Lecture 19: Febrile Illness/ID Flashcards
Rise in hypothalamic set-point due to endogenously produced pyrogens explains the etiology of a…
Fever
MC cytokines that function as endogenous pyrogens
IL-1 and IL-6
Core temperature is specifically defined as the temperature of blood within the () artery
Pulmonary artery
Fever () the amount of iron available to invading bacteria
Decreases
Generally, we prefer a rectal temp (most accurate) from birth to () years
Birth to 3 years
Same period as when fevers are MC
Tympanic temperatures are unreliable in children () months
Under 6 months of age
T/F: A well-appearing, well-hydrated child with evidence of a routine viral infection can be safely sent home with symptomatic treatment and careful return precautions
True
Most febrile illnesses are (viral/bacterial)
Viral
The MC reason to treat fever is if a child is…
Uncomfortable
NSAIDs should generally not be used in child younger than () months and Tylenol should not be used in children younger than () months
- NSAIDs should be avoided in 6 months and younger.
- Tylenol should be avoided in 3 months and younger.
NO ASA DUE TO REYE’S SYNDROME
You should see a child immediately if any of these are present.
- Child is less than () months of age
- Fever is greater than () celsius
- Child is crying ()
- Child cries when ()
- Child is difficult to ()
- () spots or dots are present on the skin
- Less than 3 months of age
- Greater than 40.6C
- Crying INconsolably/whimpering
- Crying when moved or even touched
- Difficult to awaken
- Stiff neck
- Purple spots
You should a see a child within 24 hours if:
- Child is () to () months old (unless fever occurred within 48h of dtap with no other symptoms)
- Fever exceeds () C
- Burning or pain with ()
- Fever subsided for 24h but then ()
- Fever has persisted longer than ()
- 3-6 months old
- Exceeds 40C/104F
- Urination
- Returning fever
- Longer than 72h
On average, a (viral/bacterial) infection usually disseminates faster in a younger child
Bacterial infection
Fever is MC between the ages of…
Birth to 3 years
() account for most bacterial infections in infants under 90 days
UTIs
They can’t clean down there themselves
You should be especially concerned for a serious viral infection in an infant if they lack () vaccine or ()
- HiB
- Pneumococcal
T/F: Presence of petechiae/purpura in a viral illness is very sus
True
T/F: As long as child is 90 days old, their ill appearance does not require a full eval.
False
The mainstay diagnostics for any child under 21 days old with a fever >= 38C are (3)
- UA
- Blood cultures
- LP
Inflammatory markers are optional.
In order for a 21 day or younger neonate to be D/C’d off of IV abx and discharged, they must meet all of this criteria:
- Culture results are negative for ()
- Infant appears ()
- ()
- Negative culture results for 24-36h
- Infant appears well or is improving
- No other reason to hospitalize.
For a 22-28 day old or a 29-60 day old, feverish, but well-appearing infant, the 3 diagnostics you must order initially are:
- UA
- Blood culture
- Inflammatory markers
Generally, you want to order a procalcitonin alongside an ANC or CRP. If you CANNOT order procalcitonin, then you should obtain both ()
CRP and ANC
T/F: You can treat a urine only infection in a 29-60 day old via oral abx.
True
A 61-90 day old infant needs a full septic work-up if:
- They appear ()
- Signs of a () infection AND Abnormal (), (), or ()
- They appear toxic/ill
- They have signs of a focal infection.
- Abnormal WBC, inflammatory markers, or UA
One of the most important history things in a child with a fever of unknown source is…
Immunization status
T/F: In an infant aged 3 months to 36 months, full-workup is indicated if incompletely immunized.
True
Febrile seizures are highest risk between the ages of () months and () years
6 months to 5 years
A generalized tonic/tonic-clonic seizure of less than 15 minutes and occurring within 24 hours of fever onset is most commonly known as a () and is most commonly caused by ()
Simple febrile seizures, MCC: Viral illness
Complex is focal or b2b or > 15 mins
T/F: Prophylactic anticonvulsants are recommended for children with febrile seizures.
False
Simple ones have no long-term adverse consequences
A Fever of Unknown Origin (FUO) is defined as a daily temp greater than () for 8 days with no apparent diagnosis.
38.3C or 101F
The top 3 MCC of FUOs, in order of frequency, are:
- Infectious diseases
- CT/Rheumatologic disrders
- Neoplasms
The MC autoimmune disease in children that can result in a FUO is…
Systemic JIA (juvenile idiopathic arthritis)
The MC malignancies in children that result in FUOs are (2)
- Leukemias
- Lymphomas
T/F: Most evaluations of FUOs begin inpatient.
