PAEDS - INFECTIOUS DISEASES / ALLERGIES Flashcards
FEBRILE CHILD
What system is used to assess a febrile child?
What are the main components?
- NICE traffic light system for <5
- Colour (skin, lips, tongue)
- Activity
- Respiratory
- Circulation + hydration
- Other
FEBRILE CHILD
In terms of the NICE traffic light system, what is considered amber for…
i) colour?
ii) activity?
iii) respiratory?
iv) circulation and hydration?
v) other?
i) Pallor
ii) No smile, decreased activity, not responding to social cues, wakes when roused
iii) Nasal flaring, SpO2 ≤95%, crackles in chest RR>50 (6-12m) or >40 (>12m)
iv) Tachy (>160 if <1y, >150 if 1–2y, >140 if 2–5y), CRT ≥3s, dry mucous membranes, reduced urine output
v) 3-6m temp ≥39, fever ≥5d, rigors, joint swelling, non-weight bearing
FEBRILE CHILD
In terms of the NICE traffic light system, what is considered red for…
i) colour?
ii) activity?
iii) respiratory?
iv) circulation and hydration?
v) other?
i) Mottled skin
ii) No response to cues, doesn’t wake if roused, weak, high-pitched or constant cry
iii) Grunting, RR>60, mod-severe chest indrawing
iv) Reduced skin turgor, no urine output
v) <3m temp ≥38, non-blanching rash, bulging fontanelle, neck stiffness, status, focal seizures/neuro
FEBRILE CHILD
What are some common and uncommon causes of fever?
- Common = URTI, tonsillitis, otitis media, UTI
- Uncommon = Meningitis, epiglottitis, kawasaki disease, TB
FEBRILE CHILD
What is the management of a green score?
- Manage at home with safety netting
- Regular fluids, monitor child, contact if concerned
FEBRILE CHILD
What is safety netting?
- Clear verbal ± written advice about warning signs with plan of action
- Follow up if required
- Liaise with other HCPs so direct access if child needs
FEBRILE CHILD
What is the management of an amber score?
- F2F assessment with paeds or specialist for further investigation
- ?Home with safety net
FEBRILE CHILD
What is the management of a red score?
- Urgent referral to hospital for specialist assessment (?999)
CHICKEN POX
What is chicken pox?
- Primary infection by Varicella zoster virus (human herpes virus 3)
CHICKEN POX
How does it spread?
Droplet via resp route
CHICKEN POX
How long is it contagious for?
Contagious 4d before rash + until lesions crusted (often 5d)
CHICKEN POX
What are some risk factors for chicken pox?
- Immunocompromised
- Older age
- Steroids
- Malignancy
- Neonates
CHICKEN POX
What is the clinical presentation of chicken pox?
- Prodromal high fever 38-39 often ceases when rash appears, malaise
- Very itchy, vesicular rash starts on head + trunk > peripheries
- Not infective once vesicles have crusted over (5d usually)
CHICKEN POX
What are some complications of chicken pox?
- Secondary bacterial infection
- Shingles (older children)
- Ramsay Hunt syndrome (older children)
- Risk to immunocompromised, neonates + pregnant women
- Rarer = pneumonia, encephalitis
CHICKEN POX
How does secondary bacterial infection present in chicken pox?
How is it managed?
- Small area of cellulitis or erythema, persistent fever
- Small risk staph/group A strep infection > necrotising fasciitis
- NSAIDs may increase risk, Rx with Abx (IV if severe or dehydrated)
CHICKEN POX
What is shingles?
- Reactivation of dormant virus > herpes zoster virus (shingles) in dorsal root ganglia
CHICKEN POX
How does shingles present?
Characteristic rash in dermatomal distribution, acute, unilateral, blistering painful rash
CHICKEN POX
What is the management of shingles?
PO aciclovir
CHICKEN POX
What is Ramsay Hunt syndrome?
- Herpes zoster oticus > reactivation of varicella zoster virus in geniculate ganglion of CN7
CHICKEN POX
How does Ramsay Hunt Syndrome present?
