Paeds - The Febrile Child Flashcards
1
Q
What is the Cushing’s Triad / Reflex?
A
A physiological NS response to ↑ ICP - which results in
the Cushing’s triad
Cushing’s Triad:
- ↑ BP (HTN)
- Bradycardia
- Irregular breathing - often ↓ RR
2
Q
What is Kawasaki’s disease?
A
Kawasaki’s disease is an uncommon type of systemic vasculitis (predominantly seen in children)
Features:
- 6 months - 4 years old
-
High-grade fever which lasts for > 5 days
- Fever = characteristically resistant to antipyretics (e.g. paracetamol)
- Conjunctival injection without exudate - hyperaemia / enlargement of conjunctival vessels
- Bright red, cracked lips
- Strawberry tongue - and red mucosa
- Cervical lymphadenopathy
- Red palms / soles of feet –> which later peel
3
Q
How is Kawasaki’s disease diagnosed?
A
It is a clinical diagnosis with no formal test
4
Q
How is Kawasaki’s disease managed?
A
-
High-dose Aspirin –> ↓ thrombosis risk
- Kawasaki’s = one of few indications for aspirin in children, which is normally avoided due to risk of Reye’s syndrome
- IVIG (IV immunoglobulin) - given within first 10-days, ↓ risk of coronary artery aneurysms
- Echo at 6-weeks after start of illness - to screen for coronary artery aneurysms
5
Q
What is the classic known complication of Kawasaki’s disease?
A
Coronary artery aneurysm
- occurs in ~ 1/3rd of affected children within 6-weeks of illness
- subsequent narrowing of coronary arteries from scar formation can cause MI
6
Q
What is Reye’s syndrome?
A
Severe, progressive encephalopathy affecting children, with fatty infiltration of the liver, kidneys & pancreas
Features:
- 2 yrs old = peak incidence
- Encephalopathy –> confusion, seizures, cerebral oedema, coma
- Fatty infiltration of the liver, kidneys and pancreas
- Hypoglycaemia (↓ blood sugar)
7
Q
What drug is Reye’s syndrome associated with?
A
Aspirin
8
Q
What is the prognosis of Reye’s syndrome?
A
Mortality = 15-25%
9
Q
What are the features of acute pyelonephritis?
A
- fever
- rigors (sudden feeling of cold sweat / shivering + ↑ in temp)
- loin pain
- vomiting
- white cell casts in urine
Note: in children pyelonephritis can dmg the growing kidney by forming a renal scar –> can result in hypertension / chronic renal failure
10
Q
Which organisms are most likley to cause Meningitis for the age range, neonate - 3 months?
A
-
Group B Streptococcus
- Usually acquired from the mother at birth
- More common if; 1) low birth weight babies or 2) following prolonged rupture of the membranes
- E. coli & other Gram -ve organisms
- Listeria monocytogenes
11
Q
Which organisms are most likley to cause Meningitis for the age range, 1 month to 5 years old?
A
- Neisseria meningitidis (meningococcus)
- Streptococcus pneumoniae (pneumococcus)
- Haemophilus influenzae B
12
Q
Which organisms are most likley to cause Meningitis for the age range, older than 5 years up to 60 years?
A
- Neisseria meningitidis (meningococcus)
- Streptococcus pneumoniae (pneumococcus)
13
Q
What organism can cause meningitis in immunosuppressed patients?
A
Listeria monocytogenes
14
Q
What are some signs of raised ICP that are contraindications to doing a LP to test for meningitis in a child?
A
Signs of raised ICP:
- Focal neurological signs
- Papilloedema
- Significant bulging of the fontanelle
- Disseminated Intravascular Coagulation (DIC)
- Signs of cerebral herniation
- Reduced or fluctuating GCS (< 9 or a drop of 3 or more)
15
Q
How is meningitis managed in a child?
A
-
Abx
- < 3 months –> IV Cefotaxime + IV Amoxicillin (for Listeria cover)
-
> 3 months:
- IV Ceftriaxone 80 mg/kg once daily … unless ….
