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ID Part Deux. June Board Review. Test Question. I will watch the summer olympics this year. A. True B. False. Bronchiolitis. Intro. Bronchiolitis is caused by inflammation of the bronchioles by an acute viral infection

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Id part deux

ID Part Deux

June Board Review

Test question
Test Question

  • I will watch the summer olympics this year.

    • A. True

    • B. False


  • Bronchiolitis is caused by inflammation of the bronchioles by an acute viral infection

  • *Most common lower respiratory tract infection in infants and children under 2

  • Infectious agents:

    • RSV (most common)

    • Adenovirus

    • Metapneumovirus

    • Influenza virus

    • Parainfluenza virus

Epidemiology of rsv
*Epidemiology of RSV

  • *Know the mode of transmission

    • Direct or close contact with contaminated secretions

      • Large droplets at short distances

      • Fomites

    • RSV can persist on environmental surfaces for several hours

      • ½ hour on hands

Epidemiology of rsv1
*Epidemiology of RSV

  • *Incubation period

    • Ranges from 2 to 8 days

  • *Period of communicability

    • Usually 3 to 8 days

      • Shedding can last longer in young infants and immunosuppressed people (3 to 4 weeks)

  • *Age of onset

    • Most infants infected during 1st year of life

    • Virtually all by 2 years of age

  • *Peak season

    • Winter and early spring

Question 1
Question #1

  • All of the following patients are at high risk for morbidity and mortality from RSV infection EXCEPT:

    • A. A premature infant

    • B. A 1-month-old with unrepaired congenital heart disease

    • C. A 4-month-old ex-32 WGA with BPD

    • D. A full-term infant with hyperbilirubinemia

    • E. A 2-month-old with cerebral palsy

Epidemiology of rsv2
*Epidemiology of RSV

  • *Risk factors for morbidity and mortality

    • Prematurity

    • Unrepaired congenital heart disease

      • Pulmonary overcirculation

    • Chronic lung disease

    • Airway abnormalities

      • Laryngomalacia

      • Tracheomalacia

      • Cleft lip/palate

    • Neurologic abnormalities

Clinical manifestations
*Clinical Manifestations

  • History of recent upper respiratory tract symptomsfollowed by cough, tachypnea, and increased work of breathing

  • Physical findings:

    • Nasal congestion

    • Rhinorrhea

    • Cough

    • Tachypnea

    • Increased respiratory effort

      • Nasal flaring, grunting, retractions

    • Crackles, wheezes, upper airway noise

    • Apnea

      • May be only presenting sign in young infants


  • Characteristic pattern

  • Expect worsening symptoms

    • Peak symptomatology on day 3 to 4

    • “Day of illness” important for anticipatory guidance, admission/discharge decisions, etc.


  • Based on history and physical

  • Routine lab and radiologic studies are not recommended

    • CXR not routinely recommended

      • Often are abnormal appearing (hyperinflation, atelectasis, infiltrates)

      • Do not correlate with disease severity

      • Do not guide management

      • May prompt unnecessary antibiotics for PNA which is rare in viral bronchiolitis


  • Viral studies are not recommended for diagnosis

  • *Know the laboratory diagnosis of RSV

    • Viral antigen detection

      • Enzyme immunoassay technique

      • Sensitivity mostly 80 to 90%

      • From nasopharyngeal specimens

    • Viral culture

      • Requires 1 to 5 days

      • From nasopharyngeal secretions

      • Sensitivity varies among laboratories

Question 2
Question #2

  • A 3-month-old male ex-38 WGA comes to the emergency room with a history of upper respiratory symptoms for 3 days, fever, decreased appetite and increased work of breathing. On PE his vitals are T 99 RR 45 HR 185 BP 90/65 and Sat 96% on room air, he has nasal congestion, mild retractions, and course breath sounds He has an older sister in pre-K.

