarrhea) <5 WBC/high-power field
Past Health Born >37 wk
Home with/before mom
No hospitalizations
No prior antibiotic use
No prior treatment
for unexplained
hyperbilirubinemia
No chronic disease
List the various differentials of fever.
- Infectious: anatomic approach (CNS, ears, upper and lower respiratory tract, GI, GU, skin, soft tissue, bones and joints, etc.)
- Inflammatory: mainly autoimmune (Kawasaki disease, JIA, IBD, SLE, etc.)
- malignancy: childhood cancers (leukemia, lymphoma, neuroblastoma, etc.)
- miscellaneous: drugs and toxins, post-immunization, familial dysautonomia, factitious disorder,
What organisms are responsible for Otitis media in children?
- bacterial – S. pneumoniae (decreasing since the introduction of PCV7 and PCV13), H. influenza, M.catarrhalis, group A Streptococcus (GAS)
- less common - anaerobes (newborns), Gram-negative enterics (infants)
- viral – more likely to spontaneously resolve
Discuss the risk factors of Otitis media
• Eustachian tube related:
■ dysfunction/obstruction (URTI, allergic rhinitis, chronic rhinosinusitis, adenoid hypertrophy,
barotrauma)
■ inadequate tensor palatine function (cleft palate)
■ genetic syndromes (DS, Crouzon, Apert)
■ cilia disruption (Kartagenger’s syndrome, CF)
• genetic predisposition (family history, ethnicity – First Nations peoples and Inuit, low levels of secretory
IgA or persistent biofilm in the middle ear)
• behavioral and environmental exposures (not breastfed or shorter duration of breastfeeding, prolonged bottle feeding, bottle feeding laying down, pacifier use, second-hand smoke exposure,crowded living conditions/daycare, sick contacts)
• immunosuppression/deficiency (chemotherapy, steroids, DM, hypogammaglobulinemia, CF)
Describe the clinical features of Otitis media
• acute onset of symptoms
• triad of otalgia, fever (especially in younger children), and conductive hearing loss – not all symptoms
such as fever or hearing loss may be present
• rarely tinnitus, vertigo, and/or facial nerve paralysis
• otorrhea if tympanic membrane perforated
• infants/toddlers: ear-tugging (this alone is not a good indicator of pathology), hearing loss, balance disturbances (rare), irritable, poor sleeping, vomiting, and diarrhea, anorexia
• otoscopy of TM: hyperemia, bulging, pus may be seen behind TM, loss of landmarks (e.g. handle and long process of malleus not visible), discoloration (hemorrhagic, grey, red, yellow
What are the three ‘must be criteria for making the diagnosis of Otitis media?
all of:
- presence of middle ear effusion
- presence of middle ear inflammation
- acute onset of symptoms of middle ear effusion and inflammation
Discuss step by step management of Otitis media
- >6 mo of age, generally healthy Acute onset of illness With or without fever and may or may not manifest other signs of middle ear dysfunction (e.g. vomiting) or pain, depending on age and verbal skills Suspected acute otitis media
1. Perforated tympanic membrane with purulent drainage - Treat with antimicrobials for 10 d
2. MEE present AND Bulging tympanic membrane
Mildly ill
Alert, responsive, no rigors, responding to antipyretics, mild otalgia, able to sleep
<39°C in absence of antipyretics
<48 h of illness
- After discussing with caregivers, observe for 24-48 h and ensure follow-up medical care (recommend analgesia)
- If not clinically improved or if worsening, treat with antimicrobials (10 d if 6 mo-2 yr of age and 5 d if >2 yr)
Moderately or severely ill
Irritable, difficulty sleeping, poor response
to antipyretics, severe otalgia
OR >39°C in absence of antipyretics
OR >48 h of symptoms
- Treat with antimicrobials for 10 d if 6 mo-2 yr of age and for 5 d if >2 yr
3. Without MEE OR with MEE but non-bulging or mildly
Consider viral etiology such as RSV, influenza, etc. or other infection
Reassess in 24-48 h if not clinically improved or earlier if clinically worsening, to verify the presence of effusion and signs of middle ear inflammation such as bulging tympanic membrane erythematous tympanic membrane
List the complications of Otitis media
- extracranial: hearing loss and speech delay (secondary to persistent middle ear effusion), TM perforation, extension of suppurative process to adjacent structures (mastoiditis, petrositis, labyrinthitis), cholesteatoma, facial nerve palsy, middle ear atelectasis, ossicular necrosis, vestibular dysfunction
- intracranial: meningitis, epidural and brain abscess, subdural empyema, lateral and cavernous sinus thrombosis, carotid artery thrombosis
Define Otitis media with effusion
presence of fluid in the middle ear without signs or symptoms of ear infection
Discuss the clinical features of Otitis media with effusion
• fluctuating conductive hearing loss ± tinnitus
• fullness in ear, balance problems
• ± pain, low-grade fever
• otoscopy of TM
■ discoloration – amber or dull grey
■ meniscus fluid level behind TM
■ air bubbles
■ retraction pockets/TM atelectasis
■ flat tympanogram
■ most reliable finding with pneumatic otoscopy is immobility
Who would you treat otitis media with effusion?
