Pediatrics Rotation Exam Course

Pediatric EOR: Infectious Disease (Pearls)

You have completed pediatric medicine EOR topics:

INFECTIOUS DISEASE
Atypical mycobacterial disease
Patient will present as a 3-year old with a firm inflamed swelling in the right submandibular area. Initial medical management with intravenous antibiotics was ineffective. Fine needle aspiration of the lesion reveals acid-fast bacilli on Ziehl-Neelsen staining. Subsequent biopsy demonstrates a granulomatous reaction in keeping with a Mycobacterial infection. Specific questioning reveals no family history of tuberculosis, abscesses or infections; there are no family pets, no exposure to birds and no unpasteurised milk consumption. An initial chest x-ray was normal and Mantoux testing was negative. Conventional anti-tuberculous therapy (Isoniazid, Rifampicin, and Pyrazinamide) is commenced. Definitive culture at 6 weeks isolates Mycobacterium avium intracellulare. The prescription is altered to include Clarithromycin.

Mycobacteria other than the tubercle bacillus sometimes infect humans

Atypical Mycobacterial infections in children are most frequently located in superior anterior cervical or in submandibular nodes (91%)

  • Children usually lack constitutional symptoms and present in 95% of cases with unilateral, subacute, progressive lymphadenopathy
  • The swelling is painless, firm and not erythematous
  • The majority of cases are reported in 1-5 year olds because there is increased tendency of these children to put objects contaminated by soil or stagnant water into their mouths. It may also be due to the relative poor immunity to Mycobacteria found in this age group

Mycobacterium avium complex (MAC) - HIV patients with CD4 < 50

  • Very common. Fever, diarrhea, weight loss, anemia.
  • Present in soil and water (not person to person)
  • Symptoms rarely occur in immunocompetent patients (increased in bronchiectasis). HIV patients when CD4 < 50
  • Diagnose with AFB and culture
  • Treat with clarithromycin + ethambutol for at least 12 months (+/- rifampin)
  • Prophylaxis for HIV patients with (azithromycin or clarithromycin) if CD4 < 50

Mycobacterium kansasii

  • Causes tuberculosis-like disease
  • Treat with Rifampin + ethambutol

Mycobacterium Marinum * REMEMBER MARINUM = AQUARIUM

  • Atypical mycobacterium found in fresh and saltwater - infection occurs after inoculation of the skin via abrasion or puncture in a patient with contact of an aquarium, saltwater, or marine animals.
  • Occupational hazard of aquarium handlers, marine workers, fishermen, and seafood handlers
  • Diagnose by culture.

Treat with tetracyclines, fluoroquinolones, macrolidessulfonamides for 4-6 weeks.

Epstein-Barr disease
ReelDx Rotation Room (mononucleosis)
Patient will present as → a 14-year-old boy with three days of sore throatfever, and generalized malaise. On exam, he has a temperature of 102.2 F (39.0 C), BP 96/50, and a diffuse exudate on both tonsils. He is also noted to have palpable splenomegaly, swollen, painful lymph nodes, and mild hepatomegaly. Labs show leukocytosis of 12,000/mm3 with 50% neutrophils, 12% monocytes, and 38% lymphocytes. The rapid pharyngeal streptococcal screen is negative.

Epstein Barr mononucleosis is a viral illness characterized by a classic triad of fever + lymphadenopathy + pharyngitis + atypical lymphocytes

  • The incubation period is 30-50 days, transmission via oropharyngeal secretions and saliva – “The kissing disease

DX: Diagnosed with positive heterophile antibody screen (Monospot) - may not appear early in the illness (positive within 4 weeks)

  • Atypical lymphocytes with enlarged nuclei and prominent nucleoli
  • Maculopapular rash develops in 80% of patients treated with ampicillin
  • Left upper quadrant pain secondary to splenomegaly and are at risk for splenic rupture - athletes should avoid vigorous sports for at least the first three to four weeks of the illness
  • Rapid strep test (-)

