Pediatric Infectious Disease Flashcards
Treating tetanus
- Intubation and sedation
- Muscle relaxants
- Metronidazole
Treating a wound concerning for development of tetanus
-
< 3 lifetime doses of Tdap
- Clean wound: Tdap only
- Diry wound: Tdap + Tetanus Ig
- Note: Timing does NOT matter here – only # of lifetime doses so far
-
> 3 lifetime doses of Tdap
- Clean wound, > 10 years: Tdap
- Clean wound, < 10 years: No treatment
- Dirty wound, > 5 years: Tdap
- Dirty wound, <5 years: No treatment
- Note: Timing DOES matter here
Diphtheria
- Presents with fever, dysphagia, dyspnea, and pseudomembrane at back of throat on exam
- Diagnosis: Clinical
- Treatment: Intubation and antitoxin + IV erythromycin or penicillin
Pertussis
-
Phase 1: Catarrhal phase
- Infectious
- Nonspecific cold-like syndrome
-
Phase 2: Paroxysmal phase
- Whooping cough peroxisms
- Inspiratory wheezing
- Phase 3: Resolution
- Diagnosis is clinical
- Treatment: Erythromycin + supportive therapy
Stoccato cough
- Describes the type of intermittent coughing spells with quiet intervals observed in croup and chlamydial pneumonia
Viruses that may cause pneumonia in kids
- RSV
- Adenovirus
- Influenza
- Parainfluenza
- Enteric cytopathic human orphan virus (ECHO virus)
- Coxsackie virus
Most common causes of pneumonia in the first few days of life and appropriate treatment
- Organisms:
- Group B Streptococci
- Enterobacteriaceae (ie, enteric gram negative bacteria)
- Staph. aureus
- Strep. pneumoniae
- Listeria monocytogenes
- Treatment:
- Ampicillin + gentamicin or cefotaxime
Most common causes of pneumonia in the first few months of life and appropriate treatment
- Organisms:
- Chlamydia trachomatis (often staccato cough, eosinophilia, bilateral infiltrates with hyperinflation, sometimes conjunctavitis or known maternal chlamydia)
- HSV
- Enterovirus
- Infuenza virus
- RSV
- Treatment:
- Erythromycin for C. trachomatis
- Acyclovir for HSV
- Palivizumab if severe RSV
- Oseltamavir for severe influenza
- Supportive care for enterovirus
Most common causes of pneumonia from age ~6 months to 5 years
- Organisms:
- Adenovirus
- Rhinovirus
- RSV
- Influenza
- Parainfluenza
- Pneumococcus
- Non-typable H. influenzae
Most common causes of pneumonia from age 5 years to late teens and appropriate treatment
- Organisms
- Mycoplasma pneumoniae becomes most common
- All from <5 years are still possible EXCEPT GBS and Listeria
- Treat with azithromycin or ceftriaxone, or doxycycline if over age 8
___ and ___ should always be considered as potential etiologies of pneumonia in a patient with underlying lung disease
Pseudomonas aeruginosa and Aspergillus should always be considered as potential etiologies of pneumonia in a patient with underlying lung disease
Pneumonia + erythematous vesicles on skin in all stages of progression
Varicella pneumonia
Pneumonia + retinitis
CMV pneumonia
Pneumonia in a patient exposed to stagnant water
Legionella
Pneumonia in a patient with treatment-refractory asthma
Aspergillus
Bonus: CXR may show fungus ball
Pneumonia following travel to Southwestern US
Coccidioides immitis
Pneumonia following exposure to sheep or cattle
Coxiella brunetii
Pneumonia following spelunking
Histoplasma capsulatum
For pediatric TB patients, ___ oral multidrug antibiotic therapy is advised
For pediatric TB patients, DIRECTLY OBSERVED oral multidrug antibiotic therapy is advised
Presentation of TB in kids vs adults
In young children and infants, cervical, supraclavicular, axillary, and mediastinal lymphadenopathy are more common. Otherwise it may appear just like a regular pneumonia.