  • Of the following the MOST appropriate next step in management is:

    • A. Start albuterol nebs

    • B. Give Orapred 2mg/kg

    • C. IVFs with normal saline

    • D. Supplemental oxygen

    • E. Nasal decongestants


  • *Plan the management of RSV infection

    • Supportive care

    • Hydration

    • Oxygenation

    • Other measures (bronchodilators, corticosteroids, antiviral agents, CPT, nasal suction, decongestant drops) have been shown to have impact on duration of illness, severity of clinical course, or subsequent outcomes


  • Hydration

    • ↑ RR, secretions, fever, poor feeding → dehydration

    • May require IV fluids or NG feeds

    • Bronchiolitis causes ADH release → risk for hyponatremia

      • Use isotonic fluids


  • Oxygenation

    • Results from impaired diffusion, V/Q mismatch, plugging of bronchioles

    • Goal is to maintain normal sats

    • No clear consensus on pulse ox range

      • Aim for sats between 90 to 92%

    • Monitoring

      • Schedule spot checks

      • Continuous pulse ox only for those with previous O2 requirement, risk for apnea, or with underlying cardiopulmonary conditions


  • Bronchodilators

    • AAP does not recommend routine use

    • A monitored trial may be considered, but only continued if clinical response is documented

      • Diminished work of breathing

      • Decrease in RR

      • Improvement in hypoxemia


  • Steroids

    • Based on current evidence, corticosteroids should not be used to treat bronchiolitis

  • Ribavirin

    • Should not be used routinely

    • May be considered in special situations:

      • Organ transplant, malignancy, congenital immunodeficiencies

    • Very expensive


  • CPT

    • Bronchiolitis (V/Q mismatch) is unaffected by regional CPT

  • Nasal suction

    • May increase comfort and improve feeding

    • Most beneficial before feedings and in response to copious secretions

  • Nasal decongestants

    • No proven efficacy, potential harmful side effects

    • Should not be used in children under 2

Question 3
Question #3

  • The major benefit of palivizumab prophylaxis is:

    • A. Decreased hospitalization rate

    • B. Improved treatment

    • C. Increased cost-effectiveness

    • D. Lower mortality rate

    • E. Shorter duration of illness


  • *Identify patients who may benefit from prophylaxis

    • Palivizumab (Synagis)

      • Monoclonal antibody (IgG) against RSV

    • Candidates

      • History of prematurity

      • Infants with chronic lung disease

      • Infants with hemodynamically significant congenital heart disease


  • Effectiveness of palivizumab beyond the second year is unknown

  • Prophylaxis should be administered in 5 monthly doses beginning in November

  • Not overall cost-effective

Question 4
Question #4

  • It’s December and a mom is in your office with her 6 week-old daughter is worried about RSV. Her older son who is now 4-years-old had it as a baby and had to be hospitalized. She asks you if there is anything she can do at home to help prevent her daughter from catching it.

  • All of the following are ways to reduce the risk of RSV EXCEPT:

    • A. Avoid tobacco smoke

    • B. Encourage breastfeeding

    • C. Washing hands with soap and water thoroughly

    • D. Vitamin C supplements

    • E. Alcohol-based hand sanitizer after contact


  • Strict hand hygiene and isolation


  • Avoidance of tobacco smoke

    • Independent risk factor for contracting bronchiolitis

  • Encouragement of breastfeeding

    • Contains immune factors that can prevent RSV

    • Neutralizing activity against RSV


  • Most recover without sequelae

  • A portion develop recurrent wheezing

    • 40% have subsequent wheezing episodes through 5 years of age

    • 10% have subsequent wheezing episodes after 5 years

Question 5
Question #5

  • An 11-month-old boy presents to your office with a 5-day history of fever, nasal congestion, conjunctivitis, and the development of a rash over the past 24 hours. The rash began on his head and neck and spread to his trunk and extremities. The family recently returned from a trip to Ireland. His past medical history is unremarkable, and his immunizations are up to date.

