PEDIATRIC BOARD REVIEW COURSE ADOLESCENT MEDICINE

1. PEDIATRIC BOARD REVIEW COURSE ADOLESCENT MEDICINE WARREN M. SEIGEL M.D., F.A.A.P., F.S.A.M. Chairman, Department of Pediatrics Director of Adolescent Medicine Coney Island Hospital Brooklyn, NY

2. CASE #1 Katherine is a 14 year old female who presents for a routine examination for sports. She has no complaints. Her past medical history and family history are unremarkable. On physical examination, you note that she has Tanner 3 breasts and Tanner 4 pubic hair.

3. QUESTIONS • What is your differential diagnosis? • Are Katherine’s physical findings normal? • How would you describe “Tanner 3” breast development? • How would you describe “Tanner 4” pubic hair development? • Has Katherine completed her growth spurt? • What actions would you take next?

4. PUBERTY • Physical changes associated with development • Sequence of change is similar for all adolescents • Variations in tempo and timing are common • Physical changes reflect underlying hormonal changes

5. GIRLS Breast Buds Pubic Hair Appears Growth Spurt Axillary Hair Pubic Hair Matures Breasts Mature Menarche (First Period) Adult Height BOYS Testicular enlargement Growth of penis/scrotum Appearance of pubic hair Axillary Hair First ejaculations Growth spurt Facial hair Adult Height SEQUENCE OF PUBERTY

6. Features of Female Development • Onset: 10 years (8-13) • Growth spurt: Tanner 2 - 3 • Height Achieved: 4 inches per year • Menarche: 12 years • Acne: common at Tanner 3 - 4

7. Features of Male Puberty • Onset: 9-13 years (average = 12) • Peak Height Velocity: Tanner 3 - 4 • First Ejaculations: Tanner 3 • Average Height Gained: 5-7 inches/ year • Strength Peak: Tanner 4 - 5 • Gynecomastia occurs in approximately 60%

8. CASE #1(continued) Later in the course of your history, you find out that Katherine has tried tobacco, drinks alcohol “on weekends with my friends” and “smokes weed once in a blue”.

9. QUESTIONS • From a psychosocial perspective, in what stage of adolescent development is Katherine? • What are some of the high risk behaviors that she is most likely to be at risk for in the near future? • What are the leading causes of morbidity and mortality in Katherine’s age group? • What actions would you take next?

10. FEATURES OF EARLY ADOLESCENCE(Am I Normal?) • Physical Changes and Concerns • Sense of Being “Center Stage” • Sense of Invulnerability • Wide Mood Swings • Rejection of Childhood Things • Beginnings of Emancipation • Non-Parent Adult Role Models • Same-Sex Friendships

11. FEATURES OF MIDDLE ADOLESCENCE(Am I Liked?) • Puberty (Almost) Complete • Testing/Showing Off “New Body” • Independence-Dependence Conflicts • Strong Peer Attachments • Concern With Sexual Appeal • Experimentation/Risk-Taking

12. FEATURES OF LATE ADOLESCENCE(Am I Loved?) • Definition of Adult Role in Society • Definition of Adult Role in Family • Mainly Independent Decisions, Actions • Established, Realistic, Self-Identity • Realization of Vulnerability, Limitations

13. High Risk Behaviors • Substance Abuse • Alcohol • 85% of all adolescents acknowledge use • Cigarettes • use increasing among females • Marijuana • use increased among all age groups • Cocaine • level use

14. CASE # 2 Jonathon is a 16 year old male who comes to your office complaining of a clear urethral discharge and burning on urination for the past 1 week. He admits to being sexually active, the last time being 10 days ago.

15. QUESTIONS • What is your differential diagnosis? • What additional history would you like to obtain? • What will you look for on your physical examination? • What actions would you take next?