Meningitis and miliary TB are also more common complications in pediatric cases than in adults
Because of the potential implications, a positive NAAT for C. trachomatis or N. gonorrheae performed in a child must be. . .
. . . verified with a second NAAT of a different gene sequence
Perianal condyloma accuminata in someone younger than age ___ are almost certainly acquired from birth
Perianal condyloma accuminata in someone younger than age 3 years are almost certainly acquired from birth
Signs of pinworm infection and treatment
- aka Enterobiasis
-
Intense itching, loss of appetite, episodic abdominal pain. Sometimes may induce rectal prolapse
- Classically with perianal pruritis that is worse at night
- Rash is typically perianal erythema, sometimes with visible pinworms outside of anus, as pictured
- Diagnose w/ scotch tape test
- Treat with mebendazole, albendazole, or pyrantel pamoate in two doses (now and in two weeks, to kill hatched eggs, as with scabies), and treat the entire family or all coinhabitants
Following sexual assault, ____ must be checked periodically until ___
Following sexual assault, HIV and syphilis serology must be checked periodically until 6 months after the assault
Exam findings of acute otitis media
- Symptoms: Otalgia, fever
- Signs: Red, opaque, poorly moving, bulging tympanic membrane
Treatment for recurrent otitis media or non-resolving post-otitis fluid buildup
Myringotomy and placement of pressure equalization tube
Basically acts as an acessory eustacian tube to help drain the inner ear and prevent accumulation of stagnant fluid. Indicated especially if hearing loss is noted.
Otitis media with effusion
When fluid collects behind the tympanic membrane but without signs and symptoms of acute otitis media
Sometimes called serous otitis media
Pneumatic otoscopy
Process of placing a speculum within the ear canal and then applying slight positive and negative pressure to assess TM mobility
Tympanocentesis
Minor surgical procedure in which a small incision is made into the TM to drain pus or fluid from the middle ear space.
Done by a specialist.
Why do kids get otitis media more than adults?
Because their eustacian tube is shorter and at a more acute angle, and thus more prone to becoming obstructed
This causes fluid accumulation, which in turn leads to otitis media whenever an infection spreads through the sinuses
Complications of severe otitis media
- Mastoiditis
- Temporal bone osteomyelitis
- Facial nerve paralysis
- Epidural or subdural abscess
- Meningitis
First-line treatment for otitis externa
Topical polymixin + corticosteroids
Covers skin flora + P. aeruginosa
Otitis media complicated by mastoiditis is an indication for. . .
. . . myringotomy and placement of pressure equalization tube
If an OM patient is tried on amoxicillin, then amox-clav, and is still not getting better, the next step is. . .
. . . tympanocentesis and culture
To determine what the organism is and what abx will be effective
Etiology of pneumonia in CF patients
- In early stages, usually S. aureus
- However, as structural changes occur, P. aeruginosa becomes predominant
- CF carries harbor unique strains of P. aeruginosa that produce heavy, slimy mucous, found only rarely in other conditions. This biofilm is so resistant that once established, colonization is essentially impossible to eliminate
- Colonization with Burkholderia cepacia may be associated with rapid deterioration in CF patients condition
Acute otitis media is treated with ____
Acute otitis externa is treated with ____
Acute otitis media is treated with oral amoxicillin (add clavulonic acid if ineffective)
Acute otitis externa is treated with ciprofloxacin or polymixin eardrops.
Helminth infection + macrocytic anemia
Can be seen in Diphyllobothrium latum, aka broad fish tapeworm
This helminth utilizes B12 from the gut, sequestering it and preventing the host from acquiring sufficient B12
It is acquired from undercooked fish
Laboratory studies supportive of a diagnosis of poststreptococcal glomerulonephritis
- Low C3
- Normal C4
- Positive antistreptolysin-O
- Positive antideoxyribonucleatase B
C3 and C4 in postinfectious glomerulonephritis
If only C3 is low, APSGN is most likely.
If both are low, other dianoses like SLE must be considered
Common causes of dysuria in an adolescent male
- Chlamydia
- Gonorrhea
- Ureaplasma
- Mycoplasma
- Candidal balanitis*
-
Inflamed condyloma*
- *Note: The last two are infections of the epidydimis that mimic urethritis.