- Auricular pain,
- facial nerve palsy,
- vesicular rash around ear,
- ?vertigo + tinnitus
CHICKEN POX
What is the management of Ramsay Hunt syndrome?
PO aciclovir + corticosteroids
CHICKEN POX
What is the risk of chicken pox to…
i) immunocompromised?
ii) neonates?
iii) pregnant?
i) Disseminated disease, DIC, pneumonitis (VZIG if exposed to case)
ii) Mother develops shortly before/after delivery infant > VZIG + aciclovir
iii) Risk of foetal varicella syndrome if <20w
CHICKEN POX
What is the management of chicken pox?
- Camomile lotion to stop itching
- Avoid high risk groups
- Trim nails
- School exclusion until all lesions crusted over (usually 5d after rash)
MENINGITIS
What is meningitis?
- Inflammation of the meninges which line the brain + spinal cord
MENINGITIS
How does it occur?
Microorganisms reach meninges by direct extension from ears, nasopharynx or bloodstream spread
MENINGITIS
What are the most common causes of bacterial meningitis?
- Neonates = GBS or listeria monocytogenes
- 1m–6y = N. meningitidis (gram -ve diplococci), S. pneumoniae (gram + ve cocci chain), H. influenzae
- > 6y = meningococcus + pneumococcus, rarely TB
MENINGITIS
What are some other causes of meningitis?
- Herpes simplex virus (HSV), enteroviruses, EBV + varicella zoster virus
- Aseptic/sterile by malignancy or autoimmune diseases
MENINGITIS
What are the symptoms of meningitis?
- Fever, headache, vomiting, drowsiness, poor feeding, irritable/lethargic
- Later may have seizures, focal neurology, decreased GCS/coma
- Neonates may have hypothermia, lethargy + hypotonia
MENINGITIS
What are some signs of meningitis?
- Meningism = neck stiffness (not always present), photophobia
- Bulging fontanelle, opisthotonos, signs of shock
- +ve Kernig’s + Brudzinski
- Non-blanching petechial/purpuric rash = later sign in meningococcal septicaemia (endotoxin causes DIC + subcut haemorrhages)
MENINGITIS
What is the difference between Kernig’s and Brudzinski signs?
- Kernig = pain/unable to extend leg at knee when it’s bent
- Brudzinski = involuntary flexion of hips/knees when neck flexed
MENINGITIS
What investigations would you do for meningitis?
- Blood cultures + serology (before LP + Abx unless undesirable delay)
- FBC, U+E, LFTs, CRP, blood glucose
- LP for MC&S with protein, cell count, glucose + viral PCR
- ?CT head if other signs like papilloedema
MENINGITIS
When would you not perform a lumbar puncture?
Why?
- Signs of increased ICP, focal neurology, local infection, unduly delay starting Abx or coagulopathies
- Coning of cerebellar tonsils via foramen magnum
MENINGITIS
You suspect a diagnosis of bacterial meningitis. How would a lumbar puncture confirm the diagnosis for…
i) appearance?
ii) protein?
iii) glucose?
iv) white cell count?
v) other?
i) Cloudy/turbid
ii) ++ (make protein)
iii) –– (eat glucose)
iv) ++ neutrophil polymorphs
v) Gram stain
MENINGITIS
You suspect a diagnosis of viral meningitis. How would a lumbar puncture confirm the diagnosis for…
i) appearance?
ii) protein?
iii) glucose?
iv) white cell count?
v) other?
i) Clear
ii) Normal/+
iii) Normal/-
iv) + lymphocytes
v) PCR
MENINGITIS
You suspect a diagnosis of TB meningitis. How would a lumbar puncture confirm the diagnosis for…
i) appearance?
ii) protein?
iii) glucose?
iv) white cell count?
v) other?
i) Turbid/viscous
ii) +++
iii) –––
iv) + lymphocytes
v) Acid fast bacilli
MENINGITIS
What are some complications of meningitis?