False.
Ideally, a physical exam of a febrile infant is done when the infant is currently ()
Febrile
What might bilateral red eyes in a pediatric patient suggest in terms of underlying disease?
Kawasaki’s disease
T/F: It is reasonable to order serological testing for FUOs.
True.
If an infant is ill with persistent fever and NO diagnosis, you could order ()
IgG, IgA, IgM
Generally, empiric antimicrobial therapy (is/is not) indicated in FUO.
Is NOT (unless life-threatening)
If () occurs more than 24h prior to delivery, Bacterial sepsis in newborns increases 10x.
Normal rate is 1-2 in 1000
PROM (1 in 100 births)
PROM + Chorioamnionitis = 1 in 10 live births!
The MCC of bacterial sepsis in a newborn are (4)
- GBS
- E. coli
- Listeria
- S. Aureus
Generally, bacterial sepsis of the newborn appears on day () of life
Day 1
T/F: An intrapartum maternal temperature of 100.4F or higher is a risk factor for Bacterial sepsis of the newborn.
True.
The MC presenting sign of bacterial sepsis in a newborn is…
Respiratory distress d/t PNA
The Dx of PNA in bacterial sepsis is via…
Pleural fluid from effusion
Tx of early bacterial sepsis in newborns is…
- Ampicillin
- Gentamicin/cefotaxime
Q12 hrs
Tx of late bacterial sepsis in a newborn is…
- Ampicillin
- Gentamicin/Cefotaxime
- Add on Vancomycin for staph
Late bacterial sepsis is MC due to staph aureus
10-14 days IV for proven sepsis.
Late onset bacterial sepsis of the newborn occurs after () days of life.
7 days of life.
Most likely due to staph.
Prevention of neonatal GBS infection is usually achieved via intrapartum delivery of () more than () hours prior to delivery.
Penicillin, 4 hours prior to delivery.
GBS cultures are obtained from both () and () at ()-() weeks.
- Vaginal and rectal GBS cultures
- 35-37 weeks
Prophylaxis with pencillin is indicated for women who are () or who have () GBS status at delivery.
- GBS positive
- Unknown GBS status at delivery
The MCC of aseptic/viral meningitis is…
Non-polio enteroviruses
MC before the age of 1
A full anterior fontanelle in the sitting position, a maculopapular rash, marked fever, irritability, and lethargy with an acute onset is suggestive of…
Viral meningitis
T/F: Meningeal signs are typically seen in pediatric patients.
False, generally only seen in older patients.
In both older and younger children, certain strains of () can cause flaccid paralysis in viral meningitis
Enteroviruses
Similar to polio
The most useful diagnostic lab for viral meningitis is…
PCR of enteroviruses
In 95% of cases, protein should be less than () mg/dl and glucose more than () of serum values in viral meningitis.
- Protein less than 80 mg/dl
- Glucose MORE than 60% of serum values
The general tx for an infant with viral meningitis is…
- Admit
- Isolate
- Fluids
- Antipyretics
In an infant younger than 1 month, you should consider () in your differential alongside viral meningitis and start () until you have a diagnosis.
- You should consider herpes virus encephalitis
- Start empiric acyclovir until diagnosis is made.
The MOST important sign in very young infants when it comes to bacterial meningitis is…
A tense, bulging fontanelle
CSF of bacterial meningitis should show () WBCs, () glucose, () protein
- Elevated WBCs
- Decreased glucose
- Increased protein
One might see G() diplococci on smears of CSF sediment for bacterial meningitis
G+ diplococci
Empiric abx for bacterial meningitis in newborns is…
- IV Vanco
- IV Cefotaxime/Rocephin
- Steroids prior to abx to reduce cerebral edema and lower likelihood of hearing loss per viv / I wrote IF no hx of HiB vaccine, maybe its both?
The two MC time periods to contract neisseria meningitidis are…
- First year of life
- Teen years
In order to qualify for chemoprophylaxis for neisseria meningitis, you must have () exposure
Direct exposure to respiratory secretions
Household members are high risk
MC agent for chemoprophylaxis for neisseria meningitis is…
Rifampin
A purpuric/petechieal rash in association with bacterial meningitis means it is most likely…
Meningococcemia w/ similar symptoms
T/F: You should treat meningococcemia in a newborn/kid as shock.
True
Im guessing this is for meningococcemia
T/F: Pneumococcal meningitis and meningococcemia (meningitis due to N. meningitidis) are treated the same.
