Paeds III

Question 1

How can you differentiate between Bacillus cereus causing diarrhoea compared to other infective agents? [1]

Answer 1

Bacillus cereus causes vomiting for 5hrs; then diarrhoea for 8hrs

Question 2

What syndrome can Shigella cause? [1]
Name two treatments [2]

Answer 2

haemolytic uraemic syndrome:

Treatment of severe cases is with azithromycin or ciprofloxacin.

Question 3

A patient presents with diarrhoea, right sided abdominal pain and fever.
What is the most likely cause of infection? [1]
What is a differential diagnosis? [1]

Answer 3

Yersinia enterocolitica: diarrhoea, right sided abdominal pain and fever.

Right sided abdominal pain is caused by mesenteric lymphadenitis (inflammation in the intestinal lymph nodes): appears like appendicitis}

Question 4

Which parasite is found in the small intestines of mammals and causes diarrhoea via a faecal-oral transmission? [1]

Answer 4

Giardia lamblia

Question 5

How do you treat Giardia lamblia? [2]

Answer 5

tinidazole or metronidazole

Question 6

Which overall type of pathogen most commonly causes gastroenteritis in children? [1]

Name the three most common pathogens [3]

Answer 6

Viral gastroenteritis is most common. It is highly contagious. Common causes are:
* Rotavirus
* Norovirus
* Adenovirus is a less common cause and presents with a more subacute diarrhoea.

Question 7

Describe the relationship between E. coli and haemolytic uraemic syndrome (HUS) [2]

Answer 7

E. coli 0157 produces the Shiga toxin: This causes abdominal cramps, bloody diarrhoea and vomiting.
- The Shiga toxin destroys blood cells and leads to haemolytic uraemic syndrome (HUS).

Question 8

Eating raw or undercooked pork OR spread through contamination with the urine or faeces of other mammal such as rats and rabbits.

This refers to gastroenteritis can caused infection by which pathogen? [1]

Describe the presentation [4]

Answer 8

Yersinia Enterocolitica
- Yersinia most frequently affects children
- causing watery or bloody diarrhoea
- abdominal pain
- fever
- lymphadenopathy

Question 9

What is the incubation period like of Yersinia Enterocolitica like? [1]

How long does infection last? [1]

Answer 9

Incubation is 4 to 7 days and the illness can last longer than other causes of enteritis with symptoms lasting 3 weeks or more.

Question 10

Describe how Shigella is spread [1]

What is the incubation period like? [1]

What is the treatment like? [2]

Answer 10

Shigella is spread by faeces contaminating drinking water, swimming pools and food.

The incubation period is 1 to 2 days and symptoms usually resolve within 1 week without treatment.
- Treatment of severe cases is with azithromycin or ciprofloxacin.

Question 11

Describe the presentation of Shigella gastroenteritis [3]

Answer 11

It causes bloody diarrhoea, abdominal cramps and fever. Shigella can produce the Shiga toxin and cause haemolytic uraemic syndrome.

Question 12

What is a key indicator that a patient is suffering from H.U.S? [2]

Answer 12

Blood diarrhoea and AKI symptoms

Question 13

How do you distinguish between bacterial and viral gastroenteritis?

Answer 13

Bacterial gastroenteritis:
- usually presents with high fever and severe diarrhoea, which is commonly bloody.

Viral gastroenteritis is a self-limiting condition which lasts < 14 days. The most common symptoms include:
- Acute diarrhoea
- Vomiting (80%)
- Mild fever (40%)
- A short viral prodrome may occur before the onset of diarrhoea, consisting of mild fever and nausea or vomiting.

NB: A temperature >39°C in adults or >38°C in children under 3 months old should raise suspicion of bacterial pathology.

