Infectious Diseases

Question 1

A teenager presents to your office with a 2-month history of closed comedomes. What do you advise for management?

Frequent face washing
Benzoyl peroxide
Topical retinoids
Topical clindamycin

Answer 1

Topical retinoid - best for comedones

benzoyl peroxide is best for inflammation

Question 2

5 year old with diarrhea and fever for 5 days. lethargy for 1 day. Recently returned from India where he was treated for diarrhea with Ciprofloxacin x 7days. Most likely etiology for his CURRENT presentation?
C diff
Salmonella typhii
Entamoeba histolytica
Ascaris lumbricoides

Answer 2

Salmonella typhii
from India and treated with cipro (inadequate)

Question 3

what is clostridium difficile?

Answer 3

Spore-forming bacterium
Anaerobic, Gram positive bacillus

Question 4

risk factors for c diff?

Answer 4

• Hospital exposure
• Older age
• Multiple abx
  ***ALL ANTIBIOTICS are associated with causing c diff, including surgical prophylaxis
  -immunosuppression (chemo, hypogammaglobinemia, IBD, HIV)

Question 5

which pts are more likely to have severe/fatal c diff?

Answer 5

severe/fatal c diff is uncommon

• neutropenic BMT/blood cancer pts
• hirschsprung’s dz
• IBD

Question 6

pathophys of c diff infection?

Answer 6

Colonization of C. diff via the fecal-oral route usually when gut microbiota disrupted from antibiotic use

C. difficile produces two toxins that bind to receptors on intestinal epithelial cells, leading to inflammation and diarrhеа (colitis).

Health care facilities notably problematic for infections

C. difficile spores are very RESISTANT to heat and cleaning products/hand sanitizer; survive on surfaces for long periods of time

Question 7

recurrence rate of c diff?

Answer 7

15-35% recurrence rate

Question 8

causes of c diff?

Answer 8

antibiotic use
Almost all antimicrobials have been associated with C.diff infection

Question 9

presentation of c diff?

Answer 9

asymptomatic
diarrhea (can be bloody)
fever
pain
pseudomembranous colitis
toxic megacolon
shock, hypotension
peritonitis
ileus

Question 10

Diagnosis for c diff?

Answer 10

Watery diarrhea + Positive C diff toxin stool test (or pseudomembranous colitis on colonoscopy)
***testing should only be done on diarrheal stool since many kids are asymptomatic carriers UNLESS ileus is suspected

2 Step Testing on DIARRHEAL stool (must be loose stool sample)

1.Glutamate Dehydrogenase (GDH) Enzyme immunoassay (EIA)(present in almost all strains of C Diff) = initial screen

2. EIA for toxins A and B = confirmation

*not all c diff produces toxins, cell cytotoxic assay is a second confirmatory test option

Question 11

what is mild c diff and how do you treat it?

Answer 11

<4 diarrheal stools/day

d/c precipitating antibiotic; start different antibiotic less commonly associated with CDI to treat infection

Question 12

what is moderate c diff and how do you treat it?

Answer 12

≥4 diarrheal stools/day
+/- low grade fever + mild abdo pain

PO Metronidazole, 30 mg/kg/day div QID x 10-14 days

maximum 2 g/day

Question 13

what is severe c diff and how do you treat it?

Answer 13

diarrhea + High-grade fevers, rigors (systemic toxicity)

ORAL Vancomycin, 40 mg/kg/day div QID x 10-14 days

maximum 500 mg/day (125 mg per dose orally four times per day)

**NO EFFICACY OF VANC IF GIVEN IV

Question 14

what is complicated c diff?

Answer 14

systemic toxicity and severe colitis, including hypotension, shock, peritonitis, ileus or megacolon

Pseudomembranous Colitis = severe diarrhea (+/- blood, mucous, leukocytes), abdo pain, fever, leukocytosis, systemic toxicity, and, most severe manifestation, toxic megacolon

Question 15

how do you treat complicated c diff?

Answer 15

ORAL Vancomycin, 40 mg/kg/day div QID
(If complete ileus –> RECTAL vancomycin)

PLUS

IV metronidazole, 30 mg/kg/day div QID
maximum 2 g/day
(can give IV bc enterohepatic circulation deposits some drug in the gut)

Question 16

how do you treat first recurrence of c diff?

Answer 16

Recurrences are common (25%) and do NOT imply drug resistance

Repeat same regimen used for initial episode or,
PO vancomycin 40 mg/kg/day div QID x10 days

Question 17

how do you treat second recurrence of c diff? Ie the third time the PT had c diff

Answer 17

Vancomycin in a tapered or pulsed regimen:

1) Usual PO Vanc course (40mg/kg/day QID x 10-14d)
2) 20mg/kg/day div BID x 7d
3) 10mg/kd/day once daily x7d
4) 10mg/kd/day every 2-3 d for 2-8 wks

Consider probiotics (emerging evidence)

If not resolved after taper course, consult Infectious Diseases (CPS statement reviews some advanced options not included here)

Question 18

9 y/o boy with 3 weeks cough, fatigue, fever. Has been treated with 7d Amoxicillin and 5d azithromycin for presumed bronchitis and sinusitis.
He presents with worsening of symptoms in past 3 days, specifically worse productive cough, fever. On exam, T38.5, RR 36, SpO2 94 in RA. Crackles when auscultating above the RUL. CXR as below:

What is the next best step:
RIPE therapy
Amphotericin b
Clindamycin and Cefotaxime
CT guided drainage

Answer 18

Clindamycin and Cefotaxime

this is lung abscess (see air fluid level, cavitating circular lesion on CXR)

Lung abscess usually caused by strep pneumo, staph aureus, and/or anaerobes (often polymicrobial)

Clindamycin (covers anaerobes) and Cefotaxime (for staph and strep)

Question 19

what is a lung abscess?

Answer 19

collection of FLUID in a thick-walled localized area of lung parenchyma

think of lung abscess if pneumonia consolidation is unusually persistent, or ROUND or mass-like

Question 20

What causes lung abscesses?

Answer 20

usually complication from pneumonia or occurs 1-2 weeks after aspiration (hence why anaerobes commonly found)

DDX cavitary lung lesion:
○ bacterial pneumonia (usually POLYMICROBIAL with Staph aureus and oral anaerobes; strep pneumo - less commonly)

○ septic emboli/Lemierre’s syndrome (suppurative internal jugluar thrombophlebitis )

○ TB

○ fungal/endemic mycoses,

○ malignancy, vasculitis (Wegener), pulmonary sequestration, sarcoid

Question 21

Diagnosis of lung abscess?

Answer 21

CXR with thick-walled cavity with an AIR-FLUID level

CT if uncertain diagnosis or before drainage if necessary

IR can obtain specimen if decision made to drain (ie not improving after 72hrs of abx)

Question 22

Treatment of lung abscess?

Answer 22

Clindamycin (for S. aureus or аոаerοbeѕ) and Ceftriaxone (for S pneumo)
- Can switch to oral when clinically and radiographically improving and afebrile
- Duration abx: 3-4 weeks

90% resolve with abx alone (spontaneously drain).

if not improving in 72hrs, needle aspiration or percutaneous catheter drainage

Question 23

1 mo infant who had newborn screen confirmed congenital CMV with positive urine PCR. Has passed newborn hearing test, had a normal ophtho exam, normal head imaging and is systemically well with good growth. How do you manage going forward:

Counsel the parents that there is no chance of hearing impairment
Start valganciclovir
Ongoing developmental surveillance
Repeat urine PCR at 6 months

Answer 23

Ongoing developmental surveillance

Question 24

what is the most common cause of ACQUIRED hearing loss in children ?

Answer 24

Congenital Cytomegalovirus (CMV)

○ Most common cause of hearing loss in general is genetic
○ *Hearing loss can be late and can still occur in asx babies
○ **Early detection and treatment improves hearing and developmental outcomes

Question 25

how is congenital CMV usually contracted?

Answer 25

Maternal vertical (transplacental) transmission to their unborn fetuses Rates of transmission are 10- to 15-fold higher in primary compared with non-primary maternal infection non-primary = reinfection with different viral strains or reactivation of the primary strain

Question 26

Key Features of congenital CMV?

Answer 26

90% asymptomatic Sensorineural Hearing Loss (25%) **Hearing loss can develop late (after normal newborn hearing screen)** Microcephaly and Periventricular Calcifications ("CMV for Ventricular") IUGR/SGA Thrombocytopenia (petechiae), anemia, splenomegaly Hepatomegaly, jaundice, elevated ALT Chorioretinitis

Question 27

Permanent sequalae of congenital CMV?

Answer 27

Hearing loss Neurocognitive Deficit (developmental monitoring important)

Question 28

Who to test for congenital CMV?

Answer 28

* Maternal CMV infection * Fetal ultrasound with findings suggestive of cCMV * Placental pathology consistent with CMV infection * Other indicators of potential risk: HIV exposure, Primary immunodeficiency * Features consistent with symptomatic cCMV * Failed hearing screen

Question 29

Diagnosis of congenital CMV?

Answer 29

URINE CMV PCR done BEFORE 21 days need to test >1hr post-breast feeding (to avoid false pos from infected mother)

Question 30

Classification of congenital CMV?

Answer 30

*any category of CMV can have SNHL Asymptomatic Mildly symptomatic - 1 or 2 isolated, transient, mild features of cCMV (e.g., mild transaminitis, transient thrombocytopenia) Moderate-to-severely symptomatic ○ CNS disease: microcephaly, seizures, positive CSF CMV PCR, abnormal head imaging ○ Chorioretinitis ○ Multisystem disease (e.g., HSM, IUGR, persistent hepatitis or thrombocytopenia) ○ Severe single organ disease

Question 31

Who gets treatment for congenital CMV?

Answer 31

Isolated SNHL Mod/Severe CMV: CNS, Chorioretinitis, brain calcifications severe single or multi-organ disease, severe thrombocytopenia. Do NOT treat asymptomatic kids.

Question 32

what is the treatment of congenital CMV?

Answer 32

Valganciclovir 16 mg/kg/dose PO BID x 6 MONTHS or Valganciclovir PO BID x 6 weeks (Isolated SNHL) S/e: neutropenia, thrombocytopenia, transaminitis, and elevated urea and Cr Must start before 3 months of age (but sooner = better)

Question 33

Monitoring while on treatment for congenital CMV?

Answer 33

CBCd weekly x 1 month; every 2 weeks x 2 months; monthly x 3 months AST, ALT, urea, Cr monthly x 6 months monitoring for side effects of valganciclovir (neutropenia, thrombocytopenia, transaminitis, and elevated urea and Cr)

Question 34

Follow up for congenital CMV?

Answer 34

Refer to ENT if SNHL Audiology: Frequent first 2 to 3 years, then yearly until school age. *Late onset SNHL median onset 27 mo Ophthalmology: ASAP after cCMV confirmed. Follow-up based on initial findings. Neurodevelopmental: Closely first 2 years. Frequency determined by neurological concerns and initial assessment. Can develop CP Dental (enamel hypoplasia) OT if vestibular dysfunction

Question 35

Who to refer to ID in congenital CMV?

Answer 35

Confirmed symptomatic congenital CMV SNHL Probable cases may be considered (question of congenital vs postnatal)

Question 36

A 10 year old child with rheumatic fever has an echo that shows carditis with valvular dysfunction. What do you recommend for prophylaxis? Penicillin Im q4weeks x 10 years Penicillin PO daily x 10 years Penicillin PO BID x 30 years Penicillin with dental extractions or ENT procedures

Answer 36

Penicillin PO BID x 30 years per Dr. Dunn however we usually treat IM penicillin so odd question... Rheumatic fever without carditis - 5 years or until 21 years of age Rheumatic fever with carditis, no valvular disease - 10 years or until 21 year sago Rheumatic fever with carditis, with valvular disease - 10 years or until 40 years of age (sometimes lifelong prophylaxis) - best answer addresses timeline, although route is not as preferred.

Question 37

What is rheumatic fever?

Answer 37

autoimmune sequelae of GAS pharyngitis occurs 2-4wks after strep throat

Question 38

Common age group of rheumatic fever?

Answer 38

5 - 15yrs, reflecting the group most susceptible to strep throat infections

Question 39

Pathophysiology of rheumatic fever?

Answer 39

The antibodies that react to strep pyogenes also CROSS REACT with antigens on heart muscle, heart valves, joints and brain. = MOLECULAR MIMICRY Type II Hypersensitivity reaction Once antibodies attached to cardiac tissue --> cytokine mediated inflam response and tissue destruction

Question 40

Diagnosis of rheumatic fever?

Answer 40

EVIDENCE of recent GAS infection (eg + ASOT or throat cx) and 2 major manifestations OR 1 major + 2 minor manifestations JONES Criteria Major: J - Joints (migratory polyarthritis - typically large joints) O (shape of heart) - Carditis (50%) - N - subcutaneous Nodules (collagen lumps) E - Erythema Marginatum (ring rings) S - Sydenham chorea (rapid arm/face movements) ^Autoimmune reaction against basal ganglia Typically only appears 3 MONTHS after infection Minor - arthralgia - fever - elevated acute phase reactants (ESR, CRP, fibrinogen) - prolonged PR interval

Question 41

Presentation of rheumatic fever?

Answer 41

migratory polyarthritis, large joints carditis (tachycardia, murmur) valvular stenosis Syndenham Chorea (uncontrollable movements, facial grimace, emotional lability, frequently subtle) erythema marginatum - non-pruritic, erythematous, serpiginous, macular lesions with pale centers subcutaneous nodules

Question 42

Treatment of rheumatic fever?

Answer 42

1. Eradicate GAS (to prevent recurrence and progression to rheumatic heart disease) = IM Pen G benzathine q28 d prophylaxis 2. Symptomatic relief of arthritis = Naproxen 3. Rheumatic Carditis = ECHO, treat heart failure 4. Sydenham chorea = self-limited 5. Rash = self-limited, can use antihistamines for pruritus

Question 43

Duration of antibiotic prophylaxis in rheumatic fever?

Answer 43

Rheumatic fever with carditis and residual heart disease (eg valvular) = 10 years or until 40 years of age; Sometimes lifelong prophylaxis Rheumatic fever with carditis but no residual heart disease =10 years or until 21 years of age Rheumatic fever without carditis =5 years or until 21 years of age if discrepancy, choose whichever is longer

Question 44

what is rheumatic heart disease?

Answer 44

mitral valve stenosis/regurg ar risk for Infective Endocarditis given the rough surface of the scarred up valve (from the inflammation of carditis in rheumatic fever) Management and Prevention of Rheumatic Heart Disease 1. Echo - assess severity 2. Severe Heart Failure = usually due to severe mitral regurg 3. If AV heart block also present and persistent, permanent pacing

Question 45

What is treatment recommended for in Group A strep pharyngitis?

