Toxoplasmosis, Herpes Infections, Toddler Diarrhoea

Question 1

What is Toxoplasmosis?

Answer 1

Toxoplasmosis is a protozoan parasite that spreads through food or water contaminated with oocysts, infected meat, or contact with oocysts from feline faeces.

Question 2

What is the aetiology of Toxoplasmosis?

Answer 2

Exposure should be limited by avoiding undercooked meat and cat litter (use gloves if handling)

Primary infection during pregnancy is often asymptomatic in the mother, but can result in congenital disease in the fetus.

Cats are the definitive hosts for the parasite and can excrete millions of oocysts that survive in the environment for months. Humans are intermediate hosts, and become infected by ingesting uncooked meat infected with tissue cysts (bradyzoites), by ingestion of other food or water contaminated with oocysts, or by transplacental spread of tachyzoites.

Question 3

What is the epidemiology of Toxoplasmosis?

Answer 3

Pregnant women = 27%

Without treatment, infection during pregnancy results in congenital disease roughly 44% of the time, and appropriate treatment during pregnancy lowers the risk of congenital infection to 29%.

Question 4

What would you find in the history and exam of a child with congenital toxoplasmosis?

Answer 4

Cerebral Palsy
Fetal microcephaly
Fetal intracranial calcification
Fetal hydrocephalus
Fetal IUGR

Question 5

What investigations do you do for toxoplasmosis?

Answer 5

Anti toxoplasma IgG and IgM

CT or MRI

Question 6

What is the management of toxoplasmosis?

Answer 6

Pyrimethamine
Sulfadiazine
Calcium folinate

Given to newborns with confirmed or highly suspected congenital disease to prevent or limit damage to the central nervous system and eyes and to prevent death.

Also for children.

Question 7

What are the Human Herpesviruses?

Answer 7

o HSV1
o HSV2
o VZV
o CMV
o EBV
o HHV-6
o HHV-7
o HHV-8 (Kaposi Sarcoma_

Question 8

What is the hallmark of herpes viruses?

Answer 8

• HALLMARK OF HERPES VIRUSES: after primary infection, latency is established and there is long-term persistence of the virus within the host (usually in a dormant state)
o This can be reactivated after certain stimuli

Question 9

How infective is HSV1/2?

Answer 9

HSV usually enters the body through the mucous membranes or skin
• The site of primary infection may be associated with intense local mucosal damage

Question 10

What is the associations of HSV1/2?

Answer 10

o HSV1: lip and skin lesions
o HSV2: genital lesions
o Note: but both viruses can cause both types of disease

Question 11

What is the managment of HSV?

Answer 11

o Paracetamol/ibuprofen to help with pain and fever
o ACICLOVIR (DNA polymerase inhibitor) may be used to treat severe
symptomatic skin, ophthalmic, cerebral and systemic infections
• Most HSV infections are asymptomatic, but they can present differently based on site
of infection

Question 12

How does Herpes cause gingivostomatitis?

Answer 12

Most common form of primary HSV illness in children

• Usually affects 10 months – 3 years age

Question 13

What is the presentation of Herpes gingivostomatitis?

Answer 13

o Vesicular lesions on lips, gums and anterior surfaces of tongue and hard
palate.
o They usually progress to extensive, painful ulceration and bleeding
o Often accompanied by high fever
o Illness may persist for up to 2 weeks
o Eating and drinking becomes painful – can lead to dehydration

Question 14

What is the management of ALL herpes viruses in general?

Answer 14

Fluids and bedrest

Aciclovir if severe

Question 15

What is eczema herpeticum?

Answer 15

o Widespread vesicular lesions develop on
eczematous skin
o This can be complicated by secondary
bacterial infection, which can then, in turn,
result in septicaemia

Question 16

What are Herpes Whitlows?