Question 14

Describe the typical presentation of:
- Escherichia coli [3]
- Giardiasis [1]
- Cholera [2]

Answer 14

Describe the typical presentation of: [3]

Escherichia coli:
* Common amongst travellers
* Watery stools
* Abdominal cramps and nausea

Giardiasis:
- Prolonged, non-bloody diarrhoea

Cholera:
* Profuse, watery diarrhoea
* Severe dehydration resulting in weight loss

Question 15

What is the most common cause of viral gastroenteritis in children? [1]

Answer 15

rotavirus

Question 16

Describe the typical presentation of:
- Shigella [2]
- Staph aureus [2]
- Campylobacter [3]

Answer 16

Question 17

Describe the typical presentation of:
- Bacillus cereus [2]
- Amoebiasis [2]

Answer 17

Question 18

Incubation period
1-6 hrs: [2]
12-48 hrs: [2]
48-72 hrs: [2]
> 7 days: [2]

Answer 18

Incubation period:
1-6 hrs: Staphylococcus aureus, Bacillus cereus
12-48 hrs: Salmonella, Escherichia coli
48-72 hrs: Shigella, Campylobacter
> 7 days: Giardiasis, Amoebiasis

Question 19

What are the treatments for the following: [+]
- E. coli
- Gardiosis
- Cholera
- Shigella
- Staph aureus
- Campylobacter
- Bacillus cereus
- Ameobiosis

Answer 19

Escherichia coli
- Gram Negative Rod
- Mx - Self Limiting

Giardiasis
- Flagellate Protozoan
- Mx - Metronidazole

Cholera
- Gram Negative Curved Rod
- Mx - 1. Doxycycline or 2. Ciprofloxacin

Shigella
- Gram Negative Rod
- Mx - 1. Ciprofloxacin or 2. Azithromycin

Staphylococcus aureus
- Gram + Cocci - Clustered (Grapes)
- Mx - Self Limiting

Campylobacter
- Gram Negative ‘Spiral’ Curved Rod
- Mx - Clarithromycin

Bacillus cereus
- Gram + Rod
- Mx - Mild = Self Limiting OR Severe = Vancomycin

Amoebiasis
- Mx - Metronidazole + Diloxanide Furoate (Intraluminal Agent)

Question 20

Describe how you differentiate between measles and scarlet fever [1]

Answer 20

Measles has a maculopapular rash that starts on the face and moves down the body; Koplik spots

Scarlet fever has a distinctive rash that appears 1–2 days after the onset of other symptoms, first on the neck and then spreading to the trunk and extremities; strawberry tongue

Question 21

Describe how a the rash in measles spreads around the body [1]

Answer 21

The rash typically STARTS behind the ears and then spreads to the whole body

Question 22

Describe the difference in encephalitis formed by measles encephalitis [2]

Answer 22

Encephalitis:
Acute form occurs after 1 week:
- 15% mortalitly, 25% sequelae

Subacute sclerosing panencephalitis (SSPE): after about 5 years:
- slowly progressive neurological decline, fatal

Question 23

Describe the characteristics of the rash in slapped cheek syndrome [3]

Answer 23

The rose-red rash makes the cheeks appear bright red, hence the name ‘slapped cheek syndrome’. The rash may spread to the rest of the body but unlike many other rashes, it only rarely involves the palms and soles.

The child begins to feel better as the rash appears and the rash usually peaks after a week and then fades.

some months afterwards, a warm bath, sunlight, heat or fever will trigger a recurrence of the bright red cheeks and the rash itself.

Question 24

What is the most likely complication of slapped cheek syndrome? [1]

Answer 24

Anaemia

Question 25

Deficiency of which vitamin is a risk factor for measles? [1]

Answer 25

Vitamin A

Question 26

Describe the pattern of Roseola infantum [5]

Answer 26

**Roseola** has a typical pattern of illness.: - It presents **1 – 2 weeks after infection** with a **high fever (up to 40ºC)** that comes on **suddenly**, **lasts for 3 – 5 days** and then **disappears** **suddenly**. - There may be **coryzal** **symptoms**, sore throat and swollen lymph nodes during the illness. - When the **fever settles, the rash appears for 1 – 2 days** - The rash consists of a **mild erythematous macular rash across the arms, legs, trunk and face and is not itchy.** **Children make a full recovery within a week** and **do not generally need to be kept off nursery** if they are well enough to attend.

