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Flashcards in Paediatrics Year 5 Deck (244)
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1

At her 6-hour neonatal check, a newborn infant is noted to have a flat, pink lesion on the glabella. The registrar notices that it turns darker when she cries. What is this lesion likely to be? A. Capillary hemangioma B. Nevus sebaceus C. Salmon patch D. Café-au-lait spot E. Port wine stain

Salmon patch – this is a common finding in neonates, often appearing as a flat pink or salmon- colored lesion on the eyelids, the nuchal area and the glabella. It disappears with age, although those located on the nuchal area tend to persist into adulthood. Capillary hemangioma – also known as a strawberry hemangioma are bright red. Starting off as macules that are slightly raised, they tend to grow rapidly during the first year of life. They represent a small aterio-venous malformation and can appear anywhere on the body. Treatment is not necessary as they regress spontaneously after the first year. Nevus sebaceus – (of Jadessohn) are located on the scalp. They are plaques which are hairless, yellow and resemble warts. As they have the potential to become malignant, they should be removed before adolescence. Café-au-lait spot – these are flat lesions like the salmon patch, however, as the name indicated, they are tan or light brown in color. They can occur anywhere on the body, varying in size and shape. They are sharply demarcated from the underlying skin and are often associated with neurocutaneous disorders such as neurofibromatosis. Port wine stain – this needs to be distinguished from the other more benign birthmarks. Like café- au-lait spots, it is associated with a neurological disorder – specifically Sturge-Weber syndrome. The port wine stain is unilateral, consists of dermal capillaries in the distribution of the ophthalmic division of the Trigeminal nerve (CNV1 – eyelids and upper face).

2

At his 6-hour neonatal check, an infant born by spontaneous vaginal delivery is noted to have a large swelling on the back of his head. It only involves the scalp and crosses the suture lines. What is this lesion likely to be? A. Cephalohematoma B. Caput succedaneum C. Subcutaneous fat necrosis D. Meningocele E. Craniosynostosis

Caput succedaneum – this is another birth injury that is due to bleeding into the scalp of the presenting part of the head. As it involves the scalp overlying the skull bones it does cross suture lines. They resolve rapidly over several days. Cephalohematoma – this is an example of a birth injury i.e. an injury occurring during labor and delivery. This particular example is a subperiosteal bleed, which doesn’t cross suture lines (Figure 1). This is due to the fact that it is limited to the bone. They can increase in size over the first few days of life and are a common cause of neonatal jaundice. They tend to persist for several months. Subcutaneous fat necrosis – this type of injury tends to occur with instrumental delivery such as forceps or Ventouse. They are firm, rubbery nodules, which can be located anywhere on the body, tending to occur on the back and lower extremities. Meningocele – this is a neural tube defect, spina bifida cystica, where the vertebral arches fail to form and a cyst containing CSF and the meninges protrudes. This condition is associated with low folic acid during pregnancy. Craniosynostosis – these are a series of conditions associated with a variety of autosomal dominant and recessive disorders where the suture lines fuse prior to cessation of brain and head growth. This results in a constellation of developmental delay and characteristic cranio-facial morphology. Craniosynostoses usually occur in association with syndromes, such as Apert and Crouzon syndrome.

3

A 4 week old baby presents with jaundice since the 3rd day of life. He was born at term and was of normal birth weight. He is breast fed but is not feeding well and is falling off the centiles. He has a history of bruises and mum noticed a change in the color of his stool. His mother mentions she is blood group O. What would be the most diagnostic investigation? A. Coomb’s Test B. Dipstick Urine C. Liver Function Tests D. TBIDA – radionucleotide scan E. Ultrasound Scan