Answer 45

- Within 9 days of sx onset 1st line – amox 50mg/kg/d given daily or BID (OR Pen V) x 10 days Risk of non-adherence – penicillin G benzathine IM x 1 dose Non-anaphylactic allergy – amox challenge or cephalexin Confirmed anaphylaxis – macrolide or clinda (but be aware of resistance!)

Question 46

What is the treatment for invasive Group A Step?

Answer 46

Pen G + Clindamycin Consider IVIG in severe cases +/- Surgical debridement for necrotizing fasicitis (Must be lab confirmed - isolation of a group A strep from normally sterile site +/- severe disease clinically)

Question 47

Who gets chemoprophylaxis with iGAS?

Answer 47

Only offer to close contacts of confirmed severe iGAS, if exposed between 7 days prior to index case symptom onset and 24hr post abx Start chemoprophylaxis within 24hrs, up to 7 days from last contact Close contact definition: Household contacts who spent >4hrs/day or >20hrs total with case Contacts who shared a bed or had sex with index case Contacts with had direct mucous membrane contact IVDU sharing needles All children and staff in day home childcare (not preschools)

Question 48

3-year-old girl presents with frequent fevers between 38.5-40 degree lasting 1-3 days occurring once every 4-12 weeks. She’s had multiple courses of antibiotics for possible AOM and pharyngitis. She is well in between and growing well. What is the most likely diagnosis 1. FMF 2. CVID 3. Cyclic neutropenia 4. Recurrent viral infections

Answer 48

NEED TO CONFIRM ?Recurrent viral infections - most likely diagnosis

Question 49

3 week-old admitted with proven RSV+ bronchiolitis. Noted to be mildly tachypneic with retractions on exam, requiring O2 0.5L/min. On the second day of admission, the patient becomes febrile to 39C, exam otherwise unchanged. What is the likely etiology of the fever? a) strep pneumo b) mycoplasma c) RSV d) GBS

Answer 49

RSV

Question 50

What is bronchiolitis?

Answer 50

LRTI with obstruction of small airways caused by acute inflammation, edema, necrosis and increased mucous production

Question 51

What causes bronchiolitis?

Answer 51

RSV Other viruses: human metapneumovirus (HMPV), influenza, rhinovirus, adenovirus and parainfluenza

Question 52

Common age group for bronchiolitis diagnosis?

Answer 52

<2yrs

Question 53

Diagnosis of bronchiolitis?

Answer 53

Clinical Diagnosis: tachypnea, increased WOB, crackles/wheeze, hypoxemic, dehydration Preceding URTI or viral sick contact

Question 54

DDX of Wheeze

Answer 54

Bronchiolitis Asthma Pneumonia Laryngotracheomalacia Foreign body aspiration Gastroesophageal reflux Congestive heart failure Vascular ring Allergic reaction Cystic fibrosis Mediastinal mass Tracheoesophageal fistula Consider broader ddx if: atypical (severe resp distress, no viral URTI sx, frequent recurrences)

Question 55

Investigations for bronchiolitis?

Answer 55

NONE ARE INDICATED FOR MOST (unhelpful and lead to unnecessary admissions and ineffective therapies) 1. CXR: non specific patchy hyperinflation/atelectasis - Consider if dx unclear, rate of improvement not as expected or severity of disease raises other ddx (ie bacterial pneumonia) 2. NPA viruses: Don’t need, won’t change mgmt, only for IPC and tx decision (ie Oseltamivir for influenza) 3. CBC: not useful to predict serious bacterial infection 4. Bacterial cultures: Incidence concomitant SBI in bronchiolitis is low (UTI is same rate as healthy population). No routine UA screening. 5. Blood gas: only if concern for respiratory failure

Question 56

Admission criteria for bronchiolitis?

Answer 56

*severe respiratory distress (eg, indrawing, grunting, RR >60/min) * Supplemental O2 required to keep saturations >90% * Dehydration or history of poor fluid intake * Cyanosis or history of apnea * Infant at high risk for severe disease * Family unable to cope

Question 57

Which patient populations are at risk for severe bronchiolitis? (4)

Answer 57

<35 wk GA <3 mo old at presentation Hemodynamically significant cardiopulmonary disease Immunodeficiency

Question 58

Management of bronchiolitis?

Answer 58

Mainstay of Treatment: * Supplemental Oxygen (SpO2 >90). ?maybe role HFNC * Hydration (RR>60 risk of aspiration) NG and IV equal * Gentle superficial nasal suctioning frequently * Minimize handling If not improving: Epinephrine: may reduce hospitalizations, give dose and monitor High Flow Nasal Cannula Monitoring: * CRM for high risk patients for apnea monitoring * Intermittent monitoring: lower-risk pts + all pts once feeding well, weaning from supplemental O2 and improving WOB

Question 59

What therapies are NOT recommended in bronchiolitis?

Answer 59

1. Salbutamol (obstruction rather than constriction, immature bronchiolar smooth muscles) 2. Corticosteroids: inadequate evidence for benefit 3. Antibiotics: RARE to have true bacterial infx 4. Antivirals: ?Ribavrin – not recommended 5. 3% hypertonic saline nebs: does not impact LOS 6. Chest physiotherapy 7. Cool mist therapy/isotonic aerosol *Critically ill infants beyond the scope of the statement*

Question 60

Discharge Criteria for bronchiolitis?

Answer 60

Tachypnea and work of breathing improved Maintain O2 saturations >90% without supplemental oxygen Adequate oral feeding Education provided and appropriate follow-up arranged

Question 61

7-year-old new to Canada has routine bloodwork done. It shows the following: Anti-HBsAg positive Total Anti-HBcAg positive HBsAg negative HBeAg negative What is the MOST likely diagnosis Acute Hepatitis B Infection Recent “window period” Resolved Hepatitis B infection Immunized against Hepatitis B

Answer 61

Resolved Hepatitis B infection Since HBsAg and HBeAg negative, not currently infected Patient is likely immune from previous Heb B infection given marker for immunity (Anti-HBsAg +) and from marker of prev ious infection (total anti-HBcAg +)

Question 62

What does positive HBsAg mean?

Answer 62

Acute Infection of Hepatitis B

Question 63

What does positive Anti-HBsAg (= HBsAb) mean?

Answer 63

Immune (either from vaccine or previous infection)

Question 64

What does positive Total Anti-HBcAg mean?

Answer 64

remains positive indefinitely as marker of past HBV infection

Question 65

What does positive HBeAg (hepatitis B e-antigen) mean?

Answer 65

acute or chronic infection of hepatitis B

Question 66

5 month female, term, prev healthy, growing and developing well, formula fed. Seen in follow-up after 3 episodes of bronchiolitis. Parents say she feeds well but coughs with feeds. CXR done on the last two admissions showed RUL infiltrate. What is the next best step? A. Video fluoroscopic swallow study B. Laryngoscopy C. Chest xray D. CT chest

Answer 66

Video fluoroscopic swallow study - this patient is aspirating

Question 67

What is a Video Fluoroscopic Swallow Study (VFSS)?

Answer 67

Modified barium swallow Most common study for evaluating swallowing Focuses on the oral and pharyngeal phases of swallowing with an abbreviated look at the esophageal phase

Question 68

A 6-year old male with a history of CGD. He has had 2 weeks of fever, fatigue and cough. His CXR (not shown) has patchy infiltrates. He is started on CTX. After 5 days he remains febrile and has developed chest pain. A repeat XR shows osteolytic lesions of his ribs. His blood culture from admission remains negative. What is the most likely pathogen? Mycoplasma pneumoniae MRSA Candida Aspergillosis

Answer 68

Aspergillus

Question 69

What is chronic granulomatous disease?

Answer 69

defect in phagocyte NADPH oxidase resulting in impaired phagocytic killing of pathogens (no "phagocytic respiratory burst" to kill pathogens) characterized by recurrent, life-threatening bacterial and fungal infections and granuloma formation

Question 70

Genetics of chronic granulomatous disease?

Answer 70

X-linked (65%) - gp91phox deficiency most common Autosomal Recessive (35%)

Question 71

Age of presentation in chronic granulomatous disease?

Answer 71

usually before 5 yrs old

Question 72

Presentation of chronic granulomatous disease?

Answer 72

Recurrent bacterial & fungal infections! (in order of frequency): -Pneumonia, lung abscess - abscess (anywhere, most common perianal and liver) - suppurative adenitis -osteomyelitis, - bacteremia, fungemia - cellulitis/impetigo Inhaled fungal spores (eg Aspergillus) infect lungs (pneumonia) and may spread to ribs/spine (Osteomyelitis) Granuloma (mass of granulation tissue from repeated inflammation/infection) - form in GI and GU tract most commonly Inflammation - GI: Abdo pain, diarrhea, N/V, colitis, strictures/fistula, **IBD (40%)** - Liver: elevated liver enzymes and alk phos - GU: UTI, strictures, altered kidney function, bladder granulomata

Question 73

Which pathogens cause recurrent infections in patients with chronic granulomatous disease?

Answer 73

Patients with CGD are susceptible to catalase positive pathogens (know these 5!): Burkholderia cepacia Aspergillus Nocardia Staphylococcus aureus Serratia marcescens "Burks Are Notoriously Super Sick" these bugs drive the majority of infections in CGD other catalase pos organisms: Pasteurella Listeria Candida E. Coli

Question 74

Diagnosis of chronic granulomatous disease?

Answer 74

Neutrophil function test* then genotyping to confirm *neutrophil function test options: dihydrorhodamine (DHR) 123 (neutrophile oxidase burst) NitroBlue-Tetrazolium (NBT) test

Question 75

Treatment of chronic granulomatous disease?

Answer 75

1. Antimicrobial Prophylaxis Lifelong - TMP-SMX and and Itraconazole (antifungal) and Interferon (IFN) Gamma 2. Aggressive Treatment of Infections - CULTURE all infections - Empiric abx against gram-negative, gram-positive, Nocardia, and fungal, usually weeks of abx required - Surgical drainage of collections 3. Anti-Inflammatories - Steroids or Azathioprine - Sulfalazine if IBD 4. Hematopoietic cell transplantation – Successful HCT is a definitive cure for CGD

Question 76

5yo with clear bacterial meningitis. You plan on starting on ceftriaxone and vancomycin. How would you change your management if they were unimmunized? Ceftriaxone and meropenem Ampicillin Nothing Acyclovir

Answer 76

Nothing - CTX and Vacomycin are good empiric treatment for HiB

Question 77

What is meningitis?

Answer 77

Inflammation of the meninges may be bacterial meningitis or aseptic meningitis

Question 78

What age group has the highest incidence of meningitis?

Answer 78

First month of life

Question 79

Which pathogens cause meningitis in infants up to 3 months?

Answer 79

GBS, E. Coli and Listeria

Question 80

Which pathogens cause meningitis in children >2 months?

Answer 80

Streptococcus pneumoniae Neisseria meningitidis HiB if unimmunized Listeria if immunocompromised

Question 81

Presentation of meningitis?

Answer 81

fever, poor feeding, vomiting, irritability, lethargy Inconsolable crying, prolonged/worsening irritability or progressive lethargy *Headache *Nuchal rigidity (in older kids, uncommon in infants) *Impaired consciousness

Question 82

Diagnosis of meningitis?

Answer 82

CSF isolates bacteria by PCR or culture (or bacteremia + CSF pleocytosis)

Question 83

what are the contraindications to lumbar puncture?

Answer 83

- Coagulopathy (elevated INR) - cutaneous lesions at the proposed puncture site - signs of herniation or - unstable clinical status such as shock

Question 84

When should you defer a lumbar puncture to obtain neuroimaging first?

Answer 84

When you are concerned for risk of brain herniation (pts with focal CNS lesions can get brain herniation following an LP) * papilledema * focal neurological signs * decreased level of consciousness or coma

Question 85

Complications of meningitis?

Answer 85

SIADH increased ICP

Question 86

Empiric therapy for meningitis in neonate?

Answer 86

Ampicillin and Cefotaxime

Question 87

Treatment of Meningitis in a child >2mo?

Answer 87

Empiric Ceftriaxone AND vancomycin add ampicillin to cover for Listeria if immunocompromised

Question 88

Duration of antibiotics depending on the pathogen in meningitis?

Answer 88

*Strep pneumo meningitis - 10-14d *Hib meningitis - 7-10d *Neisseria meningitidis meningitis - 5-7 days *GBS meningitis - 14-21d (longer if cerebritis or ventriculitis is present)

Question 89

When do we use steroids in managing meningitis?

Answer 89

Use dexamethasone if: Hib Meningitis (give 2hr before antimicrobials to reduce severe hearing loss) Streptococcus pneumoniae meningitis TB meningitis

Question 90

What steroid and dose do we use in meningitis?

Answer 90

Dexamethasone 0.6mg/kg/day div q6h give around the time of antimicrobials

Question 91

How does haemophilus influenzae appear on gram stain? (need this info to be able to decide which meningitis patient needs dexamethasone)

Answer 91

gram negative coccobacilli

Question 92

How does streptococcus appear on gram stain? (need this info to be able to decide which meningitis patient needs dexamethasone)

Answer 92

gram positive diplococci (Neisseria are gram neg diplococci, would NOT presumptively give steroids)

Question 93

when is a repeat lumbar puncture indicated in meningitis patients?

Answer 93

Repeat LP at 24-48hr after initiation of therapy to document CSF sterilization if: *GBS Meningitis *E coli Meningitis

Question 94

Follow up in meningitis patients?

Answer 94

formal audiology testing immediately after diagnosis

Question 95

when in meningitis prophylaxis required?

Answer 95

Haemophilus influenzae type b if household contacts who are unimmunized or <12mo (uncompleted primary Hib vaccine series) --> Rifampin ppx for all household members Neisseria meningitidis - all household members receive Rifampin ppx PLUS meningococcal vaccine should be given

Question 96

what is the prophylaxis antibiotic in meningitis?

Answer 96

Rifampin

Question 97

1y old with exudative pharyngitis. What is the most likely etiology? Viral respiratory infection Haemophilus influenzae Group A strep Mononucleosis

Answer 97

Viral respiratory infection - most sore throats are VIRAL pharyngitis (30% are group A strep)

Question 98

What causes acute pharyngitis?

Answer 98

usually VIRUSES most common bacterial cause is Group A Strep (strep pyogenes) (30% of sore throats)

Question 99

Presentation of GAS pharyngitis?

Answer 99

- Fever - Mod/severe sore throat - Very tender anterior cervical lymphadenopathy - ABSENCE of cough - Rhinorrhea - Inflamed or purulent tonsils

Question 100

Why do we need to "choose wisely" on testing for strep throat?

Answer 100

children can be asymptomatic carriers of GAS - a positive swab triggering antibiotic therapy even tho they likely have viral pharyngitis

Question 101

Indications to swab for strep throat?