  • Of the following, the BEST test for diagnosing this child’s condition is:

    • A. Measles IgM serology

    • B. Nasal aspirate for viral culture

    • C. Rubella IgM serology

    • D. Skin biopsy

    • E. Throat culture for Group A Streptococcus

Measles r ubeola
Measles (Rubeola)


  • *Transmission:

    • Direct droplet contact

    • Airborne spread

  • Incubation period: 8-12 days

  • Period of communicability: 1-2 days before any symptoms appear until 4 days after the rash appears

Clinical presentation
*Clinical Presentation



  • Exposure Fever, malaise Coryza, cough,

    conjunctivits Koplik spots Exanthum

  • Exanthem: red/ purple papules appear at hairline, then spread downward (@ toes by day 3)

    • Coalescence common on face and upper body

    • Fades in same fashion (headtoe)




Koplik spots

Control measures
*Control Measures

  • Isolation (airborne precautions)

  • Immunization/ Immune globulin

    • First determine who is susceptible

      • <2 doses of MMR vaccine after the first birthday

      • Low titers in response to vaccine administration

      • No documentation of measles by a physician

      • Immunocompromised patients

    • If susceptible:

      • MMR vaccine within 72hours of exposure

      • IM Immune globulin within 6 days of exposure:

        • Household contacts if vaccine not given within 72h

        • Immunocompromised patients

        • Infants <12mo***


  • OM

  • Bronchopneumonia

  • Laryngotracheobronchitis

  • Diarrhea

  • Acute encephalitis

  • Subacutesclerosingpanencephalitis (SSPE)


  • *Transmission:

    • Person-to-person spread via droplet inhalation

  • *Incubation period: 2 to 3 weeks

  • *Period of communicability: several days before to 2 weeks after the onset of the rash

  • In 2005, the CDC announced that rubella had been eliminated from the US

    • But, it’s still on the Boards!!

Postnatal clinical presentation
*Postnatal Clinical Presentation

14-21 d

  • Exposure Tender adenopathy (post-auricular, posterior cervical, and occipital); malaise, HA, low-grade fever, sore throat

     Exanthem (+/- Forchheimer spots)

  • Exanthem: rose-pink maculopapules on face that spread quickly to involve trunk and then extremities

    • Day 2: rash on face disappears, truncal rash coalesces

    • Day 3: rash disappears

1-5 d


Forchheimer Spots

Question 6
Question #6

  • All of the following are sequelae of congenital rubella syndrome, EXCEPT:

    • A. Sensorineural hearing loss

    • B. Cataracts

    • C. Radiolucenicies in the metaphyses of long bones

    • D. Heart disease

    • E. Craniofacial abnormalities

Congenital rubella

Highest rate of infection 1st and 3rd trimesters, morbidity associated with 1st trimester infection


Blueberry muffin lesions

Radiolucencies in metaphyseal long bones


Sensorineural deafness

Cataracts/ glaucoma



*Congenital Rubella

Question 7
Question #7

  • A mother of one of your patients is in her first trimester of pregnancy and just found out that her internationally adopted niece has contracted rubella. She wonders when it will be safe for her to be around her niece again. You tell her:

    • A. She should stay out of contact until the LAD resolves

    • B. She should stay out of contact until the fever resolves

    • C. She should stay out of contact until the exanthem resolves

    • D. She should stay out of contact until the exanthem appears

    • E. She does not need to worry…contracting rubella in this stage of her pregnancy is unlikely to cause any sequelae

Control measures1
*Control Measures

  • Primary focus: preventing CRS

    • Maintaining elevated vaccine coverage rates in children and adolescents

    • Providing adequate surveillance systems

    • Timely investigations during outbreaks

      • Active cases should be reported to local public health authorities

    • Susceptible individuals should be kept out of contact with anyone infected with rubella

      • Despite widespread vaccination, some women of childbearing age may be susceptible

Neisseria meningitidis

  • *Know the epidemiology of


    • Five serotypes: A, B, C, Y, and W-135

      • B, C, and Y cause most cases in North America

      • More than 50% of cases in infants caused by serogroup B → *NOT preventable with vaccines

    • *Leading cause of bacterial meningitis in young children

    • Most often occurs in kids 2 and younger

      • Peak in kids under 1

      • Another peak in adolescents age 15 to 18


  • Asymptomatic colonization of the upper respiratory tract is how the organism is spread

    • 10 to 40% of adolescents and adults are carriers

  • Transmission occurs from person to person through droplets from respiratory tract

    • Requires close contact

    • Outbreaks get media coverage

      • Less than 5% of cases associated with


  • Incubation period is 1 to 10 days

Question 8
Question #8

  • You are discussing with medical students the risk factors that increase the likelihood that transmission from carriers will result in meningococcal disease.

