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Year 4 - Paediatrics > Paeds - The Febrile Child > Flashcards

Paeds - The Febrile Child Flashcards

1
Q

What is the Cushing’s Triad / Reflex?

A

A physiological NS response to ↑ ICP - which results in

the Cushing’s triad

Cushing’s Triad:

  1. ↑ BP (HTN)
  2. Bradycardia
  3. Irregular breathing - often ↓ RR
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2
Q

What is Kawasaki’s disease?

A

Kawasaki’s disease is an uncommon type of systemic vasculitis (predominantly seen in children)

Features:

  • 6 months - 4 years old
  • High-grade fever which lasts for > 5 days
    • Fever = characteristically resistant to antipyretics (e.g. paracetamol)
  • Conjunctival injection without exudate - hyperaemia / enlargement of conjunctival vessels
  • Bright red, cracked lips
  • Strawberry tongue - and red mucosa
  • Cervical lymphadenopathy
  • Red palms / soles of feet –> which later peel
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3
Q

How is Kawasaki’s disease diagnosed?

A

It is a clinical diagnosis with no formal test

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4
Q

How is Kawasaki’s disease managed?

A
  1. High-dose Aspirin –> ↓ thrombosis risk
    • Kawasaki’s = one of few indications for aspirin in children, which is normally avoided due to risk of Reye’s syndrome
  2. IVIG (IV immunoglobulin) - given within first 10-days, ↓ risk of coronary artery aneurysms
  3. Echo at 6-weeks after start of illness - to screen for coronary artery aneurysms
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5
Q

What is the classic known complication of Kawasaki’s disease?

A

Coronary artery aneurysm

  • occurs in ~ 1/3rd of affected children within 6-weeks of illness
  • subsequent narrowing of coronary arteries from scar formation can cause MI
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6
Q

What is Reye’s syndrome?

A

Severe, progressive encephalopathy affecting children, with fatty infiltration of the liver, kidneys & pancreas

Features:

  • 2 yrs old = peak incidence
  • Encephalopathy –> confusion, seizures, cerebral oedema, coma
  • Fatty infiltration of the liver, kidneys and pancreas
  • Hypoglycaemia (↓ blood sugar)
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7
Q

What drug is Reye’s syndrome associated with?

A

Aspirin

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8
Q

What is the prognosis of Reye’s syndrome?

A

Mortality = 15-25%

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9
Q

What are the features of acute pyelonephritis?

A
  • fever
  • rigors (sudden feeling of cold sweat / shivering + ↑ in temp)
  • loin pain
  • vomiting
  • white cell casts in urine

Note: in children pyelonephritis can dmg the growing kidney by forming a renal scar –> can result in hypertension / chronic renal failure

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10
Q

Which organisms are most likley to cause Meningitis for the age range, neonate - 3 months?

A
  1. Group B Streptococcus
    • Usually acquired from the mother at birth
    • More common if; 1) low birth weight babies or 2) following prolonged rupture of the membranes
  2. E. coli & other Gram -ve organisms
  3. Listeria monocytogenes
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11
Q

Which organisms are most likley to cause Meningitis for the age range, 1 month to 5 years old?

A
  1. Neisseria meningitidis (meningococcus)
  2. Streptococcus pneumoniae (pneumococcus)
  3. Haemophilus influenzae B
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12
Q

Which organisms are most likley to cause Meningitis for the age range, older than 5 years up to 60 years?

A
  1. Neisseria meningitidis (meningococcus)
  2. Streptococcus pneumoniae (pneumococcus)
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13
Q

What organism can cause meningitis in immunosuppressed patients?

A

Listeria monocytogenes

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14
Q

What are some signs of raised ICP that are contraindications to doing a LP to test for meningitis in a child?

A

Signs of raised ICP:

  1. Focal neurological signs
  2. Papilloedema
  3. Significant bulging of the fontanelle
  4. Disseminated Intravascular Coagulation (DIC)
  5. Signs of cerebral herniation
  6. Reduced or fluctuating GCS (< 9 or a drop of 3 or more)
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15
Q

How is meningitis managed in a child?