Answer 101

in 3-13 year olds: CENTOR Criteria ≥ 3, do throat swab 1pt for each of: - exudate or swollen tonsils - tender or swollen anterior cervical lymph nodes - fever - NO cough score of ≥ 3 means 30-50% probability of GAS

Question 102

Diagnosis of GAS pharyngitis?

Answer 102

- POC rapid antigen test swab ○ 1hr turn around time and 95% specificity -Gold standard if bacterial culture from tonsillar swab (assuming you used CENTOR criteria to choose who to swab) (Do NOT use Anti-streptolysin O titer (ASOT) for dx of GAS pharyngitis as it cannot distinguish GAS carriage from active infection)

Question 103

Treatment of GAS pharyngitis?

Answer 103

GAS pharyngitis is self-limited, but we treat culture-proven GAS to prevent acute rheumatic fever and suppurative complications Treat within 9 DAYS of symptom onset AMOXICILLIN 50mg/kg PO qdaily x 10 d (or penicillin) Provide delayed antibiotic prescriptions (i.e., to be filled only for children with positive cultures)

Question 104

Complications of Strep pharyngitis?

Answer 104

Suppurative complications ○ Peritonsillar abscess ○ Retropharyngeal abscess ○ Sepsis Non-suppurative complications ○ Post-streptococcal glomerulonephritis ○ Acute rheumatic fever (ARF) *antibiotics prevent suppurative complications (abscess) and acute rheumatic fever, but not post-strep glomerulonephritis *M protein strains of GAS more likely to cause ARF

Question 105

when would you test for GAS pharyngitis in a <3yr old?

Answer 105

very rare! only if concern for Scarlett Fever

Question 106

when is the only time you would treat strep throat empirically?

Answer 106

Northern and Indigenous Communities - higher risk for ARF empirically treat if CENTOR score is 3 or more if testing available, then swab any child >3yrs old with a sore throat

Question 107

3 year old boy presenting with fever, anorexia, fatigue and abdominal pain. Was at his uncle’s farm and had unpasteurized goat milk. On exam he has splenomegaly. Blood culture came back positive for gram negative coccobacilli. What is the likely cause? Brucellosis Tularemia Bartonella Listeria

Answer 107

Brucellosis brucellosis and tularemia are both gram neg coccobacilli that cause zoonotic infections (from animals) tularemia is from rabbits or ticks Brucellosis is from cows, sheep, goats ("farm animals")

Question 108

Risk factors for Brucellosis (gram negative coccobacilli)?

Answer 108

consumption of unpasteurized dairy (cow, goat, sheep) direct contact with infected animal *incubation period 2-4 weeks, or months*

Question 109

Presentation of brucellosis?

Answer 109

fever, malaise, night sweats (associated with a strong, peculiar, moldy odor), bacteremia arthralgia hepatosplenomegaly (50%) elevated AST/ALT anemia leukopenia or leukocytosis thrombocytopenia

Question 110

Diagnosis of brucellosis?

Answer 110

Culture (blood, body fluid, tissue) >2 weeks apart, showing ≥4-fold rise in Brucella antibody titer presumptive diagnosis may be made by - antibody titer ≥1:160 via standard tube agglutination or - PCR Brucella DNA positive

Question 111

treatment of brucellosis?

Answer 111

6 weeks of doxycycline and rifampin (if <8yrs old, Septra and rifampin)

Question 112

presentation of tularemia?

Answer 112

fever + tender lymphadenopathy recent contact rabbit or tick (incubation period 3-5 days versus brucellosis which is 2-4 weeks)

Question 113

treatment of tularemia?

Answer 113

Gentamicin if severe Ciprofloxacin (or doxycycline) if mild infection

Question 114

3yo presents 2 days post URTI symptoms and 1 day post amoxicillin for AOM. Develops pruritic migratory rash. Also has vomiting. No lip swelling or resp symptoms. Examines well other than the rash and resolving right AOM. What do you do? Prescribe PO steroids Change to clarithromycin Stop amoxicillin, start cetirizine Prescribe topical steroids

Question 115

Review CPS beta lactam allergy https://cps.ca/documents/position/beta-lactam-allergy

Question 116

6 week old infant presents to the ED with features concerning for meningitis. A lumbar puncture is done and the CSF shows decreased glucose, increased protein, and gram-positive bacilli. What is the most likely organism? a) Listeria b) Haemophilus influenzae c) Neisseria meningitidis d) Klebsiella pneumoniae

Answer 116

Listeria GBS, Listeria and E Coli cause of meningitis in <90 days Listeria is gram pos bacilli CSF features of bacterial meningitis = high protein, low glucose, elevated PMNs (100 - 50 000)

Question 117

You have been following a 13y M with a BMI of 35kg/m2. He has been spending the majority of his time sitting in front of his computer and playing video games. Recently, he has complained of pain and swelling at his lower buttocks. On examination, you note swelling and tenderness in the gluteal cleft, with a pinpoint opening and no active drainage. Which of the following imaging tests should you do? Bone Scan MRI CT Ultrasound

Question 118

What is a pilonidal cyst?

Answer 118

person sits for extended periods -- > skin at gluteal cleft stretches --> hair follicles break and pores open ("pit") --> pores collect debris/hair from bum/back/head --> debris move deeper into the pore --> fistulas and abscesses form --> pus may discharge out of pits

Question 119

presentation of pilonidal cyst?

Answer 119

sudden onset pain at gluteal cleft, esp when sitting. Can have mucoid, purulent or bloody discharge Fever and malaise if undrained abscess

Question 120

risk factors for pilonidal cyst?

Answer 120

Overweight/obese Sedentary lifestyle or prolonged sitting Deep gluteal cleft Increased hair density in gluteal cleft Coarse hair profile Local trauma or irritation Family history

Question 121

Treatment of pilonidal cyst?

Answer 121

Sitz baths and back/bum hair removal Laser hair removal once the tracts have closed Antibiotic if cellulitis or abscess incision and drainage for abscesses Surgery (destruction of all sinus tracts and skin pores (pits)) indicated if recurrent pilonidal abscesses

Question 122

15yo teenage girl with 6 wks of fever, cervical lymphadenopathy and hemoptysis. Entire family was treated for TB when she was 8yo - she has been well since. How do you confirm the most likely diagnosis a) TST b) CXR c) CT d) sputum for acid fast bacilli

Answer 122

Sputum for acid-fast bacilli culture is definitive diagnosis in TB

Question 123

what is tuberculosis?

Answer 123

- Granulomatous disease caused by mycobacterium tuberculosis (Mtb) - gram-positive rod on acid-fast stain (shows up bright red) - Strict aerobe - Resists weak disinfectants and antibiotics

Question 124

Risk factors for tuberculosis?

Answer 124

-Indigenous children in overcrowded, poorly ventilated houses - Foreign-born children from endemic countries

Question 125

Define latent TB infection

Answer 125

Latent TB Infection (LTBI) = dormant infection, infected individual is asymptomatic and non-infectious TB Disease = bacterial replication, typically symptomatic

Question 126

What vaccination is available for tuberculosis?

Answer 126

Bacille-Calmette-Guérin (BCG) is a live, attenuated vaccine given at birth to infants residing in Canadian jurisdictions considered to have high rates of smear-positive TB BCG is contraindicated for infants with suspected or fam x of immunodeficiency

Question 127

how is tuberculosis transmitted?

Answer 127

Inhaling aerosolized droplets of Mtb, usually from cough expectorations by an adult or adolescent Source cases with cavitary disease are highly infectious and risk for transmission increases when sputum has a high density of Mtb (i.e., when bacilli are seen on the sputum smear)

Question 128

A patient has a known contact with infectious TB - what are they at risk for and when?

Answer 128

At highest risk for primary infection. Disease most likely to occur within one year of initial infection.

Question 129

A patient with remote residence in TB endemic area - what are they at risk for?

Answer 129

Latent TB Infection. Ongoing risk for reactivation as an otherwise healthy older child or as a child with an immune-suppressing condition.

Question 130

Patient with residence in or travel to area with high TB rates, even when a child has been previously treated for Latent TB infection - what are they at risk for?

Answer 130

Continued exposure to cases of clinical TB disease increases risk for acquiring new infection

Question 131

Who is most susceptible to tuberculosis infection

Answer 131

Children < 4 are most susceptible, with highest risk <1yrs (MUST know this)

Question 132

Presentation of Primary TB?

Answer 132

>90% are asymptomatic/mildly symptomatic pneumonia with hilar/mediastinal lymph nodes on CXR progressive cough fever wt loss/FTT hemoptysis Painless, fixed, enlarged cervical lymph nodes (Lymphadenitis) Meningitis (aLOC, CN palsy, HA, vomiting, sz, CSF pleocytosis with LYMPHOCYTE predominance) joint effusion, back pain (osteoarticular infections (eg vertebral TB)) sepsis unresponsive to antibiotics Miliary nodules or a ‘tree-in-bud’ pattern on chest radiograph are typical, but a diffuse alveolar pattern or acute respiratory distress syndrome can also occur

Question 133

How does latent TB cases present?

Answer 133

>90% of latent TB cases never develop disease if reactivation of tuberculosis, usually >10yrs - cavitary lesions on CXR - meningitis - enlarged nontender cervical LN - Liver/spleen Granulomas/abscesses - Osteomyelitis -Peritonitis - Pleural effusion Disseminated Disease is much rarer than with early primary symptomatic TB

Question 134

What are triggers for reactivation disease in latent TB infections?

Answer 134

Usually >10 years old, after many yrs of infection Sometimes triggered by puberty or immunosuppression - HIV, steroids, biologics, diabetes, malnutrition

Question 135

how to screen for tuberculosis?

Answer 135

Tuberculin Skin Test (TST) or Interferon-gamma release assays (IGRA) = QuantiFERON-TB Gold in-Tube and T-spot *screening tests tell you if the patient is infected, does NOT differentiate active vs latent TB infection

Question 136

how to diagnose tuberculosis?

Answer 136

Sputum Culture -> sent for acid-fast bacilli (AFB) stain and culture - Induce sputum production by inhaling hypertonic saline or obtain sample via bronchoscopy - If too young, use fasted gastric aspirates on 3 consecutives mornings

Question 137

What other test is required after you diagnose tuberculosis?

Answer 137

HIV serology

Question 138

do we prefer IGRA or TST for tuberculosis screening?

Answer 138

IGRA (more specific than TST) if <2yrs, use TST (more sensitive, and infants/young children high risk for disease progression) congenital TB, use BOTH TST and IGRA (bc such low sensitivity in infants)

Question 139

how does the tuberculin skin test work?

Answer 139

purified protein derivative (PPD) from heat-inactivated Mtb is injected intradermally Positive test = type IV hypersensitivity reaction (wheal) forms

Question 140

what constitutes a positive TST test?

Answer 140

≥10 mm induration ≥5 mm if contact of known TB case or immunocompromised Infants/young children may have 0 to <5 mm induration

Question 141

Reasons for false positives in TST?

Answer 141

cross-reactive antigens from non-tuberculous mycobacteria (NTM) BCG vaccine

Question 142

Reasons for false negatives in TST and IGRA?

Answer 142

immunosuppressed or very young/infant

Question 143

Reason for false positive in IGRA?

Answer 143

recent tuberculin skin test (TST)

Question 144

specificity of TST and IGRA?

Answer 144

TST 60% - lower bc of cross-reactivity with non-TB infections and the vaccine IGRA >95% - much more likely to have TB if positive screen

Question 145

How soon do you need to report TB to public health authority?

Answer 145

within 48 h of diagnosis

Question 146

You have identified a contact of an index case of infectious tuberculosis - what do you do?

Answer 146

isolate them CXR TST identify the index case's TB strain drug sensitivities prophylaxis (depends on age)

Question 147

TB contact who is <5 years of age with an initial TST of <5 mm - what do you do?

Answer 147

preventive prophylaxis (‘window prophylaxis’) with one TB drug ○ Drug must be sensitive to the strain of the index case Second TST 8-10 weeks following patient's last contact with the index case (“break of contact”(BOC)) BOC TST <5 mm, discontinue window ppx if positive, complete full course of ppx

Question 148

TB contact who is > 5 yrs - what do you do?

Answer 148

Prescribe prophylaxis ONLY if baseline TST or 8-10 week post-contact TST are positive (Even if no symptoms, physical exam and chest radiographs appear normal)

Question 149

how do you treat active tuberculosis?

Answer 149

4-drug therapeutic regimen: Isoniazid, Rifampin, Pyrazinamide, Ethambutol (INH, RIF, PYR, ETH)

Question 150

how do you treat latent TB infection (to prevent reactivation)?

Answer 150

CPS just states one of isoniazid, rifampin or rifapentine/isoniazid Tx depends on age: - Isoniazid + rifapentine x12 weekly observed doses or - Rifampin for 4 months or - Isoniazid for 9 months

Question 151

side effect of isoniazid?

Answer 151

peripheral neuropathy (and hepatotoxicity like other TB abx)

Question 152

side effect of rifampin?

Answer 152

drug interaction (Eg with OCP) turns body fluids orange (and hepatotoxicity like other TB abx)

Question 153

side effect of pyrazinamide?

Answer 153

hepatotoxicity like isoniazid and rifampin

Question 154

side effect of ethambutol?

Answer 154

Optic neuropathy (color blindness, decreased acuity, decreased visual fields)

Question 155

why are indigenous peoples disproportionately affected by TB?

Answer 155

* Poverty * Crowded, inadequate housing * Food insecurity * Health inequities, barriers to health access * Historical trauma (forced confinement of TB hospitals/sanatoria) * Stigma * Exposure to indoor mold, air pollutants ie tobacco/cannabis smoke * Barriers to health services Stigma may prevent seeking testing

Question 156

what are 2 sustainable, community-driven approaches to TB elimination for indigenous peoples?

Answer 156

Improving the "socio-economic conditions* that allow TB to proliferate (poverty, residential crowding, food insecurity, access to healthcare) *Indigenous Self determination*, where indigenous peoples "create programs that meet their needs based on a holistic, culturally based worldview"

Question 157

what can institutions do to reduce TB in indigenous peoples?