  • Of the following groups, the risk of disease is HIGHEST among:

    • A. School children

    • B. Vaccinated students living in college dorms

    • C. Healthy nonsmoking adults

    • D. Household contacts of an index case

    • E. Toddler in child care centers

Risk factors
*Risk factors

  • Environmental factors

    • Crowded living conditions

      • College dorms, military barracks

    • Secondary infection among household contacts is up to 800 times that in the general population

    • Active and passive tobacco smoke

  • *Understand which patients are at increased risk of invasive and recurrent meningococcal disease

    • Terminal complement deficiency

    • Hypogammaglobulinemia

    • Anatomic or functional asplenia

Clinical syndromes
Clinical Syndromes

  • *Know the major clinical syndromes of Neisseriameningitidis

    • Severe meningococcal septicemia

    • Meningococcal meningitis

  • Systemic manifestations of the organism reproducing in the blood

    • 50% have isolated meningitis

    • 10 to 15% have severe meningococcal septicemia

    • 40% have a mixed picture

Severe meningococcal septicemia
*Severe Meningococcal Septicemia

  • Characterized by sudden onset, rapid progression, and absence of localizing findings

  • More severe than meningitis

  • Fatality rate is high (40 to 50%)

  • Most patients have no immunocompromise

Severe meningococcal septicemia1
*Severe Meningococcal Septicemia

  • Symptoms and physical findings

    • High fever, shaking chills, myalgias, extremity or back pain

    • Deteriorate within 6 hours

    • Rash

      • Classically petechial

      • Often become hemorrhagic

      • Coalesce to form widespread purpura

    • Purpurafulminans

      • Aggressive spread of purpura to large areas with iscemic necrosis

      • Likely to have sudden drops in blood pressure and acute adrenal hemorrhage (Waterhouse-Friderichsen)

Severe meningococcal septicemia2
*Severe Meningococcal Septicemia

  • Early diagnosis and treatment still evades clinicians

  • Look for early clues

    • Tachycardia

    • Rash

      • Typically present in 24 hours

      • Fever and petechial rash is SMS until proven otherwise

    • True rigors

    • Severe pain in neck, back, and extremities

    • Vomiting

    • Concern of parent

    • Exposure

Meningococcal meningitis
Meningococcal Meningitis

  • *Signs and symptoms of typical bacterial meningitis

    • 1 to 3 day non-specific prodrome with low-grade fever and URI symptoms

    • Cushing triad can occur (bradycardia, HTN, resp. depression) as ICP rises

    • Meningismus

    • Mental status changes

    • Sudden and severe headache with photophobia

    • GI complaints

    • Myalgias

Question 9
Question #9

  • You are working in the ER and see a 14-month-old boy, previously healthy and fully immunized, who has had cold symptoms for the past 2 days. Late this morning, he developed a temp of 101, malaise, and discomfort. On PE you see scattered petechiae over his trunk. He is alert, but very fussy.

  • Of the following, which is the GOLD standard to make the bacteriologic diagnosis in this case?

    • A. PCR

    • B. Culture of normally sterile site

    • C. Gram stain

    • D. Antigen detection

    • E. Antibody titers

Diagnostic studies
Diagnostic studies

  • *Know the diagnostic tests for invasive meningococcal disease

    • Gram stain

      • Of CSF is highly sensitive and specific

    • Culture of sterile site

      • Gold standard

      • Can culture aspirate of purpuric lesion

    • Antigen detection

      • In CSF can support diagnosis, but high false-negative rates

    • PCR

      • Useful in patients who have already received abx

      • Use in UK, but not widely in US

Diagnostic studies1
Diagnostic Studies

  • Lab tests may return too late or may fall within normal range in a precipitous course

  • CSF

    • WBC elevated, low glucose, elevated protein

    • However, a negative LP result is an ominous finding in a patient with invasive meningococcal disease

Question 10
Question #10

  • You admitted a patient to the hospital with rapid onset of fever, petechial rash, myalgias, and mental status changes. You are worried about invasive meningococcal infection. You intubate the patient, begin IVFs, draw blood cultures and start ceftriaxone. The patient is placed on droplet precautions. The blood culture grows N. meningitidisthe next day. The nurse asks how long the patient needs to be in respiratory isolation.

