Infectious Dz and Allergies/Immunology

Question 1

Things that can affect your dx with infectious disease

Answer 1

Season
Age
General health
Fever
Previous sx
Exposure
Travel
Daycare
Immunization therapy

Question 2

Work up for infectious dz- general

Answer 2

CBC
-Left shift in CBC means high neutrophils can include bands
-Right shift is high lymphoctes
Gram stain
Cultures
LP
Rapid screening test
PCR (DNA, RNA)
Imaging

Question 3

DDx- viral- ID

Answer 3

Petechiae
Neutropenia
Lymphocytosis

Question 4

DDx- bacterial- ID

Answer 4

Petechiae
Purpura
Leukocytosis- left shift
Neutropenia
Increased ESR/CRP

Question 5

What does secondary prophylaxis include?

Answer 5

Meningococcus
Tetanus
-Dirty wound, give if they have not had shot within 5 yrs
-Clean wound, give if they have not had the shot within 10 yrs
Rabies
-Immunoglobulin, inject into wound as much as you can, then give IM injection
-Day 1, 3, 7, 14 for vaccine schedule
-Try to find the animal
-Document if they decline

Question 6

Fever without source: 1-3 mos

Answer 6

Viral
Bacteremia
-GBS
-E. coli
-Listeria monocytogenes
UTI
-E. coli
Pneumonia
-S. pneumoniae
-S. aureus
Meningitis
-S. pneumoniae
-HSV
-Enterovirus
-N. meningitidis
Bacterial diarrhea
-E. coli
-Salmonella
-Shigella

Question 7

Fever without source: 3 mos- 3 yrs

Answer 7

Viral
Occult bacteremia
- Greater than or equal to 102.2
-WBC > 15K
-Left shift
-Increased ESR/CRP
UTI
-UA, URC, BLDC

Question 8

What to do with < 3 mos with fever?

Answer 8

Usually do an LP

Neonate: run your basic tests: BCx, CBC, CXR, urine

Question 9

You don’t usually see strep in _____

Answer 9

< 2 yo

Will see URI, OM

Question 10

Fevers of unknown origin

Answer 10

Infections
Inflammatory dz
-15%
Malignancy
-10%
Fictitious

Question 11

Fever and rash in peds

Answer 11

Macular/maculopapular
-Usually measles or rubella
Diffuse erythroderma
Urticarial
Vesicular, bullous, pustular
Petichial-purpuric
Erythema nodosum

Question 12

Characteristics of measles

Answer 12

Papular lesions of trunk, neck, face
Red watery eyes
Grey-white spots in the mouth

Question 13

Characteristics of rubella

Answer 13

Typically lasts around 3 days
Body aches
Anorexia
HA
Pharyngitis
Conjunctivitis
Low-grade fever
Highly contagious, but resolves on its own

Question 14

Characteristics of roseola infantum

Answer 14

HSV 6 and 7
Abrupt fever, rose-colored maculopapular rash lasting 3-5 days
Cough

Question 15

5ths dz- characteristics

Answer 15

"Slapped cheek"
Caused by parvovirus B19
Usually occurs during springtime
Diagnose with PCr
Reoccurs with bathing, rubbing
Mild anemia, lymphopenia

Question 16

Tx for herpes zoster

Answer 16

Antivirals and pain meds

Give hydrocodone at hospital but not for the 4 wks that you’ll treat it

Question 17

Varicella zoster

Answer 17

Do not give ASA or acyclovir
Could develop post-secondary staph and strep infections with scratching and dirty fingernails
Give the vaccine at 12-15 mos and 4-6 yrs
-85% effective in preventing dz
-95% effective in reducing severity

Question 18

Impetigo characteristics

Answer 18

Bolus impetigo has clear fluid-filled cysts
Crusting, yellow, honey-crusted
See on Gram stain: purple (Gram pos) cocci in clusters
Give 2% mupirocin

Question 19

Cellulitis

Answer 19

Demarcate with a pen, tell them to come back in 24 hrs to the ER
Look for LAD, check above and below
Is there any fluctuation in the wound? Do you want to I and D?
Shot of Rocephin, then diclocycillin or Keflex

Question 20

Erysipelas

Answer 20

Just dermal area, not full thickness
Line of demarcation is very clear
Causative agent is group A strep
If IC or DM, try to convince hospitalist to admit