Answer 157

embrace truth and reconcillation culture safety training reduce barriers (care closer to home, using patient navigators, culturally appropriate operational practices eg., appointment recall management)) indigenous healing practices incr indig ppl working in organization

Question 158

what are Ghon focus and Ghon complex? Describe pathophys of primary TB infection

Answer 158

Primary TB infection is established when Mycobacterium tuberculosis (Mtb) bacilli are inhaled and replicate in the pulmonary alveoli (Ghon focus)--> Mtb engulfed by macrophages --> granuloma formation --> hilar or mediastinal lymphadenopathy (Ghon complex) --> spread of Mtb to other lymph nodes and/or hematogenous dissemination to other organs --> Mtb lies dormant but viable in calcified granulomas and patient asymptomatic = "Latent TB infection" = TST/IGRA positive, normal CXR (may have granuloma), normal exam, non-infectious

Question 159

4 year old boy admitted with postauricular swelling, erythema, otalgia, ear pushed forward, fever. Has a right sided headache. Admitted and started on IV CTX. No improvement after 24 hours. No neuro deficits/focal signs on exam. Next step? MRI head CT temporal bone IV ceftazidime and flagyl Tympanocentesis

Answer 159

CT temporal bone this pt has mastoiditis - need to look for complications such as abscesses, clots, osteomyelitis, etc.

Question 160

3 year old female has been treated for pinworms with two treatments of pyrantel pamoate spaced 2 weeks apart. She presents with perianal pruritis. What is the most appropriate treatment? Treat her entire daycare group with a single dose of Ivermectin Seal all her clothes in a bag for 2 weeks Treat her and her entire family with two doses of pyrantel pamoate Treat her with topical perianal 1% permethrin cream

Answer 160

Treat her and her entire family with two doses of pyrantel pamoate

Question 161

how do pinworms present?

Answer 161

perianal pruritis

Question 162

how to dx pinworms?

Answer 162

observing perianal parasite eggs or worms Tape against perianal area early in morning often shows eggs

Question 163

how to treat pinworms?

Answer 163

Albendazole (alternatives: mebendazole or pyrantel pamoate) all are 2 treatments, 2 weeks apart machine wash in HOT water all clothes, towels, etc vacuum all dust to prevent eggs from scattering hand hygiene

Question 164

how to treat recurrent pinworms?

Answer 164

treat entire family

Question 165

5-year-old with GAS pharyngitis started on antibiotics. When can he return to school? A. return when feeling well B. Return after 24 hours of antibiotics C. Return after 72 hours of antibiotics D. Return when antibiotic course completed.

Answer 165

Return after 24 hours of antibiotics - no longer contagious at this point

Question 166

3 week old with fever and poor feeding presenting to ED with positive urinalysis, started on cefixime. Improving after 24 hrs, culture pre abx positive 10^8 CFU for E.coli resistant to TMP-SMX, cephalosporins and sensitive to gent, ciprofloxacin. What will you do next? A) Repeat UA and UCx B) Change to nitrofurantoin C) Change to IV gent D) Change to po ciprofloxacin

Answer 166

Change to IV gent pts with UTI requiring hospitalization get IV gent pts <2mo old, get r/o sepsis treatment which is IV abx (typically IV amp and gent for this age group) since we know the bug and sensitivities, can admit with IV gent would not do PO abx for all the reasons above (CPS statement on UTI is in Nephro flashcards)

Question 167

3 year old boy who was treated for c diff 2 months ago with metronidazole. He presents with 5 watery stools per day, he is otherwise well. What is the most appropriate management? Supportive PO Vanco PO metronidazole IV metronidazole

Answer 167

PO metronidazole Repeat same regimen used for initial episode or, PO vancomycin 40 mg/kg/day div QID x10 days trying to use less vanco to avoid vanco resistant organisms (VRE)

Question 168

6mo baby and mom come in. They are going to California where there is a measles outbreak and mom wants to vaccinate. What do you tell her? Baby too young to be immunized with MMR. Baby can be immunized now with MMR in place of 12mo MMR. Baby can be immunized now with MMR and again at 12mo. Baby can be immunized one month after 6mo vaccines.

Answer 168

Baby can be immunized now with MMR and again at 12mo In a measles outbreak, 6 months and older may receive MMR vaccine, but they still need their primary series at 12 and 18 mo

Question 169

3-year-old child with recurrent episodes of acute otitis media requiring treatment. You are concerned about the possibility of antibiotic resistance. How does strep pneumo develop resistance? Beta-lactamase production Ribosome something Mutation in a protein component of the cellular wall MCR-1 Gene mutation

Answer 169

Mutation in a protein component of the cellular wall allows strep pneumo to be resistant to beta-lactam antibiotics this is bc beta-lactam antibiotics bind enzymes needed to synthesize the cell wall

Question 170

6y female presents with complaints of burning vulvar discomfort, intermittent wetness, and yellow discharge. On examination, you notice erythema to labia minora, redness to the perineum, and yellow staining on undergarment. What treatment would you use? Oral amoxicillin Encourage improved hygiene practice Topical antifungal Oral antifungal

Answer 170

oral amoxicillin GAS vulvovaginitis presents with yellow/green discharge, red and painful vulva Encourage improved hygiene practice is the treatment for non-infectious vulvogainitis. you would still recommend hygiene but need abx to treat bacterial cause

Question 171

presentation of bacterial vulvovaginitis?

Answer 171

yellow/green vaginal discharge foul smelling red, painful vulva

Question 172

presentation of non-infectious vulvovaginitis?

Answer 172

Vulvar itching, local irritation, and/or odor no vaginal discharge, or scant, white or clear, mucoid discharge

Question 173

pathogens causing bacterial vulvovaginitis?

Answer 173

GAS (strep pyogenes) Enteric organisms (shigella, yersinia) STIs Candida - uncommon Systemically unwell (measles, varicella, EBV, tuberculosis)

Question 174

treatment of bacterial vulvovaginitis?

Answer 174

use vaginal culture results to guide management hygiene measures for all pts strep pyogenes = amoxicillin or penicillin shigella/yersinia need tx, other enteric org don't STI - tx plus report candida - uncommon cause of infection in pre-pubertal child, and over-diagnosed/treated

Question 175

treatment of non-infectious vulvovaginitis?

Answer 175

Hygiene Measures (sx will resolves within 2-3 weeks) If persistent or worsening (eg progression to purulent discharge or bleeding): -Assess for foreign body -Vaginal culture (STIs, group A strep, Candida) and treat accordingly If negative culture but purulent discharge, empiric coverage with amox for 10d)

Question 176

Previously well 7yo male living on a farm presents with fever (Temp 39), abdominal pain, bloody stools (no vitals given). Stool culture positive for Yersinia. What is the most appropriate management? Septra Flagyl Cefixime Supportive care

Answer 176

Supportive Care we only tx yersinia if neonate, immunocompromised, sepsis, disseminated disease

Question 177

14y teen girl recent ear piercing. Now has redness, tenderness, loss of perichondral contours. No fever. What is the best management? IV Pip Tazo IV Cefazolin IV Ceftriaxone IV Clindamycin

Answer 177

IV Pip Tazo Pseudomonas causes puncture wound infections (eg osteomyelitis from stepping on a nail or EAR PIERCING "Perichondritis" ) Perichondritis = infection after piercing with gun (rather than sterile straight needle) then exposure to pseudomonas such as through fresh water or hot tub presents as erythematous, swollen and tender pinna, may rapidly progress to produce necrosis of the cartilage

Question 178

Which infections are most commonly caused by pseudomonas?

Answer 178

cystic fibrosis pneumonia hospital-acquired infections -Ventilator Associated Pneumonia (VAP) - catheter-associated urinary tract infection (CAUTI) - catheter-related bloodstream infection (CLABSI) folliculitis (from hot tubs) puncture wound (eg osteomyelitis from stepping on a nail or EAR PIERCING "Perichondritis" ) otitis externa (swimmer's ear) from fresh water lakes complicated UTI endocarditis in IVDU

Question 179

treatment of pseudomonas infections? (5)

Answer 179

IV Options - piperacillin-tazobactam - ceftazidime or cefepime - Meropenem (all carbapenems cover pseudomonas EXCEPT ertapenem) PO Option - Ciprofloxacin

Question 180

treatment of MSSA?

Answer 180

Cefazolin or cloxacillin

Question 181

treatment of MRSA? (6)

Answer 181

Vancomycin TMP/SMX Linezolid (100% PO bioavailability) Clindamycin Doxycycline (don't give <8yrs bc dental enamel hypoplasia and teeth discolouration) Daptomycin but can't give in lung infections (Lung surfactant disables Daptomycin)

Question 182

what are the MRSA risk factors? (7)

Answer 182

1. Prev MRSA infection in child or family contact 2. Family member is a healthcare worker 3. First nations child or pacific island origin 4. Day care attendance 5. Prolonged hospitalization in the last 1 year 6. Critically ill 7. Chronic skin condition (Atopic eczema)

Question 183

what antibiotic treats extended-spectrum beta-lactamases (ESBL)?

Answer 183

Meropenem

Question 184

3 year old boy is diagnosed with pertussis. He has a 3 month old brother who has gotten his first dose of the DTap-IPV-HB. What is your treatment for the brother? Treat with azithromycin Do a nasopharyngeal swab and treat if positive Treat if symptoms arise Do nothing

Answer 184

Treat with azithromycin - given only has had one immunization thus far, is at high risk from the affected contact. Pertussis PEP to asymptomatic household contacts within 21 days of onset of cough can prevent symptomatic infection. Coughing (symptomatic) household members should be treated as if having pertussis. Given young age, azithromycin preferred over clarithromycin or erythomycin given risk of developing IHPS (infantile hypertrophic pyloric stenosis).

Question 185

Pertussis topic review

Question 186

15yo teenage girl with 6 wks of fever, cervical lymphadenopathy and hemoptysis. Entire family was treated for TB when she was 8yo - she has been well since. What is the most likely diagnosis? A- SLE B- TB C- Blastomycosis D- Bronchiectasis

Answer 186

TB

Question 187

What is cat scratch disease?

Answer 187

zoonotic infection of Bartonella henselae (Gram negative rod-shaped bacillus) transmitted via kittens and cats

Question 188

Transmission of Bartonella henselae?

Answer 188

cat scratches (kittens with fleas are highest risk) A cat flea is how bartonella henselae is transmitted between cats Cat grooms --> bacteria bartonella henselae gets on teeth and claws --> cat bites or scratches a human --> Transmitted to humans

Question 189

presentation of Bartonella henselae infection?

Answer 189

Lymphadenitis - unilateral, tender, regional (not generalized) - axilla, cervical, inguinal Conjunctivitis - ipsilateral Fever, fatigue, headache, loss of appetite abdo pain - granulomas in liver, spleen meningitis/eye problems (neuroretinitis) hx of erythematous papules at site of cat scratch --> regress and lymphadenitis develops in 2-4 weeks

Question 190

diagnosis of cat scratch disease?

Answer 190

IgM and IgG serology for Bartonella henselae bacteriat

Question 191

treatment for cat scratch disease?

Answer 191

Azithromycin for adenitis (may shorten disease) Doxy + Rifampin for neuroretinitis/CNS

Question 192

Which do you EXCLUDE from school? Hepatitis A, day 10 of symptoms Varicella exposed 3 days ago, unimmunized child Pertussis, day 5 of treatment Campylobacter with diarrhea

Answer 192

Campylobacter with diarrhea - for diarrheal illnesses, need to wait until resolution of diarrhea to go back to school WRONG ANSWERS Hepatitis A, day 10 of symptoms - can go back to school after 1 week since onset of jaundice/illness Varicella exposed 3 days ago, unimmunized child - incubation period is 14-16 days, immunocompromised children should get post exposure prophylaxis Pertussis, day 5 of treatment - can go back to school after 5 days of treatment

Question 193

How long until kids can return to school if they have pertussis, mumps, or measles?

Answer 193

pertussis = 5 days of treatment mumps = 5 days after parotid gland swelling measles = 4 days after rash onset

Question 194

How long until kids can return to school if they have diarrhea?

Answer 194

resolution of diarrhea before returning to school resolution of diarrhea AND negative stool cultures of: -E coli - typhoid fever (salmonella typhi) - shigellosis resolution of diarrhea only for the rest: - non-typhi salmonella - C diff -campylobacter -yersinia -rotavirus

Question 195

when can kids with strep throat or impetigo go back to school?

Answer 195

after 24hrs of treatment

Question 196

when can a kid with hepatitis A go back to school?

Answer 196

after 1 week since onset of jaundice or illness

Question 197

when can chicken pox/varicella go back to school?

Answer 197

all lesions are crusted over (CPS also says return to school at any stage of rash, but chicken pox is contagious 2 days before rash and during rash) *parking lot*

Question 198

Girl with swollen eyelid with painful extraocular movements. What is the most likely etiology of her condition? Ethmoid sinusitis Dental caries Bacterial conjunctivitis

Answer 198

Ethmoid sinusitis Complication of bacterial sinusitis is orbital cellulitis hallmark of orbital cellulitis is painful eye movements

Question 199

Term neonate on day 14 of IV acyclovir for an HSV-positive vesicular rash near her eye. Full septic work up, including LP, was negative. Next best step? Stop IV acyclovir Continue IV acyclovir until day 21 Change to PO acyclovir and complete a 6 month course Repeat LP

Answer 199

Stop IV acyclovir tx for SEM HSV is 14 days of IV acyclovir only CNS HSV needs rpt LP and 6mo of suppressive PO acyclovir

Question 200

which neonates are at risk for HSV infection?

Answer 200

Consider all neonates at risk as most mothers (75-90%) are unaware of their infection with HSV Can't miss it! Significant mortality risk even with treatment!

Question 201

6d term baby, uncomplicated pregnancy admitted to NICU with fulminant sepsis, culture negative. Mom had “UTI” symptoms the last week of pregnancy. What is the most likely diagnosis? HSV Congenital toxoplasma Congenital syphilis Congenital CMV Congenital rubella Congenital varicella HIV

Answer 201

HSV

Question 202

which ways can neonates contract HSV?

Answer 202

Intrapartum (during delivery) - most common Postnatal ○ Family or healthcare workers shedding orolabial herpes or asymptomatic shedding of HSV-1 (eg. kissing babies) In utero (very rare <5%) - Congenital HSV ○ Hydrops fetalis, fetal death ○ If survive, triad of skin vesicles/scarring, chorioretinitis, and severe CNS (microcephaly, cystic encephalomalacia, hydrancephaly)

Question 203

HSV infections can be: ○ First-episode primary infection (mother has no serum antibodies to HSV-1 or -2 at onset) ○ First-episode nonprimary infection (mother has a new infection with one HSV type in the presence of antibodies to the other type) ○ Recurrent (mother has pre-existing antibodies to the HSV type that is isolated from the genital tract) what are the transmission rates to neonates for each?

Answer 203

First-episode primary (60% transmission rate to baby) Neonates at highest risk for acquiring HSV bc their mother had no pre-existing neutralizing antibodies to transmit First episode Non-Primary (30%) crossreactive antibodies are present, reducing transmission risk Recurrent (<2%) lowest risk bc Mom passes on antibodies

Question 204

Work up for neonatal HSV

Answer 204

Viral swabs for culture from oropharynx, nasopharynx, skin lesions, mucous membranes Blood for PCR – not serology Lumbar puncture: cell count, chemistry, HSV PCR *CSF studies may be negative, but does not rule out disease* Evaluation for extent of disease: LFTs, coags, lactate, renal function

Question 205

What are modifiable risk factors that we can influence to reduce the risk of transmission of HSV to babies from mothers?