Nuchal rigidity is not a reliable finding of meningitis in children until . . .
. . . ~18 months of age
While rare in adults, ___ is not an uncommon manifestation of bacterial dysentery in infants and children
While rare in adults, neurologic involvement is not an uncommon manifestation of bacterial dysentery in infants and children
Especially with Salmonella and Shigella. May include confusion, drowsiness, headache, hallucinations, seizures.
Features of hemolytic uremic syndrome
- Usually do to E. coli O157:H7, can also be caused by Shigella, Salmonella, and Yersinia.
- Usually starts 1-2 weeks after dysentery
-
Antibiotic treatment is usually not necessary for Salmonella, Yersinia, and E. coli and increases the risk of HUS, so it is often avoided even though it may shorten the duration of illness
- However, Shigella should be treated to decrease shedding of the organism and risk of transmission
Atypical presentation of pneumonia in kids
In children (and sometimes adults, but especially children) pneumonia may present with abdominal pain. In fact, this may be the most prominent symptom – however exam will reveal signs of pneumonia and tachypnea.
EBV vs CMV mononucleosis presentation
Similar general presentation, but CMV is much less likely to present with exudative sore throat and posterior cervical lymphadenopathy
EBV incubation period
30-50 days!!! So long!
So, many people often need to be prompted with this information to provide a useful history of sick contacts, since they usually are thinking only in terms of the last few days.
Monospot in kids
Not effective in kids under age 5
However, these kids rarely become sick enough with EBV at this age to become clinical anyway. It is usually the adolescents or adults that get the mononucleosis presentation of EBV.
Complications of EBV
- Splenic rupture is rare, but life threatening when it occurs – this is why we tell mono patients to avoid contact sports
- Neurologic: Bell’s palsy, seizures, aseptic meningitis or encephalitis, Gullian Barre syndrome, optic neuritis, transverse myelitis
- Tonsilar hypertrophy may compromise the airway in severe cases
- Increased risk of Burkitt’s and Hodgkin’s lymphomas
Perianal itching and white vaginal discharge in an adult makes you think of ___.
Perianal itching and white vaginal discharge in a child should make you think of ___.
Perianal itching and white vaginal discharge in an adult makes you think of candida.
Perianal itching and white vaginal discharge in a child should make you think of pinworms.
Presentation of perianal cellulitis
Very similar to pinworm infection, but will have signs of well-demarkated border and bloody stools that are not seen in pinworm infection.
Often caused by streptococci.
Strongyloides
- Type of worm endemic in all warm climates, but hyperendemic in Central America and northern South America.
- Larvae penetrate skin, then move to lungs, then to intestines
- Are autoinfectious: larvae can move from intestines, to bloodstream, to lungs and lay eggs, repeating the cycle
- This makes immunocompromised hosts susceptible to “hyperinfection”
- Can be asyptomatic or cause epigastric pain, emesis, diarrhea, malabsorption, weight loss
- Diagnosis made based on presence of larvae in feces or sampling of duodenal fluid by string test
- Treat w/ ivermectin or thiabendazole
Most infants with congenital HSV are born to mothers with . . .
. . . no prior history of herpes infection
This is because the risk of vertical transmission for primary herpes is 50%, while it is only 5% for recurrent herpes.
If you are suspecting a diagnosis of strep throat, your next question should be. . .
. . . is there an associated abscess?
Signs and symptoms that would suggest this: Asymmetrical appearing posterior oropharynx, odynophagia, severe dysphagia, increased WOB, frank stridor, trismus, and pain with passive neck motion
Diagnosis/evaluation is with lateral neck radiograph
Thumb sign
- Classic finding of epiglottitis on lateral radiograph
The most common cause of pharyngitis is ____
The most common cause of pharyngitis is respiratory virus infection
However, this present slightly differently to bacterial pharyngitis. Respiratory viruses will typically come along with the typical slough of URI symptoms when they cause pharyngitis: rhinorrhea, cough, etc. They may also present with tonsilar exudate or similar neck findings, but these other symptoms will usually be present to dinstinguish a viral and bacterial pharyngitis.
