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Year 4 PAEDS > Infections > Flashcards

Infections Flashcards

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1
Q

What % of cases of meningitis occur in children under the age of 15?

A

75%

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2
Q

What is the most common causative organism of meningitis?

A

Neisseria Meningitides

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3
Q

What are some other common causative organisms of meningitis?

A

Streptococcus pneumonias
Haemophilus Influenza B
Meningococcus C

**The last 2 are both now vaccinated against and so their incidence has dropped

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4
Q

How does infection of the meninges occur, and why is this more likely to occur in children?

A

Usually there is an infection of the nasopharyngeal mucosa first and then this infection gets into the blood. Because in children the blood brain barrier (BBB) is less developed these bugs are more likely to reach the meninges and cause infection

Infection of the meninges leads to leaking of proteins and cerebral oedema as well as inflammation of the blood vessels in the brain (cerebral vasculitis)

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5
Q

What symptoms are likely to be present in a child with meningitis and what might make diagnosis more difficult?

A

Photophobia, neck stiffness and headache are the classical distinguishing symptoms but the young child (infant) might not have these making diagnosis more difficult.
They might have NON-SPECIFIC SYMPTOMS OF INFECTION
- Fever, malaise, vomiting, anorexia

OTHER MENINGITIC SIGNS:
- Seizures, irritability, drowsiness, disorientation, altered mental state, bulging fontanelle, papilloedema, focal neurological signs

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6
Q

What investigations should be done in a child with meningitis?

A

Do NOT let investigations delay treatment
BLOODS: FBC, U&E, Glucose, CRP, Coag, Cultures
Infection screen (urine dip)
LP

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7
Q

It is not appropriate to do an LP in all children, in which ones is it contra-indicated?

A 
Raised ICP
Coagulopathy
Haemodynamic instability 
Focal neurological signs or focal seizures (more suggestive of TB meningitis)
Infection of skin at LP site 
Respiratory insufficiency
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8
Q

What is the ultimate concern in children with meningitis and what signs are there of this?

A 
SHOCK (that might be septic or neurogenic in origin but is ultimately distributive in type)
Incr HR
Decr BP (near fatal)
Increased RR
Poor CRT
Cold, mottles, clammy skin
Poor urine output 
Cyanosis 
THESE CHILDREN NEED IMMEDIATE RESUSCITATION
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9
Q

What is the antibiotic regimen in children with meningitis?

A

80mg CEFTRIAXONE
OR
50mg CEFOTAXIME
+ Amoxicillin in children under 3/12 (listeria cover)

Mild cases might be able to be treated with BenPen

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10
Q

Other than antibiotics what other management stages will be needed in a child with meningitis?

A

PHE should be notified (contact prophylaxis might be required)
STEROIDS (do NOT use in <3/12) - DEXAMETHASONE 0.15mg/kg QDS (this reduces neurological sequelae)

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11
Q

What is meningococcal septicaemia?

A

This is a sepsis caused by a meningococcus (of any type). It can occur with or without meningitis

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12
Q

What are some signs and symptoms of meningococcal septicaemia?

A 
NON-BLANCHING PURPURIC RASH (this is very concerning)
Increased HR
Increase RR
FEVER 
Poor urine output 
Increased CRT 
...Start thinking SHOCK
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13
Q

What type of meningococcal organism is most likely to cause septicaemia?

A

Meningitides serogroup B

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14
Q

How should a suspected case of meningococcal septicaemia be managed?

A

80mg CEFTRIAXONE or 50mg CEFOTAXIME
PHE alert - treat contacts prophylactically
Resuscitation - 20ml/kg 0.9% NaCl fluid bolus (monitor response and monitor Ca and K)
If child is less than 3/12 give amoxicillin to cover for listeria

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15
Q

How should non-blanching rash lesions be referred to occurring to their size?

A 
<3mm = petechial 
3-10mm = purpura 
>10mm = ecchymosis
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16
Q

Why do non-blanching rashes occur?

A 
Vascular disorders (immune complex vasculitis)
Platelet disorders 
Endotoxin release from bacteria
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17
Q

What are some common differentials in a child with a non-blanching rash?

A

MENINGOCOCCAL SEPTICAEMIA - always work to rule this out

HENOCH-SCHONLEIN PURPURA (HSP) - is another key differential

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18
Q

Where is the rash usually located in children with HSP?

A

Over the legs and buttocks

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19
Q

What is a common presenting clinical picture of HSP?

A

Usually occurs in boys between the ages of 3-10

Usually occurs after an upper respiratory tract infection

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20
Q

What other systemic problems can HSP cause?

A

It is a type of IgA complex disease - these complexes being deposited in the skin capillaries is what causes the rash
They can also be deposited in the NEPHRONS (IgA Glomerulonephritis)

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21
Q

Asides from the rash what other signs might there be of HSP?

