Peds Sessions

Question 1

Look over Brandau CIS

Answer 1

DO it now.

Question 2

Vitamin D

Answer 2

25-hydroxyvitamin D diffuses across the placental barrier so that the infant’s levels depend upon the mother

There is a correlation between the mother and infant for 1,25 dihydroxyvitamin D but fetal levels come from the fetal kidney

Question 3

stages of rickets

Answer 3

STAGE 1-D3 deficiency leading to decreased Ca absorption and Ca levels begin to decrease resulting in the INCREASE of PTH levels and mobilization of Ca from bone

STAGE 2-Phosphorus reabsorption in the kidney decreases increasing the renal tubular concentration of phosphorus. At this time there is decreased amounts of 25-D3 thus no conversion to 1,25-D3 so reabsorption of Ca from the gut does not take place meaning Ca levels are maintained by the action of PTH on bone

STAGE 3-As the calcium levels continue to fall calcification of the bony matrix becomes inadequate i.e. the solubility product (calcium x phosphorus) is not exceeded and normal mineralization of bone cannot take place.

Common findings: protruding forehead, pigeon chest, depressed ribs, kyphosis, curved humerus, large head, “ricketic rosary”, curved tibia and fibula

Question 4

Vit D dependent rickets:

Answer 4

Predisposing factors:
Lack of sunlight exposure
Lack of commercial milk products
Anticonvulsive therapy (phenobarbital or phenytoin)
Intestinal malabsorption syndromes/particularly those that cause malabsorption of fat

Clinical Features: 
Tetany
Growth retardation
Frontal bossing
Rachitic rosary
Widening of the wrists or knee joints
Seizures

Lab findings: 
**Low serum calcium
**Low serum phosphorus
High level of alkaline phosphatase
**High serum level of PTH
Low serum level of 25-D3

Question 5

hypophosphatemic Rickets/ Vit D resistant rickets

Answer 5

Not vitamin D metabolism problem but rather a phosphate leak at the level of the proximal tubule

Inherited as an autosomal dominant or X-linked dominant
Problem causes low serum phosphorus

Solubility product of calcium and phosphorus is < 35 mg/dL so no mineral precipatation occurs in the cartilaginous matrix

Lab findings:
Low serum phosphorus**
Normal level of serum calcium
Normal or slightly elevated level of PTH

**Pathognomonic finding

Question 6

Renal insufficiency Rickets

Answer 6

Both vitamin D and PTH systems are broken

Phosphorus excretion is decreased

Serum phosphorus levels increase

Synthesis of 1,25-D3 decreases

Ca absorption from the gut becomes severely reduced

Lab findings: 
**High serum level of phosphorus
**Low serum level of calcium
High level of PTH
Serum alkaline phosphatase is elevated
**Elevated serum creatinine and BUN

Question 7

transient hypoparathyroidism

Answer 7

• low serum calcium, elevated phosphorus… but normal PTH levels
  hx: infant born w/ seizures and low calcium levels

Causes are diverse and represent disruptions in the steps controlling maintenance and secretion of the hormone

Transient hypoparathyroidism can occur in the offspring of mothers with hyperparathyroidism or hypercalcemia of any cause

Always keep in mind Di-George Syndrome when see hypocalcemia:
Catch 22
- 22q11.2 deletion
- cardiac defects, abnormal facies, thymic hypoplasia, cleft palate, hypocalcemia

Question 8

Chvostek’s sign

Answer 8

= sign of hypocalcmia - tap on the facial nerve - will elicit twitching at the lip at the corner of the mouth and spasm of fascial mm. depending on severity

Question 9

DDx of neonatal hypocalcemia

Answer 9

Maternal diabetes

Birth Asphyxia

Sepsis (macrophage-generated cytokines that effect PTH secretion)

Preterm birth – levels can be all over the place

Increased calcitonin

Resistance to PTH

Decreased PTH secretion

Question 10

presentation of neonatal hypocalcemia can be confused with…

Answer 10

Hypoglycemia
Sepsis
Meningitis
Asphyxia
Intracranial bleed
Narcotic withdrawal

Question 11

clinical signs of hypocalcemia of newborn?

Answer 11

Jitteriness
Generalized convulsions
Focal seizures 
Lethargy
Poor feeding
Vomiting abdominal distention

Question 12

exanthem

Answer 12

skin eruption due to an illness

Question 13

enanthem

Answer 13

an eruption of lesions in mucous membranes

Question 14

rocky mountain spotted fever

Answer 14

• tick born disease
• Rickettsia rickettsii
• most common symptoms are high fever (> 102° F), headache, rash, and myalgias.
• petechial rash typically begins on the wrists and ankles but may be found anywhere, including the oral mucosa, as in this child

Question 15

meningococcemia

Answer 15

• gram-negative diplococcus Neisseria meningitidis
• basically develop DIC : see large dark red patches/erythema and blisters
• 50% of patients developing meningitis only, 10% developing septicemia only, and 40% developing both.
• Children with meningitis are usually febrile and ill-appearing, with symptoms of lethargy, vomiting, and nuchal rigidity.
• Septicemia leads to capillary leak, coagulopathy, profound acidosis, and myocardial failure.
• Patients must be closely monitored for hypotension, shock, pericarditis, organ failure, and coagulopathy, usually in an intensive care unit setting.

