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Flashcards in peds rheum Deck (45):
1

JIA

prolonged fever, salmon patch rash, arthritis, visceral involvement

2

scarlet fever

strawberry tongue, bilateral cervical LAD, fever, rash

3

rheumatic fever

Rash, subcutaneous nodules, fever, polyarthralgia, chorea

4

viral syndrome (enterovirus)

Fever 3-5 days, non-descript non-painful rash, can walk

5

kawasaki

fever > 5days, nonpurulent conjunctivitis, erythematous rash, swelling and erythema of extremities, unilateral LAD

6

osteomyelitis/septic joint

Low grade fever, painful walking

7

RMSF

Fever

8

Steven johnson

Severe pruritic rash, fever

9

measles

conjunctivitis, fever, rash, non-immunized

10

kawasaki

Mucocutaneous lymph node syndrome
Acute Febrile Vasculitic syndrome of early childhood

11

kawasaki symps list

Supporting Sx: Non-remitting High grade Fever > 5 days PLUS 4/5 of the following:
red macpap rash
unilat cerv adeno>1.5 cm
strawberry tongue, red fissurd lips, injected pharynx
non-pur. conjunc, bilat, painless
redness/swell of hands/feet
desquamations of tips, transfers grooves across nails -beau lines)

12

kawasaki labs

No specific diagnostic test; Elevated ESR/CRP, Anemia, Elevated WBC, Thrombocytosis, Hypoalbuminemia, Elevated AST/ALT
Case: Echocardiogram with coronary artery aneurysms

13

kawasaki complications

coronary artery aneurysm
CNS manifest (mening.)
liver dysfunc
arthritis
hydrops of gall bladder

14

kawasaki pathoma

Kawasaki Motorcycle
Hold on with Palms and Soles:
Edema
Erythema
Desquamation
Heart Racing: CAA

15

kawasaki tx

Usually self-limiting ~12 days
BUT leads to significant morbidity and mortality
IV IG (dec. CAA)
Aspirin
(Anti-inflammatory, anti-pyretic, anti-platelet)
*Possible Reye syndrome*- recommend influenza vaccine
Echocardiogram- evaluate for CAA

16

kawasaki buzz words

High-grade Fever for multiple days
Strawberry Tongue
Conjunctivitis
Thrombocytosis and peeling of fingers
Erythematous Maculopapular Rash
Coronary Artery Aneurysms
Treated with Aspirin in Childhood

17

"gelling phenomenon"

joint pain is worse in the morning and after periods of sitting and watching television

18

ESR vs CRP

ESR: concentration of fibrinogen and other inflammatory modulators that have half-lives of days to weeks.
CRP: made exclusively in the liver and can rise and fall within hours of an acute inflammatory stimulus

19

JIA (Juvenile Idiopathic Arthritis)

20

JIA types

polyarthritis
oligoarthritis
systemic: characteristic arthritis that develops with fever and rash; and exclusion of other juvenile arthritis

21

JIA comps

Chronic iridocyclitis in pauciarticular JRA (other ocular disease includes iritis, and uveitis)

Joint deformities in polyarticular JRA
(can have positive or negative rheumatoid factor)

22

common tests for GAS (rheumatic fever)

throat cx
anti–streptolysin O (ASO) and anti–deoxyribonuclease B (anti–DNAase B)

23

ASO titers

peak 3 to 6 weeks after GAS infection.
They are elevated in 80% of patients with typical rheumatic fever (and GABHS pharyngitis)
less than 50% of kicks w/ rec. GABHS skin inf.
less than 70% of patients with chorea

24

Anti–DNAase B titers

more reliable, in both pharyn. and skin GABHSpts
peak 6 to 8 weeks after GABHS infection. The elevated titers may persist for several months after infection

25

elevation of ??? in 95% rheumatic fever pts

anti–DNAase B, antistreptokinase, or antihyaluronidase

26

Jones Criteria for rheumatic fever

2 major criteria or 1 major + 2 minor + evidence of recent GAS infection (+ throat cx/RADT, rising ASO titers)
MAJOR: carditis, polyarthritis, chorea, erythema marginatum
MINOR: fever, arthralgia, elevated APPs, prol. PR interval

27

JIA tx

Hospitalization
Cardiology consult
PCN or Erythromycin (if patient is allergic to PCN)
arthritis and carditis tx: ASA 90 to 120mg/kg/day until symptoms resolve
chorea tx: Haloperidol, phenobarbital, or valproic acid

28

JIA ppx

Start prophylactic antibiotics immediately after the therapeutic antibiotic course is completed.
Continue until child is an adult and is recurrence free for 10 years (longer if they have residual heart disease)
Options for lower risk of recurrent ARF:
PCN V K, Sulfadiazine, Macrolides

Higher risk of recurrent ARF:
Benzathine PCN G intramuscularly, every 4 weeks

29

RF summary

Age range: 5-15yo
Seasonality: Winter
Preceding URI
Strep Pharyngitis
Jones criteria

30

RF: carditis

Prolonged PR interval
Varying degrees of heart block
Cardiomegaly may be noted on CXR
Inflammation of valves and endocardium
valvular regurgitation/stenosis
Mitral valve most common
(rheuMATic: Valves affected Mitral>Aortic>Tricuspid)