Question 21

Forunier’s gangrene

Answer 21

Caused by staph, strep, clostridium
Very quick progression
Need immediate surgical consult
IV clinda, surgeon may add aminoglycoside, may also use Rocephin

Question 22

Folliculitis

Answer 22

Affects follicles of hair cells
Pseudomonas, staph are causes
Chlorhexidine 1% or clinda cream

Question 23

Ringworm

Answer 23

Use KOH prep to diagnose
Will see budding, septate or aseptate hyphae
Treat with miconazole, clotrimazole
Takes time to heal
Use a thin layer, and keep it dry

Question 24

Herpetic whitlow

Answer 24

Pruritis and pustules

Valacyclovir

Question 25

Herpes gladitorium

Answer 25

Worry about eyesight Do a slit lamp exam and document when it doesn't affect the eye Otherwise, you need to call an ophthalmologist

Question 26

HPV vaccine

Answer 26

Give between ages 9-26 Quadrivalent covers 6, 11, 16, 18 3 doses 98-100% effective

Question 27

Molluscum contagiosum

Answer 27

Cause is pox virus Fleshy, skin-colored lesion with dimple Self-limiting over several mos

Question 28

What can be seen on a blood smear with mono?

Answer 28

Atypical lymphocytes

Question 29

Cat scratch or bite

Answer 29

Could affect epitrochlear LN Boggy Caused by Pasturella multocida Give Augmentin

Question 30

M. Kansaii

Answer 30

Usually a post-surgical infection Can also involve soft tissue Found in TX, LA, FL, KS, IL Treat with rifampin, methambutol

Question 31

Encephalitis types

Answer 31

``` California St. Louis Equine West Nile -Occurs in summer in North America -Sore throat, fever, aching, lethargy, HA, behavior changes, neuro deficits ```

Question 32

Encephalitis work up

Answer 32

``` Get a CSF test -Viral: nl glucose, slightly elevated protein -Bacterial: low glucose, high protein LP BCx CBC MRI ```

Question 33

Mechanism of encephalitis

Answer 33

Infection Immune-mediated response Herpes is MCC of sporadic encephalitis in children

Question 34

Colds

Answer 34

Antihistamines and decongestants are not recommended for children under 6 yrs If no better in 10-14 days consider bacterial

Question 35

Sinusitis

Answer 35

Get a water's view CT -Will show areas of exudate, inflammation, or possible Netty pot use Causes are M. catarrhalis, H. flu, S. pneumoniae With children, look for a FB Look for fever, tenderness mucopurulent d/c in nare Treat with Augmentin

Question 36

Otitis media

Answer 36

If it's happened too many times, refer to ENT for possible myringotomy

Question 37

Difficult cases of otitis externa

Answer 37

If canal is really tight, use an earwick | Put liquid lidocaine on there before inserting it

Question 38

Croup

Answer 38

Steeple sign on X-ray Usually in fall and winter mos Give dexamethasone Consider racemic epi to reduce subglottic edema

Question 39

Epiglottitis

Answer 39

See thumb print sign on X-ray Hib, staph, strep are causes Treat with tube, abx

Question 40

Pertussis

Answer 40

``` B. pertussis Spread by cough Stages -Catarrhal -Paroxysms -Convalescent Peak incidence < 4 mos Typically seen in 1-10 yos Contagious for first few weeks Runny nose, low-grade fever WBC 20K Lymphocytosis of 75-80% Give azithromycin, clarithromycin ```

Question 41

Bronchiolitis

Answer 41

Affects small bronchioles Late fall to early spring Runny nose, low-grade fever, cough Leading cause of hospitalization in infants ELISA to diagnose Primarily caused by RSV Hyperresonance on percussion with diffuse wheezes or crackles

Question 42

PNA

Answer 42

Bacterial PNA is typically lobular Not getting better, do another test, like a CT Increased interstitial marking like tree branches indicates a viral infection Treat with Z pack for CAP Induce a sputum culture with a neb

Question 43

Types of pneumonia

Answer 43

``` Atypical Bronchial SARS -Coronavirus PNA in the IC -Gram neg enteric bacteria -Virus -Fungi -Mycobacteria ```