Then answer is D – Infants become clinically jaundice when the bilirubin level climbs to 80 to 120μmol/L. There are three main reasons why more than 60% of infants become clinically jaundiced: (1) decreased life-span of fetal red blood cells (60 to 70 days) compared to adult red blood cells (120 days) (2) high red blood cell concentration in the neonate compared to the adult results in the physiological release of hemoglobin from the breakdown of the these cells and (3) hepatic bilirubin metabolism is immature. There are two reasons why neonatal jaundice is worrying: (1) may indicate an underlying pathology (e.g. hemolytic anemia, infection or metabolic disease) and (2) unconjugated hyperbilirubinemia put the infant at risk of kernicterus. Prolonged jaundice is that which extends beyond 3 weeks of age in a neonate, so this baby has prolonged jaundice. This is usually due to an unconjugated hyperbilirubinaemia but can also be due to liver disease – conjugated hyperbilirubinaemia. Pale stools, dark urine, bleeding/bruising and FTT suggest conjugated hyperbilirubinaemia so we need to check for liver disease. LFTs are not actually very useful for this so the best option here is TBIDA which would show liver uptake and competency of the biliary tree.

4

A 4 week old baby is brought in by his mother, with worsening jaundice since one week of age. He is exclusively breast-fed and growing well. Which investigation should be carried out first? A. Conjugated and unconjugated bilirubin B. Coomb’s test C. Liver Function Tests D. Septic Screen E. Thyroid stimulating hormone levels

The answer is A – conjugated and unconjugated bilirubin. This will distinguish between a hepatic cause (conjugated) vs. a systemic cause (unconjugated) such as an infection or hemolytic process. LFTs are of little diagnostic value in this case.

5

A baby is born at term by normal vaginal delivery. While being breast fed, the mother notices at 6 hours of age he is looking jaundiced. He was immediately placed on phototherapy. While receiving treatment for jaundice, which of the following investigations can help identify the most likely cause? A. Blood culture B. Blood film C. Coomb’s test D. G6PD level E. Urinalysis for reducing substances

The answer is C – Coomb’s Test. This child is presenting with jaundice at

6

The midwife bleeps you as the FY1 doctor on-call, as she is concerned about a jittery baby. The child was born at 36 weeks via emergency Caesarean section and weight 1.8 kg. He appears to be very sensitive to external stimuli when examined and appears dysmorphic with a poorly developed philtrum above his upper lip. What is the most likely diagnosis? A. Cerebral Infection B. Down’s Syndrome C. Foetal Alcohol Syndrome D. Hypocalcaemia E. Neonatal opiate withdrawal

The answer is C – Foetal Alcohol Syndrome Common causes of a ‘jittery’ neonate are: 1. Hypoglycaemia 2. Hypocalcaemia 3. Withdrawal following maternal drug and/or alcohol abuse. Of these, only foetal alcohol syndrome is associated with dysmorphism (saddle-shaped nose, maxillary hypoplasia, absent philtrum and thin upper lip). They are also growth restricted and may have cardiac defects and developmental delay.

7

A 15 year old boy presents to the endocrine clinic with persistent gynaecomastia. On examination he is on the 99.6th centile for height, has appropriate pubic hair growth and small testes. His parents are also concerned that he has always been below average at school. What is the most likely chromosomal abnormality? A. 45X B. 47XXY C. Fragile X D. Trisomy 13 E. Trisomy 18

The answer is B – 47XXY 47XXY (Klienfelter’s Syndrome) is characterised by micro-orchidism (small testes), tall stature, behavioural problems, gynaecomastia and speech delay. 45X = Turners is a female phenotype. Trisomy 13 (Patau’s) & 18 (Edward’s) = most die

8

You are the SHO on call. A two year old boy is brought in. He has been vomiting since yesterday. On examination he has dry mucous membranes; he is tachycardic with sunken eyes, with a reduced skin turgor and prolonged capillary refill time and is lethargic. You give him 20 ml/kg Bolus of 0.9% saline and he improves slightly. Assuming no further vomiting, what is his 24 hour fluid requirement if he weighs 12 kg? A. 240 ml B. 1100 ml C. 1200 ml D. 2060 ml E. 2300 ml

The answer is D – 2060ml Calculating fluid requirement: Total fluid requirement is maintenance + deficit + ongoing losses Fluid deficit in ml = % dehydration x weight (kg) x 10 Maintenance fluid = 1st 10kg: 100ml/kg 2nd 10kg: 50ml/kg >20kg: 20ml/kg First, assess the level of dehydration which in this case is severe (10%). Moderate is classified as 5% dehydration where the parameters above are not as severe and the child may be irritable but not lethargic. You can now work out the deficit: 10% x 12kg x 10 = 1200 The maintenance is: (100ml x 10kg) + (50ml x 2kg) = 1100 Total: 1200 + 1100 = 2300ml/24hrs Then minus the 20ml/kg you have already given = 240ml ..... 2300-240 = 2060mls