Standard therapy for suspected bacterial pharyngitis
-
IV penicillins or third generation cephalosporines
- If polymicrobial infection or neck abscess with anaerobes is suspected, metronidazole or clindamycin are added
- If penicillin allergic, clindamycin monotherapy is usually sufficient
-
For neck abscess:
- If no concerning signs, treat with broad spectrum abx and monitor closely
- If concerning signs (evidence of anatomical impact on surrounding structure or concern for possible spread to mediastinum), treat with broad spectrum abx and aspirate or incise and drain urgently
Anatomic compartments of the neck and relevance to neck abscesses
- Infection of the retropharyngeal space may spread to the mediastinum. The retropharyngeal space may be seeded from the lymphatics draining the oropharynx.
- Parapharyngeal abscesses are in close proximity to neurovasculature in the neck posteriorly. The parapharyngeal space may be seeded from the teeth, ears, or sinuses.
Thyroglossal duct cyst
- Cyst arising from the embryonic thryoglossal tract
- Telltale sign is that it is midline in the neck and moves up with tongue protrusion
- May become enlarged and fluctuant due to increased mucus production during or following a URI. May even burst open to the skin and discharge this mucus.
- Diagnosis involves clinical picture and usually a CT scan to ascertain cyst and thyroid anatomy
- Treatment is with surgical excision.
When Coxsackie virus causes a pharyngitis, it is typically ___
When Coxsackie virus causes a pharyngitis, it is typically ulcerative
Tinea barbae
- Dermatophyte infection of hair follicles (most commonly a Trichophyton species)
- Acquired through animal exposure, is quite common in farmers
- Often mimics acne as it is papulopustular, but lesions are much larger. Classically occurs in a strict beard-and-moustache distribution.
- Topical antifungals are ineffective – this requires oral antifungal therapy
Any male infant or child who presents with UTI requires ___ to screen for ___.
Any male infant or child who presents with UTI requires renal ultrasound and voiding cystourethrogram to screen for posterior urethral valve.
Infants and children with known vesicoureteral reflux should receive ___
Infants and children with known vesicoureteral reflux should receive prophylactic antibiotics to prevent UTIs and subsequent pyelonephritis and urosepsis
Bactirm or nitrofurantoin are the typical agnets.
Before treating for neonatal chlamydial conjunctavitis, parents be informed of the risk of. . .
. . . hypertrophic pyloric stenosis
May be caused by oral erythromycin.
Conjunctavitis within the first 24 hours of life is almost certainly. . .
. . . chemical conjunctavitis
However, we still send eye discharge for culture just in case we are missing something
Ophthalmologic complications of congenital rubella
Glaucoma
Cataracts
Retinopathy
Infectious causes of congenital or childhood hearing loss
- Congenital:
- CMV
- Toxoplasmosis
- Rubella
- Syphilis
- Acquired:
- GBS sepsis
- S. pneumoniae meningitis
- Previously causes of acquired that we no longer see in vaccinated individuals:
- Measles
- Mumps
- Rubella
- H. influenzae
If you’re going to take out a kid’s spleen, what do you need to give them?
- Pneumococcal vaccine
- Penicillin prophylaxis
The ___ vaccine is associated with thrombocytopenia and is used cautiously in ITP patients
The MMR vaccine is associated with thrombocytopenia and is used cautiously in ITP patients
Pediatric parvovirus infection looks a lot like __ or __
Pediatric parvovirus infection looks a lot like RA or lupus
The rash starts as “slapped-cheek” and then spreads to the rest of the body, but spares the perioral region.
Treatment of parvovirus B19 in children
- Usually none, apart from supportive home care with ibuprofen or acetominophen
- If there is joint involvement, a short course of oral prednisone is the treatment of choice
Testing for parvovirus B19
In children, if the presentation is classical, then there is no need for serology
Serology is only necessary of the diagnosis is unclear or if definitive diagnosis is necessary for the next steps in management