A
  1. Abx
    1. < 3 months –> IV Cefotaxime + IV Amoxicillin (for Listeria cover)
    2. > 3 months:
      • IV Ceftriaxone 80 mg/kg once daily … unless ….
      • ​also recieving calcium-containing infusions –> IV Cefotaxime
      • Ceftriaxone isn’t used if < 3-months old because it can cause jaundice (it competes with bilirubin for binding to albumin)
  2. Steroids
    • < 3 months –> NO steroids (NICE guidelines)
    • If > 12 hrs since 1st Abx dose then don’t start dexamethasone
    • IV Dexamethasone –> 4-times daily for 2-4 days
    • IV Dexamethasone if LP shows any of the following:
      1. Frank purulent CSF
      2. CSF WBC count > 1000/μL
      3. Raised CSF WBC count + protein concentration > 1 g/L
      4. Bacteria on Gram stain
  3. Fluids - any shock –> treat with colloid
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16
Q

A patient is suspected of having meningitis but is also diagnosed with meningococcal septicaemia - LP or no?

A

Pt has meningococcal speticaemia = NO LP

do blood cultures + PCR for meningococcus

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17
Q

What subsequent complications (sequalae) can meningitis cause?

A
  • Sensorineural hearing loss (most common)
  • Epilepsy
  • Paralysis
  • Psychosocial problems
  • Infective –> sepsis, intracerebral abscess
  • Pressure –> brain herniation, hydrocephalus
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18
Q

What are some common features of meningitis?

A
  • fever
  • headache
  • neck stiffness
  • papilloedema
  • drowsiness
  • decreased / change in conciousness
  • purpuric non-blanching rash (particularly with meningococcal disease)
  • nausea & vomiting
  • photophobia
  • seizures
  • Kernig’s sign - pt supine, thigh flexed to 90, straightening leg at knee is met with resistance
  • Infants: poor feeding, irritability, floppiness hypothermia, bulging fontanelle, apnoea
  • Rare: focal neurological deficit, facial palsy, balance problems (CN VIII), opisthotonus (severe hyperextension of head, neck and spine forming arching position, alike tetanus)
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19
Q

Why is IV Dexamethasone given in meningitis?

A

To ↓ risk of neurological sequalae via

anti-inflammatory action

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20
Q

What is meningitis?

A

An infection of the subarachnoid space which subsequently causes meningeal inflammation

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21
Q

What investigations might you suggest for a pt with suspected meningitis?

A
  • FBC
  • CRP
  • coagulation screen
  • blood culture
  • whole-blood PCR
  • blood glucose
  • ABG or VBG
  • Lumbar puncture (if no signs of raised ICP)
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22
Q

How would CSF results appear for meningitis of the following causes:

  • Bacterial
  • Viral
  • TB
A
23
Q

What is Herpes Simplex Encephalitis?

A

HSV encephalitis - characteristically affects the temporal lobes & inferior frontal lobes

Features:

  • Fever
  • Headache
  • Vomiting
  • Psychiatric symptoms
  • Seizures
  • focal features e.g. aphasia (often receptive dysphasia if temporal lobe affected)
24
Q

Which type of HSV causes HSV encephalitis?

A

HSV-1

causes 95% of HSV encephalitis in adults

25
Q

What investigations might you do if suspecting HSV encephalitis?

A
  • CSF = ↑ WCC, ↑ protein
  • PCR - looking for HSV
  • CT - medial temporal and inferior frontal changes (e.g. petechial haemorrhages)
    • note: these haemorrhages are normal in 1/3rd of patients
    • MRI is better - see image (hyperintensity of the affected white matter and cortex in the medial temporal lobes and insular cortex)
  • EEG pattern: lateralised periodic discharges at 2 Hz
26
Q

How is HSV encephalitis managed?

A

IV Aciclovir

27
Q

A rash that doesn’t blanch (disappear) with pressure (e.g. from a glass) is a sign of what?

A

Meningococcal disease (2 types)

  1. Meningococcal septicaemia
  2. Meningococcal meningitis
28
Q

Name 4 conditions in which you might see a non-blanching petechial/purpuric rash?

