Pediatric infectious disease
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Pediatric Infectious Disease. Brenda Beckett, PA-C. Immunizations. Reduced childhood infectious disease markedly US: 14 diseases Diphtheria, tetanus, pertussis, measles, mumps, rubella, poliomyelitis, Hib, S. pneumoniae, HBV, HAV, influenza, varicella, rotavirus. Vaccine preventable diseases.

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Pediatric Infectious Disease

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Pediatric infectious disease

Pediatric Infectious Disease

Brenda Beckett, PA-C


Immunizations

Immunizations

  • Reduced childhood infectious disease markedly

  • US: 14 diseases

    • Diphtheria, tetanus, pertussis, measles, mumps, rubella, poliomyelitis, Hib, S. pneumoniae, HBV, HAV, influenza, varicella, rotavirus


Vaccine preventable diseases

Vaccine preventable diseases

  • Viral exanthems (covered in derm)

  • Hepatitis (covered in ID)

  • Polio


Other dermatology

Other dermatology

  • Impetigo

  • Tinea

  • Molluscum

  • Cellulitis


Fever

Fever

  • Normal body temp: 37 C, 98.6 F

  • Range of 97-99.6

  • Rectal temp >100.4F (38 C) is FEVER

  • Diurnal variation

  • Age variation


Fever newborns

Fever, Newborns

  • Neonates do not have febrile response

  • <3 months old, any fever is risk of serious bacterial infection

  • May not have localizing signs

  • Warrants workup: bacteremia, UTI, meningitis, pneumonia, etc


Fever 3 years

Fever, <3 years

  • Exaggerated febrile response: up to 105

  • No localizing sx: risk of S. pneumo, N. meningititis, Hib, Salmonella

  • Observe child for alertness, irritability, consolability


Pediatric infectious disease

FUO

  • Fever of unknown origin

  • T >100.4 F lasting >14d with no obvious cause

  • List, p 463 Nelson


Febrile seizure

Febrile Seizure

  • Usually <3 yo

  • Seizure can be first sign of fever

  • Rule out other causes

  • Increased risk of repeat seizures with fever

  • Treat with antipyretics


Conjunctivitis

Conjunctivitis

  • progressive redness of conjunctiva

  • discharge

    • bacterial = profuse,purulent

    • viral = minimal, mucoid

  • unilateral ---> bilateral

  • preauricular node enlargement – viral

  • Treat: bacterial – topical antibiotics


Ophthalmia neonatorum

Ophthalmia Neonatorum

  • Conjunctivitis in the newborn

    • occurs during first 10 days of life

    • Acquired at brith

  • red, swollen lids & conjunctiva, discharge.

    • Can lead to blindness

  • Erythromycin at birth

  • Cause : includes

    • Chlamydia trachomatis

    • N. gonorrhoeae


Nasolacrimal duct obstruction

Nasolacrimal Duct Obstruction

  • Cause - obstruction in any part of drainage system

  • wet eye with mucoid discharge

    • skin irritation

    • Increased risk of bacterial conjunctivitis

  • most clear spontaneously

    • massage

    • Antibiotics for bacterial

  • surgical treatment - probing


Periorbital cellulitis

Periorbital Cellulitis

  • Infection of the structures around the eye

  • Cause :

    • S. aureus or S. pyogenes

  • Lid edema, pain, mild fever

  • Arises from local, exogenous source

  • Treatment

    • systemic antibiotics


Orbital cellulitis

Orbital Cellulitis

  • Usually from bacterial sinus infection

  • Signs of periorbital cellulitis, plus:

    • proptosis

    • restricted and painful eye movement

    • high fever

  • CT or MRI

  • Treatment – drainage, systemic antibiotics


Otitis externa

Otitis Externa

  • Cause : Pseudomonas or S. aureus

  • minor itching ---> intense pain

  • tenderness tragus/auricle

  • erythema/swelling of canal

  • purulent discharge

  • possible postauricular node involvement

  • Treatment: Otic antibiotics, drying


Otitis media

Otitis Media

  • S. pneumo, H. influenza, M. catarrhalis

  • Many resistant to penicillin

  • Major reason for pediatrics visit

  • Risks: young age, bottle feeding, fam hx, smoke exposure, viral URI


Otitis media1

Otitis Media

  • Recurrent: >6 episodes in 6 mo

  • Treat: Typmanostomy tubes

  • Sx: Fever, irritability, poor feeding, otalgia. Otorrhea (rupture)

