INFECTIOUS DISEASES Flashcards
1
Q
What is the difference in location between congenital CMV and Toxoplasmosis CNS lesions?
A
CMV: periventricular calcifications
Toxoplasmosis: calcifications scattered throughout cortex
2
Q
What are clinical features of congenital CMV infection?
A
Cataracts
Purpuric rash ("blueberry muffin")
Seizures from CMV CNS lesions
Hepatosplenomegaly
IUGR
Microcephaly
Prolonged neonatal jaundice
3
Q
What cells are involved in humoral immunity? What cells are involved in cellular immunity?
A
Humoral: B-cell
Cellular: T-cell
4
Q
Testing for HIV in child < 18 months?
Testing for HIV in child > 18 months?
A
Child < 18 months: cannot do HIV ELISA looking for antibodies against HIV since will still have maternal antibodies in system. Need to perform HIV DNA PCR which needs to be positive on two separate occasions
Child > 18 months: HIV ELISA (enzyme linked immunosorbent assay to look for HIV IgG: 99% specificity and sensitivity); if positive, confirm diagnosis with Western Blot (direct visualization of antibodies against the virus)
5
Q
What is a soft tissue complication of varicella infection?
A
GAS invasive soft-tissue infection: necrotizing fasciitis, myositis, cellulitis, toxic shock syndrome
Treatment: Penicillin and clindamycin
6
Q
What is the classical triad of Wiskott-Aldrich syndrome?
- Complications (2)
- mode of inheritance
A
Classic triad (in 1/3 of patients):
- Eczema
- Thrombocytopenia
- Immunodeficiency
Complications:
- Immunodeficiency:
- T and B cell function is reduced
- recurrent pneumonia/otitis media/sepsis/meningitis/sinusitis
- progressive
- can have hepatomegaly - Risk of malignancy (10-20%)
- leukemia/lymphoma
Mode of inheritance:
-X-linked
7
Q
How do neonates with Wiskott-Aldrich usually first present?
A
Present at birth with thrombocytopenia features: bruising, petechiae, bloody diarrhea
Eczema by 1st month of life, recurrent infections by 3 months of life
8
Q
In Wiskott-Aldrich, describe the levels of immunoglobulins seen.
A
IgA & IgE: elevated
IgM: reduced
IgG: normal, reduced or elevated
9
Q
What investigations should be ordered for 1-3 mo febrile infants meeting clinical criteria for low risk SBI?
A
- CBC + diff
- Blood culture
- Bag for urine –> cath if positive
10
Q
In febrile patients, when should a UA always be ordered? (5)
A
- All boys age < 6 months
- Uncircumcised males
- All females < 2 years old
- Prior diagnosis of UTI
- Known renal abnormality
11
Q
What is the definition of a UTI?
A
- Urine with > 10 wbc/hpf
- Colony count of single organism > 50,000/ml
- **Remember that if child has been symptomatic < 48 hrs, may have absence in WBCs
- absence in WBCs in urine does not rule out UTI!
12
Q
In children 3-36 months, what percentage of fevers are viral in origin?
A
> 95%
13
Q
Clinical presentation of lyme disease (6)?
A
- Arthritis
- Erythema migrans: painless, annular, central clearing, minimum size 5 cm
- Aseptic meningitis
- Cranial nerve palsies
- Heart block
- Ocular involvement
14
Q
What are the most common clinical presentations of urethritis (2)?
-What is the most common etiology of urethritis?
A
- Dysuria
- Penile discharge
Most common etiology: Chlamydia trachomatis (3x more common than Neisseria gonorrhoeae)
15
Q
What is the best test for chlamydia and gonorrhea?
A
Urine PCR
16
Q
What is the management of a patient diagnosed with urethritis?
- medical therapy
- advice to give patients (ie. how long to abstain from sex)
A
- Empiric treatment for chlamydia and gonorrhea
- Azithromycin 1 g PO x 1 for chlamydia
- Ceftriaxone 250 mg IM x 1 for gonorrhea - Instruct patients to abstain from sexual intercourse x 1 wk after single-dose therapy and until all partners are treated to prevent reinfection
- Test for other possible STIs (syphillis, HIV, hepatitis, etc.)
17
Q
What is a possible GI side effect of ceftriaxone?
A
Increased gallbladder sludge and subsequent cholelithiasis
18
Q
What is the pathophysiology of retropharyngeal cellulitis/abscess?
A
The retropharyngeal nodes that drain the mucosal surfaces of the upper airway and digestive tracts (between the pharynx and the cervical vertebrae, extending down into the mediastinum) become infected
- once infected, the nodes progress through 3 stages: cellulitis, phlegmon, abscess
- most patients have history of recent ear/throat/nose infection
19
Q
What are the possible causes of retropharyngeal abscess?
A
- Localized infection of oropharynx extending to the retropharyngeal lymph nodes
- Penetrating trauma
- Vertebral osteomyelitis
- Dental infection
20
Q
Retropharyngeal abscess are most common in what age group and why?
A
Most common in children < 5 years old
-after the age of 5, retropharyngeal nodes involute and thus infection is much less common in older children and adults
21
Q
What are clinical manifestations of retropharyngeal abscess? (7)`
A
Think upper airway obstruction!
- Respiratory distress
- Stridor
- Drooling
- Fever
- Refusal to eat
- Obstructive sleep apnea
- Neck stiffness/torticollis
22
Q
What is the differential diagnosis of retropharyngeal abscess? (5)
A
- Acute epiglottis
- Lymphoma
- Meningitis (if neck stiffness present)
- Foreign body aspiration
- Vertebral osteomyelitis
23
Q
What is the underlying bacterial etiology of retropharyngeal abscess?
A
Polymicrobial! Most commonly:
- GAS
- Staph aureus
- Oral anaerobes
24
Q
What is the treatment for retropharyngeal abscess?
- abx choice
- indications for surgical drainage (2)
A
Intravenous antibiotics until clinical improvement, then switch to PO abx (ideal duration of treatment unknown)
- 3rd generation cephalosporin + clindamycin
- studies have shown that > 50% of children can be successfully treated without surgical drainage
Indications for surgical drainage:
- Respiratory distress
- Failure to improve with IV abx
25
What are 4 complications of retropharyngeal abscess?
1. Significant upper airway obstruction
2. Rupture leading to aspiration pneumonia
3. Extension into mediastinum
4. Thrombophlebitis of internal jugular vein
26
What is Lemierre disease?
| -causative organism
Infection from the oropharynx extending to cause septic thrombophlebitis of the internal jugular vein and embolic abscesses in the lungs
- causative organism: fusobacterium necrophorum (oral anaerobe)
- most commonly seen in pharyngitis where peritonsillar abscess forms (ie. with GAS) and this allows the oral anaerobes to flourish within the abscess and then spread to the IJV
- infected clot forms within the IJV and can throw off emboli
27
What is the Rochester Criteria?
- 4 clinical criteria
- 4 laboratory criteria
Used for management of febrile infants 1-3 months of age: if ALL criteria are present, then the risk of having occult bacteremia is < 1% and only have to do PSWU
Clinical criteria:
1. Well appearing infant
2. No evidence of skin, soft tissue, bone, joint or ear infection
3. Term infant
4. No prior illness (ie. hospitalizations, not hospitalized longer than mom after delivery, no prior antibiotics, no jaundice, no chronic illness)
Laboratory criteria:
1. WBC 5-15 x 10^9
2. Bands < 1.5 x 10^9
3. Urine WBC < 10
4. Stool WBC < 5
28
What are the live vaccines?
