Paeds - Fever of Unknown Origin Flashcards
What questions are important to ask in the history of a patient returning from a foreign country e.g. with fever?
- Specific country + region travelled to
- Immunisation Hx - including vaccinations done prior to travelling (specific to region of travel)
- Drug Hx - stopped or started any medications due to travelling e.g. anti-malarials
- Travel precautions e.g. mosquito nets, insect spray
- Activities undertaken whilst travelling e.g. food not common to diet, fresh water swimming (schistosomiasis), exposure to animals / their bodily fluids
- Systems review for symptoms
What is Schistosomiasis?
Schistosomiasis or Bilharzia or Snail fever is a parasitic flatworm infection caused by schistosomes
3 main species of schistosome:
- S. mansoni
- S. japonicum
- S. haematobium
What causes Schistosomiasis?
Exposure to contact with fresh water contaminated with schistosomes (parasitic flatworms)
The schistosome parasites are released from infected freshwater snails
What are the features of schistosomiasis due to the Schistosoma haematobium parasite?
‘swimmer’s itch’
S. haematobium deposit egg clusters (pseudopapillomas) in the bladder –> cause inflammation
Depending on location of egg clusters, they can cause obstructive uropathy & kidney damage
Features:
- fever (usually absent in chronic infection)
- urinary frequency
- haematuria
- abdo pain
- bladder calcification - actually calcification of the egg clusters (pseudopapiillomas)
- risk factor for squamous cell bladder cancer
How is Schistosomiasis caused by S. haematobium managed?
Single oral dose of Praziquantel (anti-worm drug)
What are the features of Schistosomiasis caused by S. masoni or S. japonicum ?
These schistosomes (flat-worms) mature in the liver –> then travel through the portal system to the distal colon
Features:
- some develop progressive hepatomegaly + splenomegaly - due to S. masoni or S. japonicum travelling through portal system causing portal vein congestion
- can cause complications: liver cirrhosis, variceal disease and cor pulmonale
Is it necessary to send a stool sample for every patient with diarrhoea?
No!
You should send a stool sample for M,C&S & virology if:
- Suspect sepitcaemia
- Blood or mucus in stool
- Child is immunocompromised
Consider sending stool sample if:
- Hx of travel
- Diarrhoea persisting > 7 days
- Uncertain of diagnosis of gastroenteritis
What is Lyme disease?
Lyme disease is caused by the spirochaete (spiral twisted bacteria) Borrelia burgdorferi - spread by ticks
It is the commonest vector-borne illness in the UK & can be endemic in some areas e.g. New Forest
What are the features of Lyme disease?
Early:
- erythema chronicum migrans (pathognomic of Lyme disease) - circular‘bulls-eye’ rash with central clearing seen in ~ 80%
- fever
- arthralgia
- malaise
Late (several weeks after bite):
- Cardio:
- heart block
- myocarditis
- Neuro:
- facial (CN VII) nerve palsy
- meningitis
- neuropsychiatric manifestations (rare in children)
How is Lyme disease diagnosed?
Can be diagnosed CLINICALLY if erythema migrans is present
- 1st line = ELISA (enzyme-linked immunosorbent assay) for antibodies to Borrelia burgdorferi
- If ELISA is +ve or equivocal –> immunoblot test for Lyme disease
How are asymptomatic tick bites managed?
Reassurance
Don’t give antibiotics
How is suspected / confirmed Lyme disease managed?
-
Doxycycline (if early disease) or amoxicillin if doxy is contraindicated (e.g. pregnancy)
- If erythema migrans is present –> start Abx whilst waiting for ELISA results
- Ceftriaxone - if disease is disseminated (multi-system features)
Jarisch-Herxheimer reaction - sometimes seen after starting Abx (but more common in syphilis, another spirochaetal disease):
- fever
- rash
- tachycardia
What infections can be caught from contact with lizards?
Reptiles & bearded lizards can carry salmonella
What are important elements of a paediatric history?
- Prenatal / Pregnancy history - medical conditions developed during pregnancy, alcohol, smoking, travel, medications
- Birth history e.g. prematurity, delivery process
- Immunisation history - risk of specific infections
- Deveopmental history i.e. growth & wellbeing - hitting developmental milestones, feeding, school etc.
- Drugs (current & recent) - recent antibiotics (C.dif), immunosuppressants
- Family history - health beliefs, mental health, auto-immune, GI
- Allergies - triggers, medication, atopy
What is the most common cause of infective diarrhoea in children in the UK?
Rotavirus
(despite now being on the vaccination schedule)
What does this image show?
Erythema migrans
(also called erythema chronicum migrans)
Pathognomic of lyme disease