- also recieving calcium-containing infusions –> IV Cefotaxime
- Ceftriaxone isn’t used if < 3-months old because it can cause jaundice (it competes with bilirubin for binding to albumin)
-
Steroids
- < 3 months –> NO steroids (NICE guidelines)
- If > 12 hrs since 1st Abx dose then don’t start dexamethasone
- IV Dexamethasone –> 4-times daily for 2-4 days
- IV Dexamethasone if LP shows any of the following:
- Frank purulent CSF
- CSF WBC count > 1000/μL
- Raised CSF WBC count + protein concentration > 1 g/L
- Bacteria on Gram stain
- Fluids - any shock –> treat with colloid
16
Q
A patient is suspected of having meningitis but is also diagnosed with meningococcal septicaemia - LP or no?
A
Pt has meningococcal speticaemia = NO LP
do blood cultures + PCR for meningococcus
17
Q
What subsequent complications (sequalae) can meningitis cause?
A
- Sensorineural hearing loss (most common)
- Epilepsy
- Paralysis
- Psychosocial problems
- Infective –> sepsis, intracerebral abscess
- Pressure –> brain herniation, hydrocephalus
18
Q
What are some common features of meningitis?
A
- fever
- headache
- neck stiffness
- papilloedema
- drowsiness
- decreased / change in conciousness
- purpuric non-blanching rash (particularly with meningococcal disease)
- nausea & vomiting
- photophobia
- seizures
- Kernig’s sign - pt supine, thigh flexed to 90, straightening leg at knee is met with resistance
- Infants: poor feeding, irritability, floppiness hypothermia, bulging fontanelle, apnoea
- Rare: focal neurological deficit, facial palsy, balance problems (CN VIII), opisthotonus (severe hyperextension of head, neck and spine forming arching position, alike tetanus)
19
Q
Why is IV Dexamethasone given in meningitis?
A
To ↓ risk of neurological sequalae via
anti-inflammatory action
20
Q
What is meningitis?
A
An infection of the subarachnoid space which subsequently causes meningeal inflammation
21
Q
What investigations might you suggest for a pt with suspected meningitis?
A
- FBC
- CRP
- coagulation screen
- blood culture
- whole-blood PCR
- blood glucose
- ABG or VBG
- Lumbar puncture (if no signs of raised ICP)
22
Q
How would CSF results appear for meningitis of the following causes:
- Bacterial
- Viral
- TB
A
23
Q
What is Herpes Simplex Encephalitis?
A
HSV encephalitis - characteristically affects the temporal lobes & inferior frontal lobes
Features:
- Fever
- Headache
- Vomiting
- Psychiatric symptoms
- Seizures
- focal features e.g. aphasia (often receptive dysphasia if temporal lobe affected)
24
Q
Which type of HSV causes HSV encephalitis?
A
HSV-1
causes 95% of HSV encephalitis in adults
25
What investigations might you do if suspecting HSV encephalitis?
* **CSF** = ↑ WCC, ↑ protein
* **PCR** - looking for HSV
* **CT** - medial temporal and inferior frontal changes (e.g. petechial haemorrhages)
* note: these haemorrhages are normal in 1/3rd of patients
* MRI is better - see image (hyperintensity of the affected white matter and cortex in the medial temporal lobes and insular cortex)
* **EEG** pattern: lateralised periodic discharges at 2 Hz
26
How is HSV encephalitis managed?
**IV Aciclovir**
27
A rash that doesn't blanch (disappear) with pressure (e.g. from a glass) is a sign of what?
Meningococcal disease (2 types)
1. Meningococcal septicaemia
2. Meningococcal meningitis
28
Name 4 conditions in which you might see a non-blanching petechial/purpuric rash?