Question 44

PNA workup

Answer 44

``` CBC -Bacterial vs viral -Sputum gram stain and culture depending on child's age -Rapid viral antigen detection PCR Blood cultures CXR ```

Question 45

DDx of PNA

Answer 45

``` CF AIDS Disorders of leukocytes Disorders of cilia -Kartagener syndrome- immotile cilia GERD FB ```

Question 46

Complications of PNA

Answer 46

``` Abscess secondary to lung necrosis Empyema Effusion Bronchiectasis d/t scarring Penumatociles- thin blebs, air or fluid-filled, can sometimes pop Bronchiolitis obliterans -small airways are replaced scar tissue Sawyer-James syndrome -Severe necrotizing pneumonia -Increased translucency of lung -Adenovirus type 21 ```

Question 47

Tx of PNA

Answer 47

Do culture and MIC S. pneumoniae MIC < 2- Ampicillin/PCN/amoxicillin S. pneumoniae MIC >4- Ceftriaxone/Levoquin/Linezolid Mycoplasma- Zithromycin MRSA- Clindamycin or Vanc IV HSV- acyclovir

Question 48

Infective endocarditis

Answer 48

``` Reasons for kids to get this- wound that hasn't healed well or very infected, dental work Bacteria -Viridians step -S. aureus -Hemolytic strep A, B, C, G, D -Cause vegetation on valves, which become incompetent. Results in hemolyzing blood Fungi -Candida ```

Question 49

Workup for infective endocarditis

Answer 49

``` ESR/CRP CBC BLDC RF/ANA- may be positive Echo- consider doing TEE instead of transthoracic- more sensitive ```

Question 50

Complications of infective endocarditis

Answer 50

Emboli Abscess Aneurysm

Question 51

Tx for infective endocarditis

Answer 51

Viridians strep- PCN G 4 wks May consider Pen G plus aminoglycoside 2 wks Surgery Cure rate >90% in uncomplicated endocarditis d/t viridians

Question 52

Acute gastroenteritis

Answer 52

Diarrhea Leading cause of morbidity and common in US Person-to-person contact Contaminated food/water If you see both nausea and vomiting at the same time, consider food poisoning

Question 53

Acute gastroenteritis bacteria

Answer 53

``` E. coli Salmonella Shigella Vibrio cholera B. cereus- refried rice S. aureus- mayo ```

Question 54

Acute gastroenteritis virus

Answer 54

Rotavirus Adenovirus 40 and 41 Norovirus

Question 55

Acute gastroenteritis parasites

Answer 55

E. histolytica | Giardia lamblia

Question 56

Labs for acute gastroenteritis

Answer 56

``` BMP- worried about dehydration, look at electrolytes Sodium may be low CBC Fecal culture Ova and parasites ```

Question 57

Tx of acute gastroenteritis

Answer 57

Bacterial: 3rd gen cephalosporin S. typhi Parasite: Metronidazole Virus: supportive

Question 58

Hepatitis

Answer 58

Types A, B, C, D, E, G A= poor hand washing B+ D= chronic hep -Could lead to fulminant hep, cirrhosis and CA HBV and HCV -IV drugs, maternal fetal, blood products/needle stick

Question 59

Tx of hepatitis

Answer 59

HBV -Interferon Alpha-2B or lamivudine HCV -Interferon or in combination with ribavirin Most cases of acute viral hep resolve in time -HAV and HEV- acute -HBV, HCV, HDV= chronic, possible cirrhosis and carcinoma

Question 60

UTI labs

Answer 60

``` Ensure clean catch UA URC Imaging if necessary -Could have stone or chronic kidney or bladder infections due to vesicourethral reflux Chlamydia culture if suspect ```

Question 61

UTI possible origin in teens

Answer 61

Staph saprophyticus, chlamydia and E. coli 12-72 hours after intercourse Causes urethral syndrome and urethritis

