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Pua Santos

Rhinosinusitis Bronchitis Tuberculosis Atypical Respiratory Infections ( Chlamydia/ Mycoplasma pneumonia). RESPIRATORY DISEASES. Pua Santos. Rhinitis. Inflammation of the nasal mucosa Common etiologic agent: RHINOVIRUS

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Pua Santos

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  1. RhinosinusitisBronchitisTuberculosisAtypical Respiratory Infections (Chlamydia/ Mycoplasma pneumonia) RESPIRATORY DISEASES Pua Santos

  2. Rhinitis • Inflammation of the nasal mucosa • Common etiologic agent: RHINOVIRUS • Mannose-binding lectin deficiency – associated with increased incidence of colds in children • Acute inflammatory response appears to be responsible for the symptoms • Most common complication: Otitis Media

  3. Rhinosinusitis • Inflammation of the nares and paranasal sinuses • Bacterial Pathogens: • Streptococcus pneumoniae – 30% • Nontypable H. influenzae – 20% • Moraxella catarrhalis – 20%

  4. Pathogenesis: Bacterial Sinusitis Bacteria from the nasopharynx that enter the sinuses are normally cleared During viral rhinosinusitis, inflammation and edema – block sinus drainage, impair mucociliary clearance of bacteria

  5. Acute Bacterial Sinusitis Persistent of URTI (nasal discharge and cough) > 10-14 days without improvement Severe respiratory symptoms, including fever Purulent nasal discharge for 3-4 consecutive days

  6. Complications Orbital, periorbital cellulitis – due to close proximity to the parasinuses Intracranial complications – meningitis, cavernous sinus thrombosis, subdural empyema, brain abscess

  7. Treatment • Amoxicillin 45 mkd for uncomplicated acute bacterial sinusitis • Appropriate duration has yet to be determined – usually treat up to 7 days after resolution of symptoms • Co-amoxiclav for children with risk for resistant bactria • Age < 2 yo • Daycare attendance • Antiobiotic treatment in preceding 1-3 months

  8. Bronchitis Nonspecific bronchial inflammation and is associated with a number of childhood conditions

  9. Acute Bronchitis • Commonly preceded by viral upper respiratory tract infection • Invasion of tracheobronchialepithelium ----- activation of inflammatory cells and release of cytokines • Tracheobronchial epithelium significantly damaged or hypersensitized ----- protracted cough lasting 1-3 wk.

  10. Signs/Symptoms Usually lasts about 2 weeks and seldom 3 weeks Low grade fever, malaise Nonspecific upper respiratory infectious symptoms Dry hacking cough which later becomes purulent Chest pain exacerbated by coughing PE: Coarse and fine crackles and scattered high-pitched wheezing on auscultation Chest radiographs are normal or may have increased bronchial markings

  11. Treatment • No specific treatment • Self-limited • Antibiotics do not hasten improvement

  12. Chronic Bronchitis • Recognized in adults, controversial as a disease entity in children • ≥3 mo of productive cough each year for ≥2 yr. • Children with chronic inflammatory diseases or those with toxic exposures can develop damaged pulmonary epithelium

  13. Tuberculosis • M. tuberculosis is the most important cause of tuberculosis disease in humans. • Non-spore-forming, nonmotile, pleomorphic, weakly gram-positive rods 2-4nm long • Obligate anaerobes • Hallmark of all mycobacteria is acid fastness

  14. Transmission • Person to person, usually by airborne mucus droplet nuclei • Young children with tuberculosis rarely infect other children or adult • Tubercle bacilli are sparse in the endobronchial secretions of children with pulmonary tuberculosis, and cough is often absent or lacks the tussive force

  15. Pathogenesis Inhalation of infected droplets Development of primary parenchymal lesion (GHON complex) with spread to the regional lymph nodes Immune response (delayed hypersensitivity and cellular immunity) develops in 4-6 weeks TB infection

  16. Recommended approach to Diagnose TB in children WHO 2006 • Careful History • Contact • Signs and symptoms consistent with TB • Clinical Examination • Tuberculin skin testing • Bacteriologic confirmation, if possible • Further investigation relevant to suspicion of TB

  17. Clinical Manifestation most suggestive of childhood tuberculosis Cough or wheezing > 2 weeks Taken together is most suggestive of childhood TB disease Unexplained or prolonged fever Hx of recent weight loss or failure to gain weight 2008 PPS Evidence based CPG for Childhood TB

  18. TB symptomatic – a child with any of the 3 or more of the ff. signs/symptoms 2008 DOH-NTP Training Modules for TB in children • Cough/ wheezing of 2 weeks or more • Unexplained fever of 2 weeks or more • Either loss of appetite, weight loss, failure to gain weight or weight faltering • Failure to respond to 2 weeks of appropriate antibiotic tx for LRTI • Failure to regain previous state of health after 2 weeks of viral infection • Fatigue, reduce playfulness or lethargy

  19. Tuberculin skin test (TST) Used to screen children exposed to TB Most widely used method to demonstrate TB infection Based on a delayed hypersensitivity to certain antigens of the TB organism

  20. Tuberculin Skin Test PPS TB in infancy and childhood handbook 2010 • Mantoux test read at 48-72 hours regardless of BCG immunization • Positive if... • More than or equal to 5 mm induration in the presence of: Hx of close contact with a TB source, clinical findings suggestive of TB, CXR suggestive of TB, immunocompromised condition • More than or equal to 10 mm induration