TX: is supportive

  • Acetaminophen or ibuprofen prn
  • Corticosteroids in severe cases

Mononucleosis

Exudative pharyngitis in a patient with mononucleosis

Rash of amoxicillin use during EBV infection

Rash from amoxicillin/clavulanic use during EBV infection

Erythema infectiosum (fifth disease)
ReelDx Rotation Room (erythema infectiosum)

Erythema infectiosum (also known as Fifth's disease) is a common viral exanthem observed in pediatric patients caused by parvovirus B19

  • Slapped cheek rash on the face with circumoral pallor and 2-4 days of lacy reticular rash (blanching) on extremities (spares palms and soles)
  • Often preceded by prodrome sequence with a low-grade fever
  • Sickle cell patients are at high risk of developing aplastic crises with this disease

DX: is based primarily on clinical observations, history, and physical exam

  • Serology: associated with enlarged nuclei with peripherally displaced chromatin
  • PARVO B19-specific IgM antibodies and PCR

TX: Treatment is symptomatic

  • Resolves in 2-3 weeks

Erythema Infectiosum

Hand-foot-and-mouth disease
ReelDx Rotation Room (hand-foot-mouth disease)
Patient will present as → a 2-year-old who is brought to the office by his mother. The child has had a low-grade fever, rash, and loss of appetite for the past two days. On physical exam, there are multiple 2-3-mm grey vesicular lesions on the bilateral palms and soles and several vesicles and ulcers on the oral mucosa. The PA informs her parents that this disease typically resolves spontaneously and to keep the patient hydrated.

A common children's infection caused by coxsackievirus type A virus producing sores in the mouth and a rash on the handsfeetmouth, and buttocks 

  • Children < 10 years old with small, tender, erythematous papules or vesicles on the pharynx, mouth, hands, and feet
  • Symptoms include fever, sore throat, feeling unwell, irritability, and loss of appetite
  • Coxsackievirus is quite contagious, especially in the first week of illness. Spread by direct contact with saliva or mucus

DX: based primarily on clinical observations, history, and physical exam

TX: supportive, anti-inflammatories

  • The virus usually clears up on its own within 10 days

Hand Foot and Mouth Disease

Herpes simplex
ReelDx Rotation Room (herpes simplex)
Patient will present as → a 27-year-old female who complains of exquisite vulvar pain and blisters. She reports that she has experienced several similar episodes for the past 5 years. On examination, you find multiple painful vesicles on her left labia minora. You recall that on a previous visit, she had a positive chlamydia culture that was treated with azithromycin tablets.

The Herpes Virus: There are eight types of herpes viruses known to affect humans. They are called Herpes Human Viruses (HHV). There are two types of Herpes Simplex viruses: HSV 1- Oral lesions, HSV 2 - Genital lesions

Herpes Simplex Viruses:

  • HSV 1 - Oral lesions commonly called cold sores (tongue, lips, etc.)
  • HSV 2 - Genital lesions (vulva, vagina, cervix, glans, prepuce, and penile shaft)

Herpes Human Viruses: 

Human herpesvirus 1 Gingivostomatitis, keratoconjunctivitis, cutaneous herpes, genital herpes, encephalitis, herpes labialis, esophagitis*, pneumonia*, hepatitis*
Herpes simplex virus type 2 Human herpesvirus 2

Genital herpes, cutaneous herpes, gingivostomatitis, neonatal herpes, aseptic meningitis, disseminated infection*, hepatitis*

Varicella-zoster virus

Human herpesvirus 3

Chickenpox, herpes zoster, disseminated herpes zoster*

Human herpesvirus 4

Infectious mononucleosis, hepatitis, encephalitis, nasopharyngeal carcinoma, Hodgkin lymphoma, Burkitt lymphoma, lymphoproliferative syndromes*, oral hairy leukoplakia*