BOY LoVe The crIME
- BCG
- OPV
- Yellow fever
- Live vaccines
- Varicella
- Typhoid
- Influenza (intranasal)
- Measles/mumps
- Epidemic typhus
29
A septic baby is born preterm to a mother with a febrile, flu-like illness. The placenta was noted to have white nodules. On later imaging, the infant's organs was noted to have microabscesses. What infectious organism is the most likely culprit?
Listeria monocytogenes
30
What is the chance of acquisition of neonatal HSV infection for:
- an infant born via SVD to a mother with primary HSV genital infection?
- an infant born via SVD to a mother with recurrent HSV genital infection?
Infant born to mom with primary HSV infection: 50%
Infant born to mom with recurrent HSV infection:1-3% (due to less viral shedding and presence of maternal neutralizing antibody)
31
You scrape the base of a vesicle found on an infant and send it for the Tzanck test. You see multinucleated giant cells. What is the differential diagnosis? (3)
1. HSV
2. Varicella
3. CMV
32
What are the clinical features of infantile botulism?
- which organism and found from which sources (3)?
- why are infants affected but not older children?
- diagnosis?
- treatment?
Clostridium botulinum: intestinal colonization occurs from ingestion of spores from honey, dust, soil
- spores secrete neurotoxin that irreversibly prevents acetylcholine, thus see anticholinergic effects
- clinical features: constipation, urinary retention, symmetric progressive weakness (paralysis), ptosis, diplopia, respiratory failure, poor feeding
- in older children, they have to ingest the actual neurotoxin itself (may be present in foods) to cause disease; eating spores alone does not result in disease since the spores cannot germinate and produce neurotoxin in the gut of a child > 1 yo
- in infants <1 yo, they have lower levels of gastric acid, decreased immune system function, and decreased normal intestinal flora and thus, spores can germinate in their intestines and secrete neurotoxin
- diagnosis: presence of botulinum toxin in stool
- treatment: supportive care & human-derived botulinum antitoxin
33
Which medications are contraindicated in infantile botulism?
Aminoglycosides! Worsen neuromuscular blockade
34
What are the clinical features of infectious mononucleosis?
- infectious etiology?
- complications (4)
EBV infection = infectious mononucleosis
- clinical features: fever, exudative pharyngitis, fatigue, lymphadenopathy, hepatosplenomegaly, tonsillar hypertrophy
- complications:
1. Splenic rupture
2. Encephalitis
3. Hemolytic anemia/thrombocytopenia
4. Airway obstruction
5. Malignant association: Burkitt lymphoma, Hodgkin disease, etc.
35
What is the utility of a Monospot to diagnose infectious mononucleosis?
Monospot = looks for heterophile antibodies produced by the immune system to EBV
- sensitive test in children > 4 yo (present in >90% if has infection)
- in children < 4 yo, NOT a sensitive test; thus, specific serologies should be drawn (IgM & IgG for EBV)
36
What is the organism causing cat-scratch disease?
| -what are the clinical features? (1 predominant, 3 less common, 1 particularly in immunocompromised patients)
Bartonella Henselae (gram negative bacillus)
- clinical features:
1. Regional lymphadenopathy (predominant)
Less common:
2. Parinaud oculoglandular syndrome: inoculation of eyelid conjunctiva --> conjunctivitis and ipsilateral preauricular lymphadenopathy
3. Liver and spleen granulomas
4. Encephalitis
Immunocompromised:
5. Bacillus angiomatosis: proliferation of blood vessels --> tumor like masses in skin and organs
37
How do you diagnose cat-scratch disease?
| -treatment for: mild disease? Severe disease?
Serology
- mild disease: supportive care; self-limited with resolution in 2-4 mo, no need for abx
- severe or systemic disease: 5 d course of azithromycin to treat severe, painful lymphadenopathy but does not shorten duration of symptoms
38
What are the classic clinical features of roseola?
- infectious etiology?
- treatment?
3-5 d of high fever followed by macular papular rash which appears on TRUNK first, then spreads to extremities/neck/face as the fever resolves.
- associated with febrile seizures
- infectious etiology: Human herpes virus 6
- treatment: supportive care
39
What is the definition of AIDS?
1. CD4 count 200 or less in a patient with HIV
OR
2. The presence of an opportunistic infection in a patient with HIV
40
For a newborn born to HIV positive mom, what testing do you perform and when do you perform it?
-treatment until results are back?
1. HIV PCR at 14-21 d; if negative, repeat at 2 and 6 mo.
2. If still negative, HIV antibodies assay (ELISA) at 18 mo.
- treatment: zidovudine is given to mother prenatally, during L&D. Then start zidovudine for infant x 6 wks or until HIV PCR is back.
41
In general terms, what are the different classes of antiretroviral agents? (4)
-when initiating therapy, what is the principle?
1. Nucleoside reverse transcriptase inhibitors (NRTI)
2. Non-nucleoside reverse transcriptase inhibitors (NNRTI)
3. Protease inhibitors
4. Fusion inhibitors
- use combination of 3 or 4 agents from at least 2 classes
42
What are the complications of influenza infection? (5)
1. Pneumonia with staph aureus, strep pneumo, GAS
2. Otitis media
3. Myocarditis
4. Encephalitis
5. Guillain Barre syndrome
43
How is malaria transmitted?
- which species of parasite causes the most severe disease?
- clinical features?
- diagnosis?
By the saliva of a female Anopheles mosquito - carries plasmodium protozoa (intracellular)
- most severe disease is seen with plasmodium falciparum
- clinical features:
1. High fever
2. Chills
3. Hemolysis (anemia, jaundice, splenomegaly)
4. Cerebral malaria: increased ICP, seizures, coma, death
- diagnosis: thick and thin blood smears several samples per day x 3 days to identify parasite (thick is better to identify that parasite is there, thin is to identify species)
44
The treatment of malaria is guided by which 3 main factors?
1. Clinical status of patient: non-severe vs. severe
2. Plasmodium species
3. Drug susceptibility of the infecting parasite
45
What is the treatment for malaria?
- ie. which patients should receive oral vs. IV antimalarials?
- how long to continue treatment?
For patients with non-severe, uncomplicated malaria, can treat with PO antimalarial (chloroquine = main one, other choices include primiquine, atovaquone proguanil or quinine sulfate plus doxycycline/tetracycline/clindamycin or mefloquine)
Patients with the following factors should receive IV antimalarials (IV quinidine plus doxycycline/tetracycline/clindamycin):
1. Severe hemolysis: severe anemia, bleeding, jaundice, hemoglobinuria
2. ARDS
3. DIC
4. Renal failure
5. Impaired consciousness
6. Parasitemia > 6%
-continue therapy until parasite level < 1% (usually within 48 hrs) and patient can tolerate PO antimalarial
46
Which malaria species can result in relapse due to their latent hepatic stages?
-which malaria species can cause chronic asymptomatic parasitemia that can persist for several years?
- Latent hepatic stages: Plasmodium vivax and ovale
| - chronic asymptomatic parasitemia: Plasmodium malariae
47
When is a person with measles contagious?
5 days prior to onset of rash to 4 days after
48
What are the clinical features of measles? (3 Cs)
- what is the characteristic rash seen with measles?
