Pediatric Infectious Disease Flashcards
Otitis Media?
- Peak incidence?
- Major risk factors? 3 (whats protective?)
- Most common bugs? 3
- First line therapy?
- Alternatives? 2
- Treatment failure prompts what? 2
- Peak incidence 6-36 months
- Major risk factors include:
- caretaker smoking,
- bottle propping
- day-care attendance (Breastfeeding is protective!) - Most common bugs:
- Streptococcus Pneumoniae (50%),
- Haemophilus Influenzae (30%),
- Moraxella Catarrhalis (10-15%) - Amoxicillin first line therapy,
- alternatives include various
- cephalosporins
- macrolides,
-treatment failure usually prompts Augmentin (bad diahrrea and doesn’t taste very good) possibly -Ceftriaxone (Rocephin) IM.
Otitis media: If not absolutely sure what should you do to confirm diagnosis?
use pneumatic otoscopy
Otitis media complications? 4
- Mastoiditis,
- venous sinus thrombosis,
- brain abscess
- Scarring of the structures of middle ear
Recent research shows that the tx of AOM
with antibiotics does NOT decrease
incidence of complications!
Otitis externa is defined as?
Causes? 3
Defined as:
Inflammation of the external auditory canal or auricle
Causes:
- Infectious
- Allergic
- Dermal disease
What are the major risk factors for developing OE?
4
- swimming
- Qtip users, bobby pins, paper clips
- Humidity
- Immunocompromised/Malignant otitis externa
Otitis externa bacterial culprits? 3
Signs and symptoms? 6
Bacterial culprits
- Staph aureus
- Pseudomonas aeruginosa (swimmers ear)
- Proteus
Signs and Symptoms:
- Otalgia
- Pain at tragus or when auricle is pulled!!!!!
- Pruritis
- Inflamed auricular nodes
- Discharge
- Hearing loss
Otoscopic Exam: What will it show for otitis external?
4
- Edematous and erythematous ear canal
- May see yellow, brown, white or grey debris
- Should be no middle ear fluid (if you can see it!)
- TM should be mobile (if you can see it!)
Treatment for otitis externa?
3
- Cleaning of ear canal
- Protect ear canal from water
- Treatment of inflammation and infection (Caution: ALWAYS USE SOLUTION if you have NOT confirmed an intact TM)
What do we clean the ear canal with in OE?
Irrigate with 1:1 dilution of 3% hydrogen peroxide AT BODY TEMPERATURE (GENTLY – No high pressure if you cannot see TM!)
What otic antibiotic/steriod combinations are there? 4
Which one for use of a punctured TM?
- Cortisporin
- Cipro HC
- Tobradex
- Ofloxicin (can use if you have a punctured ™- only one)
Sore throat occurs as a result of inflammation or infection of what structures?
4
- tonsils,
- uvula,
- soft palate
- posterior oropharynx
How do you differentiate viral and bacterial pharyngitis?
- Viral is going to be more URI symptoms
2. Bacterial is more just the throat and fever with muscle aches
Pharyngitis/tonsillitis:
- More common in what age children?
- Uncommon in children younger than what age?
- What accounts for majority of cases especially in children 2-5 yrs old?
- Most common bug?
- More common in older children
- Uncommon in infants and children younger than 2 years of age
- ***Viruses
- Streptococcus Pyogenes (GABHS) is the most common bacterial cause-
What kind of complications can Streptococcus Pyogenes (GABHS) cause?
3
When do you see complications like this?
- rhumatic HD- antibodies against body- mitral valve affected
- glomerulonephritis,
- scarlet fever - bad sunburn, little bumps and chest and back, itchy, and white around the lips
Need to treat in 10 days or youll have complications
Viral pharyngitis occurs in association with other symptoms of respiratory tract infection such as what? 2
How does the pharyngitis itself present virally?
What other symptoms may be present? 3
Management?
- rhinorrhea,
- cough
Pharyngitis is usually mild
- Fatigue,
- anorexia, and
- abdominal pain may be present
Management is symptomatic
GABHS pharyngitis presentation?
6
- Beefy red tonsils with exudate
- Tender anterior cervical lymphadenopathy
- Fever
- Absence of URI symptoms (be careful with the allergic patient however)
- NOT UNCOMMON to have headache and abdominal pain
- Sometimes will have “strawberry tongue”
What is the patient with GABHS pharyngitis does have tonsils? how will it present?