Question 27

Describe the rash caused by rubella [1] What are the other significant clinical features? [4]

Answer 27

**Rash** that **starts** on the **face and spreads to the trunk and rest of body** Other clinical features: * **mild fever** * **sore throat** * **lymphadenopathy: suboccipital and postauricular** * Often associated with **arthritis and arthralgia**

Question 28

Rubella poses a serious risk to unvaccinated pregnant women. Congenital rubella infection (especially in the first 20 weeks of pregnancy) can lead to congenital rubella syndrome, which can cause severe fetal abnormalities such as: [4] What is the clinical triad? [3]

Answer 28

* Cataracts * Deafness * Patent ductus arteriosus * Brain damage Rubella is dangerous in pregnancy and can lead to congenital rubella syndrome, which is a triad of **deafness, blindness and congenital heart disease**

Question 29

What are the complications of rubella infection? [2]

Answer 29

**Complications** are **rare** but include **thrombocytopenia** and **encephalitis**. .

Question 30

A child is dx with rubella. What advise should you give them about attending school? [1]

Answer 30

Children should **stay off school for at least 5 days** after the rash appears. Children should avoid pregnant women.

Question 31

Scarlet fever occurs typically at which ages? [1] It is a reaction to which organism? [1]

Answer 31

**Scarlet fever** is a reaction to erythrogenic toxins produced by **Group A haemolytic streptococci (usually Streptococcus pyogenes)**. It is more common in children **aged 2 - 6 years** with the **peak** incidence being at **4 years.**

Question 32

Describe the clinical features of scarlet fever [4]

Answer 32

* **Coarse red rash** on the **cheeks**, sore throat, headache, fever, '**sandpaper' texture rash** * **bright red tongue / strawberry tongue** * **fever** for 24/48 hours * **rash appears first on torso** and spares palms and soles * **Cervical lymphadenopathy** *Scarlet fever is caused by an exotoxin produced by the streptococcus pyogenes (group A strep) bacteria. It is characterised by a red-pink, blotchy, macular rash with rough “sandpaper” skin that starts on the trunk and spreads outwards.* Other features:

Question 33

Describe the management for scarlet fever [2] When can children return to school? [1]

Answer 33

* **oral penicillin V for 10 days** * patients who have a penicillin allergy should be given **azithromycin** * children can **return to school 24 hours** after commencing antibiotics * ***scarlet fever is a notifiable disease***

Question 34

Name 4 complications of scarlet fever [4]

Answer 34

* **otitis media**: the most common complication * **rheumatic fever**: typically occurs 20 days after infection * **acute glomerulonephritis**: typically occurs 10 days after infection * **invasive complications** (e.g. bacteraemia, meningitis, necrotizing fasciitis) are rare but may present acutely with life-threatening illness

Question 35

Which complication of scarlet fever typically presents 10 days after infection? [1]

Answer 35

**Glomerulonephritis**

Question 36

Which complication of scarlet fever typically presents 20 days after infection? [1]

Answer 36

**Rheumatic fever**

Question 37

What are the three ddx for fever with vesicles? [3]

Answer 37

HSV VZV Hand, Foot and Mouth (cocksackie)

Question 38

Describe the presentation of chickenpox infection [2] - Include where the rash starts and timecourse [1]

Answer 38

Chickenpox is characterised by widespread, **erythematous, raised, vesicular (fluid filled), blistering lesions**. - The rash usually **starts on the trunk** or **face** and **spreads outwards affecting the whole body over 2 – 5 days.** Eventually the lesions scab over, at which point they stop being contagious. **Other symptoms:** * **Fever is often the first symptom** * **Itch** * **General fatigue and malaise**

Question 39

Describe a key skin complication of VZV infection [1] What would be key symptoms that would make you suspect this manifestation? [1]

Answer 39

**Bacterial infection** (most commonly **Strep. pyogenes**) infections of lesions: - Can cause **cellulitis** or even **necrotising** **fasciitis** Would present as: **Fever** (from initial infection), **gets better**, then develops **second wave of fever**

Question 40

Describe a CNS complication of VZV infection [1] Describe a resp. complication of VZV infection [1]

Answer 40

**Encephalitis** - presents with dramatic **cerebella ataxia** **Pneumonia** - presents with **calcifications** on **CXR**