A
  1. Meningococcal disease e.g. meningitis or septicaemia
  2. Idiopathic Thrombocytopenic Purpura (ITP)
    • low platelet count can cause petechial/purpuric non-blanching rashes + mucosal bleeding
  3. Henoch-Schonlein Purpura (HSP)
    • palpable purpuric rash symmetrically on legs & buttocks
  4. Non-accidental injury
29
Q

What is Henoch-Schonlein purpura (HSP)?

A

HSP is an IgA mediated small vessel vasculitis

Features:

  • Age usually 3-10 years
  • Boys - twice as common
  • Post- infection - often seen in children following a URTI
  • Palpable purpuric rash (with localized oedema)
    • buttocks and extensor surfaces of arms and legs
    • does not scar!
  • Abdo pain
  • Polyarthritis
  • Periarticular oedema
  • Swollen testes
  • Intussusception - occurs in 2/3% of HSP pts
  • May have IgA nephropathy features:
    • macroscopic haematuria
    • renal failure (rare)
30
Q

How is HSP managed?

A
  • Analgesia for polyarthalgia
  • Supportive for nephropathy
31
Q

What is the prognosis of HSP?

A

Usually excellent!

HSP = self-limiting, especially when there is no renal involvement

~ 1/3rd have a relapse

32
Q

What does this image show?

A

Henoch-Schonlein purpura (HSP)

33
Q

What is Staphylococcal scalded skin syndrome?

A

A painful blistering skin condition, caused by Staphylococcus aureus

Features:

  • Original infection - can be infected graze, nappy rash, conjunctivitis
  • Widespread patchy red skin (resembling scald or burn) –> progresses to join patches and blister
  • Fluid filled, thin blisters (can cover wide area)
  • Fever
  • Irritable / miserable / lethargic
  • Don’t want to be touched
  • Mucous membranes spared (unlike toxic epidermal necrolysis)
  • Nikolsky’s sign - slight rubbing of skin causes exfoliation of outermost layer
34
Q

What is toxic shock syndrome?

A

Also called Staphylococcal toxic shock syndrome, describes a severe systemic reaction to staphylococcal exotoxins

Features:

  • Fever> 38.9ºC
  • Hypotension (< 90 mmHg)
  • Diffuse erythematous rash
    • Desquamation of rash, especially of palms + soles
  • Involvement of 3 or more organs:
    • GI - diarrhoea & vomiting
    • Renal failure
    • Hepatitis
    • Thrombocytopenia
    • CNS - confusion
35
Q

What is Measles?

A

A highly contagious infectious disease caused by the measles virus (Measles morbillivirus) - causes infection of respiratory system

  • Rare in developed world due to immunisation programmes
  • Spread by droplets
  • Pts are infective from prodrome until 4 days after rashs starts
  • Incubation period = 10-14 days
36
Q

What are the features of Measles?

A
  • Prodrome: (conjunctivitis + corysa) i.e. fever, cough, runny nose, irritable, conjunctivitis
  • Koplik spots (before rash) = white spots on buccal mucosa
  • Rash = starts behinds ears –> spreads to whole body
    • Discrete maculopapular rash becoming blotchy & confluent
37
Q

How is measles managed?

A

Symptomatic management!!

  • Ribavirin - if immunocompromised pt then
  • Vitamin A - may modulate immune response, to be given in developing countries
38
Q

What does this image show?

A

Koplik Spots

(measles)

39
Q

Which if the following aren’t routinely vaccinated against in the UK?

  • Streptococcus Pneumoniae
  • Group B haemolytic Streptococcus
  • Haemophilus influenzae
  • E. Coli
  • Meningococcal type B
  • Meningococcal type C
A

Group B haemolytic Streptococcus

and

E. Coli

40
Q

What is the normal age range for the anterior fontanelle to close?

A

18-24 months

41
Q

Review the traffic light system for identifying serious illness in children with fever < 5 yrs old.

