Peds ID uworld Flashcards
causes of meningitis in children
v3 mos
- GBS
- e coli and other gram negatives
- listeria
- herpes simplex virus
3 mos to 10 yrs
- s pneumo
- neisseria meningitidis
^11 yrs
-neisseria meningiditis
tf
low wbc can be a sign of sepsis in an infant
t
espec w left shift (bands)
define neonatal sepsis
systemic bacterial infection v28 days of life
define early vs late-onset neonatal sepsis and what bug is the most common cause of each
early v7 days of life
late 7-28 days of life
GBS is the most common cause of both
most common cause of meningitis in peds v3 mos old
GBS
how have early onset vs late onset neonatal sepsis incidence changed relatively to each other and how is this accomplished
early onset, v7 days vertical transmission from mom during birth, has been much reduced thanks to Universal Screening and intrapartum abx
late onset 7=28 days horizontal transmission (person to person with unwashed hands) has not changed in incidence
signs of neonatal jaundice
non-specific
poor po, irritable, hyperthermic or hypothermic, respiratory distress, vomiting, jaundice…
symptoms of neonatal meningitis
hypotonia, full fontanelles, apnea, seizures
plus nonspecific sepsis symptoms
poor po, irritable, hyperthermic or hypothermic, respiratory distress, vomiting, jaundice.
TF
all neonates with suspected sepsisshould get bcx ucx csfcx and empiric abx
why or why not?
T
high incidence in newborns
non-specific presentation
high morbidity and mortality
TF
h flu b is a common cause of newborn sepsis
why or why not?
F
- low prevalence (herd immunity from older age vaccinations)
- protective maternal antibodies
when to think Listeria vs GBS as cause of newborn sepsis
usually GBS in kid v3mos, just the most common
think more Listeria if seems pregnant mom had flu-like symptoms after unpasteurized dairy, canned meats
chorioretinitis, hydrocephalus, intracranial calcifications in newborn think…
congenital toxoplasmosis
duration and symptoms of catarrhal phase of pertussis
1-2 weeks
mild cough, rhinitis
duration and symptoms of paroxysmal phase of pertussis
2-6 weeks cough with inspiratory whoop, posttussive emesis
duration and symptoms of convalescent phase of pertussis
weeks to months
gradual resolution of cough, whoop, posttussive emesis
diagnose pertussis
culture or pcr of nasopharynx
(or dx clinically if classic symptoms)
lymphocyte predominant leukocytosis
treat pertussis
wait to confirm diagnosis or treat based on clinical suspision?
macrolide (azythromycin, clarithromycin, erythromycin)
treat based on clinical suspicion, do not wait to confirm with nasopharyngeal pcr or cx or lymphocytosis on labs
paroxysmal cough, posttussive emesis, subconjunctival hemorrhages, lymphocytosis
think…
pertussis
tf
prior pertussiss infection and/or immunization with acellular pertussis vaccine provide lifelong immunity
F
immunity to pertussis wanes
that is why we give 5 DTaP doses during infancy
boost with Tdap age 11-18 and each pregnancy
heterophile antibody test for…
mono
tf
paroxysmal cough, posttussive emesis, subconjunctival hemorrhages, lymphocytosis
in unvaccinated patient
think flu
F
flu sx fever, cough, myalgias
this patient likely has pertussis
Congenital Rubella Syndrome
clinical triad
diagnosis
prevention
cataracts/glaucoma
sensorineural hearing loss
congenital heart disease (PDA)
Rubella IgM
PCR
maternal immunization with live attenuated rubella prior to conception
newborn
SGA small for gestational age
cataracts/glaucoma
PDA
think…
congenital rubella syndrome
prenatal maternal infection with rubella looks like…
asymptomatic
vs
prodrome fever cough conjunctivitis followed by diffuse maculopapular rash
when does maternal infection with rubella transmit greatest risk to fetus
1st trimester
common presentation of congenital toxoplasmosis
maternal exposure to cat litter
macrosephaly, chorioretinitis, diffuse intracranial calcifications
infectious disease reasons to perform c-section
combine c-section with for even better results
maternal HIV with high viral load
active genital herpes lesions
combo with prenatal antiviral therapy
tf
congenital rubella syndrome is preventable with c-section and antiviral therapy