9

A 14 year old boy previously growing normally along the 2nd centile for height is now below the 0.4th centile. He has been complaining of peri-umbilical abdominal pain for the last 6 months on and off. What would be your next step? A. Full Blood Count (FBC) B. Growth Hormone Provocation Test C. Mid-parental height calculation D. Sweat test E. X-ray wrist and hands for bone age

The answer is C – mid-parental height calculation 1st step is to assess whether child is growing within his normal range: measure height and weight. Weight is not an option in this choice of answers so sensible to focus on height. The nest best step would be to work out MPH (see red book for how to do this). Then see if 2nd or 0.4th centile lie within the MPH range. This will help to work out whether he is reaching his full potential or not. If he isn’t we can then think about more investigations.

10

An Asian mother has brought her 8 week old son to you as her GP, for a routine child health check. He was born at 36 weeks gestation. He is exclusively breast fed and is thriving. Of the following options, which oral supplements would you advise for the mother? A. Calcium B. Folic Acid C. Iron D. Vitamin B12 E. Vitamin D

The answer is E – Vitamin D Without any further information apart from ethnicity, mum is most at risk of vitamin D deficiency due to darker skin pigmentation. The amount of vitamin D in breast milk is directly related to maternal levels, therefore increasing the risk of vitamin D deficiency in the baby if mum is not supplemented. (Babies of this age would rarely be exposed to levels of sunlight in Britain adequate enough to synthesise their own vitamin D).

11

A 15-year-old boy attends an outpatient paediatric clinic complaining of short stature. He has noticed over the past two years that he has become increasingly shorter than his peers. On examination he looks well. He has pre-pubertal sized testes, and sparse pubic hair. His height has fallen from the 25th to 9th centile. His father reports he was ‘a late developer’. What is the most likely cause of this boy’s short stature? A. Acquired hypothyroidism B. Coeliac Disease C. Constitutional Delay of Growth and Puberty D. Cystic Fibrosis E. Gonadotrophin Deficiency

Correct Answer: B: Constitutional Delay of Growth and Puberty In this case, there is evidence of delayed puberty, with consequent delayed pubertal growth spurt. Constitutional delay of growth and puberty is the commonest cause of delayed puberty, and there is often history of delayed puberty in the boy’s father. There was no evidence of systemic disease to suggest either celiac disease or cystic fibrosis as a cause. Isolated gonadotrophin deficiency is rare, occurring in 1 in 10,000 males, and is therefore unlikely.

12

A 6 six year old boy presented to the developmental clinic with difficulties fitting into school. Mother states that he has trouble sustaining prolonged conversation. He appears clumsy and has occasional tantrums but he knows the capital of every European country. Of the following options, which member of the multidisciplinary team is LEAST likely to be involved in his care? A. Community Paediatrician B. Neurologist C. Occupational Therapist D. Psychologist E. Special educational needs coordinator

Correct Answer: B: Neurologist Asperger’s syndrome is characterised by: 1. Normal intelligence 2. No delay in language development 3.Impaired social and communication skills and a narrow range of obsessional interests Many members of the multidisciplinary team are involved to help manage this disorder and improve a child’s functioning. Doctors involved primarily include neurodevelopmental and community paediatricians and GPs. There is no organic neurological problem in Asperger’s syndrome; therefore a neurologist is least likely to be involved in this child’s care.

