PuaSantos

RESPIRATORY DISEASES

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

Inflammation of the nares and paranasal sinuses

Bacterial Pathogens:• Streptococcus pneumoniae – 30%• Nontypable H. influenzae – 20%• Moraxella catarrhalis – 20%

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

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

Orbital, periorbital cellulitis – due to close proximity to the parasinuses

Intracranial complications – meningitis, cavernous sinus thrombosis, subdural empyema, brain abscess

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

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

Commonly preceded by viral upper respiratory tract infection

Invasion of tracheobronchial epithelium ----- activation of inflammatory cells and release of cytokines

Tracheobronchial epithelium significantly damaged or hypersensitized ----- protracted cough lasting 1-3 wk.

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

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

• 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

• 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

• 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

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

Careful History• Contact• Signs and symptoms consistent with TB

Clinical Examination Tuberculin skin testing Bacteriologic confirmation, if

possible Further investigation relevant to

suspicion of TBWHO 2006

Hx of recent weight loss or

failure to gain

weight

Cough or wheezing > 2

weeks

Unexplained or

prolonged fever

Taken together is

most suggestive

of childhood TB disease2008 PPS Evidence

based CPG for Childhood TB

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

2008 DOH-NTP Training Modules for TB in

children

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

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

PPS TB in infancy and childhood handbook 2010

Pulmonary or Endothoracic TB• Latent TB infection• Primary Pulmonary TB• Progressive primary TB• Reactivation TB• Endobronchial TB• Miliary TB

Extrapulmonary TB

• 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

• Primary complex includes 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

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.

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

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

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

DRUGDAILY

DOSAGE, mg/kg

TWICE A WEEK DOSAGE, mg/kg

PER DOSE

MAXIMUM DOSE ADVERSE REACTIONS

Ethambutol 20 50 2.5 gOptic neuritis (usually reversible), decreased red-green color discrimination, gastrointestinal tract disturbances, hypersensitivity

Isoniazid* 10-15[†] 20-30Daily, 300 mgTwice a week, 900 mg

Mild hepatic enzyme elevation, hepatitis,[†] peripheral neuritis, hypersensitivity

Pyrazinamide* 20-40 50 2 g Hepatotoxic effects, hyperuricemia, arthralgias, gastrointestinal tract upset

Rifampin* 10-20 10-20 600 mg

Orange discoloration of secretions or urine, staining of contact lenses, vomiting, hepatitis, influenza-like reaction, thrombocytopenia, pruritus; oral contraceptives may be ineffective

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.

COMMONLY USED DRUGS FOR THE TREATMENT OF TUBERCULOSIS IN INFANTS, CHILDREN, AND ADOLESCENTS

DRUGS DAILY DOSAGE, mg/kg

MAXIMUM DOSE ADVERSE REACTIONS

Amikacin[†] 15-30 (IV or IM administration) 1 g Auditory and vestibular toxic effects, nephrotoxic effects

Capreomycin[†] 15-30 (IM administration) 1 g Auditory and vestibular toxicity and nephrotoxic effects

Cycloserine 10-20, given in 2 divided doses 1 g Psychosis, personality changes, seizures, rash

Ethionamide 15-20, given in 2-3 divided doses 1 g Gastrointestinal tract disturbances, hepatotoxic effects, 

hypersensitivity reactions, hypothyroidism

Kanamycin 15-30 (IM or IV administration) 1 g Auditory and vestibular toxic effects, nephrotoxic effects

Levofloxacin[‡]

Adults: 500-1000 mg (once daily)Children: not recommended

1 g Theoretic effect on growing cartilage, gastrointestinal tract disturbances, rash, headache, restlessness, confusion

para-Aminosalicylic acid (PAS)

200-300 (bid-qid) 10 g Gastrointestinal tract disturbances, hypersensitivity, hepatotoxic effects

Streptomycin[†] 20-40 (IM administration) 1 g Auditory and vestibular toxic effects, nephrotoxic effects, 

rash

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. 

• 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

• Occurs through the respiratory route by large droplet spread

• Incubation period is 1–3 wk

• High transmission rates have been documented within families

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

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

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

• 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

• 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

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)