- how do you diagnose measles?
Measles (paramyxovirus):
1. Cough
2. Conjunctivitis
3. Coryza
- also see fever and Koplik spots
- Morbilliform rash starting from head and spreading downwards (happens on day 5 of illness)
- diagnose measles with IgG and IgM serology
49
What are the complications of measles? (4)
| -which is the most scary?
1. Pneumonia
2. Croup
3. Otitis media
4. Subacute sclerosing panencephalitis
- rare degenerative encephalitis characterized by dementia and intellectual deterioration with seizures occurring many years after initial infection (11 yr on average)
50
What is the treatment for measles?
| -who should receive prophylactic treatment after exposure to measles? (3)
Supportive treatment
- prophylactic treatment with IVIG within 6 days of exposure REGARDLESS of immunization status should occur for:
1. Pregnant women
2. Immunocompromised
3. Infants < 1 yo
51
What are the 3 main areas of the world where malaria is found?
1. Africa
2. Asia
3. South America
52
Which population of people resist are immune to malaria?
Hemoglobin S - sickle cell anemia patients
53
What is the life cycle of a plasmodium parasite?
1. Exoerythrocytic phase:
- inoculation of parasite into bloodstream by female Anopheles mosquito
- enters hepatocytes and multiplies asexually
- hepatocytes burst releasing thousands of parasites into blood stream
2. Erythrocytic phase:
- parasites then enter the erythrocyte and multiplies asexually
- erythrocyte bursts releasing parasites (this is what causes the high fevers) that then develop into male and female and then are sucked up by mosquito during a blood meal to be transmitted to the next victim.
GROSS.
54
What is chemoprophylaxis recommended for travellers going to areas with malaria?
In Chloroquine sensitive areas: give chloroquine
| -in chloroquine-resistant areas, use atovaquone, mefloquine
55
What do you see on gram stain for Neisseria meningitidis?
Gram negative diplococci
56
What 2 age groups are most commonly affectd by Neisseria meningitidis?
-which are the common serotypes causing disease?
Children < 5 yo and adolescents
- common serotypes: A, B, C, Y, W-135
- serotype B most common in Canada
57
What is the treatment for meningococcemia?
- mortality rate of meningococcemia?
- postexposure chemoprophylaxis?
Pen G x 5-7 d
(remember that meningitis with N meningitidis is also treated with IV abx x 5-7 d only)
-mortality rate: 10%, most within 1st 48 hrs due to fulminant septic shock/DIC secondary to endotoxins
-postexposure chemoprophylaxis should occur for anyone who came into contact with oral secretions of an infected patient = use rifampin
58
What is Waterhouse Friederischsen syndrome?
Diffuse adrenal hemorrhage secondary to meningococcemia infection
59
What 6 groups are at increased risk of invasive meningococcal disease?
1. Anatomical or functional asplenia
2. Children with primary antibody deficiency disorders
3. Children with complement, properdin or factor D deficiency
4. Travellers to areas endemic for meningococcus
5. Lab personnel with exposure to meningococcus
6. Military
60
What are complications of mumps? (5)
Mumps = paramyxovirus, mainly causing parotitis (inflammation of salivary glands)
1. Meningoencephalitis
2. Orchitis
3. Arthritis
4. Myocarditis
5. Pancreatitis
61
What are the clinical features of Parvovirus B19 infection? (ie. two types)
- period of infectivity for parvovirus B19?
- other clinical features
- treatment
Two types of infection:
1. Erythema infectiosum: -fever, headaches, myalgias, polyarticular arthritis followed by slapped check facial rash followed by lacy, reticular rash on trunk and extremities
- period of infectivity occurs BEFORE the onset of rash (ie. once rash has developed, the child is no longer contagious).
2. Aplastic anemia:
- those with RBC aplasia ARE infectious at presentation and should be isolated for at least 1 wk or until resolution of fever
- seen especially in children with hemoglobinopathies
- treatment: supportive care, possible RBC transfusions
62
What are the 4 stages of pertussis?
| -do you see this in infants?
ICPC: "I caught pertussis coughing"
1. Incubation stage x 7-10 d
2. Catarrhal stage: most infectious stage, mild upper resp prodrome x 1 wk (catarrhal means INFLAMMATION OF MUCOUS MEMBRANES)
3. Paroxysmal stage: severe cough with inspiratory whoop x 1-3 mo, post-tussive vomiting
4. Convalescent stage: gradual resolution of symptoms
- infants < 3 yo usually do not have classic stages and infants < 3 mo usually don't have whoop but can have post-tussive apnea/cyanosis
63
How do you make the diagnosis of pertussis?
- what is the treatment of pertussis?
- does treatment change severity or duration of disease?
Pertussis PCR or culture
- may see leukocytosis with lymphocytosis
- treatment: azithromycin x 5 d
- treatment after paroxysmal stage begins does NOT change severity or duration of disease but does decrease infectivity
64
What is the immunization strategy to prevent pertussis?
1. Immunize infants with DTaP vaccine at 2, 4, 6, 15 mo with booster at 4 yo
2. Immunize adolescents with booster with single dose of Tdap
65
What is the chemoprophylaxis for contacts of pertussis positive individuals?
Azithromycin x 5 d regardless of immunization status in order to prevent spread
66
In a patient previously infected with pertussis OR previously immunized for pertussis, how long do their protective antibodies last?
Usually last 3-5 yrs only - this is why booster is needed in adolescence/adults
67
What are the complications of pertussis? (5)
1. Secondary pneumonia
2. Apneas
3. Pulmonary hypertension
4. Acute otitis media
5. Physical sequelae from forceful coughing: scleral hemorrhage, petechiae, laceration to frenulum
68
What animal bites may transmit rabies?
Dogs, cats, skunks, raccoons, foxes, coyotes, bats (any exposure to bats, even being asleep in the same room since bites/scratches can be tiny and not noticed!)
-first the single stranded RNA virus replicates in the tissue at the site of the bite/scratch and over weeks-months, moves along peripheral nerves until it reaches the spinal cord (concentrated in brain stem) and spreads rapidly to the brain
69
What are the clinical features of rabies?
Weeks-months after bite: rapidly progressive encephalopathy with seizures, delirium, dysphagia, hydrophobia
70
What seen on histology is the hallmark of rabies?
Negri body (clump of viral nucleocapsides that create cytoplasmic inclusions)
71
What are investigations that can be done to confirm diagnosis of rabies?
1. Animal with unknown vaccination status that bit the patient should be quarantined and observed for signs of rabies - may need to be euthanized with brain intact in order to see virus-specific antigens on brain tissue
2. Can take skin biopsy specimens of the patient or isolate the virus from saliva
72
What is the treatment for rabies?
- what do you use for postexposure prophylaxis?
- when would you give postexposure prophylaxis?
In people who are bitten, should give postexposure prophylaxis with RIG and administer rabies vaccine immediately to decrease chance of developing rabies UNLESS the animal was a dog, cat or ferret who was healthy and can be observed for 10 days, then prophylaxis can wait
- once rabies symptoms have developed, unfortunately no specific treatment available
- all animals other than the healthy dog/cat/ferret who can be observed should be caught and euthanized and have its brain tested for rabies
73
What is the timing of the rabies vaccine?
Day 0, 3, 7, 14, 28 (total of 5 doses)
74
How is rabies immunoglobulin adminsitered?
