peds rheum Flashcards
JIA
prolonged fever, salmon patch rash, arthritis, visceral involvement
scarlet fever
strawberry tongue, bilateral cervical LAD, fever, rash
rheumatic fever
Rash, subcutaneous nodules, fever, polyarthralgia, chorea
viral syndrome (enterovirus)
Fever 3-5 days, non-descript non-painful rash, can walk
kawasaki
fever > 5days, nonpurulent conjunctivitis, erythematous rash, swelling and erythema of extremities, unilateral LAD
osteomyelitis/septic joint
Low grade fever, painful walking
RMSF
Fever
Steven johnson
Severe pruritic rash, fever
measles
conjunctivitis, fever, rash, non-immunized
kawasaki
Mucocutaneous lymph node syndrome
Acute Febrile Vasculitic syndrome of early childhood
kawasaki symps list
Supporting Sx: Non-remitting High grade Fever > 5 days PLUS 4/5 of the following:
red macpap rash
unilat cerv adeno>1.5 cm
strawberry tongue, red fissurd lips, injected pharynx
non-pur. conjunc, bilat, painless
redness/swell of hands/feet
desquamations of tips, transfers grooves across nails -beau lines)
kawasaki labs
No specific diagnostic test; Elevated ESR/CRP, Anemia, Elevated WBC, Thrombocytosis, Hypoalbuminemia, Elevated AST/ALT
Case: Echocardiogram with coronary artery aneurysms
kawasaki complications
coronary artery aneurysm CNS manifest (mening.) liver dysfunc arthritis hydrops of gall bladder
kawasaki pathoma
Kawasaki Motorcycle Hold on with Palms and Soles: Edema Erythema Desquamation Heart Racing: CAA
kawasaki tx
Usually self-limiting ~12 days
BUT leads to significant morbidity and mortality
IV IG (dec. CAA)
Aspirin
(Anti-inflammatory, anti-pyretic, anti-platelet)
Possible Reye syndrome- recommend influenza vaccine
Echocardiogram- evaluate for CAA
kawasaki buzz words
High-grade Fever for multiple days Strawberry Tongue Conjunctivitis Thrombocytosis and peeling of fingers Erythematous Maculopapular Rash Coronary Artery Aneurysms Treated with Aspirin in Childhood
“gelling phenomenon”
joint pain is worse in the morning and after periods of sitting and watching television
ESR vs CRP
ESR: concentration of fibrinogen and other inflammatory modulators that have half-lives of days to weeks.
CRP: made exclusively in the liver and can rise and fall within hours of an acute inflammatory stimulus
JIA (Juvenile Idiopathic Arthritis)
JIA types
polyarthritis
oligoarthritis
systemic: characteristic arthritis that develops with fever and rash; and exclusion of other juvenile arthritis
JIA comps
Chronic iridocyclitis in pauciarticular JRA (other ocular disease includes iritis, and uveitis)
Joint deformities in polyarticular JRA
(can have positive or negative rheumatoid factor)
common tests for GAS (rheumatic fever)
throat cx
anti–streptolysin O (ASO) and anti–deoxyribonuclease B (anti–DNAase B)
ASO titers
peak 3 to 6 weeks after GAS infection.
They are elevated in 80% of patients with typical rheumatic fever (and GABHS pharyngitis)
less than 50% of kicks w/ rec. GABHS skin inf.
less than 70% of patients with chorea
Anti–DNAase B titers
more reliable, in both pharyn. and skin GABHSpts
peak 6 to 8 weeks after GABHS infection. The elevated titers may persist for several months after infection
elevation of ??? in 95% rheumatic fever pts
anti–DNAase B, antistreptokinase, or antihyaluronidase
Jones Criteria for rheumatic fever
2 major criteria or 1 major + 2 minor + evidence of recent GAS infection (+ throat cx/RADT, rising ASO titers)
MAJOR: carditis, polyarthritis, chorea, erythema marginatum
MINOR: fever, arthralgia, elevated APPs, prol. PR interval
JIA tx
Hospitalization
Cardiology consult
PCN or Erythromycin (if patient is allergic to PCN)
arthritis and carditis tx: ASA 90 to 120mg/kg/day until symptoms resolve
chorea tx: Haloperidol, phenobarbital, or valproic acid
JIA ppx
Start prophylactic antibiotics immediately after the therapeutic antibiotic course is completed.