** seen spreading in dorms **

Question 16

Measels

Answer 16

caused by rubeola virus

** measels rash starts from head and goes all the way down the body **

After exposure, the incubation period lasts for 7-14 days.

• Patients then develop a prodrome of high fevers, often > 104° F, with the classic triad of cough, coryza, and conjunctivitis.

** A couple of days later, Koplik spots develop on the buccal mucosa, appearing as white spots on an erythematous base.

Question 17

leukemia

Answer 17

see petechial lesions – worry about these!!!!

• nonspecific symptoms of anorexia, irritability and lethargy
• Subsequently one may see progressive fatigue, weight loss, pallor, bone pain, fever and petechiae

Question 18

HUS (TTP in adults)

Answer 18

associated with “bloody diarrhea” (E. coli O-157)

• patient develop progressive renal failure, anemia, thrombocytopenia.

Question 19

ITP

Answer 19

Idiopathic thrombocytopenic purpura (ITP)

• Most common cause of thrombocytopenic purpura in childhood: present with little spots, and occur in places you wouldn’t expect
• associated with bleeding and bruising
• usually follows a viral illness, and then platelets drop <20,000 (consumptive coagulopathy - AI response from viral illness results in platelet drop)
• giant, normal looking platelets
• RARELY get intracrnial bleeds, b/c the platelets that are available are large and very effective
• self-limited, lasts a few weeks to a few months

NOTE: differentiate from leukemia, which normally has around 50,000 platelets

Question 20

chicken pox

Answer 20

“dew drop on rose petal” = varicella virus

Question 21

herpes

Answer 21

see vesicular lesions - can get encephalitis and hepatitis

encephalitis complications: stroke, seizures

• worry about brain and liver*

Question 22

what infection can cause bullous?

Answer 22

staph infection

Question 23

• “sandpaper rash”- peeling in antecubital spaces and groin

Answer 23

scarlet fever - bad sore throat, sandpaper type rash (maculopapular), in lower abdominal lesion

= Group A strep infection

Question 24

urticaria

Answer 24

allergic reaction, viral reaction, strep, idiopathic causes

Question 25

steven-johnson syndrome

Answer 25

involves mucus membranes,

form of toxic epidermal necrolysis, is a life-threatening skin condition - involves peeling and stripping of skin

Question 26

Fifth’s disease

Answer 26

= “slapped cheek” syndrome
= parvovirus B19

this patient is nontoxic, often presents with this a maculopapular rash on the trunk and extremities, followed by the development of a lacy reticulated pattern on the trunk and extremity

who else can be affected by parvo?

• • can cause problem with pregnant women: can cause hydrops fetalis and anemia in baby
• • sickle cell patients: can have significant complications b/c it shuts down the bone marrow

Question 27

roseola

Answer 27

• caused by HHV 6 and 7
• an infant or young child, presents with high fever, 103-105 lasting 3-4 days and usually nothing else clinically
• high fever, irritable, feel bad … then fever breaks and 24 hours later a diffuse rash shows up
• totally benign disorder, looks really sick in the beginning

Question 28

see circular rashes, think what?

Answer 28

ringworm or nummular eczema - tx it with steroids if think its eczema or tx with lotramine if think its tinea - if it doesn’t get better then you switch!

Question 29

do skin slideshow

Answer 29

do it now!

Question 30

tuberous sclerosis

Answer 30

• see small white patch, shows up better under Wood’s lamp
• can see adenomas

** big problem: can grow tumors in the brain

classic lesions of TS are the ash leaf macule, shagreen patch (raised orange peel appearance) and adenoma sebaceum, (skin colored or pink lesion often present on face in late childhood to early adolescence) which is a misnomer as they are actually fibroadenomas and have nothing to do with the sebaceous glands.

the ash leaf lesion is often present at birth, most easily seen with a wood’s lamp.

Question 31

sturge-weber lesion

Answer 31

port wine stain

• rare congenital neurological and skin disorder
• could have hemangiomas present in the brain- can cause seizures and big problems
• Do an MRI
• this can be a devastating disorder which is the result of a capillary hemangioma which involves the skin of the face, mucous membranes, meninges and choroid plexus. You may see seizures, hemiparesis, hemianopsia and intellectual impairment. Usually lesions are unilateral.

Question 32

Neurofibromatosis

Answer 32

• presents with cafe au lait spots (greater than 1.5 cm)
• axillary freckling
• see neurofibromas, acoutstic neuromas, optic gliomas

** more than 6 lesions greater than 1.5 cm is pathognomonic for Neurofibromatosis.

Cutaneous and subcutaneous neurofibromas appear in late childhood or adolescence.

NOTE: One may also see large unilateral cafe au lait spots in Mccune Albright syndrome. This disorder includes polyostotic bone dysplasia, precocious puberty and multiple endocrine dysfunctions.