SCHP Cases Flashcards
What are the differential diagnoses of vomiting in a 7-year old?
Differential diagnosis of vomiting in this age group are include increased intracranial pressure, gastroenteritis, bowel obstruction, adrenal crisis, eosinophilic esophagitis and cyclic vomiting syndrome.
What are the challenges in diagnosing increased intracranial pressure in a nonverbal child?
Clinicians should have a high index of suspicion for such a diagnosis when there is a recent onset of vomiting and no other signs suggestive of infection. Signs that indicate high ICP can sometimes be identified: bradycardia, hypertension, papilledema (showing blurring of the optic disc showing loss of physiologic cupping and fullness of the veins) and an altered mental state.
Discuss the epidemiology and presentation of medulloblastoma.
Medulloblastoma makes up between 15% to 20% of all brain tumors in children and 30% to 55% of posterior fossa tumors. The mean age of presentation is between 5 and 7 years and males are more likely to develop the tumor compared to females with a ratio of 1.4 to 1.1 There are no known environmental risk factors.
Presentation is reliant on the age of the child. In infants under the age of one year macrocephaly, vomiting and irritability are salient features. In older children headache, vomiting and sixth nerve palsy are more common. In the case of MC, one has to have a high index of suspicion as he has language and developmental delay. In an ambulant child, a fourth ventricle mass can manifest with an unsteady gait.2 Immunohistochemical markers determine prognostic factors such as the disease free survival period following therapy and therapeutic modalities available to the child.
There is a relationship between medulloblastoma and some syndromes such as Gorlin’s and Turcot’s syndrome. There is also an association between Pitt Hopkins Syndrome (PTHS) and an increased incidence of medulloblastoma. In PTHS mutation in TCF4 gene is thought to be the link for that association.
What are the features of Pitt Hopkins syndrome?
PTHS is characterized by intellectual disability, developmental delay, microcephaly, recurring seizures and distinctive facial features. History of seizures; a feature that is present in half of the children diagnosed with the condition. 80-99% of people with PTHS has aphasia.
There are behavioural difference in some children with PTHS in the form of autism spectrum disorder features or aggressive behaviour in the way of head banging and hand biting.
What are the investigations for poststreptococcal glomerulonephritis?
Serum electrolytes, urea, creatinine Full blood count, Liver function test ASOT, Anti DNase B
Serum C3
Urine microscopy and culture
What are the investigations for poststreptococcal glomerulonephritis?
Serum electrolytes, urea, creatinine Full blood count, Liver function test ASOT, Anti DNase B
Serum C3
Urine microscopy and culture
What are the differential diagnoses for a child with coca cola urine and history of tonsillitis with puffy eyelids and swelling of his ankles?
Differential diagnosis
Acute poststreptococcal glomerulonephritis (APSGN)
Other types of glomerulonephritis
Nephrotic syndrome
Urinary tract infection
Haematuria associated with Urolithiasis or renal trauma
Alport syndrome
What investigations would you perform in a paediatric patient with 1 week history of erythematous, exudative eruptions on face, mouth, back, limbs, groin and buttocks.
Examination findings
clinically well
Vital signs: RR 25, oxygen saturation 98% on room air, Heart Rate 110bpm, Blood Pressure 107/56 mm Hg, Temp 37.0 degrees Celsius Growth parameters: 16kg (40th centile), height was 101cm (32nd centile) Skin examination: Flaccid bullae and desquamation over face (cheeks, nose and perioral), back, limbs, buttocks and groin. Systemic examination: - Chest clear. No work of breathing. - Heart sounds were dual, no added heart sounds - Warm and well perfused peripheries. Central capillary refill time was less than 2 seconds. - Abdomen was soft, non-tender, no distension or organomegaly.