  • Of the following, the BEST answer is until the child:

    • A. completes 1 day of antimicrobial therapy

    • B. deferveces

    • C. is clinically stable

    • D. is extubated

    • E. is proven not to have meningitis


  • *Plan the treatment of a Neisseriameningitidus infection

    • First step is recognition and aggressive treatment

    • Refer to emergency care facility

  • IVFs

    • Large isotonic fluid boluses

    • Giving 60 to 100 ml/kg in first hour assoc. with improved survival


  • Vasoactive agents

    • Consider inotropic/vasoactive agents such as dopamine or dobutamine

    • Works best when intravascular fluid volume is maximized

  • Airway

    • Large volume IVFs may lead to pulm edema

  • Corticosteroids

    • Physiologic doses of hydrocortisone may be beneficial in those with SMS and poor response to vasopressors

    • Dexamethasone in MM


  • Antibiotics

  • Patients treated with penicillin require oral rifampin to eradicate nasal pharyngeal carriage state

  • Require isolation and droplet precautions for 24 hours after start of antibiotics


  • *Recognize that vaccines are

    not available against N. meningitidis

    serogroup B

    • Meningococcal conjugate vaccine (MCV4)

      • Protects against A, C, Y, W-135 capsular groups

      • Recommended at 11 to 12 years of age

        • Booster at 16

      • Unvaccinated adolescents through age 18 should receive a dose at earliest opportunity

      • Age 2 to 55 for those at high risk

    • Vaccine for infants under investigation

Question 11
Question #11

  • A 2-year-old boy is diagnosed with meningococcal meningitis. IV penicillin was administered on admission, droplet precautions were begun immediately, and he received oral rifampin the next morning. No special resuscitative measures were ever required. To reduce the risk of secondary cases, prophylaxis with oral rifampin is necessary for:

    • A. Physicians who examined the patient

    • B. Nurses who delivered routine bedside care

    • C. Grandparents who live out of state and visited him in the hospital

    • D. Laboratory personnel who drew blood samples

    • E. His companions in child care

Treatment of contacts
Treatment of contacts

  • *Know that certain close contacts of patients with N. meningitidis require chemoprophylaxis

    • Household contacts

    • Child care or pre-school contact

    • Direct exposure to index case’s oral secretions (7 days before onset of illness)

      • Kissing, toothbrushes or utensils, mouth-to-mouth

    • Slept in the same dwelling during 7 days before

    • Passengers seated directly next to index case on flight longer than 8 hours

Treatment of contacts1
Treatment of Contacts

  • *Know what to recommend to a parent when it is reported that a child has been exposed to meningitis in school

    • Low risk

    • No history of direct contact to index patient’s oral secretions

    • NO chemoprophylaxis is recommended for school or work

      • Only child care centers

Treatment of contacts2
Treatment of Contacts

  • Rifampin

  • Ciprofloxacin

  • Azithromycin

  • Ceftriaxone

The virus
The Virus

  • Hepadnavirus family

  • HBcAg: protein that

    forms the nucleocapsid

    that encloses the viral


  • HBeAg: secreted soluble

    antigen believed to induce


  • HBsAg: surface antigen


  • One third of the world’s population is infected (!)

    • Endemic areas: Africa, Eastern Europe, the Middle East, Southeast and Central Asia, the Pacific Islands, and the Amazon Basin of South America

  • Vaccine administration has greatly reduced disease burden

  • *Risk groups

    • Injection drug users

    • Immigrants from endemic countries


  • Transmission

    • Virus present to some degree in most body fluids, but highest concentration is in the serum

    • *Routes of transmission

      • Percutaneous injection of body fluids

      • Sexual contact

      • Perinatal vertical transmission

    • *Incubation period: 2-6 mos

    • *Period of communicability: higher chance of transmission when patient is HBeAg+