13

You are the paediatric registrar working in a general out-patient clinic. You see a four year old boy whose parents are concerned that he has difficulty interacting with the neighbours’ children. The teachers in school reprimand him for being cheeky as he often repeats what they say. You notice that he has poor eye contact. What is the next most appropriate step in the management of this patient? A. Initiate Ritalin Treatment B. Reassure symptoms will resolve of their own accord C. Refer to Child Development Team for assessment D. Send the patient to child psychiatry team for assessment E. Send the patient to paediatric neurology

Correct Answer: C: Refer to Child Development Team for assessment. The child being described has features of autistic spectrum disorder. The 3 core features of autism which should be present by 3 years are: 1. Impaired social interaction 2. Impaired communication 3. Restricted, repetitive and stereotyped behaviour and interests. Management involves a wide variety of health professionals and varies greatly between different children; therefore a thorough assessment is required to assess each child’s needs. This is done by the child development team.

14

A 4-year-old girl is brought to the accident and emergency department after falling off her bed. Radiographic examination reveals with a right-humeral fracture. She has a past medical history of 3 previous attendances for fractures. On examination there is discolouration of the sclera and bowing of the lower limbs. Of the following, which is the most likely diagnosis? A. Achondroplasia B. NAI C. Osteogenesis imperfecta D. Osteoporosis E. Rickets

Osteogenesis imperfecta – is an autosomal recessive disorder of collagen synthesis. It typically involves blue sclera, and bowing of the legs, it would also fit to have a past medical history of fractures. Achondroplasia – is an autosomal dominant disorder which is characterized by short stature, large head and prominent forehead with a flattened nasal bridge. The limbs are short, especially the proximal aspects. Patients often have bow-legs and may present with hydrocephalus due to narrowing of the foramen magnum. These children have normal intelligence. Osteoporosis generally doesn’t affect children. Rickets – this occurs in association with vitamin D deficiency

15

A 5 year old boy presents with a 12 hour history of a painful left hip on movement. He is afebrile. An x-ray is normal. Ultrasound shows joint effusion in the affected hip. FBC and CXR are normal. What is the best management plan? A. Bed rest B. Joint Aspiration C. Plaster cast D. Skin traction E. Surgical intervention with pin fixation

This is transient synovitis (age range is 2-12 yr, child would be afebrile, sudden onset) for which the best treatment option is bed rest, skin traction is used but very rarely. Neutrophils and Acute Phase Reactants are also normal as are blood cultures and x-rays. Together the picture of Transient Synovitis is the opposite of septic arthritis.

16

A 5 year old boy is brought into A+E by his annoyed mother. She reveals that he has been constantly complaining of leg pain. On examination you notice a limp and tenderness in his right leg, but no loss of range of movement. You also notice marked bruising on his back. What is the next step in this child’s management? A. Analgesia B. Blood Film C. FBC and Clotting Studies D. Refer to child protection services E. X-ray

Correct Answer: X-ray Certain features in the history are suggestive of non-accidental injury (NAI): ‘annoyed mother, sense of delay in presentation to hospital, bruising on back. Full skeletal X-ray is useful in looking for any fractures and this is the best NEXT step. Advice from a senior colleague is always part of the management in a case like this, where NAI might be a possibility.

17

A new mother is attending her GP practice for a 6 week check-up for her daughter. On examination the GP notices asymmetrical skin creases around the hip joint which was also unstable. Which is the next most appropriate step for management? A. Arrange for X-ray of the hip B. Ask the Health Visitor to monitor C. Recommend the baby is put in double nappies D. Refer to orthopaedics E. Refer to physiotherapy

Correct Answer: D: Refer to orthopaedics Diagnosis is most likely to be Developmental Dysplasia of the Hips (DDH). DDH typically presents with asymmetrical skin-folds, limb abduction, shortening of affected limb and limp (if not diagnosed until child is walking). DDH needs early treatment from Orthopaedics with a Craig’s splint (hips held in abduction) or a Pavlik harness (restraining device) for several months. Therefore physiotherapy, health visitor follow-up and double nappies are inappropriate steps. IN suspected DDH the investigation of choice is an ultrasound scan of the hips, rather than an x- ray.

18

You are asked to see a 5-year-old boy who has been carried into the accident and emergency department by his father. His father reports that he has had a bout of the ‘flu’ over the past week and didn’t want to get out of bed this morning. There is no history of trauma. On examination, the boy is afebrile and appears well. He refuses to weight bear because it ‘hurts to walk’. What is the most likely diagnosis? A. Fracture B. Osteomyelitis C. Septic arthritis D. Slipped upper femoral epiphysis E. Transient synovitis

The answer is E – this child is refusing to weight bear following a viral illness.