Investigation performed and reasons - Skin biopsy: To investigate histopathology - FBC, EUC, LFT, CMP, CRP, ESR: To look for infection or other causes - Coeliac test: To investigate for gluten allergy - ANA, ENA, dsDNA, Complement factors, Immunoglobulin G, A, M: Look for immunological causes - HLA DQ2/DQ8 testing: Increased association with Linear IgA disease - Viral serology and PCR testing: To look for infectious causes - G6PD testing: Needed prior to commencing Dapsone - Urine culture: To look for infection, casts, protein - Respiratory viral PCR: Look for infective causes - Wound swab culture: Look for infective cause
What are your differential diagnoses for a 4 year old patient was transferred from Bathurst Hospital to the Children’s Hospital at Westmead with a 1 week history of erythematous, exudative eruptions on face, mouth, back, limbs, groin and buttocks?
Differential diagnoses - Steven Johnson Syndrome (SJS) - Toxic epidermal necrolysis (TEN) - Dermatitis herpetiformis - Bullous impetigo
A worried mother brought her 6-year-old daughter to the clinic because of redness to her face – since the previous
day.
The mother said that 10 days before, she was unwell for 2 days with headaches and a mild sore throat. She recovered
from that and had been well for the past 1 week.
What is this condition and what is the organism that causes it?
Erythema infectiosum (originally called Fifth disease)
which is caused by an erythrovirus – Human Parvovirus B19. The classical features are the redness of the
face, commonly called slapped cheek appearance and a lacy looking rash that appears on the limbs.
Parvovirus B19 has been linked to other hematologic abnormalities like thrombocytopenia and leukopenia.
If a pregnant mother gets a parvovirus B19 infection in the first 20 weeks of pregnancy it can lead to hydrops
What is the best formula to measure IV fluids in children?
An accurate weight allows safe prescribing of medicines and IV fluids in children, but in emergency situations a child’s weight is often unknown and impractical to measure.
There are various aged-based formulae for estimating weight, which can facilitate pre-hospital preparations.
The most familiar is the Advanced Paediatric Life Support (APLS) formula previously used for children aged 1-10 years, now limited to 1-5 years:
weight (kg) = (age +4) x2
The revised APLS formulae are listed below, but tend to underestimate weight in Australian children, for whom the Best Guess formulae are recommended above 12 months of age:
0-12 months (APLS): (age in months/2) + 4
0-11 months (Best guess): (age in months +9)/2
1-5 years (APLS): (age x2) +8
1-4 years (Best guess): (age+5) x2
6-12 years (APLS): (age x3) +7
5-14 years (Best guess): age x4
age = age in years (unless specified as months)
Adjust the estimated weight if the child is clearly very large or small for age, and record a formal weight whenever the child is stable.
A three year old boy with a background of Trisomy 21 presented to a large children’s hospital with systemic erythematous papular rash and fevers. His mother brought him in to hospital due to concern it could be measles, after seeing a post on Facebook.
Present History
He had a five day history of illness with cough and coryza, fevers to 39 degrees, as well as conjunctivitis, for which he
was treated by the GP with chloramphenicol ointment. There were no rigors or chills. On day four of illness he developed
a rash which began around the mouth, then trunk, then spread to the lower extremities. He had decreased oral intake,
reduced wet nappies and was generally miserable. He had failed to improve with supportive management and
antipyretics at home.
His medical history was significant for repaired ventricular septal defect, chronic suppurative otitis media with bilateral
grommets, and speech delay.
This child was fully immunized, had no sick contacts and no history of recent travel or measles contacts.
What are the differential diagnoses?
Differential diagnoses • Measles • Kawasaki disease • Scarlet fever • Adenovirus Group A streptococcus (GAS) tonsillopharyngitis with bacteremia
What is the epidemiology and management of scarlet fever?
One of GAS infection presentations is scarlet fever. Scarlet fever occurs following carriage
of GAS in the throat usually presenting with pharyngitis. In scarlet fever the release of
erythrogenic exotoxins result in a characteristic rash usually described as of sand paper in
its feel.