Question 41

A child w/ immunosuppresion becomes exposed to VZV. How would you manage this patient? [1] How would you treat them if they became infected? [1]

Answer 41

**Prophylaxis zoster immunoglobulin (ZIG)** If **infected**: **IV acylovir**

Question 42

Describe the difference between bullous and non-bullous impetigo: - location - characteristics - treatment

Answer 42

**Non-Bullous Impetigo** - occurs around the **nose or mouth**. - the exudate from the lesions dries to form a “**golden crust**”. They are often unsightly but do not usually cause systemic symptoms or make the person unwell. - **Topical fusidic acid** can be used to treat localised non-bullous impetigo. Draft NICE guidelines from August 2019 suggest using antiseptic cream (hydrogen peroxide 1% cream) first line rather than antibiotics for localised non-bullous impetigo. - **Oral flucloxacillin** is used to treat more wide spread or severe impetigo. **Bullous Impetigo** - Bullous impetigo is always caused by the staphylococcus aureus bacteria. These bacteria can produce epidermolytic toxins that break down the proteins that hold skin cells together. This causes 1 – 2 cm fluid filled vesicles to form on the skin. These vesicles grow in size and then burst, forming a “**golden crust”**. Eventually they heal without scarring. These lesions can be painful and itchy. - This type of impetigo is more common in **neonates and children under 2 years,** however it can occur in older children and adults. - It is more common for **patients to have systemic symptoms**. They may be **feverish** and **generally** **unwell**. - **Treatment of bullous impetigo** is with antibiotics, usually **flucloxacillin**. This may be given **orally** or **intravenously** if they are **very unwell** or at risk of **complications**.

Question 43

How do you treat cellulitis? [+]

Answer 43

**Eron Class I** * oral **antibiotics** (co-amox) * oral flucloxacillin as first-line treatment for mild/moderate cellulitis * oral clarithromycin, erythromycin (in pregnancy) or doxycycline is recommended in patients allergic to penicillin. **Eron Class II** * NICE recommend: 'Admission may not be necessary if the facilities and expertise are available in the community to give intravenous antibiotics and monitor the person - check local guidelines.' **Eron Class III-IV** * admit * NICE recommend: oral/IV co-amoxiclav, oral/IV clindamycin, IV cefuroxime or IV ceftriaxone

Question 44

Name four symptoms of periorbital cellulitis [4]

Answer 44

**Swelling, fever** **Proptosis**: one or both of eyes bulge from their natural position **Opthalmoplesia**: paralysis of eye muscles **Colour vision disruption**

Question 45

If a child has orbital involvement - what investigations would you perform? [1]

Answer 45

**CT scan**

Question 46

What is the difference between orbital and periorbital cellulitis? [2]

Answer 46

**Periorbital cellulitis:** - also known as preseptal cellulitis, affects the **eyelid** and **surrounding skin anterior to the orbital septum** - **secondary** to **local trauma, sinusitis or upper respiratory tract infections**. **Orbital cellulitis** - is a **post-septal infection** involving the **orbit's soft tissues posterior to the orbital septum**

Question 47

Describe the presentation of periorbital cellulitis [+]

Answer 47

* **Red, swollen, painful eye of acute onset** * **Fever** * **Partial** or **complete** **ptosis** of the eye due to swelling * **Orbital** **signs** (pain on movement of the eye, restriction of eye movements, proptosis, visual disturbance, chemosis, RAPD) must be **ABSENT** in preseptal cellulitis - their **presence** would **indicate orbital cellulitis**

Question 48

How do you investigate for preseptal cellulitis? [3]

Answer 48

**Investigations** * **Bloods** - raised inflammatory markers * **Swab of any discharge present** * **Contrast CT of the orbit** may help to differentiate between preseptal and orbital cellulitis. It should be performed in all patients suspected to have orbital cellulitis

Question 49

Management of preseptal cellulitis? [4]

Answer 49

**Mild-moderate:** - Co-amoxiclav oral - patients allergic to penicillins, clarithromycin or erythromycin can be used. **Severe**: - IV Ceftriaxone or cefotaxime - In the presence of methicillin-resistant Staphylococcus aureus (MRSA) risk factors, vancomycin or teicoplanin should be added. **Surgical Intervention**: - Although rare, surgical intervention may be required in the case of an abscess formation that does not respond to medical management alone.