19

A 7-year-old child is brought to the clinic by her parents to examine several bumps they have found on her body. Her parents noticed them several weeks ago on her neck and there are now several on her trunk. They say that the child has a tendency to scratch them. On examination – there are several pale-pink papules with umbilicated centers. The child is otherwise fit and well. To which family does the most likely causative viral agent of these lesions belong? A. Herpesviruses B. Poxviruses C. Flaviviruses D. Paramyxoviruses E. Retroviruses

Poxviruses – the causative agent is Molluscum contagiosum virus, which is a member of the poxvirus family. The vignette describes the classical presentation. The papules may be slightly pruritic and children tend to scratch and spread them via auto-inoculation (Koebner phenomenon). The papules eventually spontaneously resolve and no treatment is necessary. Herpesviruses – eight types of herpes virus infect humans; HSV1 and HSV2, VZV, EBV, CMV, HHV6 and HHV7 (roseola infantum / subitum – morbilliform rash appearing following fever on chest and abdomen) and HHV8 (Kaposi’s sarcoma-associated). Flaviviruses – Dengue fever and Hepatitis C virus (among others) Paramyxoviruses – Measles (rubeola – highly contagious; 7 to 14 day incubation period; fever, cough, coryza, conjunctivitis, enanthem (Koplik spots) on buccal or labial mucosa, maculopapular rash that spreads cephalocaudally). Live attenuated vaccine given (MMR) at: 12 to 15 months and a second dose age 4 to 6 years. Retroviruses – HIV virus

20

A 3-year-old child is brought into the emergency department. His parents are worried as he is running a fever of 38°C and has developed a rash. Examination reveals a rash at several stages of healing – some are clear 4mm vesicles on an erythematous base, while others are crusted. Which of the following complications would you worry about in an immunocompromised child? A. Secondary infection with group A streptococci B. Secondary infection with Pseudomonas aeruginosa C. Hepatic spread D. Pneumonitis E. Encephalitis

Pneumonitis – the child in the vignette has Varicella zoster virus infection (chicken pox), which is spread by respiratory droplets. It lies latent in the dorsal root ganglia and leads to herpes zoster with reactivation (shingles). Fifteen to twenty percent of immunocompromised children develop Varicella zoster pneumonitis. Secondary infection with group-A streptococci – this is the most common complication in the normal host causing scarring. Secondary infection with Pseudomonas aeruginosa – this infection commonly occurs in burns victims Hepatic spread – not a complication of Varicella zoster infection Meningitis – while Guillain-Barré syndrome, encephalitis and cerebellar ataxia all may occur in Varicella zoster, meningitis is an uncommon complication.

21

You are called to see a 13-month-old boy in the emergency department who over the past two days refuses to weight bear on his right side. The mother says that a week ago he had an ear infection for which the GP prescribed antibiotics. She decided not to give them as he seemed better. Which single investigation would most likely confirm your diagnosis? A. Radiograph of the right hip B. MRI of the right hip C. Blood culture D. Erythrocyte Sedimentation Rate (ESR) E. Full blood count with white blood cell differential

Blood culture – this child most likely has osteomyelitis secondary to untreated otitis media. Osteomyelitis can occur due to: (1) hematogenous spread – which is the most common mechanism in children (2) contiguous spread and (3) direct infection from a penetrating wound. Blood cultures are positive in 60% of cases. The most common cause in children aged 3 to 12 years is Staphylococcus aureus. The patient should be treated with IV antibiotics (flucloxacillin and benzyl-penicillin) for 3 weeks in hospital and then switched to oral for 1 to 3 more weeks. Radiograph of the right hip – radiographic findings appear after 10 days to two weeks. They usually show swelling of the surrounding tissue and periosteal elevation. MRI of the right hip – this is used when the diagnosis is uncertain. Erythrocyte Sedimentation Rate (ESR) – may be normal during the early stages of infection Full blood count with white blood cell differential – may be normal during the early stages of infection