Scarlet fever is highly contagious and remains so for two to three weeks after appearance
of the rash if not treated with antibiotics. The child would present with fever and a sore throat
for a day or two before the typical rash appears on the upper trunk making its way down to the rest of the body while
sparing the palms and soles. In typical cases the face is flushed and there is circumoral pallor with a red spotted tongue
commonly known as a strawberry tongue. See picture below1
In most cases, scarlet fever is a self-limiting illness that improves after one week. The aim
of therapy to prevent complications. GAS remains sensitive to penicillin and as such it
remains the antibiotic of choice for treatment. Duration of treatment is for ten days. For those
unlikely to comply with antibiotics for 10 days a single dose of intramuscular benzathine
penicillin is sufficient. A first generation cephalosporin, or a macrolide remain as options for
those allergic to penicillins.
What is the most common complication of group A streptococcus?
Group A streptococcus (streptococcus pyogenes) causes a wide range of infections, especially of the skin and mucosal
surfaces. The most common group A streptococcal (GAS) infection is tonsillopharyngitis (pharyngitis) which is
characterized by sore throat with tonsillar inflammation, anterior cervical lymphadenopathy and may also have
strawberry tongue and palatal petechiae [1].
GAS pharyngitis generally results from contact with the respiratory secretions of an infected person. Close contact due
to overcrowding in houses, schools or child care centers can facilitate transmission. It is most common among schoolaged
children, with peak incidence at 7 to 8 years of age. The incubation period is two to five days [1].
The aim of antibiotic treatment for GAS pharyngitis is to reduce acute morbidity, but equally to reduce complications (as
listed below), as well as transmission to close contacts.
Complications of GAS can be divided into [1]:
• Non-suppurative:
o Scarlet fever
o Acute rheumatic fever
o Post streptococcal glomerulonephritis
o Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections
• Suppurative:
o Necrotizing fasciitis
o Bacteremia
o Peritonsillar cellulitis or abscess
o Otitis media
o Sinusitis
9 year old girl presented to a tertiary paediatric hospital with intermittent headaches over a 2 month period.
History
Headaches were occurring once or twice per week, however over the preceding week, had been occurring every other day. The headaches were varying in location, from frontal to temporoparietal to occipital. Headaches were not waking her from sleep and occurred at different times of the day. There had been one vomit a week prior, and another vomit 2 days prior, but had 3 vomits the day before presentation. Normal antenatal and postnatal history. Apart from delayed speech, her development was normal, and she was doing well at school.
There were multiple presentations to General Practitioners and other hospitals prior to this presentation where provisional diagnoses of viral infection and migraine were made. She was last discharged with a plan for outpatient monitoring and neuroimaging. Due to the 3 episodes of vomiting her parents brought her to the tertiary hospital where she was admitted. On review the, headache was improving, with no further vomits. She was noted to have a reduced appetite over the past two weeks, and incidentally described an unusual ‘hissing’ sound in one ear.
What are the differential diagnoses?
Differential diagnoses • Sinusitis • Space occupying lesion: • Tumour • Abscess • Primary headache • Migraine with/without aura • Tension headache • Cluster headache • Meningitis/encephalitis • Hydrocephalus • Hypertension
Headaches are a common complaint in children and become more prevalent through adolescence. 1-2 Up to one in five children at any time will report having headaches within the past 12 months2. In younger children the prevalence is the same in boys and girls, however in adolescence, there is a significantly higher prevalence in girls.
Headaches can be divided into primary headache subtypes, which are intrinsic to the nervous system and secondary headaches with an underlying etiology. Primary headaches are much more common than secondary headaches in children.3 The most common cause of headache presentations however in children are viral illnesses or upper respiratory tract infections.4-6 Of the primary headache subtypes, the most common in children are migraines and tension-type headaches. Trigeminal autonomic cephalalgias such as cluster headaches are rare in children.