What kind of disease would be posterior cervical lymphadenopathy?
uvulitis and plaques and exudates around
Mono
GABHS diagnostics? 2
Drug of choice?
Alternatives? 2
What drug for persistance and reoccuring pharyngitis?
- Rapid antigen testing is great, but…
- Throat culture is the diagnostic of choice
- Penicillin still the drug of choice;
- -Amoxicilin
-macrolides first alternative
Z pack, clarithromycin, - clinda for ones that wont go away
Educate to take entire course of antibiotics
Epstein-Barr virus (Mononucleosis):
presentation?
5
- ***Patients have malaise
- Also presents with beefy red tonsils and exudate (Ahh, you mean that beefy red tonsils doesn’t have to be strep!?)
- Usually diffuse lymphadenopathy but particularly posterior cervical
- Splenomegaly
- Often AFEBRILE!
Epstein-Barr virus (Mononucleosis): Diagnosis:
- Initial test?
- Why might this be falsely negative?
- What might we see on CBC (suggestive)?
- What may be used if the disease is suspected but a negative Monospot?
- Management?
- Heterophile antibody testing (Monospot)
- May be falsely negative early in the course of the disease
- Atypical lymphocytes on smear
- EBV specific antibodies (can test for IgG and IgM)
- Management: education, no contact sports for 6-8 weeks. splenomegaly
What kind of virus is ebstein barr?
herpes virus
What is herpangina caused by?
Caused by enterovirus
Herpangina symptoms? 2
How does it differ from herpes simplex?
- High fever and
- small ulcers on erythematous base on tonsillar pillars, soft palate, and uvula
Different than herpes simplex- mostly on the outside of the lip
When you see ulcers and vesicles, you think what?
Virus
Hand, foot and mouth disease presentation?
2
Caused by what virus?
Management?
- Vesicles or red papules found on the tongue, oral mucosa, hands, and feet (Not as painful as herpangina- mild disease)
- Mild fever and malaise
Usually caused by coxsackie virus
Probably just need keep out of day care for a bit- no medical treatment
What would be serious infections that we would need to rule out before we move on with diagnosis?
- Peritonsillar abscess
- -Pt needs IV ABX and surgical drainage - Retropharyngeal abscess
- Epiglottitis
- Epiglotitis occurs in what population of children?
- symptoms? 5
- If they come to you in the clinic what should you do?
- ***Occurs in unimmunized child (HIB)
- High fever,
- sore throat,
- stridor
- Drooling
- respiratory distress
- Don’t examine the pharynx in the office
- Aphthous stomatitis aka?
- Main finding?
- How long does it last?
- Management?
- canker sore
- Main finding is one to several small ulcers on the insides of lips or elsewhere in the mouth
- Last 1-2 weeks
- Management: topical preparations
Gingivostomatitis:
- Caused by?
- Ulcers can develop where? 5
- Other symptoms? 2
- Lasts how many days? 5
- Management?
- If early in the course what may you want to use?
- Caused by Herpes Simplex
- Ulcers can develop on the
- buccal mucosa,
- anterior pillars,
- inner lips,
- tongue
- gingiva - Fever
- Tender cervical lymphadenopathy
- Lasts 7-10 days
- Management: topical preparations (but no corticosteroids as infection may spread)- oragel
- If early in the course, may use antivirals (oral acyclovir)
Oral Candidiasis (Thrush)
- Affects which populations?
- May occur with patients taking what? 2
- Symptoms? 2
- Physical exam?
- Treatment? 3
- Mainly affects infants or older children in debilitated state
- May occur in patients taking broad spectrum antibiotics or steroids
- Watch in the kiddo taking Advair who doesn’t wash mouth out with water afterwards
- Symptoms:
- mouth soreness,
- refusal of feedings - Physical exam: white curd-like plaques predominantly on buccal mucosa
- Treatment:
- Nystatin oral suspension
- remove plaques prior with moistened cotton-tipped applicator or piece of gauze
- Sterilize pacifiers
Sinusitis:
- When do we get suspicious that the URI is now a sinus infeection?
- Pathophysiology? 3
- ________sinusitis unusual before age 10 years (not even visible with imaging until 4-9 years of age)
- Possibility when standard viral URI symptoms persist beyond 10-14 days
- occurs when mucociliary clearance and drainage are impaired by a URI
- or allergic rhinitis
- or obstruction from some other cause
- Frontal
Sinutis is More likely in the following circumstances?