Should be administered immediately after the animal bite and infiltrated directly into the wound if present. The remainder should be given IM.
75
How is HPV transmitted?
| -clinical manifestations?
1. Direct contact
2. Autoinoculation
3. Fomites
- clinical manifestations: common warts (verruca vulgaris), periungual warts, plantar warts, anogenital warts (condylomata acuminata), squamous cell carcinoma
- all caused by different subtypes of HPV
76
Which HPV subtypes cause cervical cancer?
16, 18
77
What is the differential diagnosis of genital warts in children?
1. Inoculation during birth through infected birth canal
2. Sexual abuse
3. Incidental spread from cutaneous warts
***significant proportion of genital warts in children contain HPV types that are usually isolated from cutaneous warts
78
```
What is the treatment for warts?
-common warts
-plantar/palmar warts
-condylomata acuminata
-
```
More than 65% disappear spontaneously within 2 years
- treatment is most successful when performed regular q2-4 wks
- Common warts: liquid nitrogen or daily application of salicylic acid
- plantar/palmar warts: salicylic acid
- condylomata acuminata (anogenital warts): podophyllin application x 4-6 hr on weekly basis OR imiquimod cream 3 times weekly
79
What are the 3 most common causes of eosinophilia in children?
1. Atopic dermatitis
2. Allergic rhinitis
3. Asthma
*NOT parasites :)
80
Which infections are associated with severe eosinophilia? (5)
-which one is the most common cause of severe eosinophilia in children?
* **Remember that eosinophilia requires tissue-invasive/blood invasive parasites so you will NOT see eosinophilia with parasitic infections that are well contained within tissues or are solely intraluminal in the GI tract (ie. with giardia or enterobius vermicularis aka pinworms)
1. Toxocariasis: visceral larval migrans = most common cause of severe eosinophlia in children
- toxocara species (roundworms from dogs/cats/foxes) larvae migrating from blood into liver, heart, CNS, eyes
2. Trichinosis: trichinella spiralis (roundworm) transmitted through raw or undercooked pork or bear meat
- start off in the GI tract, then invade muscles causing edema of eyelids, myalgia, fever, eosinophilia, can become encysted in the muscle
3. Hookworm
4. Ascariasis: Ascaris lumbricoides from eating food/drink contaminated with feces
- eggs hatch in intestines, burrow through the gut and migrate to lungs. Then break into the alveoli, pass up the trachea where they are coughed up and swallowed to continue the life cycle of being pooped out and passed onto the next victim
5. Strongyloidiasis: roundworm infection
81
Worldwide, what is the most common cause of GI blood loss in children?
Hookworm infection - causes microscopic blood loss
82
What 2 fungal diseases can cause eosinophilia?
1. Aspergillosis in the form of ABPA
| 2. Coccidiodomycosis
83
What 3 drugs can be used for chemoprophylaxis for contacts of N. meningitidis?
-pregnant women?
1. Rifampin PO BID x 2 d (preferred in children)
2. Ceftriaxone IM x 1
3. Ciprofloxacin (for > 18 yo)
- pregnant women: rifampin and cipro is contraindicated - use ceftriaxone
84
Mom brings her baby to you with painful lesions on finger x 10 d. She frequently sucks on her fingers prior to the development of the lesions. There is diffuse erythema and vesicles on the finger.
- diagnosis?
- treatment?
Herpes whitlow = HSV infection of fingers or toes
- most commonly seen in infants/toddlers who suck the thumb and who are experiencing symptomatic or subclinical oral HSV-1 infection
- HSV-2 herpes whitlow develops in teenagers due to exposure to infectious genital secretions (ie. fingering)
- have itching, pain, erythema
- do NOT incise the lesion (even if it looks like it might contain pus) since this may prolong recovery and increases risk of secondary bacterial infection
- rapid improvement/recovery within 18-20 d
- no clinical trials assessing benefit of antiviral treatment for this
- BUT can start high dose oral acyclovir (2 g/d div BID PO x 10 d)
85
What is the likelihood of chronic hepatitis with the following:
- Hep A
- Hep B
- Hep C
- Hep D
- Hep E
- Hep A: 5% progress to chronic hepatitis (95% recover within 1-2 wks of illness, chronic disease is unusual)
- Hep B: >90% of perinatally infected infants, 25-50% of young children who acquire Hep B during 1-5 yo, 10% of older children and adults
- Hep C: 75% of children
- Hep D: only if there is concurrent Hep B infection
- Hep E: does not cause chronic hepatitis
86
What are the clinical features of Hep A infection?
Acute febrile illness with abrupt onset of anorexia, nausea, malaise, vomiting and jaundice
-typical duration is 7-14 d
87
What is the treatment for Hep A?
Supportive care and monitoring of liver enzymes and liver function tests for acute liver failure
88
When are patients with Hep A contagious and be excluded from school/daycare?
Contagious 2 wks before and 7 days after onset of jaundice/symptoms
89
What are the pre-exposure and post-exposure prophylaxis for Hepatitis A infection?
* **Overall: infants < 1 yo cannot get the hepatitis A vaccine
- < 1 yo: Hep A immunoglobulin (cannot get the vaccine)
- >1 yo and healthy: Hep A vaccine
- > 1 yo and immunocompromised/chronic liver disease/chronic health problems: both Hep A vaccine and Hep A immunoglobulin
***Give post-exposure prophylaxis if < 2 wks since exposure
90
What diagnostic testing do you order for Hep B?
Order: HBsAg, HBsAb, HBcAg, HBcAb, HBeAg, HBeAb, HBV DNA, liver function tests, liver enzymes
- after exposure to HBV, the following occurs:
1. HBsAg (hep B surface antigen) rises first and is the first detectable antigen to appear during infection
- also gets cleared later on
- this is what is inside the Hep A vaccine that then stimulates production of HBsAb
- if your HBsAb AND HBcAb is positive, this means prior infection
- if your HBsAb is positive but HBcAb is negative, this means prior immunization
2. HBV DNA PCR will then become positive
3. HBcAg (Hep B core antigen): found inside the virus, rises next. This is what stimulates formation of HBcAb
- if your HBcAb is positive, this means that you have been previously infected with Hep B (this is how you distinguish between prior infection vs. immunization)
4. HBeAg (Hep B e antigen): sometimes signals high levels of viral replication; induces HBeAb; not all Hep B strains have HBeAg
***If the host had Hep B and cleared the infection: see both HBsAb and HBcAb and possibly HBeAb
91
What is the treatment of acute Hepatitis B?
| -chronic?
- Acute hep B: supportive care
| - Chronic hep B: interferon alpha or lamivudine
92
What are the cilnical features of familial mediterranean fever?
- diagnosis?
- main complication?
- treatment?
Acute recurrent episodes of fever + 1 or more of the following lasting 1-4 d:
1. Sterile peritonitis
2. Arthritis/arthralgia
3. Pleuritis
- can also have erysipelas-like rash, splenomegaly but less common
- complication: may progress to development of renal amyloidosis
- diagnosis: genetic testing for FMF gene to confirm
- treatment: prevent attacks with prophylactic colchicine, also decreases progression to amyloidosis
93
What are the clinical features of PFAPA (aka marshall syndrome)?
- what differentiates PFAPA from other periodic fever syndromes?
- treatment?
Periodic Fever lasting 4 d and recurs every 2-8 wks LIKE CLOCKWORK!