f
only preventable with vaccination.. no antivirals and transmission through placental blood flow in first trimester usually, well before birth
HIV and HSV preventable with c-section and antivirals
neonatal group B strep disease manifests as…
sepsis, pneumonia, meningitis
name a group A strep
strep pyogenes
Acute Rheumatic Fever epi clinical features late sequela prevention
peak incidence 5-15yo
2x more common in girls
major JONES criteria Joints migratory arthritis, Carditis, Nodules subq, Erythema marginatum, Sydenham chrea
minor fever, arthralgias, CRP ESR, prolonged P-R interval
mitral regurgitation/stenosis late
treat GAS pharyngitis with Penicillin
child with friction rub, diffuse ST elevations continuous irregular and rapid irregular jerks subcutaneous nodules elevated ESR
suspect…
Acute Rheumatic Fever
history of untreated sore throat and fever
(pericarditis, chorea)
tf
penicillin for strep pyogenes pharyngitis because does not self-resolve
F
does self-resolve
but give 10 days oral penicillin to prevent acute rheumatic fever
treat acute rheumatic fever
why
long-acting intramuscular benzathine penicillin G until adulthood - to eradicate bacterial carriage to prevent recurrent ARF
corticosteroids for severe chorea
NSAIDS for pericarditis and arthritis
most common organism responsible for pericarditis and myocarditis in peds
also causes pharyngitis (herpangina) in young children
cocksackie virus
tf
strep pneumo is group A strep
F
strep pyogenes is group A strep
strep pneumo is “ungrouped”… because lacks lancfield carbohydrate antigen (low yield)
TF
There is a lyme vaccine
Fish
Not available ANYMORE… poor demand, side effect concerns, never a recommended immunization
Cat scratch disease Etiology Gradual or Rapid onset Clinical features Dx Tx
Bartonella henslae from cat scratch bite or flea rarely
Gradual onset
Papule at scratch site
Regional tender lymphadenopathy
W/wo Fever of unknown origin ^14 days
Clinical dx w/wo serologies
Tx with Azythromycin
How long can LAN from cat scratch take to resolve
Can take 1-2mos
TF
Cat scratch disease typically resolved spontaneously
T…
But still treat with Azyhromycin…
How long can LAN from cat scratch take to resolve
Can take 1-2mos
Where is lymphadenopathy from mycobacterium tuberculosis most common and is it tender?
Cervical lymphadenopathy
Strikingly NON-tender
Pasturella multocida infection
Vector
Time to symptoms
Symptoms
Dog or Cat bite
1-2 days to symptomatic cellulitis or other soft tissue infection
Salmonella enteritidis infection
Vector
Symptoms
Reptiles including Turtles
Mesenteric adenitis and enteritis
Impetigo
Microbiology
Clinical features
Treatment
Staph aureus, GAS pyogenes
-painful pruritic pustules, honey-crusted lesions
Staph aure
5 Factors predisposing to IMPETIGO
Colonization with staph aureus or gas pyogenes
Hot humid weather
Crowding
Poor personal hygiene
Preexisting lesion like eczema or big bite
TF
Lymphadenopathy and fever w impetigo
T local lymphadenopathy common
F fever unusual
TF
Impetigo is contagious
T
So counsel hand washing
TF
Impetigo is contagious
T
So counsel hand washing
Why treat Impetigo
How treat impetigo
Speed recovery and limit contagious transmissiom
Topical mupiricin if limited skin infection, to avoid side-effects and resistance of systemic abx
Systemic cephalexin dicloxacillin or clindamycin if extensive skin infection
TF
Consider getting antibody titers, antistreptolysin O, and skin lesion swab and culture to dx impetigo
F mostly
antibody titers take a long time to get back and not really useful
TF
Consider getting antibody titers, antistreptolysin O, and skin lesion swab and culture to dx impetigo
F mostly
antibody titers take a long time to get back and not really useful
Rubeola aka
aka measles
Measles Transmissiom Presentation Prevention Treatment
Airborn transmission
Prodrome
When is measles patient contagious
How long are infectious measles airborn particles capable of lingering in the air in a contained space like airplane or clinic waiting room
What kind of isolation / precautions
Most contagious during prodrome
Child traveled to endemic country and got measles 6 weeks later, where did he get the measles?
