Paeds - The Febrile Child Flashcards
What is the Cushing’s Triad / Reflex?
A physiological NS response to ↑ ICP - which results in
the Cushing’s triad
Cushing’s Triad:
- ↑ BP (HTN)
- Bradycardia
- Irregular breathing - often ↓ RR
What is Kawasaki’s disease?
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
How is Kawasaki’s disease diagnosed?
It is a clinical diagnosis with no formal test
How is Kawasaki’s disease managed?
-
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
What is the classic known complication of Kawasaki’s disease?
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
What is Reye’s syndrome?
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)
What drug is Reye’s syndrome associated with?
Aspirin
What is the prognosis of Reye’s syndrome?
Mortality = 15-25%
What are the features of acute pyelonephritis?
- 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
Which organisms are most likley to cause Meningitis for the age range, neonate - 3 months?
-
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
Which organisms are most likley to cause Meningitis for the age range, 1 month to 5 years old?
- Neisseria meningitidis (meningococcus)
- Streptococcus pneumoniae (pneumococcus)
- Haemophilus influenzae B
Which organisms are most likley to cause Meningitis for the age range, older than 5 years up to 60 years?
- Neisseria meningitidis (meningococcus)
- Streptococcus pneumoniae (pneumococcus)
What organism can cause meningitis in immunosuppressed patients?
Listeria monocytogenes
What are some signs of raised ICP that are contraindications to doing a LP to test for meningitis in a child?
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)
How is meningitis managed in a child?
-
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
A patient is suspected of having meningitis but is also diagnosed with meningococcal septicaemia - LP or no?
Pt has meningococcal speticaemia = NO LP
do blood cultures + PCR for meningococcus
What subsequent complications (sequalae) can meningitis cause?
- Sensorineural hearing loss (most common)
- Epilepsy
- Paralysis
- Psychosocial problems
- Infective –> sepsis, intracerebral abscess
- Pressure –> brain herniation, hydrocephalus
What are some common features of meningitis?
- 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)
Why is IV Dexamethasone given in meningitis?
To ↓ risk of neurological sequalae via
anti-inflammatory action
What is meningitis?
An infection of the subarachnoid space which subsequently causes meningeal inflammation
What investigations might you suggest for a pt with suspected meningitis?
- FBC
- CRP
- coagulation screen
- blood culture
- whole-blood PCR
- blood glucose
- ABG or VBG
- Lumbar puncture (if no signs of raised ICP)
How would CSF results appear for meningitis of the following causes:
- Bacterial
- Viral
- TB
What is Herpes Simplex Encephalitis?
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)
Which type of HSV causes HSV encephalitis?
HSV-1
causes 95% of HSV encephalitis in adults
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
How is HSV encephalitis managed?
IV Aciclovir
A rash that doesn’t blanch (disappear) with pressure (e.g. from a glass) is a sign of what?
Meningococcal disease (2 types)
- Meningococcal septicaemia
- Meningococcal meningitis
Name 4 conditions in which you might see a non-blanching petechial/purpuric rash?
- Meningococcal disease e.g. meningitis or septicaemia
-
Idiopathic Thrombocytopenic Purpura (ITP)
- low platelet count can cause petechial/purpuric non-blanching rashes + mucosal bleeding
-
Henoch-Schonlein Purpura (HSP)
- palpable purpuric rash symmetrically on legs & buttocks
- Non-accidental injury
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)
How is HSP managed?
- Analgesia for polyarthalgia
- Supportive for nephropathy
What is the prognosis of HSP?
Usually excellent!
HSP = self-limiting, especially when there is no renal involvement
~ 1/3rd have a relapse
What does this image show?
Henoch-Schonlein purpura (HSP)
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
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
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
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
How is measles managed?
Symptomatic management!!
- Ribavirin - if immunocompromised pt then
- Vitamin A - may modulate immune response, to be given in developing countries
What does this image show?
Koplik Spots
(measles)
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
What is the normal age range for the anterior fontanelle to close?
18-24 months
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
Do anti-pyretic agents prevent febrile convulsions?
NO !!
How are children with suspected meningococcal disease in the pre-hospital environment?
- Urgent transfer to hospital for IV antibiotics
- IM or IV benzylpenicillin (without delaying transfer to hospital)
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
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!
Is Niesseria meningococcus gram positive or negative?
Gram-negative
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
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)
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%)
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
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)
What investigations might you want to do for HSP?
- Vital Obs - sepsis screen
- FBC - exclude infection, anaemia, aplastic anaemia
- U&Es - assess renal function (which can be deranged in HSP)
- Urinalysis - HSP can have features of IgA nephropathy (Berger’s disease) e.g. haematuria, maybe protein
- Urine protein:creatinine ratio - quanitfy protein present in urine
What intestinal pathology is Henoch-Schonlein purpura associated with?
Intussusception
Occurs in ~ 2/3rd of HSP cases