Human herpesvirus 5

Infectious mononucleosis, hepatitis, congenital cytomegalic inclusion disease, hepatitis*, retinitis*, pneumonia*, colitis*

Roseola infantum, otitis media with fever; encephalitis

Roseola infantum and pityriasis rosea, as well as CMV in adults

Human herpesvirus 8

Not a known cause of acute illness but has a causative role in Kaposi sarcoma* and AIDS-related non-Hodgkin lymphomas that grow primarily in the pleural, pericardial, or abdominal cavities as lymphomatous effusions

Also linked with multicentric Castleman disease

*In immunocompromised hosts

View more images of herpes simplex virus infections (HSV1) and (HSV2)

Influenza
ReelDx Rotation Room (influenza)
Patient will present as → a 5-year-old with sudden onset of fever, chills, malaise, sore throat, headache, and coryza. The child is also complaining of myalgiaespecially in her back and legs. On physical exam, the patient appears lethargic, has a temperature of 102.5 F, and palpable cervical lymph nodes. Breath sounds are distant with faint end-expiratory wheezes.

Influenza is a viral respiratory infection caused by orthomyxovirus resulting in fever, coryza, cough, headache, and malaise

  • Three strains exist: A, B, and C
  • Complications from influenza are most common in the very young, very old, and those with preexisting comorbidities

DX: usually clinical, rapid antigen tests can be performed in the clinic

  • Rapid serology tests are often available and are most accurate during the first few days of illness
  • Everyone aged ≥ 6 mo should receive annual influenza vaccination
  • CXR in primary influenza pneumonia will show bilateral diffuse infiltrates
Sensitivities of rapid influenza diagnostic tests (RIDTs) are generally approximately 50-70%, but a range of 10-80% has been reported compared to viral culture or RT-PCR. Specificities of RIDTs are approximately 90-95% (range 85-100%). Thus, false-negative results occur more commonly than false-positive results.

TX:  Treatment is symptomatic (for most) or with antivirals, ideally< 48 hours. Antiviral treatment reduces the duration of illness by about one day and should be specifically considered for high-risk patients

  • Three classes of antiviral drugs are available for the treatment of influenza
    • oseltamivir (Tamiflu)zanamivir (Relenza), and peramivir (neuraminidase inhibitors) Treat A + B
    • The selective inhibitor of influenza cap-dependent endonuclease, baloxavir (Xofluza), which is active against influenza A and B
    • Amantadine and rimantadine (adamantanes) “Adamantanes = Influenza A
      • (CDC) recommends that adamantanes not be used in the United States for the treatment of influenza, except in selected circumstances
Chest radiograph from a patient with viral pneumonia showing widespread bilateral interstitial infiltrates

Image - Chest radiograph from a patient with viral pneumonia showing widespread bilateral interstitial infiltrates - by Department of Infectious Diseases, Leicester Royal Infirmary, Level 6 Windsor Building, Leicester, LE1 5WW, UK. License: CC BY 2.0

Measles
Patient will present as → a 6-year-old child who is brought to the emergency room for a complaint of high fevers and a rash. His mother reports that she thought he had “just a cold” approximately one week ago—he had a mild fever, runny nose, conjunctivitis, and cough. Then he developed a rash that started on his face and gradually spread downward. The child has no significant past medical history, however, he was adopted from Russia at age 5, and his medical history prior to adoption is unknown. On examination, the child appears lethargic and has a temperature of 104.3. There is a mild injection of his conjunctiva and a generalized macular rash. White macules are noted on his buccal mucosa.

Measles is caused by a paramyxovirus and is transmitted by respiratory droplets, it has a 10-12 day incubation period. It progresses in three phases characterized by a prodrome, enanthem, and exanthem.