Probably domestically (thanks antivaccers) Symptoms manifest 1-3 weeks after exposure
What kind of precautions for MRSA and Rotavirus
Contact precautions
Gown, gloves
What kind of precautions for flu and rsv
Droplet precautions - surgical mask
What kind of precautions for measles and varicella
Airborne precautions - negative pressure, n95 mask
Why the difference between droplet and airborne precautions
Droplets larger, shorter range - surgical mask appropriate
Airborne particles smaller, travel farther linger longer - need negative pressure and N95 masks
What is the orbital septum
Fibrous portion of the eyelids extending from the orbital rim
4 distinguishing features of orbital cellulitis vs periorbital
Pain with extraocular movement
Opthalmoplegia
Proptisis
Vision impairment
Define hypothermia quantitatively
v36C 96.8F
Empiric abx choice for neonatal sepsis
Amp and Gent
TF
CT before LP in neonate suspected of meningitis
F
Open fontanelle relieves pressure so can LP without risk of hernia
TF
Neonates do not experience cns herniation after lumbar puncture
T
F
Open fontanelle relieves pressure so can LP without risk of hernia
Galactosemia
Pres
First step in management
Infant with lethargy vomiting jaundice hepatomegaly
Stop breast feeding
Clinical presentstion of rubella infection in
Neonate
Peds
Adult
Neonate congenital sensorineural hearing loss, pda, cataracts, often intrauterine growth restriction / SGA
Peds fever and cephalocaudal spreading maculopapular rash
Adults fever and cephalocaudal maculopapular rash PLUS arthritis and arthralgias
OR asymptomatic
Confirm congenital rubella syndrome suspected clinically
Infant serum IgM
Congenital varicella syndrome
Clinical triad
Limb hypoplasia
Cataracts
Skin lesions (scarring)
Congenital syphilis symptoms
Hepatomegaly
Nasal congestion/snuffles
Osteoarticular destruction
Maculopapular rash
Sensorineural hearing loss late if goes untreated
Most common pathogens of orbital cellulitis
Staph aureus
Strep pneumo
Other strep
Laterality of eye swelling in cavernous sinus thrombosis
Often starts unilaterally but quickly progresses to bilateral (24-48 hours)
Cranial nerves passing through cavernous sinus, can be affected by cavernous sinus thrombosis
III IV V VI
Inflammatory demyelinating condition causing acute vision loss and pupillary defects
Optic neuritis
Most common causes of osteomyelitis in infants and children
Infants
STAPH AUREUS
GBS
Ecoli
Children
STAPH AUREUS
Strep pyogenes
When to suspect
Staph epidermidis
Pseudomonas
Klebsiella
As causes of osteomyelitis
Staph epidermidis - prosthesis
Pseudomonas - uti or urinary instrumentation hx
Klebsiella - uti hx or urinary instrumentation hx
Cat bite
Microbiology
Management
Pateurella multocida
Gram negatives
Irrigate/clean
Amoxicillin/clavalunate (Augmentin) ppx
-amox gets pasteurella, added clav grants coverage to oral anaerobes
Td booster
Do not suture closed
TF
Obs and close follow-up for cat bite not located on hands feet or genitalia in immunocompetent patient
F
Can obs in this situation if dog or human bite
But cat bites need augmentin (amox/clavalunate) because risk of infection is much higher
TF
Azithromycin pox for cat scratch
F
Azithromycin does get bartonella but no need for ppx for scratch – ppx with augmentin is for cat BITES
Clindamycin coverage
Gram positive skin flora
(Staph aureas, strep pyogenes
Oral anaerobes
lyme endemic areas in US
a little Virginia and north of there va md de pa ny new england
also minnesota and wisconsin… west great lakes`
erythema migrans
spreading annular rash with central clearing
e.g. lyme
lyme causative organism
borrelia burgdorferi
ixodes scapularis vs anaplasmosis vs babesiosis (tick)
first sign of lyme disease usually
how long after tick bite