- Hearing (sensorineural) loss is key complication
- Seizures + epilepsy, cerebral abscess, encephalitis + hydrocephalus
- Cognitive impairment, cerebral palsy + LD
MENINGITIS
What is the management of bacterial meningitis?
- Supportive = correct shock with fluids, oxygen if needed
- <3m = IV cefotaxime + amoxicillin (cover listeria from ?pregnancy)
- > 3m = IV ceftriaxone + IV dexamethasone to reduce frequency + severity of hearing loss + neuro damage (NOT before 3m)
MENINGITIS
What is the management of viral meningitis?
- Milder so supportive + aciclovir if HSV or VSZ
MENINGITIS
You see a child with a non-blanching petechial rash in GP and are concerned about meningococcal septicaemia so call for an ambulance.
What immediate treatment should you give if possible?
- IM benzylpenicillin
MENINGITIS
What shoudl be given to close contacts?
- Single dose ciprofloxacin or rifampicin
- Ciprofloxacin is prefered as can use for any age, pregnant ladies + does not interfere with OCP
MENINGITIS
What are the drawbacks with giving ciprofloxacin to a close contact?
- Do not give in myasthenia gravis or previous sensitivity,
- can cause tendinitis
- can trigger seizures
MENINGITIS
What are the drawbacks with giving rifampicin to a close contact?
- Affect hormonal contraception,
- not advised in pregnancy
- have to monitor LFTs + renal function
MENINGITIS
What Public Health aspects are important in terms of meningitis?
- Meningitis B vaccine at 8w, 16w + 1y (men C at 1y too) and ACWY offered to teenagers + uni students
- Bacterial meningitis + meningococcal = notifiable diseases
ENCEPHALITIS
What is encephalitis?
- Inflammation of the brain parenchyma
ENCEPHALITIS
What causes it?
- Mostly viral – herpes viruses (HSV 1 if child or 2 if neonate from birth, VZV), enteroviruses, EBV, resp viruses
- Non viral = any bacterial meningitis, TB, lyme disease
- Non-infective = autoimmune antibodies against brain
ENCEPHALITIS
What is the clinical presentation of encephalitis?
- Similar to meningitis = fever, headache, photophobia, neck stiffness
- KEY difference = altered mental state (behavioural change, confusion)
- Acute onset focal neurology (hemiparesis, dysphasia, focal seizures)
ENCEPHALITIS
What are the investigations for encephalitis?
- FBC, U+Es, blood cultures + serology for viral PCR
- LP for MC&S with protein, cell count, glucose + viral PCR
- CT/MRI head to visualise brain as ?focal changes, particularly temporal lobes
ENCEPHALITIS
What would the CSF analysis show in encephalitis for…
i) appearance?
ii) protein?
iii) glucose?
iv) white cell count?
i) Clear
ii) Normal/+
iii) Normal/–
iv) + lymphocytes
ENCEPHALITIS
What is the management of encephalitis?
- IV aciclovir to cover HSV, Abx in case bacterial meningitis
- Supportive therapy in HDU/ICU if needed
SEPTICAEMIA
What is septicaemia?
- Bacteria proliferates into bloodstream as host response includes release of inflammatory cytokines + activation of endothelial cells which can lead to septic shock
SEPTICAEMIA
What are the causes of septicaemia?
- Most common = N. meningitidis
- Neonates = GBS or gram -ve organisms from birth canal
SEPTICAEMIA
What are some risk factors?
- Sickle cell disease
- immunodeficiency
SEPTICAEMIA
What are the symptoms and signs of septicaemia?
- Fever, poor feeding, irritable/lethargic, Hx of focal infection
- Fever, purpuric non-blanching rash, multi-organ failure
SEPTICAEMIA
How does shock present?
- Tachycardia + tachypnoea
- Cold peripheries
- Capillary refill >2s
- Hypotensive
- Oliguria
SEPTICAEMIA
What is the management of septicaemia?
- Septic screen (FBC, U+Es, blood cultures, urine MC&S, LP/CSF, CXR, acute phase reactant like CRP)
- Aggressive fluid resus, ?ICU
- Broad-spec Abx until cultures back
KAWASAKI DISEASE
What is Kawasaki disease?