Question 62

Vulvovaginitis

Answer 62

MC gyn in children

Question 63

Causes of vulvovaginitis

Answer 63

``` Physiological leukorrhea- nl Non-specific: nl Bacterial -3 criteria: homogenous d/c, pH >4.5, a little fishy odor -Also see clue cells -Treat with metronidazole Candidiasis -Treat with metronidazole Enterobiasis- pinworms -Treat with mebendazole Giardiasis -Treat with metronidazole Molluscum contagiosum -Treat with curretage Phthirius pubis: crabs -Treat with permethrin Scabies -Treat with permethrin Staph/strep -Treat with dicloxacillin or 1st gen cephalosporin FB ```

Question 64

UTI parenteral tx

Answer 64

Cephtriaxone or gentamycin

Question 65

UTI oral tx

Answer 65

Cephalosporin Augmentin Septra/Bactrim

Question 66

chlamydia

Answer 66

``` 70% of women are asymptomatic Gram neg May lead to PID -Abd pain -Adnexal tenderness -Pain on cervical motion -Fever Tx -Rocephin + doxy or Azithro ```

Question 67

Syphilis

Answer 67

Treponema pallidum Great imitator Primary-chancre Secondary- fever, LAD, rash, condolomata lata lesion Tertiary- organ damage, neurosyphilis, aorta Diagnose with dark field microscopy

Question 68

Tx of syphilis

Answer 68

Primary- 2.4 mil U pen G benzathine q2-4h x 10 days Secondary: 2.4 mil u pen G x 3 wks (3 doses) Tertiary: 3-4 mil U pen G q4h x 10-14 days

Question 69

HSV

Answer 69

``` Pre-herpatic pain Vesicular HSV culture Rx -Acyclovir/Famcivlovir/Valacyclovir Post-herpatic pain lasts 3-4 wks Meds reduce recurrence by 75% ```

Question 70

H. ducreyi

Answer 70

Bacterial See chancre Culture Tx: Azithro 1 gm po

Question 71

Granuloma inguinale

Answer 71

Cause is Klebsiella Requires bx for staining Tx: Doxy

Question 72

Trichomoniasis

Answer 72

``` Vulvular inflammation 70% asymptomatic D/c- frothy bubbly Strawberry cervix Diagnose with KOH Tx: metronidazole ```

Question 73

Candidiasis

Answer 73

``` Thick d/c with itch Candida albicans Consider DM/BCP/ current or recent abx KOH Fluconazole or nystatin for tx ```

Question 74

Genital warts

Answer 74

``` HPV aka condylomata acuminata Firm grey to pink Cervical neoplasia or dysplasia HPV 16 and 18 (70% cancer) Tx: Podofilox or cryo ```

Question 75

Type I allergy

Answer 75

Immediate IgE Anaphylaxis, angioedema, urticaria

Question 76

Type II allergy

Answer 76

Cytotoxic IgM, IgG, complement, phagocytosis Cytopenia, nephritis

Question 77

Type III allergy

Answer 77

Immune complex IgM, IgG, complement, precipitins Serum sickness, vasculitis

Question 78

Type IV allergy

Answer 78

Delayed T-lymphocytes Contact dermatitis

Question 79

Idiopathic allergy

Answer 79

Effector mechanism varies | Non-specific rash

Question 80

Dx of allergies

Answer 80

``` Skin patch testing RAST (radioallergosorbent test) panels CXR CT sinuses Serum immunoglobulins ```

Question 81

Allergic rhinitis

Answer 81

Eosinophilic inflammation of nasal mucosa PE will show a transverse nasal crease Eosinophils will be present in nasal secretions and elevated on CBC Non-allergic rhinitis is more likely vasomotor, infectious, or secondary to a FB

Question 82

Allergic rhinitis medications

Answer 82

Mild: antihistamines PRN Moderate: routine administrations of LTRA (Leukotriene receptor antagonist)- Singulair (montelukast) Severe: topical nasal steroid, immunotherapy, antihistamine, or LTRA

Question 83

Systemic anaphylaxis

Answer 83

Rapid onset allergic reaction d/t the widespread degranulation of mast cells after crosslinking of IgE on the mast cell surface Often secondary to bee stings, food exposures, or drug administration Severe manifestations: airway obstruction, hypotension

Question 84

Stings

Answer 84

Good to watch if you have FHx Tx: Children younger than 16 with diffuse urticaria require epi Children >16 are treated as adults and require subQ epi Any child with a systemic rxn to a bee sting requires referral to an allergist Any child with a life-threatening rxn to a bee sting requires venom immunotherapy which is 98% effective in preventing future rxns

Question 85

Anaphylaxis therapy

Answer 85

Epi is primary Antihistamines are secondary For severe event steroids may prevent late-phase rxn

Question 86

Angioedema

Answer 86

Hereditary angioedema: autosomal dominant d/o characterized by the absence or abnormal function of the C1 esterase inhibitor which results in increased vascular permeability Angioedema related to allergic rxn: self-limiting, episodic, commonly triggered by minor trauma Give benadryl, dexamethasone

Question 87

Asthma causes

Answer 87