A

Fever
Symmetrical rash over buttocks and legs
Joint pain and swelling particularly of the ankles and knees
Abdominal pain (haematemeiss, maleana, intussusception)
Haematuria
Nephrotic syndrome (Rare)

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22
Q

What treatment options are there for HSP?

A

Usually treatment is supportive and the disease will be self limiting
Monitor for kidney function
CORTICOSTEROIDS sometimes given but therapeutic value is unclear

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23
Q

How should meningococcal septicaemia be dealt with in the GP?

A

Give a dose of IM BenPen and send to hospital urgently (Ambulance)

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24
Q

Which agent causes chicken pox?

A

Varicella Zoster Virus (VZV)

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25
What is the classical clinical presentation of chicken pox?
Children vary very much in how unwell they are. (Can have wheeze, fatigue, breathlessness, malaise, loss of appetite or be completely fine) Usually there will be a fever for a couple of days and then a MACULOPAPULAR RASH will develop that will turn into VESICULAR RASH that usually starts on the head/trunk and then will spread all over the body. ITCHY++ The vesicles will burst and then scab over
26
What is the incubation period for chicken pox?
2 weeks (10-21 days)
27
How long will children be infective for with chicken pox?
4 days before the appearance of the rash and 5 days after the rash first appeared
28
What are some complications of chicken pox?
USUALLY VERY UNCOMPLICATED - Infection of the lesions with group A staph - can lead to toxic shock or necrotising fasciitis - Encephalitis - commonly of the cerebellum (cerebellitis) - the prognosis for this is actually quite good - Purpura fulminans - widespread vasculitis and necrosis - Pneumonia
29
How should children with chicken pox be managed?
SUPPORTIVE - Short nails prevent bad excoriations - Keep them cool to help comfort with fever - Calamine lotion can soothe itching - SCHOOL EXCLUSION from 5 days after onset of rash Immunocompromised patients can be given VZIG prophylactically or IV acyclovir for treatment
30
When does conjunctivitis usually occur in a child's life?
It is a common infection and can occur at any time. There is a notable peak in the neonatal period due to infections obtained from the birth canal
31
What are some symptoms of conjunctivitis?
Red, irritated, itchy, weeping eye
32
What features might make you consider a bacterial cause of conjunctivitis and what are some common agents?
If the weeping is purulent and sticky (rather than serous as in viral)
33
If you decide the conjunctivitis is bacterial how could you consider treating it?
Chloramphenicol drops or neomycin topical ointment
34
What is general management for all infective conjunctivitis?
Cleaning with saline or water regularly is recommended and this will usually lead to the infection clearing up in 3 or 4 days
35
If conjunctivitis occurs in the first 48 hours after birth what should you consider?
That it might be caused by gonococcus from the mother's genital tract
36
How should conjunctivitis caused by gonococcus be treated?
Gonorrhoea is common penicillin resistant in the UK so treatment with third gen cephalosporin is advised (CEFOTAXIME)
37
If a baby presents with conjunctivitis 1-2 weeks after birth what organism should you consider?
Chlamydia trachomatis
38
How should conjunctivitis caused by chlamydia be investigated and how should it be treated?
Can be investigated using immunofluorescence screening | Should be treated with oral erythromycin
39
What is the cause of infectious mononucleosis?
EBV
40
What affect does EBV have and what malignancy is it associated with?
It affects the pharyngeal epithelial cells and B cell lymphocytes - It's effect on B lymphocytes also causes its link with Burkitt's Lymphoma
41
Which age of children does infectious mononucleosis most commonly occur in?
Peak in adolescence due to its common route of spread (kissing) - AKA the kissing disease
42
What are some common clinical features of infectious mononucleosis?
Fever Malaise Tonsilopharyngitis - this can be extensive and very painful sometimes limiting oral intake and very rarely breathing Lymphadenopathy (prominent cervical lymphadenopathy is key feature) Petechiae on soft palate HEPATOSPLENOMEGALY (good diagnostic clue) Maculpapular rash Jaundice
43
What investigations should you do in a child who you suspect to have infectious mononucleosis?
Seroconversion of IgG and IgM to EBV Positive Monospot test Atypical lymphocytes of BLOOD FILM (Big T cells)
44
How long does infectious mononucleosis last?
Symptoms usually last 1-3 months then resolve
45
How should we manage infectious mononucleosis?
Symptomatic treatment - disease is self-limiting If considerable obstruction consider corticosteroids Treat concurrent bacterial infection of tonsils with penicillin
46
What should you never give someone who has infectious mononucleosis?
AMOXICILLIN or AMPICILLIN | It will cause a florid maculopapular rash when there is an EBV infection
47
If a child has a prolonged fever what should you always suspect?
Kawasaki's disease
48
What is Kawasaki's disease?
It is a VASCULITIS with mucocutaneous lymph node involvement
49
Who does Kawasaki's disease usually affect?