What is the epidemiology?
- Idiopathic medium-sized vessel systemic vasculitis, mainly affects 6m–5y
- More common in children of Japanese or Afro-Caribbean ethnicity
KAWASAKI DISEASE
What is the diagnostic criteria for Kawasaki disease?
Fever + 4 (MyHEART) –
- Mucosal involvement (red/dry cracked lips, strawberry tongue)
- Hands + feet (erythema then desquamation)
- Eyes (bilateral conjunctival injection, non-purulent)
- lymphAdenopathy (unilateral cervical >1.5cm)
- Rash (polymorphic involving extremities, trunk + perineal regions
- Temp >39 for >5d
KAWASAKI DISEASE
What are the 3 phases of Kawasaki disease?
- Acute (1–2w) = child most unwell, fever, rash, lymphadenopathy
- Subacute (2–4w) = acute Sx settle, desquamation + Risk of coronary artery aneurysms
- Convalescent (2–4w) = remaining Sx settle, blood markers normalise slowly
KAWASAKI DISEASE
What is a key complication of Kawasaki disease?
- Coronary artery aneurysm + sudden death
KAWASAKI DISEASE
What are some investigations for Kawasaki disease?
- FBC (raised WCC), raised ESR + CRP, raised platelets (week 2)
- Echocardiogram with close follow up (6w) to rule out aneurysm
KAWASAKI DISEASE
What is the management of Kawasaki disease?
- Prompt IVIg to reduce risk of aneurysm + aspirin to reduce risk of thrombosis
- If fever persists = infliximab, steroids or ciclosporin
KAWASAKI DISEASE
What are the side effects of IVIG in the management of Kawasaki disease?
- anaphylaxis,
- aseptic meningitis,
- organ dysfunction
KAWASAKI DISEASE
Why is the management of Kawasaki disease unique?
Prognosis?
- Aspirin normally contraindicated in children due to risk of Reye’s syndrome (swelling of the liver + brain)
- 50% evidence of cardiac impairment + mild MR, long-term follow up
MEASLES
What is measles?
- Infection with measles virus (Morbillivirus) via droplets (highly contagious)
MEASLES
What is a risk factor?
Avoidance of MMR vaccine
MEASLES
What is the clinical presentation of measles?
- Prodromal Sx for 3–5d (CCCK) – Cough, Coryza, Conjunctivitis, Koplik spots
- Maculopapular rash starts on forehead, neck + behind ears > down to limb, trunk
- Fever, marked malaise
MEASLES
What are Koplik spots?
- White spots on buccal mucosa = pathognomonic
MEASLES
What are the investigations for measles?
Clinical Dx with serological (blood or saliva) testing for epidemiology
MEASLES
What are some important complications of measles?
- Otitis media (commonest complication)
- Pneumonia (commonest cause of death)
- Diarrhoea
- Febrile convulsions, encephalitis
- Subacute sclerosing panencephalitis rare where 5-10y after primary measles > loss of neuro function, dementia + death
MEASLES
What is the management of measles?
- Notifiable disease
- Best treatment is prevention with MMR vaccine
- Viral illness so supportive (fluids, isolate if in hospital)
- Antivirals in immunocompromised
- School exclusion for 4d from rash onset
RUBELLA
What is rubella?
How does it spread?
- Mild notifiable disease occurring in winter + spring
- Spreads via respiratory route, often from known contact, prevention via vaccine
RUBELLA
What is the clinical presentation of rubella?
- Mild prodrome (low-grade fever, sore throat, coryza)
- Pink maculopapular rash starts on face then spreads down to cover whole body
- Rash not itchy in children but is in adults
- Suboccipital + postauricular lymphadenopathy
RUBELLA
What are the investigations for rubella?
- Clinical Dx
- Serological confirmation if any risk of exposure of a non-immune pregnant woman
RUBELLA
What are some complications of rubella?
How can it be reduced?