APHTHOUS STOMATITIS
Pharyngitis
Adenitis (cervical)
-most common cause of recurrent fevers in children
-other periodic fever syndromes have IRREGULAR intervals in between fevers whereas PFAPA has VERY regular intervals between fevers
-treatment: steroids, cimetidine
94
What are clinical features of TRAPS?
- mode of inheritance?
- complication?
- treatment?
TNF-receptor-associated periodic syndrome
- periodic fever lasting 1-3 weeks, with abdominal pain, pleuritis, rash, myalgias, EYE involvement (periorbital edema, conjunctivitis)
- mode of inheritance: AD
- complication: amyloidosis
- treatment: steroids
95
What are clinical features of Hyper-IgD syndrome? (HIDS)
| -treatment?
Periodic fever syndrome with abdominal pain, cervical adenopathy, splenomegaly
- fevers occur at irregular intervals
- seen in Dutch families usually
- see elevated IgD levels but is not diagnostic since other autoinflammatory disorders can cause this
- treatment: steroids
96
What are the 4 common periodic fever syndromes?
1. PFAPA: most common
2. TRAPS (TNF-receptor associated periodic syndrome)
3. Hyper-IgD syndrome
4. Familial mediterranean fever syndrome
97
Name a distinguishing feature for each of the following:
- PFAPA
- Familial mediterranean fever
- TRAPS
- hyper IgD syndrome
PFAPA: fever occurs at REGULAR intervals like clockwork
Familial mediterranean fever: fevers are usually shorter in duration than in other periodic fever syndromes, only one treated with COLCHICINE (not steroids)
TRAPS: autosomal dominant, EYE involvement (periorbital edema, conjunctivitis)
Hyper IgD syndrome: elevated IgD levels, does NOT progress to amyloidosis
98
Which infections have been found to cause guillain barre syndrome? (2)
-what about vaccines? (4)
Infections:
1. Campylobacter
2. Mycoplasma pneumoniae
Vaccines:
1. Rabies
2. Influenza
3. Oral polio
4. Conjugated meninococcal vaccine (serogroup C)
99
Which children should receive the Pneumovax (PPV23) vaccine? (6)
High risk children > 2 yo:
1. Asplenia
2. Sickle cell disease
3. Antibody deficiencies
4. HIV infection
5. Chronic lung, heart, kidney disease
6. Diabetes mellitus
100
What is the most common congenital infection?
CMV
101
What is the most common outcome of congenital CMV infection?
Sensorineural hearing loss (58%)
102
What are the clinical features of Q fever?
- how is it acquired?
- treatment?
Coxiella burnetii:
- airborne, from FARM ANIMALS, EXTREMELY infectious and resistant to chemical and physical treatments
- associated with farm visits, lamb birthing season
- causes fever, mild interstitial lymphocytic pneumonitis (lives in the lungs) & hepatomegaly due to lymphocytic lobular hepatitis
- only 40-50% of people infected with C. burnetii develop symptoms
- can see leukocytosis, thrombocytopenia, elevated liver enzymes
- diagnose by serology (abs to C. burnetii antigens)
- self-limited illness
- treat with doxycycline in any age (benefits >> tooth discoloration in children < 8 yo)
103
What is the main difference between neonatal chlamydial conjunctivitis and gonorrheal conjuncitivitis in terms of prognosis?
-what is the treatment for each?
Gonorrheal conjunctivitis: leads to corneal perforation and blindness if left untreated
-treatment: Ceftriaxone IM or IV x 1 dose, saline eye irrigation q10-30 minutes, until purulent discharge has cleared, must r/o sepsis
Chlamydial conjunctivitis rarely involves the cornea; usually isolated to conjunctiva and is self-limited (BUT can progress to chlamydial pneumonia which is bad)
-treatment: erythromycin PO x 2 wks (may prevent subsequent chlamydial pneumonia). CANNOT treat with topical therapy alone since this will NOT clear the chlamydia from their resp tract and thus not prevent pneumonia
104
Among neonates with conjunctivitis: what is the timing for the various etiologies?
- chemical
- Neisseria gonorrhoeae
- Chlamydia trachomatis
Chemical: onset less than 2 days
N. gonorrhea: onset 2-7 days
C. trachomatis: onset 5-14 days
105
What is ophthalmia neonatorum?
| -prophylaxis?
Conjunctivitis in the 1st month of life with concerns re: C. trachomatis and N gonorrhea perinatal acquisition
-prophylaxis: erythromycin 0.5% ophthalmic ointment
106
What are the clinical stages of syphilis?
1. Primary: painless, single genital ulcer (chancre) appearing 3-6 wks after inoculation
2. Secondary: follows 6-8 wks later with fever, generalized lymphadenopathy (especially inguinal), disseminated maculopapular rash on body/palms/soles, condylomata lata, mucous membrane lesions
3. Tertiary syphilis: does not happen in children; involves cardiovascular, neurologic and msk systems
4. Latent syphilis = asymptomatic infection
a. Early latent: acquisition within the preceding year
b. late latent: acquisition within unknown duration
107
What is the treatment of early syphilis (primary, secondary, early latent) vs. late syphilis (tertiary, late latent) vs neurosyphilis?
Early syphilis: single IM dose of benzathine pen G
Late syphilis: IM doses of benzathine pen G x 3 at weekly intervals
Neurosyphilis: IV aqueous crystalline pen G x 10-14 d
108
What are clinical findings of congenital syphilis that are usually present within few days of birth?
1. HSM
2. Snuffles (rhinitis)
3. Lymphadenopathy
4. Copper rash on palms/soles/perioral/perianal
5. Pneumonia
6. Osteochondritis
109
What are late clinical findings of untreated congenital syphilis? (7)
Usually appear after 2 years of age:
1. interstitial keratitis (corneal scarring)
2. 8th CN palsy (deafness)
3. Hutchinson teeth (bifid teeth)
4. Mulberry molars (multiple enamel spots on molars)
5. Saddle nose deformity
6. Frontal bossing
7. Clutton joints (symmetrical joint swelling, usually in knees)
110
What is Hutchinson's triad?
1. Interstial keratitis
2. 8th cranial nerve palsy
3. Hutchinson teeth
Indicative of congenital syphilis
111
What testing should be completed for an infant if congenital syphilis is suspected?
1. Quantitative treponemal syphilis test (TP-PA)
2. Direct fluorescent antibody staining by scraping skin or mucous membrane (FTA-ABS)
3. Nontreponemal reaginic antibody assays: VDRL (venereal disease research lab) & RPR (rapid plasma reagin)
112
What is the treatment and f/u of congenital syphilis?
| -neurosyphilis: treatment and f/u?
Pen G x 10-14 d with repeat of nontreponemal antibody titres at 3, 6, 12 months to document falling titres
-neurosyphilis: serologic testing + CSF q6months x at least 3 years or until CSF findings are normal
113
What are the 2 most common causes of acute unilateral lymphadenitis in normal healthy children?
1. S. aureus
| 2. GAS
114
What are the 2 most common causes of chronic infectious lymphadenitis in children?
1. non-TB mycobacteria
| 2. Bartonella henselae
115
What is the most common organism causing meningitis in children with VP shunts?
1. Staph aureus
| 2. Coag neg staph
116
When do you treat campylobacter with antibiotics? (4)
- choice of abx?