Answer 205

deliver by C/S maternal acyclovir during preg, from 36wks gestation avoid fetal scalp probe, forceps, vacuum (reduce blood mixing) avoiding early or prolonged rupture of membranes

Question 206

Broadly speaking, how do neonates with HSV present? (which day of life is more common as well - DOL)

Answer 206

usually within the first 4 weeks 1. Skin, eye and mucous membrane (SEM) (7-14 DOL) 2. CNS HSV (14-21 DOL) 3. Disseminated HSV (particularly liver and lung) (5-10 DOL)

Question 207

how does CNS HSV present?

Answer 207

neonate in first 4 wks of life Can be subtle Seizures, lethargy, irritability, tremors, poor feeding, temperature instability (fever or hypothermia), and full anterior fontanel

Question 208

how does Skin, Eye and Mucous membrane (SEM) HSV present?

Answer 208

neonate in first 4 wks of life vesicles (clustered, coalesced) ulcers to mouth, palate, tongue

Question 209

work up for neonatal HSV?

Answer 209

HSV PCR of CSF, skin lesions, mucous membranes and blood -CNS HSV can be very subtle! Any pt with suspected HSV needs LP! * EEG, Head CT/MR (HSV meningitis) * liver enzymes (HSV hepatitis) * CBC for platelets (thrombocytopenia) * Kidney fxn (baseline before starting acyclovir) * Coagulopathy

Question 210

If CSF PCR is negative but suspicious for HSV, what can you do?

Answer 210

2 options -Repeat CSF PCR within 72 hours of starting acyclovir (can be false negative in first 24h) -Simply complete 21 days of IV acyclovir for presumed CNS HSV

Question 211

how does disseminated HSV present?

Answer 211

neonate with: - unexplained elevated LFTs (hepatitis) - pneumonia Neonatal sepsis in first week of life -Fever, hypothermia, irritability, lethargy -respiratory distress, apnea, pneumonia -abdominal distension, hepatomegaly, hepatitis, ascites - Thrombocytopenia affects multi-organs, esp liver and lungs may not have vesicles/skin findings

Question 212

why is it important not to miss neonatal hsv?

Answer 212

high risk of mortality eg disseminated HSV is >80% mortality untreated, 29% mortality even with treatment

Question 213

Diagnosis of neonatal HSV?

Answer 213

HSV PCR of muc membranes or CSF note: ○ swab of mucous membranes must be >24hr after delivery (otherwise contaminated from Mom) ○ CSF PCR can be negative in the first 24-48hr of CNS HSV infection

Question 214

treatment of neonatal HSV?

Answer 214

Acyclovir 60mg/kg/day IV divided q8hrs: Disseminated – 21 days CNS – 21 days Repeat LP at end of treatment; if still positive, need to extend acyclovir Skin Eye Mouth – 14 days

Question 215

if ocular involvement in neonatal HSV, you treat with IV acyclovir and what else?

Answer 215

topical 1% trifluridine + optho consult

Question 216

duration of treatment for neonatal SEM HSV?

Answer 216

14 days of IV acyclovir then stop

Question 217

duration of treatment for neonatal CNS HSV?

Answer 217

21 days minimum of IV acyclovir ○ Repeat LP near end of 21 day course § If PCR positive, extend treatment with weekly CSF testing § Only stop IV acyclovir when CSF negative then Suppressive PO acyclovir x 6 months

Question 218

asymptomatic newborn, mom with active HSV lesions - approach?

Answer 218

if Vaginal birth and after rupture of membranes (ROM) = 10 days acyclovir regardless of swab results *swab, bc if positive, need lumbar puncture to test CSF (will need to extend acyclovir duration if CNS HSV) Maternal recurrent HSV = swab, NO empiric acyclovir If born by C-section and before rupture of membranes (ROM) = swab, NO empiric acyclovir

Question 219

can you breastfeed if mother has HSV?

Answer 219

No contraindication to breastfeeding unless there are herpetic lesions on the breast Mothers with oral lesions must wear a mask

Question 220

follow up required for neonatal HSV?

Answer 220

potential for significant neurological sequelae (destructive brain lesions) neurodevelopmental, ophthalmological and hearing assessments

Question 221

Mom with history of HSV but no active lesions or on acyclovir ppx - approach for baby?

Answer 221

No acyclovir No swabs If maternal primary HSV in 3rd trimester -> swab baby Parents and caregivers should be educated about the signs and symptoms of Neonatal HSV

Question 222

when to suspect neonatal HSV? No need to memorize, just a reminder

Answer 222

Consider HSV in all unwell infants <6wk - HSV mimics other types of sepsis! infants not responding to antibiotics Negative bacterial cultures at 24 hours Pneumonia of uncertain etiology, not improving with abx, or CXR in keeping with viral pneumonia Unexplained hepatitis Unexplained bleeding from venipuncture sites or unexplained coagulopathy Seizures Isolated fever

Question 223

Contact precaution duration for neonates or moms with HSV?

Answer 223

until all lesions have crusted asympto babies with active hsv moms - need contact precautions for 14 d (incubation period) or until tests return neg *recall samples MUST be taken >24 hr after delivery to prevent contamination from Mom

Question 224

Q36. 4 year old boy with fever, irritability, widespread rash, and nuchal rigidity. CSF gram stain shows gram negative diplococci. Most likely organism? Neisseria meningitidis E. coli Streptococcus pneumoniae Haemophilus influenzae

Answer 224

Neisseria meningitidis = Gram - cocci one of the 2 pathogens that cause meningitis in children (strep pneumo and N meningiditis) Bacterial Meningitis Pathogens = Strep pneumo and Neisseria meningitidis in <3mo = GBS, E Coli, Listeria streptococcus pnemoniae = gram + cocci in chains/pairs ("diplococci") Neisseria meningitidis = Gram - cocci Group B Streptococcus = gram + cocci in chains E. coli = gram - bacilli rods Listeria = gram + bacilli Haemophilus influenzae = Gram negative coccobacilli

Question 225

5 yr went camping with family 2 weeks ago. Now has unilateral facial palsy and expanding circular erythematous rash on back. What test to confirm diagnosis? A. Lyme serology B. HSV serology C. PCR for boresi? (Something unfamiliar) D. NPS for mycoplasma

Answer 225

Lyme serology facial palsy and erythema migrans rash hx of camping

Question 226

What is Lyme disease?

Answer 226

tick-borne illness caused by the bacteria Borrelia burgdorferi transmitted to humans through the bite of infected black-legged ticks

Question 227

typical age group for tick bites?

Answer 227

5-9 years old is peak incidence

Question 228

is lyme disease reportable?

Answer 228

yes

Question 229

how does Lyme disease present?

Answer 229

Early localized Lyme - erythema migrans ("bull's eye) - fever, malaise, headache, mild neck stiffness, myalgia and arthralgia Disseminated Lyme ("Later (extracutaneous) Disease") Multiple erythema migrans **facial nerve palsy** meningitis carditis (heart block) arthritis (usually knee) ~4mo after tick bite

Question 230

Diagnosis of Lyme disease?

Answer 230

Early Localized Lyme Disease = Clinical diagnosis (B burgdorferi antibodies not detectable within 4wks of bite) Disseminated Lyme Disease 2 Step testing: 1) ELISA (screen) 2) IgM and IgG Western Blot (confirmatory) If meningitis: intrathecal IgM and IgG

Question 231

treatment of Lyme disease?

Answer 231

PO doxycycline Erythema Migrans = 10 days Facial palsy or Meningitis = 14 days Arthritis = 28 days Carditis = admit as might need pacemaker for heart block, 14d of IV CTX If recurrent arthritis, re-treat with 28d of PO doxycycline or IV ceftriaxone for 14-28d

Question 232

Patient with Lyme disease is receiving treatment with PO doxycyline - develops worsening clinical status, fever, headache and myalgias. What is this and how to manage?

Answer 232

Jarish-Herxheimer reaction Fever, headache, myalgia and an aggravated clinical picture lasting <24h that can occur when therapy is initiated NSAIDs should be started CONTINUE antibiotic

Question 233

Patient appropriately treated for Lyme disease - persistent fatigue and joint/muscle aching for months after wards. What is this?

Answer 233

Persistent post-treatment lyme disease syndrome (PTLDS) =lingering symptoms of fatigue and joint/muscle aching >6 months 10-20% of cases No treatment Long-course antibiotic treatments do not provide long-term improvement in PTLDS cases

Question 234

Asymptomatic patient had a tick attached and feeding for >36 hr - how to manage?

Answer 234

tick attached >36 hr = single dose PO doxycycline as prophylaxis Lyme disease unlikely if tick attached for <36 hrs

Question 235

How to prevent Lyme disease?

Answer 235

Landscaping between wooded areas and play areas DEET (20-30%) or icaridin repellent shower within 2hr of being outdoors full body check daily for ticks

Question 236

7 year-old previously healthy and fully immunized boy with a history of 2 days of mild UTI symptoms presents with acute onset of fever, cough, stridor, and respiratory distress. 2 doses of nebulized epinephrine, and one dose of dexamethasone provided no improvement. What is the most appropriate treatment? (REPEAT ENT) IV steroids IV magnesium sulfate IV clindamycin and cefotaxime Nebulized budesonide and epinephrine

Answer 236

IV Clindamycin and Cefotaxime - bacterial tracheitis given immunized, respiratory distress with stridor, NOT responsive to epi and dex -not epiglottitis as no indication of drooling or unimmunized tx for bacterial tracheitis =Vanco OR Clindamycin PLUS Ceftriaxone OR Cefotaxime x 7-10 days

Question 237

10yo had 5 days of amoxicillin followed by 7 days of azithromycin for presumed bronchitis or sinusitis. CXR showed patchy opacities in the right upper lung with mild pleural effusion. Continue to have ongoing low grade fever and cough. What is the definitive treatment? Amphotericin B RIPE for TB Percutenous drainage IV Clindamycin and cefotaxime

Answer 237

RIPE for TB this patient sounds like they have TB (pneumonia not responsive to antibiotics, multifocal patches on lungs, persistent cough and correct age group for reactivation of latent TB) - would test and treat with RIPE (Per 4th years, this Q is phrased as "what is the definitive treatment" rather than next step)

Question 238

Q41 Sickle cell patient has been bitten by a dog. Aside from checking the dog's immunization status and the patient's tetanus status, what is your management? Observe Amox-clav Ceftriaxone Topical fucidin

Answer 238

Amox-Clav sickle cell pts at risk for infection from encapsulated organisms, which includes Capnocytophaga (from dog bite or cat bite)

Question 239

Which types of infections are patients with sickle cell disease at risk for?

Answer 239

Encapsulated organism infections Sickle cell disease - usually functionally asplenic or post splenectomy

Question 240

which bacteria are encapsulated organisms?

Answer 240

Strep pneumo - most common, >50% of post-splenectomy crisis! SALMONELLA (from reptiles or food/water) Capnocytophaga (from dog bite or cat bite) E coli Bordetella holmesii (Bordetella species cause Pertussis) Hemophilus influenzae type b (now rare due to Hib vaccine) Neisseria meningitidis (uncommon) sickle cell pts more susceptible to severe or fatal malaria and to infection by the protozoan Babesia

Question 241

sickle cell pts more susceptible to severe or fatal malaria and to infection by which pathogen?

Answer 241

protozoan Babesia

Question 242

Antibiotic prophylaxis recommendations for children with asplenia or hyposplenia?

Answer 242

< 5 yrs = amoxicillin >5 yrs = Penicillin V (lifelong)

Question 243

Which patients are at risk of fulminant bacterial sepsis from encapsulated organisms?

Answer 243

functionally asplenic - sickle cell, thal major, hereditary spherocytosis Splenectomy or congenital absence of spleen - first 3 yrs after spleen removed (or first 3 years of life if congenital) is highest risk, but at risk LIFELONG

Question 244

Patient with sickle cell disease presents with fever - what do you do?

Answer 244

emergency! sepsis in asplenic/hyposplenic pts can die within hours! send to ER blood cx Ceftriaxone (+vanco if penicillin resistant strep pneumo)

Question 245

patient with sickle cell wants to go to malaria endemic zone - chill or nah?

Answer 245

not chill asplenic/hyposplenic pts at risk for severe malaria need to sleep under insecticide-treated bed net or air-conditioned accommodation insect repellent *note: Consider malaria in Fever DDX up to 1 year from returning from endemic region in sicklers*

Question 246

which supplementary vaccines do asplenic/hyposplenic pts need?

Answer 246

S pneumoniae, Hib and N meningitidis (encapsulated org) *more details on schedule in CPS statement, ?need to memorize (CPS Preventing and treating infections in children with asplenia or hyposplenia)

Question 247

Mom with chicken pox 7 days before delivery. Mgt for baby Nothing VZIG and vaccine Vaccine alone Full septic workup

Answer 247

nothing? newborns whose mom had chicken pox 5 d before delivery or 2 days of delivery need ppx

Question 248

Topic Review of Varicella, chicken pox, congenital/neonatal varicella. include complication of nec fasc

Question 249

Newborn baby with asymmetric lower limbs born to 24 yo mother who is unvaccinated. Works in daycare and had febrile illness with rash – was diagnosed with HFM. What is the most likely diagnosis? HSV Congenital toxoplasma Congenital syphilis Congenital CMV Congenital rubella Congenital varicella HIV

Answer 249

Congenital varicella

Question 250

What are clinical manifestations of congenital VZV?

Answer 250

Skin: Cutaneous defects Cicatricial scars Hypopigmenation Bullous lesions Extremities: Hypoplastic limb Muscular atrophy and denervation Joint abnormalities Absent or malformed digits GU: Hydronephrosis/hydroureter Eye: Chorioretinitis Microphthalmia Anisocoria CNS: Intrauterine encephalitis with cortical atrophy microcephaly Seizures Mental retardation GI: Esophageal dilation/reflux

Question 251

Diagnosis for Congenital Varicella in infant

Answer 251

Serology - IgM! Viral culture or PCR of vesicular lesion

Question 252

What is the window of highest risk to infants to develop neonatal varicella?

Answer 252

Infants born to women (non-immune) who develop varicella (not zoster) within 5 days of delivery are at risk for disseminated or fatal disease

Question 253

What is the treatment for neonatal varicella?