``` Allergens -Pollen, mites, animal dander, mold Irritants -Tobacco smoke Viral infections -RSV -URI Exercise ```

Question 88

Allergy meds

Answer 88

``` Antihistamines -1st gen: sedation problems -2nd gen: preferred where sedation a problem LTRA -Similar efficacy to antihistamines Mast cell stabilizers Topical corticosteroids -Most effective, block more aspects of allergic inflammatory response ```

Question 89

Allergic conjunctivitis

Answer 89

If bacterial, will have matted eyes, exudative drainage, whereas allergic has clear fluid Acute or chronic, seasonal and perennial Itching and excessive tearing Tx is with saline eye drops and antihistamines

Question 90

Causes of a cough in a child <1

Answer 90

``` CF Resp tract infection Aspiration Dyskinetic cilia Lung/airway malformation Edema ```

Question 91

Long-term controlled meds for asthma

Answer 91

``` ICS LTRAs -Zafrilukast > 5 yrs BID -Montelukast QD --6 mos-5 yrs 4 mg --6-14 yrs 5 mg --15 yrs and above 10 mg ```

Question 92

LABA

Answer 92

``` Relax airway smooth muscle No anti-inflammatory BID >5 yrs Maintenance Prevention of exercise-induced asthma ```

Question 93

Omalizumab (Xolair)

Answer 93

Anti-IgE AB Mod to severe asthma 12 yrs and older SubQ q2-4 wks

Question 94

SABA

Answer 94

Bronchodilator Acts in 5-10 mins 4-6 hr duration Prophylaxis

Question 95

Ipratropium

Answer 95

Relieves bronchoconstriction Decreases mucus hypersecretion Reduces cough Not for long-term use

Question 96

Corticosteroids

Answer 96

Acute exacerbation 3-10 days 1-2 mg/kg/day then 1 mg/kg/day days 2-5

Question 97

General tx principles in asthma

Answer 97

Step up-step down therapy All children should have short acting MDI ICS preferred for all children-persistent asthma Rules of two; -Sx 2 or more days/week -Sx 2 or more nights/mo

Question 98

Primary immunodeficiency

Answer 98

Refers to a group of more than 300 rare, chronic disorders in which the immune system fails toa ct appropriately Red flags: -Severe infections requiring hospitalizations at an early age -Persistent or recurrent illnesses -Infections secondary to obscure or uncommon organisms

Question 99

Things to check with immunodeficiency

Answer 99

CBC to look for neutropenia or lymphopenia (SCID), esosinophils (allergic dz) or anemia (chronic dz) Serum immunoglobulin levels should be obtained: IgG, IgA, IgM, IgE, IgD

Question 100

DiGeorge syndrome

Answer 100

Partial immune defects with low T-cell numbers and functions that tend to improve with age Known as velocardiofacial syndrome or catch 22 syndrome because of the Cardiac anomalies, Abnormal facial features, Thymic hypoplasia, Cleft palate and Hypocalcemia stemming from deletions in chromosome 22q11.2

Question 101

Wiskott-Aldrich syndrome

Answer 101

X-linked disorder that results from defects in both cell-mediated and humoral immunity. There is a predisposition of lymphoproliferative disorders Children presents with the triad of thrombocytopenia (low platelets), eczema and recurrent infections

Question 102

Chediak-Higashi syndrome

Answer 102

Abnormality of secondary granule that results in defective neutrophil and NK cell function Usually presents with partial oculocutaneous albinism Most cases progress to a lymphoproliferative syndrome with generalized fever, jaundice, hepatomegaly and pancytopenia

Question 103

Stem cell therapy

Answer 103

This is the only cure available for primary immunodeficiency Stem cells are found in bone marrow, cord blood and peripheral blood The main risk associated with stem cell therapy is GVHD