  • Prodrome: 1-3 days of "the three C's" -coughcoryzaconjunctivitis, as well as fever
  • Enanthem (48 hours prior to exanthem) Koplik spots - are pathognomonic for measles and present as small red spots with a blue-white center on the buccal mucosa
  • Exanthem (2-4 days after onset of fever): consists of a morbilliform, brick red erythematous, maculopapular, blanching rash, which classically begins on the face and spreads cephalocaudally and centrifugally to involve the neck, upper trunk, lower trunk, and extremities

DX: Clinical diagnosis of measles requires a history of fever of at least three days, with at least one of the three C's (cough, coryza, conjunctivitis)

  • Observation of Koplik's spots is also diagnostic of measles.
  • Laboratory diagnosis with confirmation of positive measles IgM antibodies or isolation of measles virus RNA from respiratory specimens

TX: The mainstay of treatment is supportive care and prevention with vaccines - MMR (live attenuated) at 12-15 months, then again at 4-6 years of age

  • Immunoglobulin administration is indicated for use in exposed high-risk individuals (pregnant women and infants) to alter clinical disease
  • Vitamin A reduces morbidity and mortality in all patients
  • Patients must be isolated for 1 week after the onset of rash

Rubeola (Measles)

View more images of Rubeola (Measles)

Mumps
Patient will present as → a 5-year-old male is brought to the clinic with acute onset of painful swollen parotid glands. His mother reports that he was fine last night, but awoke with the swelling this morning. He has no significant past medical history, but it is documented in his chart that his mother declined the recommended standard immunizations for children because of personal beliefs. On examination, the child appears well and has a temperature of 100.8 F. His right parotid gland is slightly more swollen than the left, but they both are markedly swollen and tender.

Mumps is a viral disease that is part of the paramyxovirus family. It presents with parotitis (painful parotid gland swelling), orchitis, or aseptic meningitis. It is transmitted through respiratory droplets and has an incubation period of 12-14 days

  • Prodrome of fevermalaise, and anorexia
  • Parotid enlargement(usually bilateral but not always synchronous) 24 hours later
  • Swelling of submaxillary and submandibular glands
  • Orchitis(usually unilateral) with testicular enlargement two to three times the normal size
  • Mumps is the most common cause of pancreatitis in children

DX:

  • During an outbreak, a diagnosis can be made by determining recent exposure and parotitis. Usually, the disease is diagnosed on clinical grounds, and no confirmatory laboratory testing is needed
  • If there is uncertainty about the diagnosis, a test of saliva or blood may be carried out; a newer diagnostic confirmation, using real-time nested (PCR) technology, has also been developed
  • As with any inflammation of the salivary glands, the serum level of the enzyme amylase is often elevated
  • CSF demonstrates increased lymphocytes and decreased glucose 

TX:

  • There is no available cure for mumps, and treatment is supportive
  • Symptoms usually last for 7-10 days, and patients are contagious for up to 9 days after onset
  • May need to provide scrotal support if painful or swollen testicle (as in case presentation)

MMR vaccine is given at 12-15 months then again at 4-6 years of age

Mumps PHIL 130 lores

A child with mumps and significant parotid swelling

Pertussis
Patient will present as → a 24-year-old with an increasing cough for 3 weeks.  The cough comes and goes sometimes lasting for 10 minutes and causing gasping inhalations.  The cough was preceded by a mild cough and cold 2 weeks ago.  She has completed all immunizations required to attend school and has no known drug allergies

Whooping cough (pertussis) is a highly contagious respiratory tract infection marked by a severe hacking cough followed by a high-pitched intake of breath that sounds like a whoop. Gram-negative bacteria Bordetella pertussis – highly contagious

  • Consider in adults with cough >2 weeks, patients < 2 years old
    • Catarrhal stage: cold-like symptoms, poor feeding, and sleeping
    • Paroxysmal stage: high-pitched "inspiratory whoop"
    • Convalescent stage: residual cough (100 days)

Diagnosed by a nasopharyngeal swab of nasopharyngeal secretions – culture

Tx: macrolide (erythromycin/azithromycin); supportive care with steroids / beta2 agonists

  • Vaccination: 5 doses – 2, 4, 6, 15-18 mo, 4-6yrs (DTap)
  • 11-18 yo = 1 dose Tdap
  • Expectant mothers should get Tdap during each pregnancy, usually at 27-36 weeks
Pinworms
Patient will present as → a 4-year-old is brought to the office by his mother because the daycare teachers noticed he is unusually restless at school. The mother also noticed that he has not been sleeping well lately and has started wetting the bed at night. The child is alert and cooperative but scratches his buttocks while you are interviewing. Cellophane tape applied to the perianal area reveals football-shaped ova under the microscope.