  21. Clinical Forms • Pulmonary or Endothoracic TB • Latent TB infection • Primary Pulmonary TB • Progressive primary TB • Reactivation TB • Endobronchial TB • Miliary TB • Extrapulmonary TB

  22. Latent TB Infection • Latent tuberculosis infection (LTBI) occurs after the inhalation of infective droplet nuclei containing M. tuberculosis • A reactive tuberculin skin test (TST) and the absence of clinical and radiographic manifestations are the hallmark of this stage • Untreated infants with LTBI have up to a 40% likelihood of developing tuberculosis • Greatest risk for progression occurs in the 1st 2 yr after infection

  23. Primary Pulmonary Tuberculosis • Primary complexincludes the parenchymal pulmonary focus and the regional lymph nodes. • About 70% of lung foci are subpleural, and localized pleurisy is common. • Nonproductive cough and mild dyspnea are the most common symptoms. • Systemic complaints occur less often. • Pulmonary signs are even less common

  24. Progressive Primary Tuberculosis • A rare but serious complication of tuberculosis in a child occurs when the primary focus enlarges steadily and develops a large caseous center • Liquefaction can cause formation of a primary cavity associated with large numbers of tubercle bacilli • High fever, severe cough with sputum production, weight loss, and night sweats are common • Physical signs include diminished breath sounds, rales, and dullness or egophony over the cavity.

  25. Reactivation Tuberculosis Rare in childhood, more common in adolescent More common in children who acquire initial infection after 7 years old Pulmonary tuberculosis in adults usually represents endogenous reactivation of a site of tuberculosis infection established previously in the body History of fever, cough, hemoptysis, weight loss

  26. Endobronchial Tuberculosis Hyperemic and edematous lymph nodes impinge upon the wall of a bronchus – occlude the lumen usually the right middle lobe bronchus Right Middle Lobe Syndrome: adherence of LN through the airway wall – ulceration of mucosa – Granulation tissue – obstruct lumen of the bronchus

  27. Miliary Tuberculosis • Occurs when massive numbers of tubercle bacilli are released into the bloodstream, causing disease in 2 or more organs • Bacilli spreads via lymphatics to capillaries of most organ system • Liver, Spleen, Marrow and Brain – most oxygenated organs

  28. COMMONLY USED DRUGS FOR THE TREATMENT OF TUBERCULOSIS IN INFANTS, CHILDREN, AND ADOLESCENTS From American Academy of Pediatrics: Red book: 2009 report of the Committee on Infectious Diseases, ed 28, Elk Grove Village, IL, 2009, American Academy of Pediatrics, p 689.

  29. Table 207-5 -- LESS COMMONLY USED DRUGS FOR TREATING DRUG-RESISTANT TUBERCULOSIS IN INFANTS, CHILDREN, AND ADOLESCENTS* In general, the treatment for most forms of extrapulmonary tuberculosis in children, including cervical lymphadenopathy, is the same as for pulmonary tuberculosis. Exceptions are bone and joint, disseminated, and CNS tuberculosis, for which there are inadequate data to recommend 6 mo therapy. These infections are treated for 9-12 mo.

  30. MycoplasmaPneumoniae • Major cause of respiratory infections in school-aged children and young adults • Etiology: • Mycoplasmas are the smallest self-replicating biologic system, dependent on attachment to host cells, complete absence of a cell wall, double-stranded DNA • fastidious, and growth in commercially available culture systems is too slow to be of practical clinical use

  31. Transmission • Occurs through the respiratory route by large droplet spread • Incubation period is 1–3 wk • High transmission rates have been documented within families

  32. Pathogenesis • A possible mechanism of M. pneumoniae disease is the release of various proinflammatory and anti-inflammatory cytokines • Disease produced by M. pneumoniae is complex • Immunologic response of the host may be responsible for the manifestations of disease itself as well as for protection against infection

  33. Clinical Manifestation Tracheobronchitis and bronchopneumonia are the most commonly recognized clinical syndromes associated with M. pneumoniae infection Characterized by gradual onset of headache, malaise, fever, and sore throat, followed by progression of lower respiratory symptoms, including hoarseness and cough Coughing usually worsens during the 1st wk of illness, with all symptoms usually resolving within 2 wk

  34. Treatment Macrolides are effective in shortening the course of mycoplasmal illnesses, although they do not have bactericidal activity Recommended treatment: Clarithromycin (15 mg/kg/day divided bid PO for 10 days) or Azithromycin (10 mg/kg once PO on day 1 and 5 mg/kg once daily PO on days 2-5

  35. Chlamydophilapneumoniae • Common cause of lower respiratory tract diseases, including pneumonia in children and bronchitis and pneumonia in adults • C. pneumoniae is primarily a human respiratory pathogen • Transmission probably occurs from person to person through respiratory droplets

  36. Clinical Manifestation • Pneumonia usually occurs as a classic atypical (or nonbacterial) pneumonia characterized by mild to moderate constitutional symptoms • Fever, malaise, headache, cough, and often pharyngitis • Severe pneumonia with pleural effusions and empyema has been described • Milder respiratory infections have been described, which can manifest as a pertussis-like illness

  37. Treatment Erythromycin (40 mg/kg/day PO divided twice a day for 10 days) Clarithromycin (15 mg/kg/day PO divided twice a day for 10 days) Azithromycin (10 mg/kg PO on day 1, and then 5 mg/kg/day PO on days 2-5)

  38. … Thank You…

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