- resistent to which drugs/
1. High fever
2. Severe diarrhea
3. Immunocompromised
4. Toxic
- treatment: Azithro or erythro PO, IV gent, tobra or meropenem
- resistant to penicillins, cephalosporins, vanco
117
Child is on prednisone for nephrotic syndrome. When would you give vaccines?
if on steroids for > 14 d, considered immunosuppressed and do NOT get live vaccines until off-steroids x 1 month
118
What are clinical features of rubella?
- period of infectivity?
- most severe neuro complication?
Clinical features:
1. Macular, coalescing rash on FACE, then moves downwards
2. Fever
3. Pharyngitis
4. Conjunctivitis
5. Lymphadenopathy
6. Transient arthropathy
7. Forckheiner spots: rose-colored spots on oropharynx
-period of infectivity 6 days pre rash up to 6 days
post rash
-CNS complication: rubella panencephalitis
119
You have a 3 mo child with tender swelling over the mandible bilaterally with fever and irritability. Hyperostosis on xray. Diagnosis?
-differential diagnosis for hyperostosis on xray?
Caffey's
- usually related to mandible
- differential diagnosis: hypervitaminosis A (but no fever/irritiability, subacute onset)
120
What is the triple therapy for H. Pylori?
1. Clarithro + amoxil OR flagyl + PPI
121
What are 2 organisms that are transmitted via cat bites?
1. Pasteurella
| 2. Eichenella
122
What is the most common congenital cardiac defect seen with congenital rubella syndrome?
PDA
123
How long do children with congenital rubella syndrome stay infectious?
Shed virus in urine/stools x 1 year
124
When do you treat salmonella infections?
1. Infants < 3 mo
2. Immunocompromised
- increased risk of bactermia --> meningitis
125
What are clinical features of neonatal chlamydial pneumonia?
| -treatment?
1. Absence of fever
2. Eosinophilia
3. Cough
4. Bilateral interstitial markings
- treatment: erythromycin
126
What are 3 viral causes of erythema nodosum?
- common bacterial causes? (5)
- common fungal causes? (3)
- other causes?
Viral:
1. Hep B
2. EBV
3. Mumps
Bacterial:
1. Mycoplasma
2. Bartonella henselae
3. GAS
4. Yersinia
5. TB
Fungal:
1. Histoplasmosis
2. Blastomycosis
3. Coccidiocomycoses
Other causes:
1. OCP
2. Sulfa drugs
3. SLE
4. IBD
127
What are the types of meningococcus vaccines?
- schedule for each?
- what populations are at increased risk of meningococcal disease (6)?
1. MCV-C: conjugate vaccine serogroup C (most common in adolescents)
- brand names: mejugate, meningitec, neissvac-C
2. MCV-4: conjugate quadrivalent serogroup: A/C/Y/W135
- brand names: menactra, menveo
3. 4CMenB: conjugate vaccine serogroup B (most common in preschool kids)
All children:
- MCV-C @ 12 mo
- MCV-4 @ 12 yo (grade 7)
Children at increased risk of meningococcal disease: (asplenia, immunocompromised = primary antibody disorder, complement deficiency, perperdin deficiency, factor D deficiency, travellers to high meningococcus areas, military, lab workers, cochlear implants )
- MCV-C @ 2, 4, 6, 12 mo
- MCV-4 @ 2 yo and q5yr
- 4CMenB starting at @ 2 mo (also for outbreaks, close contacts of person with serogroup B)
Remember that conjugate >>> polysaccharide vaccines in inducing an immune response
128
Worst prognosis of HIV occurs with which complication?
PCP infection
129
For a child < 5 yo with close TB contact, what is considered a positive TST?
5 mm is positive
130
What are the 2 side effects of isoniazid?
| -prevention?
1. Peripheral neuropathy: prevent by giving pyridoxine (vit B6)
2. Elevated liver enzymes
131
What TB medication causes retrobulbar neuritis?
Ethambutol
132
When does a positive TST no longer be attributable to a BCG vaccine?
If the child received BCG vaccine more than 10 years ago, will not affect TST result
133
In a child who requires immunosuppression and thus TST and MMR vaccine, what is the optimal timing for each test in order to avoid false negative TST caused by MMR vaccine?
Either give both the same day OR do TST 4 wks after MMR
134
What 2 antibiotics can be used to treat chlamydia trachomatis?
1. Azithromycin
| 2. Doxycycline
135
When do the sinuses develop during childhod? (ie. pneumatization)
1. Ethmoid present by birth, pneumatises first!
2. Maxillary present at birth but pneumatises 2nd at 4 yo
2. Sphenoid: complete by 5 yo
3. Frontal: begins at 3-7 years of age, complete by age 12 years
136
Which injuries warrant inquiry into tetanus status? (3)
| -pathogenesis of tetanus infection?
1. Penetrating wounds from dirty object (nail, splinter, glass, etc.)
2. Animal bites
3. Burns/frostbite
- clostridium tetani = produces tetanus toxin that blocks normal inhibition of antagonistic muscles on which voluntary coordinated movement depends = affected muscles sutain maximal contraction and cannot relax
- does not affect sensory nerves so patients remain conscious and in severe pain
**Basically anything except a clean, minor wound
137
What are common clinical features of tetanus infection?
1. Most common presenting symptom: trismus (masseter muscle spasm or lockjaw)
2. Risus sardonicus: abnormal spasm of the facial muscles that looks like a creepy smile
3. Opisthotonos when abdo/lumbar/hip/thigh muscles are involved
4. Laryngeal and resp muscle spasm = airway obstruction/asphyxiation
5. Fever due to sustained muscle contraction (increased metabolic rate)
6. Autonomic effects: tachycardia, dysrhythmias
- lasts up to 4 wks
7. Generalized tetanic spasms (seizures) leading to rhabdomyolysis and renal failure, intramuscular hematomas, spinal fractures
- can be triggered by any sights/sounds/touch
**overall: see LOCKJAW, think tetanus!
138
How do you make the diagnosis of tetanus?
| -what is the single most common risk factor for neonatal tetanus?
Clinical findings - routine lab results are usually normal, neither EEG or EMG show characteristic pattern
-neonatal tetanus: lack of maternal immunization
139
What is the management of tetanus infection?
1. Tetanus immunoglobulin 500 U IM ASAP: if the tetanus toxin is already bound at the NMJ then there is nothing you can do about this but TIG neutralizes toxin that hasn't bound yet
2. Surgical wound debridement
3. Antibiotics: Pen G x 10-14 d
4. Muscle relaxants: diazepam or rocuronium (flaccid paralysis, requires I&V but at least gives muscles a break)
5. Supportive care
140
What is the immunization schedule for tetatnus prevention?
DTaP at 2, 4, 6, 18 months with booster at 4-6 yo and q10y after
141
When would you consider giving tetanus prophylaxis with tetanus vaccine, tetanus immunoglobulin or both in a patient with a wound?
- clean minor wounds vs. all other wounds
- immunization status
- dose of tetanus immunoglobulin
A) If the patient has received LESS than 3 tetanus toxoid vaccines or imm status unknown:
- always give tetanus vaccine (Td or TdaP)
- if wound is clean/minor: no TIG
- if wound is contaminated: YES TIG
B) If the patient has received 3 or more tetanus toxoid vaccines:
- don't have to give tetanus vaccine UNLESS > 10 yrs since last dose for clean/minor wounds or > 5 yr for contaminated wounds
- don't have to give TIG ever
****So overall, clean/minor wounds NEVER need TIG; contaminated wounds only need TIG if patient has received 24 hrs since injury, unable to be debrided)
142
What is the treatment of latent TB?