1. **Meningococcal disease** e.g. meningitis or septicaemia
2. **Idiopathic Thrombocytopenic Purpura** (ITP)
* low platelet count can cause petechial/purpuric non-blanching rashes + mucosal bleeding
3. **Henoch-Schonlein Purpura (**HSP)
* palpable purpuric rash symmetrically on legs & buttocks
4. **Non-accidental injury**
29
What is Henoch-Schonlein purpura (HSP)?
HSP is an **IgA mediated small vessel vasculitis**
Features:
* Age usually **3-10 years**
* **Boys** - twice as common
* **Post- infection** - often seen in children following a URTI
* **Palpable purpuric rash** (with localized oedema)
* **buttocks** and **extensor surfaces** of arms and legs
* does not scar!
* **Abdo pain**
* **Polyarthritis**
* **Periarticular oedema**
* **Swollen testes**
* **Intussusception** - occurs in 2/3% of HSP pts
* May have **IgA nephropathy** features:
* macroscopic haematuria
* renal failure (rare)
30
How is HSP managed?
* **Analgesia** for polyarthalgia
* **Supportive** for nephropathy
31
What is the prognosis of HSP?
Usually excellent!
HSP = self-limiting, especially when there is no renal involvement
~ 1/3rd have a relapse
32
What does this image show?
Henoch-Schonlein purpura (HSP)
33
What is Staphylococcal scalded skin syndrome?
A **painful blistering skin** condition, caused by **Staphylococcus aureus**
Features:
* **Original infection** - can be infected graze, nappy rash, conjunctivitis
* **Widespread patchy red skin** (resembling scald or burn) --\> progresses to join patches and blister
* Fluid filled, thin **blisters** (can cover wide area)
* **Fever**
* Irritable / miserable / lethargic
* Don't want to be touched
* **Mucous membranes spared** (unlike toxic epidermal necrolysis)
* **Nikolsky's sign** - slight rubbing of skin causes exfoliation of outermost layer
34
What is toxic shock syndrome?
Also called Staphylococcal toxic shock syndrome, describes a **severe systemic reaction to staphylococcal exotoxins**
Features:
* **Fever**\> 38.9ºC
* **Hypotension** (\< 90 mmHg)
* **Diffuse erythematous rash**
* Desquamation of rash, especially of palms + soles
* Involvement of **3 or more organs**:
* GI - diarrhoea & vomiting
* Renal failure
* Hepatitis
* Thrombocytopenia
* CNS - confusion
35
What is Measles?
A **highly contagious infectious** **disease** caused by the measles virus (**Measles morbillivirus**) - causes infection of respiratory system
* Rare in developed world due to immunisation programmes
* Spread by droplets
* Pts are infective from prodrome until 4 days after rashs starts
* Incubation period = 10-14 days
36
What are the features of Measles?
* Prodrome: (conjunctivitis + corysa) i.e. **fever**, **cough**, **runny nose**, **irritable**, **conjunctivitis**
* **Koplik spots** (before rash) = white spots on buccal mucosa
* Rash = **starts behinds ears** --\> spreads to **whole** **body**
* Discrete **maculopapular rash** becoming blotchy & confluent
37
How is measles managed?
**Symptomatic management!!**
* **Ribavirin** - if immunocompromised pt then
* **Vitamin A** - may modulate immune response, to be given in developing countries
38
What does this image show?
Koplik Spots
(measles)
39
Which if the following aren't routinely vaccinated against in the UK?
* Streptococcus Pneumoniae
* Group B haemolytic Streptococcus
* Haemophilus influenzae
* E. Coli
* Meningococcal type B
* Meningococcal type C
**Group B haemolytic Streptococcus**
and
**E. Coli**
40
What is the normal age range for the anterior fontanelle to close?
18-24 months
41
Review the traffic light system for identifying serious illness in children with fever \< 5 yrs old.
* Children \< 5yrs with fever + what symptoms put them at **high** risk?
* Children \< 5yrs with fever + what symptoms put them at **intermediate** risk?