Answer 253

VariZIg within 48-96 hours of exposure IVIg as alternate if no VariZig available (pooled donors) Treatment if rash develops Acyclovir 30mg/kg/day IV divided q8hr

Question 254

2 year old fully immunized boy falls at the park and sustains laceration. After cleaning and suturing wound closed, what do you need to do? PO Antibiotics Tetanus immunoglobulin and toxoid (vaccine) Tetanus toxoid (vaccine) Nothing else

Answer 254

nothing since fully immunized and <5yrs since tetanus vaccine, nothing (true for clean or dirty wounds)

Question 255

Wounds - when are the only times that we give tetanus immunoglobulin with the tetanus vaccine?

Answer 255

dirty wound in unvaccinated pt (or >10yrs since vaccine)

Question 256

Term baby born to 24 yo G1 mom with limited prenatal care. At 2 weeks of life, baby has worsening rhinitis, red/brown rash worse on hands and feet, and diffuse lymphadenopathy. Which investigation will reveal the diagnosis? HHV6 testing Rubella VDRL Urine for CMV

Answer 256

VDLR - concerned for congenital syphilis

Question 257

What are early clinical manifestation of syphilis?

Answer 257

IUGR Hepatomegaly Jaundice Lymphadenopathy Pneumonia alba non-immune hydrops Hemolytic anemia (DAT-) snuffles neurosyphilis condyloma lata Maculopapular rash followed by desquamating peels to palms and soles Pseudoparalysis

Question 258

Describe features of maternal history that indicates infant evaluation in congenital syphilis

Answer 258

- not treated or inadequately treated - less than 4-fold drop in non-treponemal titer (RPR) - treatment within 30days of birth - treatment with non-penicillin regimen - relapse or reinfection after treatment (ie new partners, sex work)

Question 259

Describe late onset manifestations of congenital syphilis

Answer 259

CNS - GDD Eye: Interstitial keratitis Ears: SNHL Face: Saddle nose, frontal bossing, arch palate Teeth: Hutchinson's teeth, mullberry molars Skin - linear scars MSK: Saber shins, clutton joints

Question 260

Workup for congenital syphilis (possible/probable/proven)

Answer 260

Physical exam for signs and symptoms of congenital infection Serologies: Treponemal test – will be reactive for life after infection Non-treponemal (RPR) – titres will decline with treatment Long bone xrays CSF: cell count, prot, gluc, VRDL CBC-diff Liver enzymes and LFTs Ophthalmology Audiology +/- MRI brain

Question 261

Treatment for congenital syphilis

Answer 261

Maternal: primary, secondary or early early latent: Benzathine Penicillin G IM 1-2 doses Late latent, 3ry, unknown duration: Benzathine Pen G IM weekly x 3 doses Infant: 10 day course of Penicillin G 50,000 IU/kg/dose q12h if <1 week of age, q8h 1-4 weeks of age, q6h > 4weeks if proven/probable/possible No abx, close follow-up if asymptomatic and mom treated Recommend AGAINST single IM dose of benzathine pen G in unknown cases

Question 262

Risk factors for congenital syphilis

Answer 262

injection drug use crystal methamphetamine or other substance use the sale or purchase of sex experiencing homelessness inconsistent condom use multiple sex partners PMHx of sexually transmitted and bloodborne infections (STBBIs)

Question 263

Term well infant born to Mom who was untreated for N. gonorrhea - what to do next? A- Conjunctival eye swab B- Conjunctival eye swab with IM Ceftriaxone C- Full septic work-up (swab, blood cx, CSF) D- Observe

Answer 263

Conjunctival eye swab with IM Ceftriaxone (single dose) we always prophlyax babies with gonorrhea exposure bc untreated gonorrhea can cause blindness and corneal perforation

Question 264

Recommended serological follow-up for infants born to mothers with reactive serology

Answer 264

Question 265

Newborn with conjunctivitis - dx and next steps?

Answer 265

Ophthalmia Neonatorum swab for chlamydia trachomatis NAAT and gonococcal culture if mom has active gonorrhea at time of delivery, also give single dose ceftriaxone to baby (no empiric tx for chlamydia)

Question 266

presentation of Ophthalmia Neonatorum?

Answer 266

Mother with active gonorrhea Neonate with bilateral purulent eye discharge and significant eyelid edema (conjunctivitis) within 1st week of life Can also present as -scalp abscess (from scalp electrode site infection presumably) -bacteremia -arthritis -meningitis

Question 267

What complications can occur if gonorrhea ophthalmia neonatorum goes untreated?

Answer 267

corneal ulceration, perforation of the globe or blindness

Question 268

what prophylaxis exists in Canada against gonococcal ophthalmia neonatorum? Should we give it?

Answer 268

Topical erythromycin 0.5% Legally we have to (CMPA) CPS no longer recommends it given high resistance of neisseria gonorrhea

Question 269

why do we not give newborns oral erythromycin?

Answer 269

associated with pyloric stenosis

Question 270

Well baby born to mom with untreated N gonorrhoeae infection at the time of delivery - what do you do?

Answer 270

conjunctival N gonorrhoeae culture + single dose of ceftriaxone 50 mg/kg IV/IM

Question 271

Unwell baby born to mom with untreated N gonorrhoeae infection at the time of delivery - what do you do?

Answer 271

Conjunctival, blood and CSF culture for N gonorrhoeae Consult ID - for management decisions Prolonged IV Ceftriaxone course, 7 or more days

Question 272

Boy with CP and recurrent aspirations. Presents with fever and work of breathing. He has a right lower lobe infiltrate on CXR. What is the most likely pathogen? Strep pneumo Staph aureus Mycoplasma Mixed anaerobe

Answer 272

Mixed anaerobes (Oral flora that was aspirated into the lungs)

Question 273

where in the lungs does aspiration pneumonia present?

Answer 273

RLL due to fairly straight orientation of right mainstem bronchus

Question 274

Pathogens causing aspiration pneumonia?

Answer 274

anaerobic oral flora

Question 275

Unimmunized 3 year old with rhinitis which is purulent for five days. Nasal culture is positive for haemophilus influenzae. Low grade fever. What do you do next: Supportive management Amoxicillin Cephalosporin X-ray of sinuses

Question 276

1 month old child and his Mom have rash (See photo). How to treat the child? Corticosteroid Sulphur Permethrin Antibiotics

Answer 276

Sulphur - safe for infants with scabies 5% Permethrin is first line in scabies but must be >3mo

Question 277

Girl with tick bite, target lesion two weeks later. Mom picked a tick off her scalp. Tx with amox x14d, lyme serology negative, 2-3 weeks later presents with myalgias, fatigue, missed some school. How do you manage? A. Monitor and counsel that symptoms will get better. B. Repeat serology C. Amox x 14 days D. Doxy x 14 days

Answer 277

Monitor and counsel that symptoms will get better Persistent post-treatment lyme disease syndrome (PTLDS) =lingering symptoms of fatigue and joint/muscle aching >6 months (10-20% of cases) abx don't improve PTLDS

Question 278

3-year-old boy is referred to you for left parotid erythema, swelling, and tenderness. He is afebrile. He has had 2 previous episodes of this in the last 6 months, always on the left side, spontaneously resolving in 3-5 days. A salivary culture shows Strep viridans. What is the most likely diagnosis? Viral parotitis Bacterial parotitis Juvenile recurrent parotitis Salivary gland duct stone

Answer 278

Juvenile Recurrent Parotitis Pt is school age, recurring every few months and self-resolves Strep viridans is a common colonizer, likely not causing the infection, plus it is self-resolving without abx

Question 279

A school-aged boy presents with a 2x2.5 cm axillary node. He lives on a farm and has many pet cats. What do you do? Excisional biopsy I&D Start antibiotics

Answer 279

Start antibiotics cat scratch disease tx (Bartonella henselae Azithromycin for adenitis (may shorten disease) Doxy + Rifampin for neuroretinitis/CNS

Question 280

Baby has rash in photo, hepatosplenomegaly, cataract and bone changes. Which is the most likely diagnosis?

Answer 280

Congenital rubella syndrome - classic triad is cataracts, PDA (usually, or other cardiac abnormalities) and SNHL, “blueberry muffin rash” but can also have bony lucencies and HSM

Question 281

what are the features of congenital rubella syndrome?

Answer 281

"RUBELLA" R Retinopathy ("salt and pepper" retinitis) U U can't hear (SNHL) B Bones (radiolucent), BLUEBERRY muffin rash E Eyes (cataracts) L Little head (microcephaly) A patent ductus artereosis (pdA) higher incidence in India and Afghanistan

Question 282

Kid who lives on a farm with diarrhea and has AXR findings in the right lower quadrant. What organism should you test for before asking GI for a scope? Yersinia Giardia Entamoeba histolytica

Answer 282

Yersinia yersinia mimics appendicitis as it localizes to the RLQ presents this way due to inflammation of the terminal ileum and mesenteric lymph nodes with a normal appendix

Question 283

what is Yersinia enterocolitica?

Answer 283

gram neg bacillus

Question 284

how does yersinia present?

Answer 284

acute bloody diarrhea, fever, abdo pain mesenteric adenitis, terminal ileitis pseudoappendicitis (mimics appendicitis bc localizes to RLQ, fever, abdo pain, diarrhea) 1-2 wks later: reactive arthritis (large joints) erythema nodosum,

Question 285

transmission of Yersinia?

Answer 285

consuming undercooked pork (pigs) uncommon: waterborne, household pet exposure, person-to-person transmission, and blood transfusion

Question 286

risk factors for yersinia infection?

Answer 286

<5yrs, high iron levels, immunosuppression

Question 287

indications for treatment of yersinia?

Answer 287

neonate immunocompromised yersinia bacteremia consider if "pseudo-appendicitis" picture with RLQ pain secondary to mesenteric adenitis and terminal ileitis (appendix is fine)

Question 288

if planning to treat yersinia, what do you choose?

Answer 288

Septra x 5 d

Question 289

Child with cerebral palsy, history of choking with feeds, presents with fever and tachypnea. On CXR there is a cavitation lesion with air fluid levels in the right lower lobe. What is the most likely pathogen? a) Strep pneumo b) Staph aureus c) Mycoplasma d) Mixed anaerobes

Answer 289

mixed anaerobes - lung abscess that developed after aspiration (thus oral anaerobes in abscess)

Question 290

6 month old, mother with hepatitis C (antibody positive, HCV RNA positive). Babe is well with normal liver enzymes and negative anti-HCV antibody. What do you do? Reassurance, no further testing needed Repeat HCV serology in 6 months Liver biopsy Measure HCV RNA

Answer 290

Reassurance, no further testing needed if HCV antibody at 6 months is non-reactive, that means that baby not get Hep C transmitted from Mom (can trust the antibody at 6mo and older) no HCV infection and no more tests required

Question 291

what are high risk features for acquiring hepatitis C in youth or pregnant women?

Answer 291

IVDU, unregulated tattoo/piercing correctional facility unprotected sex where blood may be mixed (eg. anal sex no condom)

Question 292

In mothers with hepatitis C, what is the percentage risk of vertical transmission?

Answer 292

5.8% risk of transmission to newborn in HCV infected mothers 10.8% if mother also has HIV that is not optimally controlled

Question 293

presentation of hepatitis C in children?

Answer 293

usually subclinical Severe hepatitis (1-6% of cases) Decompensated liver disease (0.5-2%) Extra-hepatic (uncommon) membranoproliferative glomerulonephritis sub-clinical hypothyroidism autoimmune thyroiditis Elevated ANA

Question 294

who gets screened for hepatitis C infections?

Answer 294

screen in ANY of the following: neonates born to Hep C positive mothers IV drug use unregulated tattoo/piercing correctional facility unprotected sex where blood may be mixed (eg. anal sex no condom)

Question 295

Baby born to mother with hepatitis C infection - next steps?

Answer 295

HCV RNA PCR testing at 2 - 6 months + HCV Antibody serologic testing at 18-24 months **HCV RNA PCR should NOT be done in <2 mo**(contamination with maternal blood or passive transfer of maternal HCV RNA)

Question 296

what labs do you need to see to know that a young child got infected with hepatitis C from their mother?

Answer 296

baby's mom has hepatitis C, so you send: HCV RNA PCR testing at 2 - 6 months + HCV Antibody serologic testing at 18-24 months at 18mo, the antibody is reactive, so you repeat the PCR the PCR is positive = infected

Question 297

what labs do you need to see to know a young child is not infected with hepatitis C?

Answer 297

hepatitis C antibody non-reactive at >6 months (antibody non-reactive means that their body has never seen hepatitis C thus ruling out infection (must be >6mo)) or antibody reactive but negative PCR at >18 mo (they cleared the infection)

Question 298

What percentage of infants infected vertically with hepatitis C clear the infection?

Answer 298

20-30% by 2-3 yrs old

Question 299

what perinatal factors can we manage to avoid hep C transmission to baby during delivery?

Answer 299

Avoid interventions that promote the mixing of fetal and maternal blood, such as fetal scalp electrodes or episiotomy (C/S or vaginal delivery are both fine)

Question 300

can mothers with hepatitis C breastfeed?

Answer 300

breastfeeding is safe in hepatitis C NO breastfeeding if mother’s nipples are cracked, damaged, or bleeding, or if she is co-infected with HIV

Question 301

what is the risk of not catching hepatitis C infection?

Answer 301

progression to cirrhosis or hepatocellular carcinoma spread of infection to others

Question 302

how often should we test for hepatitis C in teens with risk factors for hepatitis C?

Answer 302

every 6-12 months send hep c antibody --> if positive, do HCV RNA PCR risk factors: IV drug use, unregulated tattoo/piercing correctional facility unprotected anal sex

Question 303

treatment of hepatitis C?

Answer 303

Fully managed by hep C specialist babies may clear it if not, direct-acting antivirals (DAAs) in >3 yr olds

Question 304

pediatrician management of hepatitis C?

Answer 304

Report positive hep C infection Screen for STIs Regular serologic screening for Hep B, Hep A and HIV Vaccination for HBV and HAV should be given if non-immune. Educate parents/families that there is ○ no known risk of transmission in saliva, urine, or stool ○ no need for special precautions at home ○ Day care and play/sport activities is unrestricted ○ parents are not obliged to notify day care staff or school authorities of their child’s HCV infection

Question 305

8yo male with rheumatoid arthritis on Humira. Goes in a hot tub and gets a rash with follicles 24 hours later. What is the pathogen? Staph Aureus Kingella Kingae GAS Pseudomonas

Answer 305

Pseudomonas associated with folliculitis from hot tubs and fresh water

Question 306

You are seeing a 1-year-old girl whose grandmother was just diagnosed with smear-positive tuberculosis. The girl sees her grandmother every weekend. Her initial TST and chest X-ray are negative. What do you do? Give isoniazid with vitamin B6 for 8 weeks and then repeat the TST Treat with rifampin, isoniazid, ethosuximide, and pyrazinamide Tell her to take vitamin B6

Answer 306

Give isoniazid with vitamin B6 for 8 weeks and then repeat the TST Child contacts <5 years of age with an initial TST of <5 mm: -preventive prophylaxis (‘window prophylaxis’) with one TB drug -second TST 8-10 weeks following patient's last contact with the index case (“break of contact”(BOC)) -if BOC TST <5 mm, discontinue window ppx

Question 307

14-year-old female being treated for 2 days with an oral antibiotic develops oral ulcers, target skin lesions, low grade fever, and right upper quadrant pain. Which antibiotic is most likely to have caused these symptoms? a) Trimethoprim-sulfamethoxazole b) Cefixime c) Amoxicillin d) Azithromycin

Answer 307

Trimethoprim-sulfamethoxazole

Question 308

what is DRESS?