True.
MC bacteria for bacterial conjunctivitis
- Strep Pneumo
- H flu
- M cat
Same as AOM top 3
Pseudomonas if contact lens wearer
Bacterial conjunctivitis is characterized by () discharge from the eye, and kids often complain that when they wake up, they feel as if their eyes are ().
- Mucopurulent discharge
- Eyes feel stuck together
A child remain contagious for bacterial conjunctivitis until they have taken their abx for at least () hrs.
24 hours
T/F: Bacterial conjunctivitis requires abx tx.
False. Self-resolving, abx speeds it up.
MCC of viral conjunctivitis
Adenovirus
Viral conjunctivitis is (very/not very) contagious, is (unilateral/bilateral), and has () discharge, and sometimes shows () on the conjunctiva
- Very contagious
- Starts unilaterally, then spreads
- Watery discharge
- Hyperemic conjunctivitis
Can combine with URI and bilateral conjunctivitis
T/F: Preauricular LAN is seen in pharyngoconjunctival fever
Truee
Besides the usual viral conjunctivitis S/S, epidemic keratoconjunctivitis also has ()
Ptosis
The only treatment for viral conjuncitivitis is…
Just isolate for 2 weeks + supportive care.
No antivirals indicated.
Allergic rhinitis and conjunctivitis are often associated together, and they are type () HSR.
Type 1 HSR.
Eye drops for allergic conjunctivitis
Olopatadine BID
Antihistamine + Mast cell stabilizer
Severe allergic conjunctivitis is also known as… () conjunctivitis, and includes giant papillae of upper tarsal conjunctiva, ptosis, keratitis, and characteristic white dots.
Vernal conjunctivitis
Recurrent, bilateral allergic conjunctivitis
The characteristic white dots within vernal conjuncitivits are accumulations of…
Eosinophils (mostly)
Tx of vernal conjunctivitis
Same as allergic: Olopatadine drops
Atopic conjunctivitis is most commonly associated with…
Eczema
The condition that is the #1 reason children get abx in the US is…
AOM
Top 3 organisms for AOM
This better be engraved onto your brain by now
- Strep Pneumo
- H flu
- M Cat
Viral URI also often precedes AOM
Top RFs for AOM (4)
- Prior Viral URI
- Smoke exposure
- Eustachian tube dysfunction
- Cleft palate
If you smell something funky during your otoscopic exam for AOM and see purulent material, you should suspect ()
Perforated tympanic membrane
According to the AAP, a diagnosis of AOM requires:
- A () of abrupt signs and symptoms
- Presence of () effusion indicated by () of the TM, () of the TM, or ().
- S/S of middle ear inflammation by either erythema of the () or () resulting in decreased sleep and normal activity.
- Hx of abrupt S/S
- Middle ear effusion
- Bulging of TM
- Absent mobility of TM
- Otorrhea
- Distinct erythema of the TM
- Otalgia resulting in decreased sleep/normal activity
The only age range you need to immediately treat with AOM is… or if they have 48hrs of ear pain, fever, otorrhea.
24 months or younger
A patient with AOM but incomplete HiB vaccination history should be treated preferably with…
A cephalosporin (H Flu more likely): Cefdinir
Idk i wrote this in
First line tx for AOM is:
2nd line tx for AOM is:
- Amoxicillin
- Augmentin if amoxicillin failed
For those with severe allergies to penicillins, AOM is treated with (3)
- Macrolides
- Clindamycin
- Bactrim
Presence of tympanostomy tubes with infection but NO systemic symptoms can use ()
Drops (ciprodex, ofloxacin)
A white, plaque-like appearance on the TM due to chronic inflammation is known as…
Tympanosclerosis
A pearly/greasy mass seen in a retraction pocket in the ear or perforation is a …. and is treated primarily with…
- Cholesteatoma
- Surgical repair
Usually perfs heal within 2 weeks
Generally, a child should improve within ()-() hours after starting abx for AOM.
48-72 hours
Generally, you would expect a child to follow up ()-() weeks after AOM dx. The one exception is if they are aged 2 or older and ()
- Normal followup: 8-12 weeks.
- Exception: age 2+ WITHOUT language/learning delays
Recurrent AOM is () or more episodes in 6 months, or () in a year
- 3+ eps in 6 months
- 4 in a year
Chronic OM with effusion is defined as lasting greater than () months or failing to respond to initial abx therapy.