31

RF: skin/ST

(typically only in carditis patients)
Subcutaneous nodules over bony prominences
present up to a month
Erythema marginatum
annular erythema, usually present on the trunk and proximal portions of the extremities, sparing the face

32

RF: CNS

Sydenham Chorea
abrupt, purposeless, nonrhythmic, involuntary movements that cease during sleep
muscular weakness
emotional disturbances; ranges from outbursts of inappropriate behavior to transient psychosis
Occur 3-8 months after GAS infection

33

RF labs

elev. ESR, CRP
CXR: mild effusion
EKG: prol. PR interval
Echo: mitral valve regurg
+ASO

34

erythema nodosum

type of panniculitis, inflammation of subcutaneous fat in the skin, usually first evident as an outcropping of erythematous nodules that are highly sensitive to touch
Most located symmetrically on the ventral aspect of the lower extremities
tests: CBC, ESR, ASO titers, Excisional biopsy (when clinical diagnosis is in doubt)

35

Henoch Schonlein Purpura

Small-vessel vasculitis associated with abrupt onset of a rash, palpable purpura most common; GI manifestation, arthritis and arthralgia, and late renal manifestations, commonly after exposure to triggering antigen (eg infectious agent)
tests: CBC, ESR, abdominal US, urinalysis, ASO titers, Excisional biopsy (when clinical diagnosis is in doubt)

36

Immune thrombocytopenic purpura

Thrombocytopenia associated with petechia or purpura; bleeding (e.g., gingival, gastrointestinal, mucocutaneous); symptoms of end-organ ischemia (in patients with thrombotic disease)
tests: CBC with peripheral smear, coagulation studies, platelet-associated antibody (immunoglobulin G), electrolytes, BUN, creatinine, LDH, urinalysis

37

leukemia

Nonspecific symptoms of fever, easy bleeding, skin findings (e.g., petechiae, purpura), bone pain, fatigue, hepatosplenomegaly, lymphadenopathy
tests: CBC, ESR, coagulation profile, bone marrow biopsy

38

meningococcemia

Malaise, fever, rash (e.g., maculopapular rash, petechiae, ecchymosis), and hypotension with possible associated symptoms of meningitis or tenosynovitis
tests: CBC, PT/aPTT, fibrinogen, fibrin degradation productions, blood culture, CSF analysis and culture

39

polyarteritis nodosa

Multisystem involvement from segmental inflammatory, necrotizing vasculitis of the small- and medium-sized muscular arteries leading to general symptoms of fever, weakness, weight loss, malaise, myalgia, rash (e.g., livedo reticularis, purpura), headache, and abdominal pain
tests: Biopsy of involved organ, urinalysis, CBC, ESR, CRP, angiography

40

RMSF

Headache; fever associated with a centripetal rash (involving palms and soles, spreading to arms, legs, and trunk) that is often petechial; report of recent tick bite or outdoor activity in endemic area
tests: Immunofluorescence staining of tissue specimen or serologic analysis for Rickettsia rickettsii, CBC, electrolytes

41

HSP (Henoch Schonlein Purpura/IgA vasculitis)

most common vasculitis in children (about 50% of cases).

S/S
Hallmark: non-thrombocytopenic palpable purpura.
LE and buttocks
Colicky abdominal pain (50%)
Occult blood (50%)
Arthritis(50-67% kiddos)
Mainly in knees and ankles
]renal involvement (hematuria) (1/3rd kiddos)
screen monthly with UA for 6 months, nephritis is a late finding
recent URI (2/3 cases)
elevated ASO (50%)

42

HSP dx

triad of purpura, abdominal pain, and arthritis
Non-blanching palpable purpura of LE and butt
absence of thrombocytopenia
Skin biopsy(rare): characteristic IgA deposits in vessel walls
Renal biopsy (only indicated if nephritis develops): membranoproliferative glomerulonephritis similar to IgA nephropathy

43

HSP comps

considered benign
hosp. if abd pain, GI bleed, intussusception, renal involve
-5% kids-->renal failure
-2-3% intussusception (60% ileoileal)
-33% recurrence rate

44

HSP tx

min: supportive
mild: acetomin/NSAIDs
mod: corticosteroids
sev: cortsters + adj. immunsuppr (cyclophosphamide, IVIG) or plasmapheresis

45

HSP labs

Abdominal CT:marked bowel wall thickening from the vasculitis
Abdominal US: identify constipation, intussusception, or other GI involvement
ASO titers – Previous strep inf
BMP (electrolytes, BUN, Cr) – monitor for renal insufficiency
Blood culture – Evaluate for bacteremia or sepsis as possible cause
CBC – identify WBC, HCT, Hgb, platelets
Anemia could indicate GI bleed
Identify thrombocytopenia
CRP, ESR – indicate inflammatory reaction
IgA levels – typically elevated in HSP, but nonspecific
PT/PTT – Elevated levels make bleeding diathesis more probable
UA – Assess for renal involvement
Serology – Evaluate for cause of infection