  • Children < 5yrs with fever + what symptoms put them at high risk?
  • Children < 5yrs with fever + what symptoms put them at intermediate risk?
A

High risk - worth learning:

  • pale/mottled/ashen/blue - skin, lips or tongue
  • no response to social cues
  • appearing ill to a healthcare professional
  • does not wake or if roused does not stay awake
  • weak, high-pitched or continuous cry
  • grunting
  • RR > 60
  • moderate or severe chest indrawing
  • ↓ skin turgor
  • bulging fontanelle
42
Q

Do anti-pyretic agents prevent febrile convulsions?

A

NO !!

43
Q

How are children with suspected meningococcal disease in the pre-hospital environment?

A
  1. Urgent transfer to hospital for IV antibiotics
  2. IM or IV benzylpenicillin (without delaying transfer to hospital)
44
Q

What tests might you send an LP sample for in suspected meningococcal meningitis?

A
  • Protein - high in bacterial & TB meningitis and normal/raised in viral
  • Glucose - low in bacterial and TB and ~60% of plasma glucose
  • LDH - high in bacterial meningitis and low in viral
  • Microscopy and gram stain
  • Culture & Sensitivity
  • PCR - for virology, pneumococcus and meningococcus
45
Q

For a patient with suspected bacterial meningitis, which order should you conduct an LP and giving Abx?

A

Ideally: LP –> Abx

However …

If suspecting meningitis / bacterial meningitis you should not delay giving IV-antibiotics !!

Useful results can still be obtained from an LP up to 72hrs after starting antibiotics!

46
Q

Is Niesseria meningococcus gram positive or negative?

A

Gram-negative

47
Q

Where does a LP needle need to be inserted?

A

Into the L4/L5 inervertebral space

or L3/L4

  • Identify the anterior superior iliac crests and draw an imaginary line between them
  • In the midline of this line is the L5 vertebrae
  • The L4/L5 space is just above
48
Q

What are some contraindications to doing an LP?

A
  • Shock or respiratory insufficiency
  • Convulsions
  • Extensive or spreading purpuric rash i.e. potential meningococcal septicaemia
  • Bleeding disorder e.g. low platelets, anti-coagulants, known clotting-issue
  • Local infection
  • Signs of ↑ ICP:
    • Focal neurological signs
    • Papilloedema
    • Significant bulging of the fontanelle
    • Disseminated Intravascular Coagulation (DIC)
    • Signs of cerebral herniation
    • Reduced or fluctuating GCS (< 9 or a drop of 3 or more)
49
Q

Of the common bacteria which can cause meningitis, which has the poorest prognosis?

A

Streptococcus Pneumoniae

  • Of common pathogens, Streptococcus Pneumoniae has the highest mortality (up to 30%)
  • Neisseria meningitides the lowest (3-10%)
50
Q

A 3 year old boy is brought to see his GP. He is previously well. He has a 3 day history of fever and rash. No vomiting or diarrhoea. Pulse 110, respiratory rate 22, temperature 38.1 degrees C. He is pale and has a bright red rash on both cheeks with clear demarcation. Throat and ears normal. Chest clear. No other rash noted, no lymphadenopathy.

What is the diagnosis?

  • Scarlet Fever
  • Kawasaki Disease
  • Slapped cheek syndrome
  • Henoch Schonlein pupura
  • SLE
A

Slapped cheek syndrome

  • Condition is caused by parovirus
  • Can be issue for pts with haemoglobin disorders
51
Q

What is the difference between petechiae, purpura and ecchymoses?

A
  • Petechiae are < 3 mm (broken capillary)
  • Purpura are 3-10 mm & non-blanching (bleeding under skin)
  • Ecchymoses are > 1 cm (bleeding under skin) - hard to differentiate from bruise (which is caused by trauma)
52
Q

What investigations might you want to do for HSP?

A
  1. Vital Obs - sepsis screen
  2. FBC - exclude infection, anaemia, aplastic anaemia
  3. U&Es - assess renal function (which can be deranged in HSP)
  4. Urinalysis - HSP can have features of IgA nephropathy (Berger’s disease) e.g. haematuria, maybe protein
  5. Urine protein:creatinine ratio - quanitfy protein present in urine
53
Q

What intestinal pathology is Henoch-Schonlein purpura associated with?

A

Intussusception

Occurs in ~ 2/3rd of HSP cases

Year 4 - Paediatrics (16 decks)

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