  • Exam: Effusion, erythema, decreased mobility


Otitis media2

Otitis Media

  • Treat: based on age and severity

    • < 6moAntibiotics

    • 6mo-2yr ABX for certain, observation or ABX for uncertain

    • >2yrObservation or ABX for severe


Acute viral rhinitis

Acute Viral Rhinitis

  • Under age 5 --> 6-12 colds per year

  • Symptoms :

    • clear to mucoid rhinorrhea/nasal congestion

    • *fever

    • mild sore throat/cough

  • Management :

    • saline drops/bulb suction


Sinusitis

Sinusitis

  • Symptoms :

    • URI lasting longer than 10-12 days

    • low-grade fever, cough, HA in older child

    • malodorous breath

    • intermittent AM periorbital swelling/redness

      Trt: amox, augmentin, azythromycin


Thrush

Thrush

  • Cause : Candida albicans

  • mainly affects infants

    • refusal of feedings (?soreness of mouth)

  • lesions are white plaques on buccal mucosa

    • cannot be washed away

    • bleed if scraped

  • treatment - nystatin oral suspension


Lymphadenopathy

Lymphadenopathy

  • Most prominent in 4-8 yo

  • Cervical most common

  • Location can differentiate cause of infection


Patient presentation

Patient Presentation

  • 5 year old with sore throat x48 hrs

  • Temp 101 at home last night

  • Other history questions?

  • PE: erythematous pharynx, white exudate. Enlarged ant. Cervical nodes

    DD???


Pharyngitis tonsillitis

Pharyngitis/Tonsillitis

  • School-age 5-15 years

  • Symptoms :

    • sorethroat

    • fever/chills

    • general malaise

    • referred ear pain

    • headache

    • abdominal pain/vomiting


Pharyngitis tonsillitis1

Pharyngitis/Tonsillitis

  • Signs :

    • red, inflamed posterior pharyngeal wall

    • swollen, erythematous tonsils

    • petechiae and beefy red uvula

    • tender cervical adenopathy

  • Causes: Group A strep, rhinovirus, EBV, etc


Pharyngitis tonsillitis2

Pharyngitis/Tonsillitis

  • Scarlet fever: strawberry tongue

  • Peritonsillar abscess: “hot potato voice”

  • Strep pharyngitis: Always treat with abx, definitively diagnose strep

  • EBV: blood test - “monospot”, EBV titers

  • Viral pharyngitis: URI sx


Mononucleosis

Symptoms :

prodromal phase

fever

sorethroat

*tender lymph nodes

abdominal pain

Signs :

exudative pharyngitis/tonsillitis

**lymphatic enlargement - posterior cervical, axillary, inguinal

splenomegaly, less often hepatomegaly

Mononucleosis


Mononucleosis1

Mononucleosis

  • Lab: Positive monospot or EBV titer

  • Treat: usually supportive unless lymphadenopathy is severe, then oral steroids


Patient presentation1

Patient Presentation

  • 18 month old with “wheezing”

  • URI sx for 2-3 days

  • No fever

  • Other history questions?

  • DD??


Larnygotracheobronchitis croup

Larnygotracheobronchitis(Croup)

  • Cause : parainfluenza virus type 1

  • peak age 6 months to 2 years

  • Symptoms :

    • URI (prodrome)

    • harsh, barking (seal-like) cough

    • hoarseness

    • inspiratory stridor

    • fever (absent or low-grade)


Treatment for croup

Treatment for Croup

  • Self-limiting

    • mist

    • hydration

  • Dexamethasone Injection

    • 0.3-0.6mg/kg, repeated in 12 hours

  • Racemic epinephrine

    • via nebulizer

    • rebound effect in 2 hours


Epiglottitis

Epiglottitis

  • *true medical emergency

  • cause : Haemophilus influenza type B

  • sudden onset of fever

  • dysphagia / drooling / muffled voice

  • inspiratory retractions / soft stridor

  • **sitting position

  • *cherry-red, swollen epiglotittis

  • **Endotracheal intubation


Bronchiolitis

Bronchiolitis

  • RSV = respiratory syncytial virus

  • winter and early spring

  • peak age 2-10 months

  • fever

  • URI ---> wheezing and tachypnea

    • nasal flaring, retractions, crackles/wheezing

  • labs : CXR, nasal swab/washing


Treatment

Treatment

  • Usually self-limiting, supportive

    • 3-7 days

  • Hospitalization, O2

    • younger than 6 months of age

    • respiratory distress, hypoxemia

    • underlying disease

  • Ribavirin (antiviral therapy)