3+ months
The initial tx for effusions that occur after an episode of AOM is…
Watchful waiting
Generally, if a child has MEE (middle ear effusions?) that persist over 3 months and start causing delays in language, you should refer them to…
Audiology
Hearing => language
The MC pediatric infectious disease overall is…
Viral rhinitis (common cold)
The top cause of viral rhinitis is…
Rhinovirus
hehe
- Sudden onset of clear/mucoid rhinorrhea
- Nasal congestion, sneezing
- Sore throat and cough
- Fever
- Feeding changes
All suggest what pediatric illness?
Viral rhinitis
The two symptoms that tend to persistent for 2-3 weeks in viral rhinitis are…
- Cough
- Rhinorrhea
You should not treat cough with honey in someone younger than…
1 year old
The MC form of HSV-1 infection in children is…
Acute gingivostomatitis
Grouped vesicles on an erythematous base
LAN in the () region and () region are common in acute gingivostomatitis
- Cervical region
- Submandibular region
High fever, irritability, and drooling often occur in infants infected with HSV-1 because they have…
Acute gingivostomatitis
You want to avoid () or () foods with active herpetic gingivostomatitis
Acidic or salty foods
Bland diet
The mainstay of tx for herpetic gingivostomatitis is…
Supportive tx.
Antivirals are only indicated if severe.
Oral candidiasis/thrush (can/can’t) be washed off
CanNOT
A common atopic condition, (), can predispose a child to thrush because it uses ()
Asthma due to inhaled corticosteroids.
Tx of oral thrush is via…
Oral nystatin rinse
Hand Foot Mouth disease is caused by…
Coxsackie Virus
HFMD is usually (pruiritic/not)
Non-pruiritic
HFMD is treated primarily with…
Supportive care.
Resolves in 3-5 days usually.
Herpangina is caused by…
Coxsackie Virus
Same as HFMD
A linear pattern of ulcers with erythematous halos on the anterior tonsillar pillars, soft palate, and uvula with none on the anterior mouth is most likely….
Herpangina
Herpangina is treated with…
Supportive care.
Same as HFMD
You would expect more atypical findings in strep pharyngitis if the child is aged () or younger
3 yo or younger
You should NOT test a child for strep pharyngitis if they show:
* (c)
* (c)
* (c)
* Anterior (s)
* Ulcers/vesicles in the ()
* Diarrhea
- Cough
- Congestion
- Coryza
- Anterior stomatitis
- Throat
In a child younger than 3, you should test them for strep pharyngitis if…
- Prolonged () drainage
- Tender () LAN
- () fever
- Prolonged nasal drainage
- Tender anterior cerivcal LAN
- Low grade fever
The preferred tx for strep pharyngitis is…
Amoxicillin
its yummier
Patient education for strep pharyngitis:
- You are contagious for () hours after your first dose
- You should change your toothbrush after () days
- 24 hours after first dose
- 1 day
You perform a rapid antigen strep test which comes back negative. You still suspect strep pharyngitis. Your next step is to…
Send for bacterial cultures
Infectious mononucleosis is caused by…
EBV
Although strep pharyngitis and mono have similar symptoms, the LAN in mono is located ()
Posterior cervical LAN is more Mono
Besides URI stuff, Mono also affects (organ)
Hepato and splenomegaly.
A child being treated for suspected strep pharyngitis with amoxicillin develops a rash. You suspect that the reason for their rash is…
They actually have mono
Under the age of (), mono causes mild symptoms.
Age of 4.
If a monospot test is negative but you still suspect mono, you should order () next
Anti-EBV antibodies
The most notable lab finding on CBC for mono would be….
Atypical lymphocytosis
Tx of mono is via…
- Supportive tx
- NO CONTACT SPORTS for 4-5 weeks
Viral pharyngitis is MCC by…
Adenovirus
Viral pharyngitis is very similar to strep pharyngitis, but can also lead to ()
Pneumonia
Viral pharyngitis is treated primarily with…
Supportive care.
MCC of viral croup is…
Parainfluenza virus
MC age range for viral croup is () months to () years
3 months to 3 years
- Clinical diagnosis
- Seal like cough
- Prodrome of URI followed by cough
- Inspiratory stridor
Most likely suggests…
Viral croup
Pertussis is treated with…
- Erythromycin for 14 days
- Clarithomycin for 7 days
- Azithromycin for 5 days (also rec if younger than 1)
Bactrim for allergies
T/F: Pertussis contacts need prophylaxis
Truee
The MCC of CAP in children older than 6 months is…
Strep Pneumo
Chlamydia if younger than 6, v weird. Often follows a lower resp infxn.