**High risk** - worth learning:
* pale/mottled/ashen/blue - skin, lips or tongue
* no response to social cues
* appearing ill to a healthcare professional
* does not wake or if roused does not stay awake
* weak, high-pitched or continuous cry
* grunting
* RR \> 60
* moderate or severe chest indrawing
* ↓ skin turgor
* bulging fontanelle
42
Do anti-pyretic agents prevent febrile convulsions?
NO !!
43
How are children with suspected meningococcal disease in the pre-hospital environment?
1. Urgent **transfer** to hospital for IV antibiotics
2. **IM** or **IV benzylpenicillin** (without delaying transfer to hospital)
44
What tests might you send an LP sample for in suspected meningococcal meningitis?
* **Protein** - high in bacterial & TB meningitis and normal/raised in viral
* **Glucose** - low in bacterial and TB and ~60% of plasma glucose
* **LDH** - high in bacterial meningitis and low in viral
* **Microscopy and gram stain**
* **Culture & Sensitivity**
* **PCR** - for virology, pneumococcus and meningococcus
45
For a patient with suspected bacterial meningitis, which order should you conduct an LP and giving Abx?
Ideally: LP --\> Abx
However ...
**If suspecting meningitis / bacterial meningitis you should not delay giving IV-antibiotics !!**
Useful results can still be obtained from an LP up to 72hrs after starting antibiotics!
46
Is Niesseria meningococcus gram positive or negative?
Gram-negative
47
Where does a LP needle need to be inserted?
Into the **L4/L5 inervertebral space**
or L3/L4
* Identify the anterior superior iliac crests and draw an imaginary line between them
* In the midline of this line is the L5 vertebrae
* The L4/L5 space is just above
48
What are some contraindications to doing an LP?
* **Shock** or **respiratory insufficiency**
* **Convulsions**
* Extensive or spreading **purpuric rash** i.e. potential meningococcal septicaemia
* **Bleeding disorder** e.g. low platelets, anti-coagulants, known clotting-issue
* **Local infection**
* **Signs of ↑ ICP**:
* Focal neurological signs
* Papilloedema
* Significant bulging of the fontanelle
* Disseminated Intravascular Coagulation (DIC)
* Signs of cerebral herniation
* Reduced or fluctuating GCS (\< 9 or a drop of 3 or more)
49
Of the common bacteria which can cause meningitis, which has the poorest prognosis?
**Streptococcus Pneumoniae**
* Of common pathogens, Streptococcus Pneumoniae has the highest mortality (up to 30%)
* Neisseria meningitides the lowest (3-10%)
50
A 3 year old boy is brought to see his GP. He is previously well. He has a 3 day history of fever and rash. No vomiting or diarrhoea. Pulse 110, respiratory rate 22, temperature 38.1 degrees C. He is pale and has a bright red rash on both cheeks with clear demarcation. Throat and ears normal. Chest clear. No other rash noted, no lymphadenopathy.
What is the diagnosis?
* Scarlet Fever
* Kawasaki Disease
* Slapped cheek syndrome
* Henoch Schonlein pupura
* SLE
**Slapped cheek syndrome**
* Condition is caused by parovirus
* Can be issue for pts with haemoglobin disorders
51
What is the difference between petechiae, purpura and ecchymoses?
* **Petechiae** are \< 3 mm (broken capillary)
* **Purpura** are 3-10 mm & non-blanching (bleeding under skin)
* **Ecchymoses** are \> 1 cm (bleeding under skin) - hard to differentiate from bruise (which is caused by trauma)
52
What investigations might you want to do for HSP?
1. **Vital Obs** - sepsis screen
2. **FBC** - exclude infection, anaemia, aplastic anaemia
3. **U&Es** - assess renal function (which can be deranged in HSP)
4. **Urinalysis** - HSP can have features of IgA nephropathy (Berger's disease) e.g. haematuria, maybe protein
5. **Urine protein:creatinine ratio** - quanitfy protein present in urine
53
What intestinal pathology is Henoch-Schonlein purpura associated with?
**Intussusception**
Occurs in ~ 2/3rd of HSP cases