22

You are the pediatric registrar on call in the emergency department. An 11-month-old child is brought in by her mother with irritability and several episodes of vomiting. The mother says that the child has been like this since waking and has a tactile fever. The mother adds that she is bothered by bright lights. Following a thorough history and examination, you perform a lumbar puncture. Which CSF findings would be in keeping with aseptic meningitis? A. Low glucose B. Leukocytes C. High protein D. High opening pressure E. PMNs

Leukocytes – this is the only finding listed that is a typical CSF finding in aseptic meningitis. The rest are all features of a pyogenic infection. Aseptic meningitis is typically caused by a virus, usually an enterovirus. Other viral causes include herpes viruses, adenoviruses, and paramyxoviruses. Enterovirus-associated meningitis is often seen in the summer and fall. Treatment is supportative unless herpes virus – acyclovir. The most common causes of meningitis based on age-group: Neonate to 3/12: GBS Listeria monocytogenes and Escherichia coli Over 3/12: Neisseria meningitides, Streptococcus pneumoniae and Haemophilus influenzae Children younger than 1/12 should receive ampicillin and an aminoglycoside (gentamicin to cover for Listeria) or a cephalosporin (cefotaxime). Children over 1 month should receive ceftriaxone or cefotaxime and ampicillin If Streptococcus pneumoniae is suspected, then vancomycin should be added

23

A four year old ‘precious child’ of an ‘alternative’ Chelsea mum presents to A+E with a maculopapular rash which began on the face and is not itchy. On examination the child complains of headache and has prominent suboccipital and post auricular lymphadenopathy. Mother is 7 weeks pregnant with her second child. What is the most appropriate management? A. Advise that the child does not attend nursery for 15 days B. Check maternal serology C. Give mother prophylaxis measles immunoglobulin D. Perform lumbar puncture E. Prescribe oral penicillin

Correct Answer: B: Check Maternal Serology The question implies that the child may not have received the MMR vaccine, and therefore the clinical history suggests measles infection. Risk of transmission to mother and foetus is high so mother’s immunity must be checked via maternal serology tests. Rubella infection during pregnancy causes foetal abnormalities such as deafness, cardiac disease, eye problems and mental retardation. The risk is higher in early pregnancy (90% at 9/40) Rubella is a live vaccine so would need to give mother maternal Ig if serology tests show she is not immune. Antibiotics would be of little use in this case as measles is a viral infection.

24

An 8 year old boy presented to the GP with a fever lasting 3 weeks, for which he received no medication. It was associated with a cough, loss of appetite and lesions on his lower limbs that were well defined and tender. What is the most likely cause of these symptoms? A. Drug Reaction B. Inflammatory Bowel Disease C. Mycoplasma pneumonia D. Streptococcal infection E. Tuberculosis

Correct Answer: E: Tuberculosis The leg lesions are erythema nodosum which can be associated with all of the above. The other symptoms are classically TB, particularly the anorexia and duration of symptoms. There is no indication the child is on any medication, making a drug reaction unlikely. There is also no history of diarrhoea, which would make the diagnosis of inflammatory bowel disease more likely. Streptococcal infections typically are not associated with a cough.

25

A mother comes into A+E with her one year old baby who has had a 4 day history of fever, irritability and a rash. The mother says that whilst stroking her child, the skin peels off. On examination purulent crusting around the eyes is noted. What is the most likely diagnosis? A. Kawasaki’s Disease B. Necrotising Cellulitis C. Pemphigoid D. Scalded Skin Syndrome E. Scarlet Fever

Correct Answer: D: Scalded Skin Syndrome Staphylococcal scalded skin syndrome (SSSS) presents with a red rash followed by diffuse separation of the epidermal skin. It is associated with fever and irritability and purulent, crusting, localised infection around the eyes, nose and mouth. Desquamation of the fingers and toes can be seen in both Kawasaki’s and scarlet fever, but it is not widespread. The key feature of necrotising cellulitis is necrosis which is not seen here. Pemphigoid is characterised by bullae, which although can be a feature of SSSS, are not mentioned in this case.