Pinworm classically causes symptoms at what time of the day?
At night
This sticky test is used to diagnose pinworm
The Scotch tape test

Pinworm infection, also known as enterobiasis vermicularis, is a human parasitic disease caused by the pinworm (a type of roundworm). The most common symptom is itching in the anal area. This can make sleeping difficult.

  • Perianal itching, especially at night (eggs are laid at night)
  • Eggs cling to the fingers while itching and are transmitted to other people either directly or through food or surfaces
  • The eggs can thrive for 2-3 weeks on an inanimate object

DX: "scotch tape test' done in the early morning. You can see the eggs under microscopy

TX: albendazole or mebendazole

Enterobius vermicularis

Image of the eggs of the human parasite Enterobius vermicularis, or “human pinworm,” captured on cellulose tape under significant magnification.

Roseola
ReelDx Rotation Room (roseola)
Patient will present as → a mother who brings her 8-month-old infant into the clinic with a complaint of high fevers for three days. She denies any other symptoms. On examination, the child appears very well and is playful with you despite having a temperature of 103.9 F. A complete physical examination and urinalysis are done, and no source of the fever is found. You send her home with fever control measures and a follow-up appointment for the next day. The next day, the child is afebrile but has a generalized pink maculopapular rash

Roseola, also known as exanthema subitumroseola infantumrose rash of infantssixth diseasebaby measles. Caused by HHV 6 and 7

  • Typically, the disease affects a child between six months and two years of age and begins with a sudden high fever (102-104°). This can cause, in rare cases, febrile convulsions due to the sudden rise in body temperature, but in many cases, the child appears normal
  • After a few days, the fever subsides, and just as the child appears to be recovering, a red rash appears
    • A blanching macular or maculopapular rash starts on the neck and trunk and spreads to the face and extremities. Occasionally, the rash is vesicular. It is generally nonpruritic. The rash typically persists for one to two days
  • Only childhood viral exanthem that starts on the trunk -  spreading to the legs and neck

DX: The diagnosis is clinical

TX: Treatment is supportive, and in most cases, roseola is a benign and self-limited disease

  • Fever can be controlled with antipyretics (e.g., acetaminophen) if it is associated with discomfort
  • The rash resolves without treatment
OSC Microbio 21 03 roseola5th

Blanching macular or maculopapular rash starting on the neck and trunk and spreading to the face and extremities

View more images of Roseola

Rubella
Patient will present as → a mother who brings her 14-month-old daughter for evaluation of a rash. The mother describes the rash as beginning on the face and subsequently spreading to the rest of her body over one day. She also reports that her daughter has a mild fever and redness in her eyes. She has not been vaccinated per her parents’ preferences. The temperature is 100°F (37.8°C). There is mild bilateral nonexudative conjunctivitispostauricular lymphadenopathy, and petechiae on the soft palate and uvulaPink maculopapules are found in the face, neck, trunk, and extremities. The rash disappears in three days.