Answer 308

Drug reaction with eosinophilia and systemic symptoms (DRESS) rare, potentially life-threatening, drug-induced hypersensitivity reaction

Question 309

presentation of DRESS?

Answer 309

maculopapular rash --> coalescing erythema fever, lymphadenopathy, heme changes (high eso, neuts, etc) LIVER injury (90%) - RUQ pain, transaminitis

Question 310

what causes DRESS?

Answer 310

drug reaction that occurs 2-8 wks after drug sulfa drugs (TMP-SMX), vancomycin, anti-seizure, allopurinol

Question 311

what is Stevens-Johnson Syndrome and toxic epidermal necrolysis (TEN)?

Answer 311

severe mucocutaneous reactions triggered by medications extensive necrosis and detachment of the epidermis

Question 312

what is the difference between Stevens-Johnson Syndrome and toxic epidermal necrolysis (TEN)?

Answer 312

<10% BSA = SJS >30% BSA = TEN (in between is overlap)

Question 313

presentation of Stevens-Johnson Syndrome?

Answer 313

prodrome of fever and flu-like sx mucocutaneous - red, coalescing, blistering rash (painful!) -oral and ocular blisters/erosions, redness, pain

Question 314

what causes Stevens-Johnson Syndrome and toxic epidermal necrolysis (TEN)?

Answer 314

sulfa abx (TMP-SMX), NSAIDs, anti-seizures develop 4 days to 4 weeks following drug exposure

Question 315

6-year-old girl with fever and the following rash on her face (slapped cheek appearance). When can she return to school? a) She can return once she feels well enough to do so b) She can return after resolution of her rash c) She can return after resolution of her fever

Answer 315

She can return once she feels well enough to do so - Parvovirus B19 not infectious after onset of rash (slapped cheek)

Question 316

presentation of Parvovirus B19 ?

Answer 316

1-4d of fever, running nose "slapped cheek" rash (Fifth disease; erythema infectiosum) - young children Glove and Sock Palpable Purpura - adolescents Aplastic Crisis (transient) arthropathy for 1-2 wks

Question 317

when are patients with parvovirus B19 infectious?

Answer 317

highly infectious during aplastic crisis and before onset of rash once slapped cheek appears, no longer infectious

Question 318

Girl with left submandibular large lymph node, TST is 15mm, IGRA negative. What is the cause? Mycobacterium tuberculosis Nontuberculous mycobacterium

Answer 318

Nontuberculous mycobacterium IGRA is >95% specific to tuberculosis bc it doesn't cross-react with non-tuberculosis mycobacterium (whereas TST does) both TB and non-TB cause lymphadenopathy likely non-TB since TST is positive and IGRA is negative

Question 319

3-year-old boy, unimmunized, fell and sustained a deep laceration in the playground. After cleaning and suturing the wound, what would you give? Tetanus toxoid and Tetanus immunoglobulin Tetanus toroidal Tetanus Ig and cephalexin Tetanus toxoid and cephalexin

Answer 319

Tetanus toxoid and Tetanus immunoglobulin dirty wound since fell in dirt we give immunoglobulin with vaccine if dirty wound in unimmunized or >10yrs since vaccine

Question 320

Mom presents in labour. Uncomplicated pregnancy. Serologies protective, but you note that HIV was never done. What do you do? No need for testing Rapid HIV test for mom, treatment for mom and prophylaxis for baby if positive Test baby once born, if positive then treat Test mom after delivery, if positive then treat

Answer 320

Rapid HIV test for mom, treatment for mom and prophylaxis for baby if positive combination antiretroviral therapy (cART) initiated within 6 to 12 h of birth

Question 321

2m term baby, with presumed uncomplicated pregnancy born admitted to with progressive respiratory failure. Bronch identifies PJP pneumonia. What is the most likely diagnosis? HSV Congenital toxoplasma Congenital syphilis Congenital CMV Congenital rubella Congenital varicella HIV

Answer 321

HIV

Question 322

HIV exposed infant - low risk (mom has low viral load (<50copies/ml last 4 weeks of pregnancy) and on medication, received AZT IV intrapartum). What is management?

Answer 322

Start PO AZT (Zidovudine) mono-therapy (2 weeks) Order blood HIV PCR - Antibody will be positive because maternal CONTRAINDICATION for breastfeeding

Question 323

HIV exposed infant - maternal low prenatal care, higher viral load (>50copies/ml last 4 weeks of pregnancy), high risk behaviours. Management of infant

Answer 323

Triple therapy (AZT, 3TC, nevirapine) within 72 hours HIV PCR on baby and mom - could be in window period No breastfeeding Consult ID

Question 328

5yo boy with erythematous papules in between fingers and on flexural surfaces. On exam, you note burrows in between his fingers. Dad has same symptoms. Brother and mom don't. What do you do? Treat the boy only Treat boy and dad Treat boy and household Treat boy, household, and school contacts

Answer 328

Treat boy and household for scabies with 5% permethrin cream

Question 329

6-year-old boy who was treated for C. difficile 2 months ago with metronidazole. He now is having 5 watery loose stools per day and his stool toxin returns positive for C. difficile again. What do you do? Oral metronidazole Oral vancomycin IV metronidazole + PO vancomycin Do nothing

Answer 329

PO metronidazole can use tx for first recurrence - per Dr. Dunn, first re-infection, treat with Oral Vancomycin.

Question 330

What is the classic triad of congenital toxoplasma?

Answer 330

Cerebral Calcifications HydroCephalus (or microcephaly) Chorioretinitis (Convulsions)

Question 331

Treatment for congenital toxoplasmosis?

Answer 331

for infant (antiprotozoal): pyrimethamin + sulfadiazine + folinic acid 12 months for pregnant woman (pre-natal dx toxo): spiramycin up to 18 wk or same tx as infant if after 18mo

Question 332

Which of the following is NOT true about HPV vaccination? Recommended for all individuals 9-26 years of age Individuals 9-20 years of age should receive 2 doses Individuals 21-26years of age should receive 2 doses Individuals 27+ years of age can receive HPV vaccine Immunocompromised people should receive 3 doses The non-valent vaccine should be used It is safe to administer during pregnancy

Answer 332

Individuals 9-20 years of age should receive 2 doses NACI has released statement (not on CPS), effectiveness of 1 dose is now sufficient for ages 9-20.

Question 333

What antibiotic do we use to treat osteomyelitis? A. Cloxacillin B. Cefazolin C. Ceftriaxone

Answer 333

Cefazolin

Question 334

osteomyelitis topic review https://cps.ca/documents/position/osteoarticular-infections-in-children

Question 335

11 yo girl with migratory rash, wrist and knee joint pain, fever, and a positive ASOT. Her echo and ECG are normal. She needs no prophylaxis She needs 5 years of penicillin prophylaxis She needs 10 years of penicillin prophylaxis She need prophylaxis until she turns 18

Answer 335

She needs 5 years of penicillin prophylaxis Rheumatic fever without carditis =5 years or until 21 years of age

Question 336

1 month old term baby with staccato cough, tachypnea, and conjunctivitis. Mild inspiratory crackles diffusely. Mild multifocal patchy infiltrates on chest x-ray. Most likely pathogen? RSV Ureaplasma Chlamydia Bordetella pertussis

Answer 336

Chlamydia - "Staccato cough" neonatal chlamydia presents with conjunctivitis and pneumonia atypical PNA (multifocal patchy infiltrates)

Question 337

neonatal chlamydia CPS review

Question 338

7-year-old boy recent immigrant from west Africa to Canada. Has paroxysmal fevers, sweating, headache. On exam has hepatomegaly and pallor. What test will reveal the diagnosis? Thick and thin smear TST Head CT Peripheral blood smear

Answer 338

Thick and thin smear - x3 separated over 12-24 hours for malaria dx

Question 339

malaria topic review

Question 340

Mom no prenatal care. At 31 weeks found to have syphillis. Treated. RPR 1/32 to 1/16. Delivered premature at 34 weeks. How to treat baby. IV penicillin IV cefotax Iv amp/gent No treatment

Answer 340

IV Penicillin 3 weeks later after treatment, with less than a 4 fold drop in mom’s titre (1/32 to 1/16) -> requires treatment Pen G 50 000 IU/kg q12h <1week age, q8h 1-4 weeks of age, q6h > 4 weeks. Discourage use of single/weekly dosing of long acting benzathine penicillin. Avoid treating with non penicillin antibiotics

Question 341

Child with chickenpox. An area of the rash has worsened over the past few hours and become red, indurated, 6x8cm with a blue-ish hue and very painful. Temp 39 degrees. What is the most appropriate treatment? Pip-tazo Ceftriaxone Penicillin and clindamycin Cefotax and vanco

Answer 341

Penicillin and Clindamycin necrotizing fasciitis from varicella

Question 342

3 year old patient presents with 2 days of severe ear pain. On exam has temp of 39.1, left tympanic membrane is erythematous and bulging. What should be management? Amoxicillin 75-90 mg/kg/day divided bid x 10 days Amoxicillin 75-90 mg/kg/day divided bid x 5 days Give an amoxicillin prescription and fill at 24h if still symptomatic Follow up in 24-48h

Answer 342

Amoxicillin 75-90 mg/kg/day divided bid x 5 days (Over age 2 - can treat for 5 days in acute otitis media)

Question 343

Girl who has abdominal pain, intermittent diarrhea, and bloating for the last 2 weeks. She has not lost weight. Started when she was on a 3 week camping trip. What do you treat with? Cipro Metronidazole Supportive care

Answer 343

Metronidazole Giardia is a parasite - need to treat

Question 344

what is Giardia Duodenalis “Bever Fever”?

Answer 344

protozoan parasite found in fresh water

Question 345

presentation of giardia?

Answer 345

watery diarrhea, flatulence, abdo pain, nausea

Question 346

treatment for giardia?

Answer 346

Metronidazole 5-10 days rehydration, usually oral

Question 347

6 year old at on active chemo for osteosarcoma with class exposure to chickenpox. What should you do Give immunization now VZIG within 72 hours Nothing if had fully immunized Acyclovir

Answer 347

if patient was immunized against varicella (12 +18mo), nothing if patient was not immunized, or bone marrow transplant, give Varicella Immunoglobulin

Question 348

Girl with tick bite, target lesion two weeks later. Mom picked tick off her scalp. Tx with amox x14d, lyme serology negative, 2-3 weeks later presents with myalgias, fatigue, missed some school. How do you manage? Monitor for spontaneous resolution of symptoms Repeat serology Amox x 14 days Doxy x 14 days

Answer 348

Monitor for spontaneous resolution of symptoms “Persistent Treatment Lyme Disease Syndrome (PTLDS)” which occurs in 10-20% of individuals after treatment, up to 6mo

Question 349

Baby born term with petechia, BW 1600g, jaundice, splenomegaly. What condition is Mom most likely to have? Rubella CMV Toxo HSV

Answer 349

CMV - petechiae from thrombocytopenia, SGA, jaundice, splenomegaly

Question 350

Term neonate is born to a woman with a history of recurrent genital HSV. There were no lesions present at the time of delivery and the infant was born vaginally. Up to how many weeks after birth is this neonate at risk of becoming ill with a perinatally acquired HSV infection? 2 weeks 6 weeks 16 weeks 36 weeks

Answer 350

6 weeks

Question 351

7 yo F lives on farm and has fever up to 39.1, abdo pain and bloody diarrhea. Stool culture shows yersinia. How do you manage? TMP/SMX Metronidazole Cefixime Supportive care

Answer 351

Supportive care for Yersinia We treat only if neonate, immunocompromised, mesenteric adenitis/pseudo-appendicitis/enterocolitis

Question 352

2 day old term neonate develops a vesicle to their upper lip. The nurse asks you to come assess. The baby is well appearing with normal vital signs. What is the most likely diagnosis? Sucking blister HSV Epidermolysis bullosa Varicella

Answer 352

HSV - SEM type

Question 353

14 year old girl who recently got an ear piercing. Ear lobe is erythematous and swollen. Now cartilage contours gone. What do you treat with? IV cefaz IV Clox IV Clinda IV Piptazo

Answer 353

IV pip-tazo, need to cover pseudomonas for dirty puncture dx = perichondritis

Question 354

5 yo M admitted with orbital cellulitis. Eye Improves after 3 days of IV ceftriaxone. Today complains of a headache and becomes confused. What is the most likely diagnosis? Venous Sinus Thrombosis Autoimmune demyelinating encephalopathy Encephalitis Meningitis

Answer 354

Venous Sinus Thrombosis

Question 355

what is orbital cellulitis?

Answer 355

infection of the orbit (eyeball, muscles that move the eye, etc.) SURGICAL EMERGENCY

Question 356

presentation of orbital cellulitis?

Answer 356

Pain with eye movement Visual impairment/blurry vision Proptosis (eye bulging out) Chemosis (conjunctiva look swollen and gelatinous) If Complications (ie frontal osteomyelitis, cavernous sinus venous thrombosis): ○ Severe headaches, vomiting and signs of intracranial involvement

Question 357

What are the complications of orbital cellulitis?

Answer 357

Vision loss (10% of cases of orbital cellulitis) Abscess ○ Subperiosteal Abscess + Frontal Bone Osteomyelitis = Potts Puffy Tumor Venous sinus thrombosis = clot in brain's venous sinuses --> prevents drainage --> Hemorrhage --> Stroke ○ associated with a lateral gaze palsy Intracranial infection (epidural or subdural abscess; meningitis)

Question 358

what is the source of the infection in orbital cellulitis?

Answer 358

Sinuses - strep pneumo, H flu (think if unimmunized) Skin: staph aureus

Question 359

antibiotic treatment of orbital cellulitis?

Answer 359

ceftriaxone, vancomycin add metronidazole if secondary to chronic sinusitis

Question 360

management of orbital cellulitis?

Answer 360

admit, NPO (until decision made about surgery) ENT/Optho consult urgently CT scan orbits, sinus and brain blood culture ceftriaxone, vancomycin, metronidazole

Question 361

what is preseptal cellulitis?

Answer 361

infection of the anterior eyelid (not involving the orbit or other ocular structures)

Question 362

How does preseptal cellulitis present and how to differentiate from orbital cellulitis?