26

A one year old boy is brought to A+E by his parents with a history of 6 days of high fever. On clinical examination the child is irritable, has cervical lymphadenopathy, red swollen palms, red eyes and a rash. What would be the most appropriate treatment? A. Ibuprofen B. IVIG C. IV penicillin D. Steroids E. Supportive Treatment

Correct Answer: C: IVIG This is describing Kawasaki’s disease. The diagnosis is clinical: fever >5 days + 4 other features of: • conjunctival injection • red mucous membranes • cervical lymphadenopathy • rash • red and oedematous palms and soles or peeling of fingers and toes. Treatment is: • IVIG (to reduce risk of coronary artery aneurysms) • Aspirin (to reduce risk of thrombosis, but aspirin is not an option in this question) Scarlet fever (the main differential diagnosis) is treated with penicillin.

27

A 2 year old boy presents to Paediatric Accident and Emergency with a four day history of fever, malaise and lymphadenopathy. He saw his GP two days ago and was prescribed amoxicillin. He has since developed a widespread maculopapular rash covering 70% of his body. What is the most likely pathogen causing this presentation? A. Cytomegalovirus B. Epstein-Barr Virus C. Measles D. Human Herpes Virus-6 E. Rubella

Correct Answer: B: Epstein-Barr Virus Although all of the above can cause fever, Epstein-Barr Virus is the correct answer. When prescribed amoxicillin or ampicillin, children with EBV infection will sometimes develop a morbilliform rash, not too dissimilar to that seen in measles. The constellation of fever, malaise, lymphadenopathy in the light of this amoxicillin-associated rash should point towards a diagnosis of EBV. Always remember Kawasaki’s Disease should be considered in the differential diagnosis.

28

A 4-year-old girl presents to the accident-and-emergency department with a five day history of high fever and a rash. On examination, he is miserable, with a non-purulent conjunctivitis, an erythematous patchy rash and marked cervical lymphadenopathy. What is the most appropriate treatment for this girl’s condition? A. Intravenous ceftriaxone B. Intravenous dexamethasone C. Intravenous diphenhydramine D. Intravenous flucloxacillin E. Intravenous immunoglobulin

The answer is E – this child has Kawasaki’s disease.

29

A 10 month old boy presents with a two day history of worsening difficulty in breathing and wheeze. Prior to this he was experiencing coryzal symptoms. His 4 year old sister has recently had an upper respiratory tract infection after attending nursery. On examination there is a respiratory rate of 58, nasal flaring, tracheal tug and subcostal and intercostal recession. There is a widespread polyphonic wheeze on auscultation. Pulse oximetry reveals an oxygen saturation of 91% in room air. What is the most likely diagnosis? A. Aspiration B. Bronchiolitis C. Foreign Body inhalation D. Pneumonia E. Pneumothorax

Correct Answer: B: Bronchiolitis This is unlikely to be pneumonia as might expect focal signs such as an area of consolidation. A pneumothorax is unlikely as there is no evidence of hyper-resonant percussion notes, decreased breath sounds or asymmetrical chest expansion. With foreign body inhalation, one would expect a more sudden onset of symptoms. There is no history to suggest aspiration as cause of this respiratory distress. A widespread polyphonic wheeze and increased work of breathing, with a history of coryzal illness and close contacts with viral URTIs is a typical presentation of acute viral bronchiolitis.

30

A 10 month old boy presents to accident and emergency with a three day history of worsening difficulty in breathing. The boys parents report a fever of 38.5oC measured at home during this time. On examination the child is tachypnoeic and there is slightly reduced chest expansion on the right. On auscultation there is reduced air entry at the right lower zone, and also some crepitations at the right base. You also notice the child is grunting during expiration. Pulse oximetry reveals an oxygen saturation of 91% in room air. What is the most likely diagnosis? A. Aspiration B. Bronchiolitis C. Foreign Body inhalation D. Pneumonia E. Pneumothorax

Correct Answer: D: Pneumonia This is most likely to be pneumonia as there are focal signs suggestive of pneumonia. Also end expiratory grunting is often indicative of pneumonia or a lower respiratory tract infection. The grunting is due to glottal closure, which produces a positive end expiratory pressure and helps keep the lower airways patent. Grunting is also seen in infants who are acidotic.