- treatment of pulmonary TB?
- treatment of TB with HIV coinfection?
- treatment of TB meningitis?
A) Latent TB = positive TST in context of known exposure to TB positive close contact but normal CXR and asymptomatic
-treatment: isoniazid x 9 months to prevent reactivation
B) Treatment of pulmonary TB (fully drug susceptible): 6 months total isoniazid (+/- pyradoxine) + rifampin with pyrazinamide in first 2 months
-drug resistant or unknown susceptibility: add ethambutol to first 2 mo regimen
C) TB with HIV coinfection
-extend isoniazid + rifampin to 9 mo total
D) TB meningitis -extend isoniazid +rifampin to 12 mo total
-add corticosteroids (decrease mortality rates, decreases neurologic sequelae = prednisone 2 mg/kg/day x 4-6 wks, then taper
143
What is the Ghon complex?
- where is the most common site of TB infection?
- Extrapulmonary sites?
initial focus of TB infection in the lung with enlarged regional lymph nodes
- most common site of TB infection: lungs (80%)
- extrapulmonary sites: lymph node (67%), meninges, pleura, miliary (disseminated), skeletal (13%)
144
What are the 2 categories of TB infection?
1. Latent: positive TST but asymptomatic and normal CXR
| 2. Active TB: TB infection with symptoms and radiologic findings
145
What is the most common form of extrapulmonary TB?
TB lymphadenopathy
146
In TB CNS disease, where are the 2 sites of greatest involvement?
Brainstem and meninges
- more common in children 6 mo-4 yo
- get CN palsies (3, 6, 7 since they're on brainstem)
147
What is Pott disease?
TB in the spinal vertebrae
148
What test is the most specific way to confirm pulmonary TB?
Sputum culture
| -can do induced sputum with jet nebulizer and chest percussion followed by NP suctioning
149
What is the utility of gastric aspirate vs. bronchoscopy for diagnosing TB?
Gastric aspirates for culture may be the only option for young children BUT it only yields organism in <50% of cases
-bronchoscopy is even WORSE yield!
150
If a patient has been infected with TB, when will the TST become positive?
Tuberculin sensitivity develops 3 wks-3 mo after infection
151
When is a TST considered positive?
- 0-4 mm (1)
- 5-9 mm (6)
- >10 mm (1)
- 0-4 mm: HIV infection with immune suppression AND high likelihood of having TB (ie. close contact of active case, abnormal xray or from population with high prevalence)
- 5-9 mm:
1. HIV
2. Immunosuppressed (chemotherapy)
3. Children suspected of having TB
4. Close contact of active contagious case within 2 years
5. Abnormal CXR with fibronodular disease
6. End stage renal disease
- >10 mm: all other cases
152
A child who you suspected may have TB ends up having a negative TST and IGRA. What is your diagnosis?
Could still have TB! Negative TST or IGRA does NOT exclude active TB!
-in all cases of suspected TB, you should do everything you can to get a culture diagnosis always always always
153
Before starting therapy for TB disease, what baseline testing should be completed? (4)
1. Liver enzymes (AST, ALT)
2. Bilirubin
3. HIV serology
4. Baseline ophtho assessment in younger children (due to risk of retrobulbar neuritis due to ethambutol)
154
What are the indications for use of pyridoxine in conjunction with isoniazid in treatment of TB? (5)
1. Children who have milk/meat deficient diets
2. Adolescents who are breastfeeding or pregnant
3. Children with nutritional deficiencies
4. Symptomatic HIV infection
5. Breastfed infants
155
A child with latent TB who you've been treating with Isoniazid for the last 3/9 months comes to you with anorexia, n/v, abdo pain, dark colored urine, jaundice and pale colored stools. What is your management?
Isoniazid can cause hepatotoxicity and lead to death or need for transplant!
-tell them to stop taking isoniazid ASAP and do liver work up
156
In infants and children < 4 yo, what is the risk of progression of LTBI to active TB disease without treatment?
40%
157
How would you treat the following:
1. TB exposure, > 4 years old and immunocompetent
2. TB exposure < 4 yo OR immunocompromised
3. TB exposure in an infant
4. TB infection
5. TB disease
1. TB exposure in > 4 yo and immunocompetent:
- no treatment
- TST now and repeat 2-3 mo after contact with source case is broken (since incubation period before TST will become positive is 3 wks - 3 mo)
- further treatment will be based on TST results +/- symptoms +/- CXR findings
2. TB exposure in < 4 yo OR immunocompromised: high risk of LTBI becoming active disease -empirically treat with isoniazid x 2-3 months
- TST now and repeat TST in 2-3 mo with further treatment as in previous answer
3. TB exposure in an infant: high risk of LTBI becoming active disease
- empirically treat with isoniazid x 2-3 mo
- TST now and repeat TST in 2-3 mo
- TSTs are less reliable in infants thus look at TST results of other children in the family to make decisions about stopping chemoprophylaxis
4. TB infection: ie. LTBI = isoniazid x 9 mo
5. TB disease: 6 months for pulmonary and most extrapulmonary forms, 9 mo for HIV coinfection, 12 mo for TB meningitis
158
What are 2 findings on lateral neck xray with retropharyngeal abscess?
1. Air fluid level in retropharyngeal space
| 2. Increased width of retropharyngeal space
159
What are complications of otitis media? (6)
| -what is the definition of chronic suppurative otitis media?
1. Meningitis
2. Lateral sinus thrombosis
3. TM perf
4. Intracranial abscess
5. Hearing loss
6. Cholesteatoma
***Chronic suppurative otitis media: purulent drainage from perforated tympanic membrane > 6 wks
160
What are the indications for tympanostomy tubes?
1. Failed antibiotics for recurrent AOM
2. Chronic otitis media
3. Tympanic membrane retraction with ossicular erosion or cholesteatoma formation
161
What is the age range of children who typically get bacterial tracheitis?
- what is the age range of peritonsillar abscess?
- what is the age range of retropharyngeal abscess?
Between 3 mo - 3 yrs
- peritonsillar abscess: adolescents most common
- retropharyngeal abscess: < 5 yo most common
162
How do you diagnose mastoiditis?
| -What is the treatment of mastoiditis?
- Diagnosis: physical exam shows mastoid swelling and redness with protrusion of the ear forward
- treatment: IV antibiotics (3rd generation cephalosporin ie. ceftriaxone) = if no improvement or if still febrile in 48 hrs, may need mastoidectomy
163
A patient presents with trismus, drooling and a hot potato voice. What is the most likely diagnosis?
- treatment?
- most severe complication?
Peritonsillar abscess
- will see unilateral tonsillar swelling with a deviated uvula
- treatment: surgical drainage and antibiotic therapy x 10-14 days (usually IV penicillin or something with GAS coverage)
- most severe complication: rupture of the abscess with resultant aspiration pneumonitis
164
What is the treatment for PCP pneumonia?
TMP-SMX IV with or without steroids (for severe hypoxemia)
165
What is the most common causative organism in endocarditis?
Strep viridans most common
-can also see S. epidermidis, S. auresua, HACEK organisms (hemophilus, actinobacter, cardiobacterium, Eikenella, Kingella)
166
What are the clinical manifestations of cryptosporidium infection?
-treatment?