7
Treatment?
- Persistent symptoms
- Worsening symptoms following stability
- Patient starts to improve from 4. URI and then becomes worse
- Facial pain
- Maxillary teeth pain
- Malodorous breath
Amoxicillan or Augmentin-more so
- What is Croup?
- caused by what virus?
- What other organisms can cause this? 3
- Most common age?
- Key features? 4
- Infection causing inflammation of the larynx, trachea and bronchi
- Most often caused by parainfluenza virus
- Can be caused by other organisms such as
- RSV,
- influenza virus
- adenovirus - 6 months to 3 years most common age
- Key features:
- URI symptoms
- with barking cough and
- stridor (wait a minute, where else do we see stridor?)
- Fever usually absent or low grade
Management of croup?
2
`1. Racemic epi and
- dexamethasone- in ER
- -In clinic day three give them dex
How do you differentiate croup from epiglottis?
Lateral XRAY (steeple sign for croup and thumb print for epiglottis + toxic kid)
Croup treatment:
- Generally?
- With barking cough and stridor?
- Stridor at rest? 2
- If symptoms resolve within 3 hours?
- Hospitalize if what?
- Generally steroids are used
- -Dexamethasone 0.6mg/kg IM one dose - Barking cough, no stridor at rest
- -Supportive therapy, hydration, minimal handling, mist therapy, cold air - Stridor at rest
- -Oxygen,
- –nebulized racemic epinephrine - If symptoms resolve within 3 hours of steroid and epinephrine use, can be safely discharged
- Hospitalize if recurrent epinephrine treatments are required or if respiratory distress persists
Epiglottitis presents how?
6
Management?
Abx?
Generally present with SUDDEN onset
- Fever
- Dysphagia
- Drooling
- Muffled “hot potato” voice
- Inspiratory retractions
- Soft stridor
- DO NOT EXAMINE THIS PATIENT!!!!
- GET a STAT soft-tissue lateral PORTABLE X-ray of the neck
- AND PREPARE TO INTUBTE IMMEDIATELY!
- CALL IN YOUR PEDIATRIC ANESTHESIA FOLKS NOW!
Third generation cephalosporins
cephtriaxone
Possible presentation in mumps? 5
Treatment?
Presents in a variety of ways:
- parotid gland swelling common,
- aseptic meningitis,
- transient pancreatitis,
- orchitis or oophoritis,
- epididymitis
Treatment: supportive
Four keys with GABHS:
- Fever
- Severe sore throat
- Tender anterior cervical adenopathy
- ABSENCE of viral URI symptoms!
The primary reason we treat strep throat is to prevent ___________… the magic number is initiating treatment by about day___.
rheumatic fever
9
You want a guaranteed PANCE question…
- What test? = EBV (always remember however that this can be negative early in the course of the illness)
- ______________ in the smear?
- EBV treatment?
- heterophile antibody test
- atypical lymphocytosis
- education and avoiding contact sports for 6-8 weeks
URI symptoms persisting beyond 10-14 days?
likely sinusitis
Kawasaki disease aka?
What is it?
Mucocutaneous lymph node syndrome
Vasculitis of unknown etiology affecting medium sized arteries - bilateral conjunctivitis
Typical labs for Kawasaki includes?
3
- hypoalbuminemia
- thrombocytosis
- elevated ESR
What is the diagnosis criteria for Kawasaki?
6
- Fever for 5 or more days + 4 of 5 additional criteria:
- Rash
- Mucous membrane involvement
- Unilateral cervical adenopathy
- Nonpurulent conjunctivitis
- Swollen hands and feet
Other findings for kawaski may include? 5
What other things do we need to monitor?
Other findings may include
- fever,
- strawberry tongue,
- vascular aneurysms,
- abdominal pain, and
- swollen, reddened joints- every month and
three months after that they are monitired wtih EKGs
Primary complication of Kawasaki disease includes?
2
What does this lead to? 4
What is kawasaki the leading cause of in children in the US and Japan?
Treatment? 2
- Coronary vasculitis and
- aneurysm formation leading to
- arrhythmias,
- infarction,
- CHF, and
- even death
Acquired heart disease
Treatment: High-dose Aspirin and 2 days of IV immunoglobulin
- Rubeola (Measles) caused by what?
- History should focus on what? 2
- What is pathogonomic for measles? Spread pattern?
- Other symptoms?