Answer 362

Eyelid swelling and redness No headaches, vomiting, blurred vision, painful eye movements

Question 363

treatment of preseptal cellulitis?

Answer 363

PO amox-clav x 7 d usually outpatient treatment indications to admit preseptal cellulitis: - failure of treatment as an outpatient -concerns about spread of infection

Question 364

What is the gold standard to diagnose congenital CMV? Urine PCR at 1 week of age Serum PCR at 1 week of age Urine PCR at 4 weeks of age Serum PCR at 4 weeks of age

Answer 364

Urine PCR at 1 week gold standard is urine PCR before 21 days of life

Question 365

14-year-old male presents with a 48-hour history of a painful lesion under his right eye. It is purulent in nature, just inferior to his eyelashes, and about 8 mm in diameter. There is some surrounding erythema. Eye movements are normal and there is no conjunctival injection. What is the best initial management? 1. IV cefazolin 2. Incision and drainage 3. Apply warm compresses 4. IV acyclovir

Answer 365

warm compresses - this is a stye styes are usually NOT infected despite swelling/discharge

Question 366

What are the indications for probiotics? a. Treating C. Difficile diarrhea b. Preventing antibiotic associated diarrhea c. Reducing the intensity of viral diarrhea in immunocompromised children d. Preventing atropic dermatitis

Answer 366

CPS recommends probiotics for preventing antibiotic associated diarrhea AND atopic dermatitis ?could choose atopic dermatitis since there are more RCTs, could also choose abx-associated diarrhea as that is commonly prescribed

Question 367

15 year old girl presents to the emergency department with fever, malaise, myalgias. She has nausea and vomiting and dizziness. She has a diffuse erythematous macular rash and a strawberry tongue. Her vitals are 75/40, HR 190, RR30 and temperature 40C. What is the MOST likely causative organism? A. Staph aureus B. Rickettsia rickettsii C. Borrelia burgdorferi D. Neisseria meningitidis

Answer 367

Staph aureus Staph toxic shock syndrome (TSS): woman of menstruating age (usually 15-25yrs), in shock, with classic TSS of high fever, vomiting, diarrhea, sore throat, headache, and myalgias, diffuse erythematous macular rash (sunburn-like or scarlatiniform) and strawberry tongue classic TSS from tampon left in too long

Question 368

how to treat staph toxic shock syndrome?

Answer 368

cefazolin plus clindamycin usually requires intensive care remove tampon, nasal packing, or other source of infection cefazolin to treat MSSA Clinda = reduce toxin production

Question 369

9 day old baby born at 32 weeks, with increasing apnea over 24 hours. Mom GBS + with no prophylaxis. Culture drawn and grow gram + cocci in clusters. What is the most likely organism? A. GBS B. Strep viridans C. Staph aureus D. CONS

Answer 369

?CONS GBS = gram pos cocci in chains/pairs Coagulase negative staph = gram + cocci in clusters

Question 370

4mo old, grandpa has cavitary TB and lives in the home. TST and CXR are negative. What is the best next step? A. Give INH and RIF B. Repeat TST in 8-10 weeks C. Repeat CXR in 4 weeks D. Gastric aspirate culture x3

Answer 370

for <5yrs, we give one agent for TB ppx empirically and repeat TST in 8-10 wks usually INH (with B6) ?question options misremembered

Question 371

Boy with verrucous lesion on anus and wart on hand. Mom has no HPV. What is the mode of transmission? A. Self-inoculation B. Perinatal transmission C. Sexual abuse D. Hetero-inoculation

Answer 371

Self-inoculation

Question 372

HPV topic review https://cps.ca/documents/position/HPV

Question 373

Dad and son have recurrent pinworms despite being treated 3 times with oral mebendazole. What is the best treatment option? A. Treat all family members with Abendazole x 1 B. Treat all family members with Mebendazole now, and again at 14 and 28 days C. Treat son and dad with Pyrantel x 1 D. Treat son and dad with Pyrantel now and again at 14 and 28 days

Answer 373

Treat all family members with Mebendazole now, and again at 14 and 28 days Essentially the right answer is always to treat the entire family and you need at minimum two doses two weeks apart

Question 374

A pregnant woman develops chicken pox 7 days prior to delivery of a term infant. What do you do for the baby: A. No intervention needed B. 10 days Acyclovir for baby C. VZIG D. Varicella vaccine

Answer 374

no intervention needed Newborn infants of mother who develop varicella 5 days before until 48 hours after delivery require varicella immunoglobulin

Question 375

What is the best treatment for lice when there is known resistance in a geographical area? A. Resultz B. Pyrethrin (R+C Shampoo) C. Permethrin 1% (Nix Cream Rinse) D. Dimethicone

Answer 375

Permethrin 1% (Nix Cream Rinse) If two permethrin applications 7 days apart do not eradicate live lice, do a full treatment from a different drug class (eg Pyrethrin) Permethrin and Pyrethrin are both approved for use in >2mo. Alternatives Resultz approved for >4yrs and Dimeticone approved for >2yrs.

Question 376

What type of environmental decontamination do you need to undertake after a child has been diagnosed with lice infestation.

Answer 376

Because lice live close to scalp, environmental cleaning is not warranted. At most, washing items in close or prolonged contact with head (hats, pillowcases, brushes, combs) may be warranted. Wash in hot water and dry for 15 mins.

Question 377

girl presents for scalp itching and is found to have nits and lice. What do you recommend regarding return to school? a) After completing treatment b) Immediately c) After she is found to have no evidence of infection

Answer 377

Immediately

Question 378

lice topic review 2024 updated CPS statement https://cps.ca/documents/position/head-lice

Question 379

Kid with ALL, 1 month off of chemo. Sibling with Varicella. Doesn't tell you anything about the ALL kid having symptoms or not. VZIG Varicella vaccine Admit and start acyclovir + VZIG

Answer 379

VZIG give after 1 month of immunosuppression

Question 380

Ex 28 weeker, 8 weeks chronological age. Due for routine vaccinations. When do you administer rotavirus vaccine Now On discharge from unit At 8 weeks corrected age Does not qualify

Answer 380

Now give first dose around 6 weeks complete series by 8 mo as rotavirus increases risk for intussusception when given older

Question 381

How do you treat? IV Ancef PO Keflex IV acyclovir PO acyclovir

Answer 381

PO Keflex (cephalexin covers staph and strep which can both cause impetigo)w

Question 382

what is impetigo?

Answer 382

contagious, superficial bacterial infection usually from Staph (MSSA) or Group A Strep

Question 383

presentation of impetigo?

Answer 383

papules progressing to vesicles, pustules, and **honey-coloured crust** Less commonly, bullous impetigo and ecthyma (Ulcer with adherent crust)

Question 384

treatment for impetigo?

Answer 384

if just a few lesions = Topical mupirocin ointment TID x 5d If numerous lesions, = PO cephalexin x 7 days

Question 385

West nile most common presentation Asymptomatic Low grade fever

Answer 385

Asymptomatic

Question 386

Child with sickle cell anemia, bitten by dog Topical mupiricin PO Amox-Clav IM CTX Observe and f/u 24 hr

Answer 386

PO Amox-clav covers Capnocytophaga which is an encapsulated bacteria that sickle cell kids are at risk for with dog/cat bites

Question 387

Mom with Gonorrhea, well baby Conjunctival swab and await result Conjunctival swab and IM Ceftriaxone Conjunctival swab, CSF culture, Blood culture and IM Ceftriaxone

Answer 387

Conjunctival swab and IM CTX

Question 388

Mom HCV Ab and RNA positive. 6 month baby HCV Ab positive. What do you do? No further testing Repeat HCV ab in 6 months Get an HCV PCR Refer for liver biopsy

Answer 388

Get an HCV PCR (which they should have gotten already by guideline)

Question 389

Baby who was IUGR, had failed newborn hearing screen. Urine is CMV + What is the best treatment? Nothing Po valganciclovir x 2 months Po valganciclovir x 6 months

Answer 389

PO valganciclovir x 6 months isoalated SNHL is indication for treatment, as is CNS, chorioretinitis, etc.

Question 390

Sickle cell kid is going away - what is she at risk for? Typhoid fever Hepatitis

Answer 390

Typhoid fever caused by Salmonella typhi (encapsulated bacteria) sickle cell pts at high risk for infection with encapsulated org

Question 391

You are seeing a 4mo with a 24 hour history of poor feeding. He has just started solids. On examination, there is facial and limb weakness. Pupillary response is normal? DTR are absent. Botulism SMA Mytonic dystrophy

Answer 391

Spinal Muscular Atrophy - deep tendon reflexes absent, hypotonic/weak, facial involvement, fasciculations (Eg tongue) Infantile Botulism - constipation, poor feeding, acute onset, progressive weakness/hypotonia beginning with facial weakness

Question 392

Newborn from mother known with Hepatitis B. What is the best treatment? Give hep B vaccine and Ig <12 hours Give hep B vaccine <12 hours and Ig within 7 days Give hep B vaccine now and within follow-up Ig at 1 month Give hep B vaccine now and do serology in one month

Answer 392

Give hep B vaccine and HBIg in newborn <12 hours old continue with vaccine series for hep B at 2mo and 6mo test for antibodies against hepatitis B at 9-18mo, - give another vaccine if inadequate antibody protection

Question 393

6 month old, mother with hepatitis C (antibody positive, HCV RNA positive). Babe is well with normal liver enzymes and negative anti-HCV antibody. What do you do? Reassurance, no further testing needed Repeat HCV serology in 6 months Liver biopsy Measure HCV RNA

Answer 393

Reassurance, no further testing needed

Question 394

Boy with 2 day history of mouth sores and rash. Preceded by 1 wk of fever and cough, given amox and acetaminophen. What is most likely cause ? (Give picture of rash - hands and lips looked similar to below) HSV amoxicillin mycoplasma acetaminophen

Answer 394

mycoplasma this is Mycoplasma-Induced Rash and Mucositis (MIRM) *New term is Reactive Infectious Mucocutaneous Eruption (RIME)

Question 395

Baby with pneumonia on CXR, CBC shows eosinophilia - management? Erythromycin Ceftriaxone Nothing Ampicillin

Answer 395

Erythromycin x 14 days pneumonia and eosinophilia, and conjunctivitis are classic features of neonatal Chlamydia trachomatis infections

Question 396

Kid with varicella 3 days later presents with fever, blue indurated painful rash on leg. What’s the management? Pen and clinda Cloxacillin & Gentamicin Vanco & Ceftriaxone

Answer 396

Penicillin and Clindamycin necrotizing fasciitis is a complication of varicella typically tx with cefotaxime/cefazolin + clindamycin need to cover for Group A Strep (main cause of nec fasc)

Question 397

Which is true of ophthalmia neonatorum a) The most common organism is Neisseria Gonorrhea, but it is now almost always resistant to the prophylaxis, therefore prophylaxis is not indicated b) Ophthalmia neonatorum can lead to significant eye injuries and blindness, therefore antibiotic prophylaxis is indicated c) The most efficient way of preventing it is through screening and treatment of pregnant women rather than the current prophylaxis.

Answer 397

The most efficient way of preventing it is through screening and treatment of pregnant women rather than the current prophylaxis (Rather than giving all babies erythromycin topical ointment to the eyes)

Question 398

Child with acute otitis media is taking amoxicillin and has two episodes of bloody diarrhea, Is otherwise afebrile and well. Besides discontinuing the current antibiotic, what else would you do to manage this child? Close follow up PO metronidazole PO vancomycin PO clindamycin

Answer 398

Close follow up (mild C diff as <4 abN stools per day)

Question 399

Woman 28 weeks pregnant, with 2 and 5 year old children at home. What is the best way to prevent influenza in the new baby within the first 6 months of life? 1. Inactivated vaccine for mom right now 2. Inactivated vaccine for mom after birth 3. Inactivated vaccine for dad and two kids, no vaccine for mom 4. Inactivated vaccine for dad, live attenuated vaccine for two kids, no vaccine for mom

Answer 399

Inactivated vaccine for mom right now pregnant women and infants <6mo are highest risk for severe influenza, important for pregnant women to get vaccinated to protect babies in first 6 mo of life

Question 400

A child is receiving high dose prednisone for nephrotic syndrome. He is due for his DPTP-Hib. When can you give it? Today 1 month 6 months 11 months

Answer 400

1 month wait 1 month to immunize if on systemic steroids

Question 401

Newborn baby with 0.8 x 0.4 cm blister on right hand. Term infant, normal pregnancy. Mom had normal antenatal screening with no concerns, normal physical exam. Born by spontaneous vaginal delivery. What should you do? a. Reassure b. Treat with antibiotics c. Treat with acyclovir

Question 402

Toddler with long history of eczema currently receiving treatment with topical steroids comes in with an acute worsening of his rash, as shown below. What is the best treatment? Cefazolin Acyclovir Reassurance Topical nystatin

Answer 402

Acyclovir eczema herpeticum (HSV infection from poorly treated eczema)

Question 403

presentation of eczema herpeticum?

Answer 403

punched out erosions/vesicles on background of poorly controlled asthma Confirm with viral culture/PCR from lesion

Question 404

management of eczema herpeticum?

Answer 404

acyclovir(IV if unwell of <1urs, or PO otherwise) if V1 involved, optho consult Add antibiotics if necessary Saline compresses help wound-healing Lesions heal over 2-6 weeks

Question 405

9 week old baby presenting with fever (~39.5). Tachycardic and irritable. Labs demonstrated WBC 4.5 (60% neutrophils, 40% leukocytes), serum glucose 4.5. LP done, shows 400 RBCs, 100 WBCs, glucose 1.5, protein normal. Gram stain of CSF is negative for bacteria. How do you treat? Ampicillin and cefotaxime Vancomycin and ceftriaxone Cefuroxime and Acyclovir Acyclovir alone

Answer 405

Ceftriaxone and Vancomycin suspicious for bacterial meningitis since low glucose would expect higher WBCs ~100 WBC in CSF after correcting for RBCs (for every 400 RBCs, expect 1 WBC) >3mo we don't consider HSV (ie no acyclovir) May end up treating for culture negative meningitis

Question 406

neonate has congenital CMV and the audiology screen shows sensorineural hearing loss. How do you treat? Valganciclovir for 4 weeks Valganciclovir for 6 months Reassure

Answer 406

Valganciclovir for 6 months

Question 407

What is the management for perianal abscesses in infants <12mo?

Answer 407

Conservative Mx: - ALL => Improved HYGIENE + warm water SITZ BATHS after bowel movements - If surrounding cellulitis => ANTIBIOTICS - If abscess not draining on own, recurrent perianal abscesses, fistula formation => I&D Try to avoid I&D as it has higher risk of complications and fistula formation!