A febrile child younger than 3 months with pneumonia should be treated empirically with 2 abx:
- Ampicillin
- Gentamicin
Bc PNA is the first sign of sepsis in newborn?
An afebrile infant aged 1-6 months of age with pneumonia due to chlamydia is treated with…
Azithromycin
Amoxicillin is first line tx for pneumonia in children aged () months to () years
6 months to 5 years
Atypical pneumonia, more common in children older than 5 years, sometimes presents with a () rash and is caused usually by ()
- Erythema multiforme rash
- Mycoplasma
,
1st line tx for atypical pneumonia is..
Azithromycin
Augment 2nd
- Koplik spots
- Cough, coryza, Conjunctivitis
- Maculopapular rash beginning on forehead
What childhood exanthem is this
Rubeola/measles
Has an O because its the ORIGINAL measles
The fever in rubeola/measles peaks when the rash ()
When rash appears
Anyone with exposure to measles/rubeola within the past 72 hours is treated with…
Vaccine
If they’re at least 6 months old.
Rubella’s main clinical significance is due to…
Congenital defects
its very rare since theres a vaccine.
Congenital rubella causes primarily:
* (eye)
* (cardiac)
* (ear)
- Cataracts/glaucoma
- VSD/PDA
- Sensorineural hearing loss
EYE HEART (RUB)Y (EAR)RINGS
I heart ruby earrings is how i remember the main congenital rubella things
Erythema infectiosum/Fifth’s disease is caused by…
Parvovirus B19
Slapped cheek rash describes…
Erythema infectiosum/Fifth’s disease
High Fived the cheeks
Getting infected with erythema infectiosum while pregnant may cause…
Hydrops fetalis
The more systemic complications of fifth’s disease are… (2)
- Arthritis
- Aplastic crisis
Roseola infantum is caused by…
HHV6 and HHV7
The main characteristic of roseola is…
Acute febrile illness
Abrupt onset of high fever, followed by a rash.
MCC of exanthemous fevers in age group.
The MC age range for roseola is… () months to () years)
6 months to 3 years.
The only thing you treat in roseola is…
Fever with tylenol.
Otherwise its benign.
Jones Criteria is used to diagnose rheumatic fever. To be diagnosed with rheumatic fever, you need () major criteria or () major + () minor criteria.
- 2 major criteria
- 1 major + 2 minor criteria
Major Jones criteria mnemonic for rheumatic fever is JONES, which stands for…
- Joint involvement
- O = heartshaped, myocarditis
- Nodules, subcutaneous
- Erythema marginatum
- Sydenham chorea
Sydenham chorea mainly involves jerky, uncontrollable and purposeless movements of the hands, arms, shoulder, face, legs, and trunk
Minor Jones criteria for rheumatic fever is CAFEPAL, which stands for…
- CRP
- Arthralgia
- Fever
- ESR
- Prolonged PR
- Anamnesis of rheumatism
- Leukocytosis
Anamnesis just means history of
The underlying cause of rheumatic fever is…
GABHS
- GABHS is eradicated via (abx)
- Arthritis is managed via (NSAIDs)
- Sydenham chorea is self-limited
in Rheumatic fever
- Penicillin G IM
- Aspirin or Naproxen
Who gets secondary prevention of rheumatic fever and what is the regimen?
- Anyone with an attack and risk for recurrence.
- Long acting PCN G every 3-4 weeks.
The main cause of acquired heart disease in the US for children is…
Kawasaki’s disease
Peaks at age 2.
Kawasaki’s disease requires 4 of out 5 criteria + fever, which are:
1. () cavity changes
2. Bilateral, painless, nonexudative ()
3. () LAN >= 1.5 cm and unilateral
4. Polymorphous ()
5. () changes
- Oral/lip cavity (cracking, strawberry tongue)
- Conjunctivitis
- Cervical
- Polymorphous Exanthema (stocking-glove)
- Extremity changes (redness/swelling/desquamation)
As soon as you suspect Kawasaki’s Disease, the initial imaging you need is…
Echocardiogram
Lots of heart complications.
What lab findings are abnormal with Kawasaki’s?
- CBC
- LFTs
- CRP and ESR
- UA
- CBC showing leukocytosis + thrombocytosis
- Elevated LFTs with hypoalbuminemia
- ESR > 40, CRP > 3
- UA with > 10WBCs/hpf
Initial tx of kawasaki’s is with () and ()
High dose IVIG and ASA
After level () risk, Kawasaki’s must be followed by a pediatric cardiologist.
Level 2 or higher risk.