- direct viral infection of the epidermis (highly contagious)
2.
- immunization status,
- travel, contact with infected persons
- ***Koplik spots are pathognomonic (tiny white dots on a red base appearing on buccal mucosa 1 or 2 days prior to onset of rash)(PANCE ?)
- —Rash is dark red raised (Morbilliform) and begins at hairline and spreads to involve trunk, arms, legs, and eventually hands and feet - High fever,
- dry cough,
- rhinitis,
- conjunctivitis with clear discharge,
- distinctive rash
Rubella (German Measles)
1. What is the most important reason that we vaccinate for Rubella?
- Results form what?
- Most common complications are?
- Describe the rash? 3
- Rash may be preceded by what? 3
- Often have what other symptom?
- ***Diagnosis difficult as this appears as a nonspecific viral illness (MUST ask about what?
- How do we confirm diagnosis?
- ***Most important reason we vaccinate is to prevent spread to pregnant women to avoid congenital rubella syndrome
- Result from direct infection of dermis
- arthritis and arthralgia
- Rash is
- fainter than seen with measles,
- begins on face and progresses caudally,
- ***does not coalesce
5.
- low-grade fever,
- malaise, and
- URI symptoms
- Often have lymphadenopathy involving posterior auricular, suboccipital, and posterior cervical nodes
- immunization history-
Serum IgM reliable way to confirm diagnosis
Roseola
1. Results from ______?
Infection is very common
- Complications uncommon (_______ can occur during the febrile period)
- Virus is acquired from what?
- Abrupt onset of high fever which lasts for _____ days (occasionally respiratory or GI symptoms are present)
- Resolution of fever is followed by development of what that spontaneously resolves (may not appear for 1-2 days until after fever breaks)?
- Usually the parents have not brought the kid in for the ______ but for the _____!
- HHV-6
- seizures
- close contact with saliva from parents or siblings
- 3-7
- erythematous maculopapular rash
- fever, rash!
Roseola- most common presentation?
What do we need to make sure not to miss?
Roseola- infantile seizures
Super high fevers and then it goes away
MAKE SURE YOU ARENT MISSING MENINGITIS
- Aka for fifths disease? 2
- Caused by?
- Illness usually mild and may include what kind of symtpoms? 3
- Describe the rash?
- At what point are the children not contagious?
- Multiple synonymous terms including erythema infectiosum and slapped cheek disease
- Parvovirus B19
- low-grade fever,
- URI symptoms
- mild malaise (may not have any of these symptoms)
- Rash is flat, lacy, reticular, often pruritic, located on cheeks, trunk, and extremities
- Children are NOT contagious once the rash appears
Varicella (Chickenpox)
1. Childen now vaccinated at what age?
- Describe the rash and its spread?
- How do the lesions progress? - Other symptoms may include what? 2
- Hx of contact with another infected (either varicella or herpes zoster) person within previous_____days
- Lesions are described as what?
- Children now vaccinated at one year of age and booster given
- Generalized pruritic vesicular rash beginning on face, neck, or upper trunk and spreads outward (mucous membranes may be involved)
- –Lesions are in different stages! - fever and malaise
- 10-21
- “Dew drop on a rose petal”
- Contagious from ____ days prior to onset until when?
- Management? 2
- ___________ may be given to patients exposed to varicella who are at risk for severe disease
- If you’ve had the vaccine can you stil get the disease?
- 1-2, the lesions have crusted
- Supportive
- acyclovir may be useful in immunocompromised patients
- Immune globulin
- you can still get the disease (usually much more mild) – BUT – Once you have had the disease, you have lifelong immunity
Wht complications do we want to watch out for with chicken pox?
2
- Encephalitis and
- shingles/zoster for complication
Dew drops on a rose petal
Varicella rash starts where and travels where?
Start at chest and move outward
Pityriasis Rosea
1. First sign is what? What does this often resemble?
- Following this what may happen?
- Describe the shape of the lesions
- Lesions resolve in how many weeks and may be what?
- First sign of disease is often a “herald patch” which may resemble psoriasis or tinea corporis
- Following the herald patch (which is much larger than the later lesions) multiple new lesions appear, usually on the central trunk
- Lesions are often oval with long axis paralleling the lines of skin stress (this may result in inverted “Christmas tree” appearance)
- Lesions resolve in 6-10 weeks and may be pruritic (story you often get is that this rash appeared but it hasn’t gone away)
- Bronchiolitis is what?