• expectant: 90% resolve by 3 mo
• document hearing loss with an audiogram
• no statistical proof that antihistamines, decongestants, antibiotics clear disease faster
• surgery: myringotomy with tympanostomy (ventilation) tubes ± adenoidectomy (if enlarged or on
insertion of second set of tubes after first set falls out)
• tympanostomy (ventilation) tubes to equalize pressure and drain ear
List the complications of otitis media with effusion
- hearing loss, speech delay, learning problems in young children
- chronic mastoiditis
- ossicular erosion
- cholesteatoma especially when retraction pockets involve pars flaccida
- retraction of tympanic membrane, atelectasis, ossicular fixation
Hirschsprung’s disease
History
Physical examination
Investigations
History
- Delayed meconium
- FTT
- Bilious vomiting
- Chronic constipation since birth
Physical examination
- Abdo distension
- DRE: tight anal sphincter, empty ampulla, blast sign (expulsion of gas and stool after DRE)
Investigations
- Barium enema: narrow/normal rectum, dilated colon proximal to aganglionic segment, with transition zone
Definitive Dx by rectal biopsy: absence of ganglion cells
Pyloric stenosis
Suggestive Findings
- Projectile non-bilious emesis within 30mins after feeding, fatigue, dehydrated, palpable “olive” in RUQ, decreased stools, hunger
Diagnostic approach
- CBC, electrolytes, Cr, BUN, ABG (hypokalemia, hypochloremic metabolic alkalosis),
- U/S of the pylorus, upper GI study (if U/S nondiagnostic)
Pyloric stenosis 2
History
- Symptom onset 3–8 wk old
- FTT, “ hungry vomiter”
- M > F
- Projectile non-bilious vomiting, immediately postprandial
Physical examination
- ± Visible peristalsis
- Possible palpable epigastric mass (“olive sign”)
Investigations
- U/S: hypertrophied pylorus (increased muscle thickness and length)
- Lytes/blood gas: hypochloremic, hypokalemic metabolic alkalosis
GERD
Suggestive Findings
- Fussiness after feeds
- spit-ups
- arching of back
- poor weight gain
Diagnostic Approach
- Empiric trial of acid suppression,
- pH monitoring study
- upper GI study
- endoscopy
GERD 2
History
- Regurgitation/emesis,
- feeding aversion,
- “ colicky baby,” irritable
- Apnea,
- stridor,
- aspiration,
- wheeze
- Sandifer syndrome: back-arching, chin lifting, neck contortions due to discomfort
Physical examination
- ± FTT (in GERD)
- ± Hoarseness/stridor/wheeze
Investigations
- Empiric trial of acid suppressant
- Endoscopy: esophagitis
- 24- ph probe /impedance study: acidic/nonacidic reflux, strength of association with suspected signs/symptoms
- ± Upper GI series: R/O obstruction/stenosis, malrotation
Management of GERD
conservative (infant)
- thickened feeds
- frequent and smaller feeds
- elevation of head
- changing formula to hydrolyzed protein or amino acid-based formula
■ breastfeeding infants – mothers exclude milk and egg in diet
conservative (older children/aldoscent)
- same as adult management
- diet helps symptoms, not the disease;
- avoid EtOH, coffee, spices, tomatoes, and citrus juices
- only beneficial lifestyle changes are weight loss (if obese) and elevating the head of bed (if nocturnal symptoms)
medical
■ short-term parenteral feeding to enhance weight gain
■ H2-blocker, PPI: decreases gastric acidity, decreases esophageal irritation
◆ recommended when failure of conservative measures, moderate – severe disease or biopsyproven
esophagitis
■ domperidone, metoclopramide: generally not recommended for GERD, reserved when concurrent
gastroparesis
◆ acid-suppressants or motility agents not recommended for infants with uncomplicated reflux
• interventional (indicated for failure of medical therapy):
■ Nissen fundoplication
■ insertion of gastrojejunal tube for post-pylorus feeds
Complications of GERD
Complications
- esophagitis
- strictures
- Barrett’s esophagus
- FTT
- aspiration
- oral feeding aversion
