pediatric infectious disease brenda beckett, pa-c

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

Viral exanthems (covered in derm) Hepatitis (covered in ID) Polio

Other dermatology

Impetigo Tinea Molluscum Cellulitis

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

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

Exaggerated febrile response: up to 105 No localizing sx: risk of S. pneumo, N.

meningititis, Hib, Salmonella Observe child for alertness, irritability,

consolability

FUO

Fever of unknown origin T >100.4 F lasting >14d with no obvious

cause List, p 463 Nelson

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

progressive redness of conjunctiva discharge

– bacterial = profuse,purulent– viral = minimal, mucoid

unilateral ---> bilateral preauricular node enlargement – viral Treat: bacterial – topical antibiotics

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

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

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

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

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

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 Media

Recurrent: >6 episodes in 6 mo Treat: Typmanostomy tubes

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

Exam: Effusion, erythema, decreased mobility

Otitis Media

Treat: based on age and severity– < 6mo Antibiotics– 6mo-2yr ABX for certain, observation

or ABX for uncertain– >2yr Observation or ABX for severe

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

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

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

Most prominent in 4-8 yo Cervical most common Location can differentiate cause of

infection

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

School-age 5-15 years Symptoms :

– sorethroat– fever/chills– general malaise– referred ear pain– headache– abdominal pain/vomiting

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/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

Lab: Positive monospot or EBV titer Treat: usually supportive unless

lymphadenopathy is severe, then oral steroids

Patient Presentation

18 month old with “wheezing” URI sx for 2-3 days No fever Other history questions? DD??

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

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

*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

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 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)

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

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

S. pneumo and HiB – immunizations Viral (RSV) Sputum?

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 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

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 Pneumonia

Labs : – serum immunoglobins usually high– nasopharyngeal swab– peripheral eosinophilia > 400 cells/mm3

CXR :– diffuse infiltrates and hyperexpansion

Treatment :– Erythromycin, azythromycin

Meningitis

Causative organisms change with age Preceding URI sx HA, irritability, nausea, nuchal rigidity,

lethargy, photophobia, vomiting Fever Kernig and Brudzinski signs LP

Patient Presentation

7 month old with 24 hrs of vomiting, diarrhea

No fever Other history questions? DD??

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

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

body weight mucous membranes skin turgor / color fontanelles pulse/BP/respirations/perfusion tears urinary output

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

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

Infants :– strong-smelling urine– Irritability– Or just fever

Preschooler :– abdominal pain– vomiting– strong-smelling urine– fever

UTI

School-age : ‘classic’– Dysuria, frequency, urgency, secondary

enuresis, foul-smelling urine, fever, flank pain

Treat: Neonates 10-14 daysOlder children 7-14 days

Recurrent UTI’s

Renal ultrasound VCUG

– vesicoureteral reflux Causes :

– infrequent or incomplete voiding– poor perineal hygiene– pinworms– bubble baths

Antibiotic Dosing in Children

Dose based on weight Taste Dosing schedule