16. CHLAMYDIA TRACHOMATIS • MALES • Urethritis • Epididymitis • Asymptomatic • FEMALES • Asymptomatic • Cervicitis

17. CHLAMYDIA: SIGNS AND SYMPTOMS • MALE: Burning, Urethral Discharge, Pain in Epididymis • FEMALE: Vaginal/Cervical Discharge, Pelvic Pain, Painful Intercourse, Burning, Pelvic Inflammatory Disease (PID) MAY BE NO SYMPTOMS IN MALE OR FEMALE

18. CHLAMYDIA TRACHOMATIS • DIAGNOSIS • Culture: “gold standard” • Leukocyte esterase; urine dip in males • Enzyme linked assay (EIA or ELISA) • Direct Fluorescent Antibody (DFA) • DNA probes • Nucleic Acid Amplification Tests (NAATs)

19. CHLAMYDIA TRACHOMATIS • TREATMENT • Azithromycin 1 gm single dose by mouth • Doxycycline 100 mg by mouth twice daily for 7 days • PARTNER TREATMENT!!! • Follow-up “Test of Cure” recommended

20. GONORRHEA: SIGNS AND SYMPTOMS • MALE: Yellow “Drip” from Penis, Burning, Pain in Epididymis • FEMALE: Vaginal/Cervical Discharge, Heavy Menses, Painful Intercourse, Burning, Frequency MAY BE NO SYMPTOMS IN MALE OR FEMALE

21. Neisseria Gonorrhea • MALE • Urethritis • Epididymitis • FEMALES • Asymptomatic • Cervicitis • Bartholin’s gland abscess • Pelvic Inflammatory Disease (PID)

22. NEISSERIA GONORRHEA • DIAGNOSIS • Culture: “Gold Standard” • Leukocyte esterase suggestive in males • DNA probes, PCR, EIA are all available • Nucleic Acid Amplification Tests (NAATs)

23. NEISSERIA GONORRHEA • TREATMENT • Ceftriaxone 125 mg IM in single dose • Cefixime 400 mg PO in single dose • Ofloxacin 400 mg PO in single dose • Ciprofloxacin 500 mg PO in single dose ADDITIONAL TREAMENT FOR CHLAMYDIA TRACHOMATIS IS TYPICAL

24. SYPHILIS: SITE OF INFECTION • MALE: Penis, Anus, Mouth, Lips • FEMALE: Vulva, Vagina, Cervix, Anus, Mouth, Lips • INFANT: Acquired During Pregnancy, Birth Defects, Death Spread to entire body in male and female including heart and brain!

25. SYPHILIS: SIGNS AND SYMPTOMS • PRIMARY SYPHILIS • Chancre on sex organs • SECONDARY SYPHILIS • Fever, rashes, generalized illness • TERTIARY SYPHILIS • Infection of brain, blood vessels

26. SYPHILIS • PRESENTATION • Primary chancre • Indurated ulcer with smooth borders • Painless • Incubation of approximately 3 weeks • Healing in approximately 6 weeks

27. SECONDARY SYPHILIS • CONSTITUTIONAL SYMPTOMS • Fever, malaise, adenopathy, musculoskeletal • SKIN AND MUCOUS MEMBRANE FINDINGS • Rash – begins on trunk • Rash – involves palms and soles • Condyloma lata – moist plaques • Alopecia SKIN LESIONS ARE HIGHLY INFECTIOUS!

28. Diagnosis – Syphilis • Serologic – nontreponemal • RPR, VDRL, ART • Serologic – treponemal • FTA-ABS, MHATP,TPHA

29. Treatment – Syphilis • Less than 1 year duration – • Benzathine Penicillin-G 2.4 million units IM • Greater than 1 year duration – • Benzathine Penicillin-G 7.2 million units, 3 divided doses

30. Trichomonas • Males • Generally asymptomatic • Females • Malodorous vaginal discharge • Cervicitis • Vulvitis with labial edema

31. Trichomonas • Diagnosis • Observation of flagellate on saline wet mount • Treatment • Metronidazole 2 gm po x 1 dose

32. Bacterial Vaginosis • Non-gonococcal • Non-chlamydial • Non-trichomonal • Non-candidal • Due to Gardnerella vaginalis