Clinical manifestations1
*Clinical Manifestations

  • Extrahepatic

    • Polyarteritisnodosa

    • Membranoproliferative glomerulonephritis

    • Leukocytoclasticvasculitis

    • Arthalgias/arthritis

    • Erythematous or urticarial rash that precedes hepatic manifestations

Clinical manifestations2
*Clinical Manifestations

  • Hepatic

    • Acute self-limited hepatitis

    • Acute fulminant hepatitis

    • Chronic hepatitis

    • Cirrhosis

    • Hepatocellular carcinoma

Clinical manifestations3
Clinical Manifestations

  • Acute self-limited hepatitis

    • Nausea, fever, abdominal pain, jaundice, fatigue, general malaise

    • Increased transaminases

    • Resolution of infection within 6 months

      • HBsAbseroconversion

  • Acute fulminant hepatitis

    • Associated change in mental status brought on by hepatic encephalopathy

    • More common presentation during infancy

Question 12
Question #12

  • True or False: Perinatally-acquired HBV infections are less likely to cause chronic infections than infections acquired later in life

    • A. True

    • B. False

Clinical manifestations4
Clinical Manifestations

  • Chronic HBV infection

    • Presence of HBsAg in serum for at least 6 months or presence of HBsAg without IgMHBcAb

    • *The younger a person is exposed, the more likely he/she will become chronically infected

      • 90% of exposed infants become chronically infected

      • 25-50% of exposed 1-5yo

      • Only 6-10% of those exposed >5yo

    • Usually asymptomatic in childhood

Clinical manifestations5
Clinical Manifestations

  • Chronic HBV infection (con’t)

    • Progresses through 3 phases:

      • Immune tolerance

        • No liver inflammation

        • High viral counts

        • HBeAg+

      • Immune clearance

        • Increasing liver inflammation (with resulting damage)

        • Decreasing viral counts

        • HBeAbseroconversion

      • Residual

Clinical manifestations6
Clinical Manifestations

  • Cirrhosis/ HCC

    • Up to 25% of children with chronic HBV infection develop cirrhosis or HCC

    • Factors that contribute to risk

      • Race

      • Genotype of the virus

      • Alcohol consumption

      • Coinfection with HCV,

        HDV, HAV, or HIV

Question 13
Question #13

  • You are reviewing a patient’s HBV serum markers. You see that the patient’s HBsAb is positive, along with the total HBcAb. The HBsAg and the HBcAbIgM are both negative. Of the following, the most appropriate interpretation of these labs is:

    • A. Immune recovery after HBV infection

    • B. No prior infection, not immune

    • C. Chronic HBV infection

    • D. Acute HBV infection

    • E. Immune after Hep B vaccination

Question 14
Question #14

  • You are reviewing yet another patient’s HBV serum markers. This patient has a positive HBsAg and total HBcAb, with a negative HBcAbIgM and HBsAb. Of the following, the most appropriate interpretation of these labs is:

    • A. Immune recovery after HBV infection

    • B. No prior infection, not immune

    • C. Chronic HBV infection

    • D. Acute HBV infection

    • E. Immune after Hep B vaccination

Screening in chronic hbv infections
Screening In Chronic HBV Infections

  • Liver enzymes

    • Q6mos

  • Serum AFP

    • Q6mos

  • Ultrasound of the liver

    • Q12 mos


  • Goal of therapy: long-term remission (eradication not possible with current therapies)

    • Loss of detectable HBV in the serum

    • Loss of HBeAg

  • Available therapies:

    • Interferon

      • Stimulates host immune system to maximize its own antiviral effect

    • Nucleotide/side antivirals (lamivudine)

      • Interferes with the reverse transcription of HBV

Question 15
Question #15

  • A 38 wga M is born to a 24 yo G1P0 via NSVD. Upon review of the maternal labs, you notice that Mom is HBsAg+. The baby is currently 10h old and is eating, sleeping, urinating and stooling normally. Of the following, the most appropriate course of action in this infant is:

    • A. Immediate administration of the Hep B vaccine

    • B. Immediate administration of HBIG

    • C. Immediate administration of both the Hep B vaccine and HBIG

    • D. Start lamivudine

    • E. No interventions are necessary in the infant


  • Two types of therapy:

    • HBV vaccine

    • HBIG

  • CDC has set a goal for eliminating transmission of HBV in the US

    • Universal immunization of infants at birth

    • Prevention of perinatal HBV transmission via routine screening of all pregnant woman and appropriate immunoprophylaxis for exposed infants

    • Routine immunization of children and adolescents that have not been previously immunized

    • Immunization of previously unimmunized adults