erythema migrans (spreading annular rash with central clearing
1-2 weeks after bite
maybe flu-like fatigue headache myalgias arthralgias
and regional lymphadenopathy
what percentage of lyme patients recall tick bite
25%
prevent lyme
avoidance and rapid recognition and removal of ticks
- repellants DEET (NN diethyl metatoluamide), Permethrin
- long clothing
- tick checks and bathing (wash away unattached ticks)
lyme prophylaxis
doxycycline reserved for pts with ixodes scapularis (tick) attachment for ^36 hours
swimming in brackish water off the new england coast may expose to what infectious disease
vibrio vulnificus
- cellulitis
- sepsis with hypotension and bullous skin lesions
most common viral meningitis pathogens
90% are non-polio enteroviruses, such as echovirus and coxsackie virus
age preference of viral meningitis
infants
and decreases with age
viral meningitis
csf analysis
treatment
time to resolution
pleocytosis with lymphocyte predominance (may be neutrophil predominance early)
protein normal to slightly elevated
glucose normal
supportive treatment
7-10 days to resolution in most patients
bacterial meningitis
csf analysis
pleocytosis with neutrophil predominance
increased protein
decreased glucose
bacteria on gram stain
tuberculous meningitis
csf analysis
acuteness of presentation
lymphocyte predominant pleocytosis (like virus, not bacteria)
very high protein, low glucose (like bacterial)
subacute presentation
which is the more common viral meningitis, ebv or enteroviruses?
non-polio enteroviruses (coxsackie, echo) 90% of cases
when to suspect the following as causes of acute cervical adenitis
staph aureus strep pyogenes anaerobic bacteria (prevotella buccae) bartonella henslae mycobacterium avium adenovirus abv/cmv
staph aureus - pronounced erythema, tenderness
strep pyogenes - pronounced erythema, tenderness
anaerobic bacteria (prevotella buccae) - dental caries, peridontal disease
bartonella henslae - papular nodular site of cat scratch or bite
mycobacterium avium - gradual onset, nontender
adenovirus - bilateral, pharyngoconjunctivitis
ebv/cmv - bilateral, mono
acute unilateral lymphadenitis most common cause most common age most common nodes affected what happens if left untreated tx
strep pyogenes GAS
staph aureus
v5yo
submandibular nodes
untreated can progress to suppuration and abscess
tx w empiric clindamycin (MRSA and GAS coverage)
most common cause of acute bilateral lymphadenitis
adenovirus and other URIs
ebv and cmv too
most common cause of Subacute unilateral lymphadenitis in peds
mycobacterium avium
-very slow onset, non-tender lymph node
perianal pruritus, especially at night,in peds
think…
dx
tx
pinworm (enterobius vermicularis)
eggs on tape test
albendazole or pyrantel pamoate
-treat patient and all household contacts
in addition to nocturnal perianal pruritus, how might pinworm enterobious vermicularis present in a prepubertal female
vulvovaginitis
life cycle of pinworm enterobious vermicularis
adults live in intestines
females migrate distally to lay eggs in perianal skin at night
scratch, mouth, swallow, repeat
typical distribution of atopic dermatitis (eczema) in kids
does it typically involve the groin or genitals?
do symptoms change with time of day?
popliteal and antecubital fossas (flexor surfaces)
spares groin and genitals typically
no symptom change with hour, present throughout
healthy prepubertal female with vaginal pruritus, erthema, discharge, history of recent abx use, think…
candidal vulvovaginitis
differentiate vulvovaginitis from pinrowrm enterobious vermicularis vs candida
pinworm enterobiuos vermicularis will have excoriated and erythematous perianal area as well
dry thickened erythematous plaques on popliteal and antecubital flexor surfaces in a school-aged child think..
