Recurrent infections

Question 1

A 2-year-old attends your practice with their parents who are concerned about the number of illnesses they are getting. Since starting child-care 6 months ago the child has developed frequent fevers with various illnesses. The child has never been admitted to hospital even though the parents have attended multiple emergency departments and general practitioners. The child has also missed daycare for extensive period because she keeps becoming unwell. The child is has normal growth and development, and never had any surgery.

Answer 1

Impression
The features of this stem highlight that the child has had recurrent illnesses since starting childhood. Of particular note, is the temporal relationship of having starting child care to the time-course of these infections. Furthermore, given the child has not been hospitalised with any of these infections, it is unlikely that they have been severe which may represent some form of immunodeficiency (primary, secondary). Therefore, it is most likely that these recurrent illnesses are related to regular exposure to sick contacts whilst at childcare.

DDx
- atopic illness (asthma, eczema): ie allergic rhinitis
- Haematological malignancy
- chronic ilnesses: resp, cardiac, GIT, CF, etc.

Goals:
- Thorough Hx/Ex/Ix to exclude significant current pathology
- Screen for any evidence of primary and secondary immunodeficiency
o haematological malignancy (leukaemia, lymphoma)
o being young
o chronic diseases
o malnutrition
o medications: steroids, chemotherapy

Question 2

Recurrent infections - History

Answer 2

History
- PC: how many times sick, dates, severity, types of illnesses, any hospital admissions
- REDFLAGS: for PID; more than 8 infections in a year, poor growth, repeat hospital admission for IV antibiotics, easy bruising (haematological), weight loss
- RISK: fail history of immunodeficiency
- FAMILY HISTORY! (FMFS, etc)
- medications (steroids)
- other medical conditions
- Paediatric Hx: immunisations, obstetric history, developmental milestones

Question 3

Recurrent infections - Examination

Answer 3

Examination
- General appearance + vitals
- Systems review: evidence of skin, resp infection
- lymph nodes examination
- abdo: splenomegaly, bruising
- ENT if indicated: polyps for ?atopic illness, eczema may be other indication

Question 4

Recurrent infections - Investigations

Answer 4

Investigations
May not be indicated if the child is well and no red flags of Primary/secondary immunodeficiency.

If concerned:
- FBC + blood film and differential (haematological)
- consider total serum immunoglobulin (with input from immunologist), lymphocytes subsets

Relevant investigations for any current infections
- nasal aspirate, urine sample, stool sample, etc

Question 5

Recurrent infections - Management

Answer 5

Management
Benign:
If no suggestion of underlying pathology and is just recurrent infections due to exposure to sick contacts;
- Education of the parents: common occurrence, child has naive immune system and is susceptible to regular infections with exposure at childcare. Very common in normal children
- reinforce childhood immunisations
- hygiene practices at school and home
- Safety-netting: to return or present to ED if any signs of serious infection (Fevers, rigors, drowsiness, poor feeding, non-remitting vomiting/diarrhoea, etc)

If P/SID is suspected:
- referral to paediatric immunologist
- children with suspected PID should not be administered live vaccinations (MMR, varicella, BCG, rotavirus)