Question 50

If periorbital cellulitis doesn't improve after 48 hours of treatment - what alternative dx should you suspect? [1]

Answer 50

Clinical improvement should be seen within 48 hours of initiating appropriate antibiotic therapy. If no improvement is observed, reassess the patient and consider alternative diagnoses such as **orbital cellulitis.**

Question 51

Define what is meant by orbital cellulitis [1] Where does the infection most commonly come from in the body? [1]

Answer 51

**Orbital cellulitis** is the result of an **infection** affecting the f**at and muscles posterior to the orbital septukm**, within the **orbit** but **not involving the globe.** It is usually caused by a spreading upper respiratory tract infection from the sinuses and carries a high mortality rate

Question 52

The clinical features of orbital cellulitis are grouped into five classic signs, collectively known as the '5 P's'. Describe the 5 Ps [5]

Answer 52

**Pain**: - Pain is a prominent feature of orbital cellulitis and is usually described as **throbbing or a deep ache**. - The pain often **intensifies with eye movements** and can **radiate** to the **forehead, cheek, or teeth**. **Proptosis** (**Exophthalmos**): - This refers to a **forward displacement or protrusion of the eyeball.** - It is due to **inflammation and oedema of the orbital contents, or in severe cases, formation of an abscess**. - Proptosis can be assessed clinically by lateral inspection or measured with an exophthalmometer. **Periocular Swelling (Oedema):** - Periocular swelling and redness result from the **inflammatory response within the orbital tissues**. - The patient may present with **swollen eyelids, chemosis (swelling of the conjunctiva), and erythema.** It's crucial to **distinguish** this sign from **preseptal** **cellulitis**, which affects **only the eyelid and periorbital tissues, without the involvement of the orbital contents.** **Pupil Involvement and Visual Changes**: - This may present as **blurred** **vision**, **decreased visual acuity,** diplopia (**double** **vision**), or even **loss of vision in severe, advanced cases**. - **A relative afferent pupillary defect (RAPD)** may be present, indicating optic nerve involvement. These features necessitate urgent attention, given the risk of permanent vision loss. **Palsy (Ophthalmoplegia)**: - Due to the inflammation and swelling in the orbit, there can be **restriction or paralysis of the extraocular muscles, leading to impaired eye movements (ophthalmoplegia)**. This can further contribute to the complaint of diplopia.

Question 53

Describe the differences between primary and secondary amenorrhoea [2]

Answer 53

**primary**: defined as the failure to establish menstruation by 15 years of age in girls with normal secondary sexual characteristics (such as breast development), or by 13 years of age in girls with no secondary sexual characteristics **secondary**: - cessation of menstruation for 3-6 months in women with previously normal and regular menses, or 6-12 months in women with previous oligomenorrhoea

Question 54

Describe the initial investigations for amenorrhoea [5]

Answer 54

**exclude pregnancy** with urinary or serum bHCG **full blood count, urea & electrolytes, coeliac screen, thyroid function tests** **gonadotrophins** - low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure) raised if gonadal dysgenesis (e.g. Turner's syndrome) **prolactin** **androgen levels** - raised levels may be seen in **PCOS** **oestradiol**

Question 55

Define what is meant by precocious puberty in boys and girls [2] What are the two types? [2]

Answer 55

**Precocious puberty** is characterised by the onset of **secondary sexual characteristics** before the **age of 8** in girls and **9 in boys** **central precocious puberty (CPP)**: - resulting from **premature activation of the hypothalamic-pituitary-gonadal axis** **peripheral precocious puberty (PPP)**: - due to **excessive sex steroids independent of gonadotropin secretion.**

Question 56

Tx for CPP and PPP? [2]

Answer 56

**GnRH analogues** are first-line treatment for **CPP** while **PPP** **requires targeted therapy depending on underlying cause.**