Continue until child is an adult and is recurrence free for 10 years (longer if they have residual heart disease)
Options for lower risk of recurrent ARF:
PCN V K, Sulfadiazine, Macrolides
Higher risk of recurrent ARF:
Benzathine PCN G intramuscularly, every 4 weeks
RF summary
Age range: 5-15yo Seasonality: Winter Preceding URI Strep Pharyngitis Jones criteria
RF: carditis
Prolonged PR interval Varying degrees of heart block Cardiomegaly may be noted on CXR Inflammation of valves and endocardium valvular regurgitation/stenosis Mitral valve most common (rheuMATic: Valves affected Mitral>Aortic>Tricuspid)
RF: skin/ST
(typically only in carditis patients)
Subcutaneous nodules over bony prominences
present up to a month
Erythema marginatum
annular erythema, usually present on the trunk and proximal portions of the extremities, sparing the face
RF: CNS
Sydenham Chorea
abrupt, purposeless, nonrhythmic, involuntary movements that cease during sleep
muscular weakness
emotional disturbances; ranges from outbursts of inappropriate behavior to transient psychosis
Occur 3-8 months after GAS infection
RF labs
elev. ESR, CRP CXR: mild effusion EKG: prol. PR interval Echo: mitral valve regurg \+ASO
erythema nodosum
type of panniculitis, inflammation of subcutaneous fat in the skin, usually first evident as an outcropping of erythematous nodules that are highly sensitive to touch
Most located symmetrically on the ventral aspect of the lower extremities
tests: CBC, ESR, ASO titers, Excisional biopsy (when clinical diagnosis is in doubt)
Henoch Schonlein Purpura
Small-vessel vasculitis associated with abrupt onset of a rash, palpable purpura most common; GI manifestation, arthritis and arthralgia, and late renal manifestations, commonly after exposure to triggering antigen (eg infectious agent)
tests: CBC, ESR, abdominal US, urinalysis, ASO titers, Excisional biopsy (when clinical diagnosis is in doubt)
Immune thrombocytopenic purpura
Thrombocytopenia associated with petechia or purpura; bleeding (e.g., gingival, gastrointestinal, mucocutaneous); symptoms of end-organ ischemia (in patients with thrombotic disease)
tests: CBC with peripheral smear, coagulation studies, platelet-associated antibody (immunoglobulin G), electrolytes, BUN, creatinine, LDH, urinalysis
leukemia
Nonspecific symptoms of fever, easy bleeding, skin findings (e.g., petechiae, purpura), bone pain, fatigue, hepatosplenomegaly, lymphadenopathy
tests: CBC, ESR, coagulation profile, bone marrow biopsy
meningococcemia
Malaise, fever, rash (e.g., maculopapular rash, petechiae, ecchymosis), and hypotension with possible associated symptoms of meningitis or tenosynovitis
tests: CBC, PT/aPTT, fibrinogen, fibrin degradation productions, blood culture, CSF analysis and culture
polyarteritis nodosa
Multisystem involvement from segmental inflammatory, necrotizing vasculitis of the small- and medium-sized muscular arteries leading to general symptoms of fever, weakness, weight loss, malaise, myalgia, rash (e.g., livedo reticularis, purpura), headache, and abdominal pain
tests: Biopsy of involved organ, urinalysis, CBC, ESR, CRP, angiography
RMSF
Headache; fever associated with a centripetal rash (involving palms and soles, spreading to arms, legs, and trunk) that is often petechial; report of recent tick bite or outdoor activity in endemic area
tests: Immunofluorescence staining of tissue specimen or serologic analysis for Rickettsia rickettsii, CBC, electrolytes
HSP (Henoch Schonlein Purpura/IgA vasculitis)
most common vasculitis in children(about 50% of cases).
S/S
Hallmark: non-thrombocytopenic palpable purpura.
LE and buttocks
Colicky abdominal pain (50%)
Occult blood (50%)
Arthritis(50-67% kiddos)
Mainly in knees and ankles
]renal involvement (hematuria) (1/3rd kiddos)
screen monthly with UA for 6 months, nephritis is a late finding
recent URI (2/3 cases)
elevated ASO (50%)
HSP dx
triad of purpura, abdominal pain, and arthritis
Non-blanching palpable purpura of LE and butt
absence of thrombocytopenia
Skin biopsy(rare): characteristic IgA deposits in vessel walls
Renal biopsy (only indicated if nephritis develops): membranoproliferative glomerulonephritis similar to IgA nephropathy
HSP comps
considered benign
hosp. if abd pain, GI bleed, intussusception, renal involve
- 5% kids–>renal failure
- 2-3% intussusception (60% ileoileal)
- 33% recurrence rate
HSP tx
min: supportive
mild: acetomin/NSAIDs
mod: corticosteroids
sev: cortsters + adj. immunsuppr (cyclophosphamide, IVIG) or plasmapheresis
HSP labs
Abdominal CT:marked bowel wall thickening from the vasculitis
Abdominal US: identify constipation, intussusception, or other GI involvement
ASO titers – Previous strep inf
BMP (electrolytes, BUN, Cr) – monitor for renal insufficiency
Blood culture – Evaluate for bacteremia or sepsis as possible cause
CBC – identify WBC, HCT, Hgb, platelets
Anemia could indicate GI bleed
Identify thrombocytopenia
CRP, ESR – indicate inflammatory reaction
IgA levels – typically elevated in HSP, but nonspecific
PT/PTT – Elevated levels make bleeding diathesis more probable
UA – Assess for renal involvement
Serology – Evaluate for cause of infection