atopic dermatitis (eczema)
define lichen sclerosus
benign, chronic, progressive dermatologic condition characterized by marked inflammation, epithelial thinning, and distinctive dermal changes accompanied by pruritus and pain. usually occurs in the anogenital region, but can develop on any skin surface and in women, men, and children
perianal and vulvar pruritus with vaginal discharge or bleeding, hypopigmentation and ecchymosis of affected area, think…
lichen sclerosus
classic croup(laryngotracheitis
pathogen
age
symptoms
parainfluenza
6mos-3years
barky cough, stridor, hoarse voice
classic epiglottitis
pathogen
age
symptoms
h flu
unvaccinated children
sore throat, dysphagia, drooling, tripoding
classic bronchiolitis
pathogen
age
symptoms
RSV
v2yo
wheezing, coughing
what does steeple sign on neck xr signify
subglottic edema eg in croup
treatment
and purpose of treatment
for croup
corticosteroids (dexamethasone) for mild cases
racemic epi nebulized for stridor at rest
to reduce subglottic edema
laryngomalacia
mechanism
pres
infectious symptoms?
collapse of supraglottic structures during inspiration
chronic inspiratory stridor beginning in neonatal period, worse in supine position
no infectious symptoms (no fever, rhinorrhea, congestion, cough)
retropharyngeal abscess
age
symptoms
v4yo
high fever, muffled voice, limited neck rotation due to pain
malaria path clinical features complications dx prevention protective factors
path - plasmodium falciparum vivax ovale malariae parasites by mosquito bite
clinical features - CYCLIC FEVERS q2-3days with OTHER NON-SPECIFIC SYMPTOMS aka periodic febrile paroxysms, nonspecific malaise headache nausea vomiting abdominal pain diarrhea myalgia pallor jaundice petechiae hepatosplenomegaly
complications
- peds - hypoglycemia metabolic acidosis seizure coma
- adults - jaundice acute renal failure acute pulmonary edema
dx - thin and thick peripheral blood smears with giemsa-stained parasites visualized microscopically
prevention - antimalarials (atovaquone, doxycycline, mefloquine, chloroquine, hydroxychloroquine), nets, insecticides
protective factors - hemoglobinopathies (HbS HbC thalassemias), partial immunity from prior malaria infection
why is malaria particularly scary in infants and young children
increased susceptibility to life-threatening complications
-eg CEREBRAL MALARIA seizures delirium coma
why is ciprofloxacin kept on hand by travelers
to treat traveler’s diarrhea
-e coli, campylobacter, shigella, salmonella
malaria should be suspected in…
any ill patients who have traveled to an endemic tropical region - symptoms are NON-SPECIFIC malaise headache nausea vomiting abdominal pain diarrhea myalgia pallor jaundice petechiae hepatosplenomegaly
ESPECIALLY if FEBRILE PAROXYSMS aka cyclic fevers q2-3 days
fever and parotitis after a non-specific prodrome in an unimmunized child
think…
Mumps
Mumps presentation
complications
age most common
how do symptoms vary by age
fever and parotitis after a non-specific prodrome in an unimmunized child
aseptic meningitis (fever headache nuchal rigidity)
orchitis in postpubtertal males
-infertility possible
most common in school-age children - mild disease or even asymptomatic
more severe and more complications (aseptic meningitis, orchitis) in adolescents and adults
primary reason for universal mumps vaccination
prevention of orchitis
tf
facial nerve palsy and mastoiditis are complications of parotitis from mumps
false
mumps - fever and parotitis in unvaccinated… potentially aseptic meningitis and orchitis as compx
facial nerve palsy and mastoiditis can complicate otitis media
tf
pneumonia is a complication of primary measles or varicella infections
T…!
tf
mumps is usually self-limited
T
self-limited fever and parotitis
but may be complicated by aseptic meningitis or orchitis/infertility