Answer 16

o Painful, erythematous and oedematous white
pustules on the site of broken skin (usually on fingers)
o It is spread by autoinoculation from gingivostomatitis
and infected adults kissing children’s fingers. A less
common cause if contact with genital herpetic lesions

Question 17

How does Herpes manifest on the skin?

Answer 17

• Mucocutaneous junctions and damaged skin are
particularly prone to HSV infection
• Cold sores are recurrent HSV lesions on the
gingival/lip margin
• Eczema Herpeticum
• Herpetic Whitlows

Question 18

What is HSV eye disease?

Answer 18

• HSV can cause blepharitis or conjunctivitis
• It can involve the cornea and cause dendritic
ulceration
• This can result in corneal scarring and loss of
vision
• ANY CHILD with herpetic lesions near or
involving the eye require urgent ophthalmic
assessment

Question 19

Why is disseminted herpes infection bad?

Answer 19

High morbidity and mortality

Immunocompromised:
o Cutaneous lesions can spread to involve adjacent sites (e.g. oesophagitis,
proctitis)
o Pneumonia and disseminated infections involving multiple organs are major
complications

Question 20

Summarise Herpes in children

Answer 20

Most are ASYMPTOMATIC
• Gingivostomatitis - may necessitate IV fluids and aciclovir
• Skin manifestations - mucocutaneous junctions (e.g. lips) and damaged skin
• Eczema herpeticum - may result in secondary bacterial infection and septicaemia
• Herpetic whitlows - painful pustules on the fingers
• Eye disease - blepharitis, conjunctivitis and corneal ulceration
• CNS - aseptic meningitis, encephalitis
• Pneumonia and disseminated infection in the immunocompromised

Question 21

What are the most common causes of Diarrhoea in a Toddler?

Answer 21

Most common cause in
developed world is cows’ milk
intolerance

Toddler diarrhoea

Coeliac disease

Post-gastroenteritis lactose
intolerance

Question 22

How common is Toddler’s Diarrhoea?

Answer 22

Most common cause of persistent loose stools in preschool
children

Mainly affects 1-4 years of age

Question 23

What is the aetiology of Toddler’s Diarrhoea?

Answer 23

Aetiology thought to be due to imbalance of fluid, fibre
and undigested sugars that reach large bowel causing
excessive fluid to be passed out into stools

Question 24

What are the clinical features of Toddler’s Diarrhoea?

Answer 24

o Typically >2 watery stools per day (can be up to 8-10/day)
o Stools: vary in consistency, smelly, pale, contain undigested vegetables e.g.
sweetcorn, carrots
o May have associated mild pain
o Well and thriving child

Question 25

What is the management of Toddler’s Diarrhoea?

Answer 25

o Reassure parent
o Usually self-resolving by 4-5 years of age
o Dietary advice
o If changes do not improve symptoms → refer to specialist

Question 26

What dietary advice do you give for Toddler’s Diarrhoea?

Answer 26

▪ Avoid sugars e.g. fruit juices, fizzy drinks, sweets, chocolate → stick
to water and milk as drinks
▪ Avoid excessive drinks
▪ Limit high-fibre foods e.g. Weetabix, baked beans

Question 27

Why should you refer to a specialist if Toddler’s diarrhoea does not improve?

Answer 27

In some cases, it might be from undiagnosed coeliac disease or
excessive ingestion of fruit juice (especially apple juice). Sometimes
can be temporary cow’s milk allergy after gastroenteritis.
▪ After most probable causes have been excluded, most cases are a result
of dysmotility of the gut (form of IBS) and fast-transit diarrhoea →
these tend to improve with age

Question 28

Infant with faltering growth?

Answer 28

consider coeliac disease and cow’s milk

protein allergy

Question 29

Following bowel resection, cholestatic liver disease or exocrine pancreatic
deficiency?

Answer 29

consider malabsorption

Question 30

In otherwise well toddler with undigested vegetables in stool?

Answer 30

consider chronic non-specific (Toddler’s) diarrhoea