33. Bacterial Vaginosis • Symptoms • Vaginal discharge- grey-white, thin , watery • Pruritis and itching may accompany • Worsens with intercourse • Malodorous • Diagnosis • Saline wet prep with “clue” cells

34. Bacterial Vaginosis • Treatment • Metronidazole 500 mg PO bid X 7 days

35. Genital Herpes: Site of Infection • Males: Blisters on Penis, Scrotum, Buttocks • Females: Blisters on Vulva, Vagina, Cervix, Buttocks • Infants: Systemic

36. Genital Herpes: Signs and Symptoms • Primary Infection: Very Painful Painful Urination 1-3 weeks • Repeat Infections: Less Painful 1 Week or less

37. Herpes Simplex - HSV • Skin lesions appear at site within 2-14 days • Grouped papules on erythematous base • Ulceration Erosion • Very painful • Constitutional symptoms

38. Genital Herpes: Treatment • Treat Virus • Treat Symptoms • No sex until 1 week after blisters heal • Treat partner only if infected

39. Treatment:Genital Herpes • Primary • Acyclovir 400 mg oral tid X 7-10 days • Recurrent • Acyclovir 400 mg oral tid X 5 days • Prophylaxis/Suppressive Therapy • Acyclovir 400 mg oral bid

40. Genital Herpes • 1.First Episode • Acyclovir (ACV) 200 mg (400mg for proctitis) • PO 5x per day for 7-10 days • 2. Recurrent Episodes – usually no treatment, if necessary: • A) ACV 200 mg PO 5x per day for 5 days • B) ACV 400 mg PO TID for 5 days • C) ACV 800 mg PO BID for 5 days • 3. Suppressive Therapy • A) ACV 400 mg PO BID • B) ACV 200 mg po 2-5 times/day • 4.Severe disease • ACV 5 -10 mg/kg IV every 8 hours X 5-7 days • 5. No role for topical ACV

41. Human Papilloma Virus • Most common viral STI, and most common STI in the USA • Increasing prevalence among teens • Associated with majority of Pap smear abnormalities

42. Human Papilloma Virus • Treatment • Podophyllin • Cryotherapy with liquid nitrogen • Podofilox ( home treatment ) • Interferon available (not currently recommended) • Quadravalent Vaccine currently available and recommended for all females 9 – 26 years of age

43. CASE # 3 Over the past 6 months, Marianne, a 15 year old girl in your practice, has missed 8 days of school because of severe, episodic lower abdominal pain that coincides with menses. Menarche was at age 13 and menses are regular. She states that she is not sexually active. Findings on physical exam are normal.

44. QUESTIONS • What is your differential diagnosis? • What will you look for on physical examination? • What actions would you take next?

45. Normal Menstruation • Normal menstruation is an indication that the hypothalamic--pituitary--ovarian--uterine axis is intact and responsive.

46. Physiology of Menses • FSH - stimulates the maturation of ovarian follicles - directs the conversion of androgens in the granulosa cells of the ovary to estrogens • LH - stimulates theca cells of the ovary to produce androgens - midcycle LH surge stimulates ovulation

47. Physiology of Menses • Estrogens- stimulate the proliferation of endometrial epithelial and stromal cells. Stimulate glandular formation. • Progesterone- produced by corpus luteum, causes the endometrium to function in a secretory manner, leading to increased blood vessel growth and tortuosity.

48. Normal Menstrual Cycles Follicular Phase Ovulatory Phase Luteal Phase

49. Follicular Phase • Endometrial proliferation under estrogen influence • Endometrial stroma becomes compact • Estrogen triggers midcycle LH surge • Cervical mucus is watery

50. Ovulatory Phase • Following ovulation, corpus luteum produces both Estrogen and Progesterone. • Progesterone exerts suppressive effect on Estrogen resulting in the conversion of the endometrium to a secretory state.