  • "3-day rash"  pink light-red spotted maculopapular rash first appears on the face, spreads caudally to the trunk and extremities, and becomes generalized within 24 hours (lasts 3 days)
  • Cephalocaudal spread of maculopapular rash, lymphadenopathy (posterior cervical, posterior auricular)
  • Although the distribution of the rubella rash is similar to that of rubeola, the spread is much more rapid, and the rash does not darken or coalesce
  • Teratogenic in 1'st trimester - In pregnancy, rubella is a TORCH infection and can cause serious complications, including hearing loss, ocular and cardiovascular defects, and mental retardation (congenital rubella syndrome)

DX: Laboratory diagnosis of rubella is warranted when congenital rubella syndrome is suspected or when the diagnosis is sought for a condition compatible with the known complications of postnatal rubella, such as arthritis

  • Serologic assays, primarily enzyme immunoassays (EIA), are used most frequently
  • Rubella virus-specific IgM antibodies are present in people recently infected with the Rubella virus but these antibodies can persist for over a year and a positive test result needs to be interpreted with caution
  • The presence of these antibodies along with, or a short time after, the characteristic rash confirms the diagnosis

Tx: The mainstay of treatment is supportive care and prevention with vaccines - MMR (live attenuated) at 12-15 months, then again at 4-6 years of age

  • Immunoglobulin administration is indicated for use in exposed individuals to alter clinical disease

Distinguish from measles by → confluent maculopapular rash, coryza (stuffy nose), and Koplik spots (in measles)
Varicella infection
ReelDx Rotation Room (Chicken Pox)

Varicella (chickenpox): primary infections - clusters of vesicles on an erythematous base

Patient with varicella (chickenpox) will present as → a 3-year-old with fatigue, irritability, and a low-grade fever that he has had for 3 days. According to the patient’s mom, the child attends a daycare where a virus is “going around.” On physical examination, the child does not look ill. His temperature is 98.6 F (38 C). His skin examination shows scattered, small vesicles on an erythematous baseThe rash was seen first on the face and seems to be spreading to the trunk.

  • Dewdrops on a rose petal in different stages.
  • The rash starts on the face and spreads down.
  • Acutely causes chickenpox - becomes latent in the dorsal root ganglion
  • Symptomatic treatment may use acyclovir in special populations
Varicela Aranzales

Child presenting with classic itchy red skin spots associated with the chickenpox virus.

ReelDx Rotation Room (Shingles)

Herpes zoster (shingles): varicella reactivation causing a maculopapular rash along one dermatome

Patient with herpes zoster (shingles) will present as → a 67-year-old male who presents to your clinic with a two-day history of a painful rash on his left flank radiating to his back. This was preceded by burning pain in the same region several days prior. The patient does not recall any history of childhood exanthems and is not up to date on his immunizations. Vital signs are stable. Physical exam reveals a maculopapular rash in a dermatomal distribution on the left flank and extending into the back.
  • If testing is deemed necessary - PCR or direct immunofluorescence (DFA) are the tests of choice
  • Hutchinson’s sign - lesion on the nose -> is an early indicator of ophthalmic (eye) shingles
  • Zoster ophthalmicus: shingles involving CCN V, dendritic lesions on slit lamp exam if keratoconjunctivitis is present
  • Zoster Oticus (Ramsay-Hunt Syndrome): facial nerve (CN VII) otalgia, lesions on the ear, auditory canal, and TM, facial palsy, auditory symptoms
  • Treat shingles with acyclovir, valacyclovir, and famciclovir - given within 72 hours to prevent post-herpetic neuralgia
  • Postherpetic Neuralgia: pain > 3 months, paresthesias, or decreased sensation. Treat with gabapentin or TCA, topical lidocaine gel, and capsaicin

Vaccination:

  • Varicella Vaccine
    • Children receive the first dose at age 12 through 15 months and the second dose at age 4 through 6 years
    • People 13 years of age and older who have never had chickenpox or never received the chickenpox vaccine should get two doses at least 28 days apart
  • Recombinant zoster vaccine (RZV, Shingrix) is recommended to prevent shingles in adults 50 years and older
    • 2-dose series 2-6 months apart
    • Should be given to patients who previously received Zostavax (ZVL) ⇒ administered at least two months after ZVL
Herpes zoster 3days passed

A single stripe of vesicles around the right side of the body (adult)

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