- Rare but > encephalitis, arthritis, myocarditis + thrombocytopenia
- Congenital rubella syndrome > cataracts, CHD + sensorineural deafness
- Avoid pregnant women, school exclusion 4d from rash, ensure vaccinated
MUMPS
What is mumps?
How does it occur?
- RNA paramyxovirus, occurs in winter + spring, spreads via resp droplets where virus replicates in epithelial cells
- Virus accesses parotid glands before further dissemination
MUMPS
What marker may be raised?
Raised amylase
MUMPS
What is the clinical presentation of mumps?
- Fever, malaise + parotitis
- Parotitis often unilateral initially then bilateral > uncomfortable + may have earache or pain when eating/drinking
- May have hearing loss but often unilateral + transient
MUMPS
What are some complications of mumps?
- Viral meningitis + encephalitis
- Orchitis (usually unilateral, may reduce sperm count + lead to infertility)
- Pancreatitis
MUMPS
What is the management of mumps?
- Notifiable disease
- Prophylaxis via vaccine
- Clinical Dx, manage Sx as viral
- School exclusion for 5d of onset of parotid swelling
HAND, FOOT + MOUTH
What is hand, foot and mouth disease caused by?
- Caused by coxsackie A16 virus
HAND, FOOT + MOUTH
How does it present?
- Mild viral URTI (sore throat, cough, fever)
- Painful red vesicular lesions on hands, feet, mouth + tongue (often buttocks too)
HAND, FOOT + MOUTH
What is the management of hand, foot and mouth disease?
- Subsides within few days, supportive with fluids, analgesia
- Very contagious, avoid sharing towels + bedding, good handwashing
- Only exclude from school if unwell
GLANDULAR FEVER
What is glandular fever, or infectious mononucleosis, caused by?
- Epstein-Barr virus (EBV), particular tropism for B lymphocytes + epithelial cells of pharynx
GLANDULAR FEVER
How is it spread?
Oral contact ‘kissing disease’
GLANDULAR FEVER
What is the clinical presentation of glandular fever?
- Triad of severe sore throat (tonsillopharyngitis can limit oral intake), lymphadenopathy (cervical) + pyrexia
- May have petechiae on soft palate, splenomegaly + headache
GLANDULAR FEVER
What are the investigations for glandular fever?
- FBC (lymphocytosis)
- positive Monospot test with heterophile antibodies
GLANDULAR FEVER
What are the complications of glandular fever?
- Splenic rupture,
- haemolytic anaemia,
- chronic fatigue,
- EBV associated with Burkitt’s lymphoma
GLANDULAR FEVER
What is the management of glandular fever?
- Conservative (fluids, analgesia)
- Avoid alcohol + contact sports for 8w after to reduce risk of splenic rupture
- Avoid amoxicillin as can cause florid, pruritic maculopapular rash
SCARLET FEVER
What is scarlet fever?
- Reaction to strep pyogenes (group A beta haemolytic) toxin - strep A
SCARLET FEVER
How is it spread?
- Via respiratory droplets
SCARLET FEVER
What is the clinical presentation of scarlet fever?
- Prodrome = sore throat, fever, vomiting + abdo pain
- Red-pink diffuse rash that is ‘rough sandpaper-like’ + ‘pinhead’, starts on trunk + spreads outwards
- May have exudative tonsils + strawberry tongue
- Tender cervical lymphadenopathy
SCARLET FEVER
What is the investigation of choice for scarlet fever?
- Throat swab (but start Abx)
SCARLET FEVER
What are some complications of scarlet fever?
- Otitis media (#1),
- quinsy,
- post-strep glomerulonephritis,
- rheumatic fever
SCARLET FEVER
What is the management of scarlet fever?
- Notifiable disease
- Phenoxymethylpenicillin for 10d to prevent rheumatic fever
- Supportive (fluids, pain relief)
- School exclusion until 24h after Abx
SLAPPED CHEEK
What is slapped cheek syndrome, or erythema infectiosum?
- Caused by parvovirus B19, outbreaks common during spring months
SLAPPED CHEEK
What is important to note in slapped cheek syndrome?
Infects red cell precursors in bone marrow which can cause complications