GI stuff! Crampy abdominal pain, vomiting, watery diarrhea
- can cause bad disease in immunocompromised patients
- treatment: supportive therapy for immunocompetent children, nitazoxanide for immunosuppressed with severe disease
167
What is the underlying organism causing traveler's diarrhea?
Enterotoxigenic E coli
168
What is the principle reservoir of Yersinia?
Pigs!
169
What is the most common cause of spontaneous bacterial peritonitis in a previously healthy child?
- nephrotic syndrome?
- children with dialysis catheters and VP shunts?
- children with cirrhosis?
Treatment?
Previously healthy child, nephrotic syndrome = both strep pneumo
- catheters/VP shunts: S. epidermidis, S. aureus
- cirrhosis: E coli
***Treat with 3rd generation cephalosporin, add vanco if catheter related infection
170
What is the management of necrotizing fasciitis?
Emergent surgical debridement with antibiotic therapy
171
What is the msot common organism causing VP shunt infections?
Coag-negative staph
172
What is the treatment for chlamydia trachomatis neonatal conjunctivitis?
-Neisseria gonorrhea neonatal conjunctivitis?
Chlamydia: Erythromycin PO x 14 d
Gonorrhea: Ceftriaxone x 1 dose
173
A child has been bitten by a dog. What clinical feature can help differentiate other organisms from a pasteurella infection?
Pasteurella infections cause pain and swelling within the FIRST DAY of the bite whereas other bacteria cause pain and swelling AFTER the 1st day (take more time to develop)
174
What is the diagnostic criteria for toxic shock syndrome?
Need all 3 major criteria:
1. Acute fever
2. Hypotension
3. Erythroderma with convalescent desquamation rash
-AND-
3/7 minor criteria
1. Mucous membrane inflammation (vaginal, oropharyngeal, strawberry tongue)
2. GI: Vomiting or diarrhea
3. Renal abnormalities (urea or cr > 2x normal)
4. Liver abnormalities (bilirubin or liver enzymes > 2x normal)
5. Muscle abnormalities (myalgia or CK > 2x normal)
6. CNS abnormalities (altered LOC)
7. Thrombocytopenia
-AND-
Absence of another explanation and negative blood cultures (except occasionally for Staph aureus)
175
How can you differentiate between mumps and other viral infections?
Mumps = do NOT see rash
-usually have bilateral parotitis (2nd side can appear a day after the first side), can have displacement of the uvula, fever, orchitis
176
What infectious disease has a rash that is described as "dewdrop on a rose petal"?
Varicella
177
What is the most common cause of death in Reye syndrome?
- pattern of liver dysfunction? (ie. what do you see on liver enzymes and liver function tests?)
- mortality risk?
- two viruses involved in pathogenesis of Reye syndrome?
Increased ICP (from cerebral edema) and subsequent herniation
- up to 40% mortality
- see elevated liver enzymes and ammonia but NORMAL total bilirubin
- two viruses involved: influenza and varicella in a patient on ASA therapy
178
A patient presents to the ED with a GTC seizure and fever. During the lumbar puncture which turns out to be normal, he has a large watery stool with blood and mucus. What is the most likely diagnosis?
Shigella infection!
-in Shigella infection, increased risk of seizure and the seizure PRECEDES diarrhea which distinguishes shigella from other GI infections (like campylobacter)
179
What type of organism causes leptospirosis?
- where do cases typically occur?
- which animals spread leptospirosis?
Spirochete = spiral bacteria
- typically occur in tropical countries
- found in livestock, birds, dogs (major reservoir in USA), cats, rats: usually people get exposed via contaminated water or soil or contact with animals
180
What are the clinical manifestations of leptospirosis?
- key distinguishing feature?
- Weil syndrome?
- how is the diagnosis made?
***Most infections are mild or subclinical!!!! Most patients clear the infection without any symptoms
KEY: illness follows biphasic course = initial (septicemic = see leptospires in blood, CSF, other tissues) phase lasting 2-7 days, followed by brief period of well-being before onset of a second symptomatic leptospiric phase (this is where leptospires move into the tissues and you can't find them anymore in blood and csf)
1. Septicemic stage: flu like symptoms with myalgia, headache, abdo pain, vomiting, fever, conjunctival injection, photophobia
- ----asymptomatic phase---
2. Second stage: aseptic meningitis (pleiocytosis aka elevated WBC and elevated proteins, normal glucose), uveitis, rash, fever
**Can also get icteric leptospirosis (Weil Syndrome) where immune phase is characterized by jaundice, renal failure, thrombocytopenia, cardiovascular collapse = this is very rare!
Diagnosis: serologies, microscopis agglutination test (serogroup specific assay), ELISA
181
What is the treatment for leptospirosis?
Penicillin in children < 9 yo, tetracycline in children > 9 yo x 7 days
-early treatment may shorten duration/severity of infection
182
How long can it take for osteomyelitis changes to show up on a plain radiograph?
Early soft tissue changes take 3 days to develop and bone changes take up to 12 days after onset of osteomyelitis
183
What are the clinical features of Rocky Mountain Spotted Fever?
- how is this infection transmitted?
- treatment?
Classic triad: fever, headache, rash
1. Prodromal period with headache, malaise, pain and tenderness of calf muscles in children is very common
2. Abrupt onset of fever and chills
3. Maculopapular rash on the flexor surfaces of the wrists and ankles, then moves in a central direction, typically involves palms and soles
- rash can then become hemorrhagic within 1-2 days
- can cause CNS depression, seizures, etc.
- transmitted by ticks from Dermacentor family (rickettsia rickettsii is the organism carried by the tick)
- treatment: Doxycycline regardless of the child's age!
184
A patient gets a puncture wound through a tennis shoe. What is the most likely organism to cause an infection?
-what about a patient who gets a puncture wound through her bare foot?
Tennis shoe = pseudmonas since shoe is warm and moist
Bare foot = staph aureus since it is bare skin
185
What are 3 common complications of staphylococcal pneumonia?
1. Pleural effusion
2. Empyema
3. Pyopneumothorax
186
What is the management of a perianal abscess?
Usually I&D only is adequate but depending on age/clinical status, may need antibiotics
187
After what age should a genital wart in a child alert you towards the possibility of child abuse?
3-4 yo
| -before then, perinatal or diaper changed by someone with a finger wart is more likely
188
What is the risk of acute --> chronic Hep B infection based on mode of transmission?
* ***Likelihood of going onto chronic infection is inversely related to age
- Perinatal infection is MOST likely to go on to chronic Hep B
- horizontal transmission in childhood is in the middle
- Adult infection is LEAST likely to go on to chronic Hep B infection
189
What is the management of a patient who has been exposed to varicella?
- healthy person
- pregnant woman
- immunocompromised
Healthy person: vaccinate with varicella vaccine
Pregnant women and immunocompromised:
- check VZV IgG serologies,
- If negative, give VZV IgG since they cannot receive the vaccine
190
What is considered a positive TST?
> 5 mm IF:
1. exposed to a close contact with known or suspected TB
2. clinical symptoms of TB
3. immunocompromized (HIV) or on immunosuppressants
> 10 mm IF:
1. < 4 yo
2. travelling to or from high TB prevalence country
3. living with adult that is high risk (IVDU, long term care, etc.)
4. at risk for disemminated TB (diabetes, malnutrition, etc.)
> 15 mm IF:
-any child > 4 yo without any other RFs