  • Immunoglobulin anti RSV (Synagis)


Pertussis whooping cough

Pertussis(Whooping cough)

  • Cause : Bordetella pertussis

  • most common and most severe under 1 year

  • adults frequently source of infection

  • Three stages of disease

    • catarrhal stage

    • paroxysmal stage

    • convalescent stage


Pertussis

Pertussis

  • Labs :

    • WBC = 20-30K, 70-80% lymphs

    • nasopharyngeal swab for PCR, culture

  • Treatment :

    • erythromycin 40-50mg/kg/24hours x 14 d

    • nutritional support

    • steroids/albuterol


Pneumonia

Pneumonia

  • S. pneumo and HiB – immunizations

  • Viral (RSV)

  • Sputum?


Mycoplasma pneumonia

Mycoplasma Pneumonia

  • Most common cause of pneumonia in school-age children

  • peaks in fall

  • slow onset of symptoms

    • scratchy throat

    • low-grade fever

    • headache

    • dry, non-productive cough


Mycoplasma pneumonia1

Mycoplasma Pneumonia

  • Signs :

    • widespread crackles

    • decreased breath sounds

  • CXR - patchy infiltrates

  • Labs :

    • WBC = normal

    • cold agglutinin titer = 1:32 or greater

  • Treatment – erythromycin, azythromycin


Chlamydial pneumonia

Chlamydial Pneumonia

  • Acquired from infected mother at delivery

  • Age : 2-12 weeks

  • Symptoms/Signs :

    • *conjunctivitis

    • rhinitis and cough (resembles pertussis) / OM

    • scattered inspiratory crackles / tachypnea

    • **wheezes rarely present

    • no fever


Chlamydial pneumonia1

Chlamydial Pneumonia

  • Labs :

    • serum immunoglobins usually high

    • nasopharyngeal swab

    • peripheral eosinophilia > 400 cells/mm3

  • CXR :

    • diffuse infiltrates and hyperexpansion

  • Treatment :

    • Erythromycin, azythromycin


Meningitis

Meningitis

  • Causative organisms change with age

  • Preceding URI sx

  • HA, irritability, nausea, nuchal rigidity, lethargy, photophobia, vomiting

  • Fever

  • Kernig and Brudzinski signs

  • LP


Patient presentation2

Patient Presentation

  • 7 month old with 24 hrs of vomiting, diarrhea

  • No fever

  • Other history questions?

  • DD??


Acute viral gastroenteritis

Acute Viral Gastroenteritis

  • Rotavirus - cause of 80% of infections in infants and young children (4-24 months)

  • winter months

  • vomiting, followed by profuse, watery diarrhea and low-grade fever

  • abdominal pain, nausea, cramping


History

History

  • duration, frequency, description of stool

  • duration, frequency of vomiting

  • amount and type of fluids and solids ingested

  • frequency of urination

  • exposure to others with V/D


Signs of dehydration

Signs of Dehydration

  • body weight

  • mucous membranes

  • skin turgor / color

  • fontanelles

  • pulse/BP/respirations/perfusion

  • tears

  • urinary output


Treatment1

Treatment

  • Infants :

    • continue breast feeding

    • oral rehydration solution-->1/2 strength formula-->full strength formula

  • Older child :

    • sips of clear fluids

    • ORT

      **New vaccine


Pinworms

Pinworms

  • Most common parasitic disease in children

  • cause : Enterobius vermicularis

  • symptom : perianal itching, esp. nocturnal

  • labs : adhesive tape test

  • treatment : mebendazole 100 mg CH


Urinary tract infection

Urinary Tract Infection

  • Infants :

    • strong-smelling urine

    • Irritability

    • Or just fever

  • Preschooler :

    • abdominal pain

    • vomiting

    • strong-smelling urine

    • fever


Pediatric infectious disease

UTI

  • School-age : ‘classic’

    • Dysuria, frequency, urgency, secondary enuresis, foul-smelling urine, fever, flank pain

      Treat:

      Neonates 10-14 days

      Older children 7-14 days


Recurrent uti s

Recurrent UTI’s

  • Renal ultrasound

  • VCUG

    • vesicoureteral reflux

  • Causes :

    • infrequent or incomplete voiding

    • poor perineal hygiene

    • pinworms

    • bubble baths


Antibiotic dosing in children

Antibiotic Dosing in Children

  • Dose based on weight

  • Taste

  • Dosing schedule


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