- Can progress to what?
- What kind of pts have poorer outcomes? 3
- HOw does it present? 4
- Management?
- Inflammatory process of the smaller lower airways, usually caused by RSV
- Can progress to respiratory failure and is potentially fatal
- Infants with
- congenital heart disease,
- chronic lung disease (usually former premature infants), or
- immunodeficiencies at risk for severe disease and poorer outcomes - Presentation is usually
- fever,
- URI symptoms, and accompanied
- tachypnea and
- wheezing
Management is supportive care
Generally the prognosis is excellent
(Note: RSV can survive for 6 hours on countertops)
- Bronchiolitis is not always caused by RSV. Other viruses that can cause this include what? 2
- Disease has a wide spectrum, less severe cases often termed as what?
- Prevention?
- What treatment is usually reserved for severely ill or immunocompromised patient and given by inhalation?
- Adenovirus
- parainfluenza virus.
- “the happy wheezer”
- Palivizumab (Synagis) is an IM monoclonal Ab that provides passive prophylaxis against RSV
- Ribavirin, which is a synthetic nucleoside analog with activity against RSV
- How does bronchitis present? 3
- What will you find on PE, imaging and labs? 3
- The presence of mucopurulent sputum does not imply a bacterial infection. Due to the presence of what?
Antibiotics are usually not helpful…but tempting
- ***URI symptoms with cough and malaise
- Coarse bronchial sounds
WBC normal, CXR clear
Most of the time it is viral! - desquamated bronchial epithelial cells and live/dead white blood cells!
Most cases of pneumonia in children are of what origin?
So how do we treat?
Most cases in children are viral, but…
Unable to predict which cases are viral so we treat with antibiotics, plus…
Causes of bacterial pneumonia vary with age
How would you differentiate viral and bacterial pneumonia?
- Viral pneumonia often with prodrome of rhinorrhea, cough, low-grade fever, and pharyngitis (this is what confuses things)
- Bacterial pneumonia presentation more abrupt! Often presentation is high fever, cough, chest pain, and shaking chills
Pneumonia is a wide spectrum disease
- In some cases _______may be the only sign of underlying pneumonia
- Elevated _____?
- CXR- Much more variable than with adults, don’t often see a classic ______________?
- tachypnea
- WBC
- lobar consolidation
Treatment considerations for pneumonia:
1. What if they have astham?
Bronchodilators? Tight. Asthma- give them oral steriods
Pertussis (Whooping Cough)
- Caused by what bacteria?
- How contagious?
- What do we have to worry about with people that have gotten the vaccine?
- Who is at risk for serious complications with pertussis?
- Duration?
Making a comeback
- Caused by Bordetella Pertussis
- Highly communicable disease
- Not all individuals will seroconvert with vaccination. Many will lose immunity over time
- The danger with pertussis is in the small infant… the infection is not what kills but the respiratory distress from the coughing
- **Duration 4 – 12 weeks
Pertussis (Whooping Cough)
Guidelines for Diagnosis
5
What do we have to do with the results of testing?
- Ask about immunization status!
- Classic Presentation suspect Pertussis
- Cough for > 2 weeks, suspect Pertussis
- Nasal swab for culture (Bordet-Gengou culture medium)
- Nasal swab for PCR more sensitive
- -Sent to State Lab
- -Results in 3 to 7 days
- Pertussis (Whooping Cough)
Treatment? 2
(treatment of choice?) - Timeline for treatment?
- Why do we treat?
- Erythromycin for 14 days
- Azithromycin for 5 to 7 days****
- Usually treat awaiting lab results if history of known exposure
- Will not shorten course of cough unless given in early phase but will prevent transmission (some patients will cough for 3 months! You must educate the patient/family)
Bronchiectasis
- Characterized by what?
- This condition is the end result of a variety of pathophysiologic processes, usually including some combination of what?
- In developed nations, _____________ is the most common cause of bronchiectasis in children
- abnormal dilation and distortion of the bronchial tree, resulting in chronic obstructive lung disease
- Infection and
- impaired airway drainage or obstruction
- cystic fibrosis (CF)
Bronchiectasis
PATHOPHYSIOLOGY — In general, induction of bronchiectasis requires two factors:
- An infectious insult
- Impaired mucus clearance, airway obstruction, or a defect in host defense
Not common in practice anymore…..CF patients
Palmar rashes think what?
K-S