Children between 6 months and 4 years of age (peak incidence at the end of the first year)
50
What clinical features must be present to make a diagnosis of Kawasaki's disease?
A fever that has been present for 5 days + 4/5 of - Conjunctivitis - Mucositis / irritation around the mouth and lips - Desquamation / redness of the hands and feet - Cervical lymphadenopathy - Polymorphous rash
51
What investigations should you do if you suspect a child has Kawasaki's disease?
There is no specific diagnostic test for Kawasaki's disease but you should always do an ECHOCARDIOGRAM?
52
What is a potentially fatal complication of Kawasaki's disease?
Coronary artery aneurysms - this is why you should always do ECHOCARDIOGRAM to rule it out (affects approximately 1/3 of children in the first 6 weeks of disease)
53
What treatments should be given for Kawasaki's disease?
IVIG High dose aspirin Echo monitoring
54
Why is aspirin not normally given in children?
Risk of REYE'S SYNDROME - Encephalopathy in children ***Should still give aspirin in Kawasaki's
55
In what way will otitis media present?
It will either be acute or recurrent - important to get an idea of which one because recurrent OM is more at risk of glue ear and hearing loss
56
What age are children more susceptible to acute OM and why?
6-12 months because they have short eustachian tubes that don't flush out contents as effectively
57
When should you consider examining the ears in a child?
Examine in every child with a fever | Ear infections are really common and fairly easy to treat
58
What will you see on otoscope examination in OM?
A bulging tympanic membrane - loss of the light reflex as the middle ear has become filled with fluid
59
What symptoms will children with OM present with?
``` Ear pain (otalgia) Coryzal symptoms - current or preceding Fever Irritation Tugging of the ears Hearing loss Discharge from the ear (if membrane has ruptured) ```
60
What common pathogens cause OM?
RSV, Rhinovirus, Pneumococcus, HiB and mortadella catarrhalis
61
What possible complications are there of OM?
Mastoiditis and meningitis can both occur
62
When should you consider treatment for OM?
if the symptoms persist for 4 days or longer or don't improve if there is purulent discharge from ear If child is immunocompromised if they are systemically unwell? Otherwise it is probably self limiting
63
How should OM be managed?
Advise analgesia regimen | Abx can be given - they reduce pain but not the duration of the disease. Consider AMOXICILLIN 5days
64
What is the concern if the child keeps having recurrent ear infections?
That this will lead to ear infection with effusion (OME) | Also known as glue ear or serous otitis media
65
How does recurrent OM present?
Multiple, distinct episodes of OM | Other than that might be asymptomatic apart from some hearing loss
66
In who is glue ear more common?
Children between the ages of 2-7
67
In glue ear how will the ear appear on otoscope examination?
The membrane will look DULL and retracted
68
What management should you consider for glue ear?
Usually the effusion will resolve spontaneously but if it does not or it is causing problems (e.g. hearing problems) can consider GROMMETS Also consider an adenoidectomy - the adenoids can act as a reservoir for bugs that can spread to the eustachian tubes and cause recurrent infections.
69
What are the symptoms of preseptal cellulitis?
Fever + Redness + Tenderness + Oedema of the eyelid UNILATERAL ... if it is bilateral then consider other causes
70
What is the likely causative organism for orbital cellulitis?
DEPENDS ON AGE OF CHILD - if young and unimmunised consider HiB In older children it is more likely to be caused by spread from paranasal sinuses (so staph or strep infections) or dental abscesses
71
What complication of orbital cellulitis should you be concerned about? What are some signs of this?
Involvement of the orbit Proptosis / exophthalmos Painful / limited ocular movement Reduced visual acuity
72
What investigations should you do in someone who has preseptal cellulitis?
Inflammatory markers CRP and ESR Swabs of the site for specific organism Consider blood cultures in orbital Consider CT in orbital
73
How should preseptal and orbital cellulitis be managed?
They should all be referred to secondary care services - orbital cellulitis is an emergency and should be sent in immediately ABX Preseptal cellulitis can be managed with oral co-amoxiclav Orbital cellulitis will require admission and IV abx
74
What is the causative agent of impetigo?
Staphylococcus aureus
75
Where does impetigo occur and how infectious is it?
usually occurs around the nose and the mouth It is VERY infectious Can also occur on the neck and hands
76
How does an impetigo rash appear?
It will initially be macular and then will become vesicular/pustular. As these vesicles rupture they will scan over with a HONEY COLOURED SCAB - this is classical of impetigo
77
How do we treat impetigo?
HYGIENE - advise on good hand washing, not towel sharing or sharing any personal care products, avoid scratching and consider washing toys Stay off school/pre school for 48hours after starting abx Usually topical FUSCIDIC acid (three time a day for 5 days) is enough. If the rash is more widespread then consider oral treatment FLUCLOXACILLIN 125-250mg QDS for 7 days

Year 4 PAEDS (18 decks)

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