-
Fever Without a Source (FWS):
- Children with fever lasting 1 w or less without adequate explanation after a through Hx and P/E.
- FWLS- fever without localizing signs synonymous
- Fever of Unknown Origin (FUO)
- 7 days or > without source despite W/U
- Bacteremia
- Bacteria in the blood
- Typically found on Blood C+S
-
Septicemia
invasion of the bloodstream by virulent microorganisms and especially bacteria along with their toxins from a local seat of infection accompanied especially by chills, fever, and prostration
-
Fever in infants <3 months things to consider
- Mother history of fever
- Mom’s Group B strep status
- Prophylaxis
- Mom’s STI hx
- Hx PROM
- ill contacts
- immunization+/-
- bulging fontanel
-
workup in fever less than 3 months
- CBC, WBC < 15,000 (reassuring)
- Absence of bandemia (reassuring)
- Blood C+S
- Preliminary results in 24 h.
- Procalcitonin/C-Reactive protein
- U/A and C+S, Stool C+S
- If blood, mucous or diarrhea is present
- Lumbar puncture, Age 28 days or less
- Ill appearing, High risk for bacterial infection
- Prior to Abx therapy
- S/S of dz, Sz
- CXR
-
empiric trmt in <28 day old SBI
- ampicillin/ cefotaxime or amp/ aminoglycoside
- or acyclovir if herp expected
-
empiric trmt 29-90day SBI
- well appearing no CSF pleocytosis- ceftriaxone
- CSF pleo or ill appearing- vanco and amp/ ceftri or cefotaxime
-
fever in infants 3-36 months (infectious)
- Fever can be caused by infectious and noninfectious processes
- Vast majority of infants with fevers have an infectious process
-
fever 3-36 months Noninfectious etiologies to consider
- Drug fever
- Immunization reactions
- Malignancy (leukemia)
- Inflammatory conditions ( Idiopathic arthritis)
-
Fever in infants 3-36 months therapy if unimmunized
- ceftriaxone im
- clindamycin iv then po if PCN/ ceph allergy
-
Worrisome S/S
- Bulging fontanels
- Vomiting
- Irritability
- Inconsolability
- >1 febrile sz
- Petechiae
-
Out patient therapy for fever
- Acetaminophen 15 mg/ kg every 4 hrs
- Ibuprofen 10 mg/kg every 6 hours
- Alternating between Acetaminophen and Ibuprofen can be done every three hours
- Abx where appropriate
-
OM causes
- RSV
- Streptococcus pneumoniae
- Haemophilus influenzae
- Moraxella Catarrhalis
-
OM peak incidence and prevalence
- 1-2 yo, 80% have it by age 3
- Mc cause of childhood hearing loss
-
OM risk factors
- Age 6-18 months
- Parental Hx OM as child
- Day Care Attendance
- Lack of breastfeeding
- Smoking
- Pacifier use
- Native Americans, Alaskan and Canadian Eskimos
-
OM Clinical Manifestations
- Hx of acute onset signs/symptoms
- Pain
- Precludes normal activity or sleep
- Middle Ear Effusion(MEE)
- Bulging of the TM
- Limited or absent mobility of the TM
- Air-fluid level behind the TM
- Otorrhea
-
Treatment OM
- Amoxicillin 90mg/kg divided into every 12 or 8 hours
- Pen allergic
- Macrolide
- Clindamycin
- Most cases improve within 48-72 hours with
- treatment
-
OM Complications
- Hearing Loss
- Ruptured TM
- Mastoiditis
- Facial paralysis
- Labyrinthitis
- Petrositis
- Brain Abscess
- Meningitis
-
Erythema InfectiosumEtiology
- Caused by parvovirus 19 (Erythrovirus)
- Typically seen late winter and spring April and May
-
Erythema Infectiosum SS
- Fever
- Coryza
- Headache
- Mild gastrointestinal distress; nausea/diarrhea
- “Slapped-cheek” occurs ~ 1 week of symptom onset
-
Erythema Infectiosum treatment and prognosis
- supportive Tylenol- Motrin
- Prognosis
- Occasionally transient aplastic crisis may occur.
-
Varicella Prevalence
- Prior to immunization universally communicable infection
- winter and spring
- Higher rates in families
- contagious 24-48 hr before the rash and until vesicles are crusted, ~3-7 days (begins 14-16 days after exposure)
-
Varicella Clinical Manifestations
- Fever, usually 100-102°F but may be as high as 106°F
- malaise, anorexia, headache
- occasionally mild abdominal pain occurs 24-48 hours before the rash appears.
- Varicella lesions often appear first on the scalp, face, or trunk.
-
Treatment and prognosis
- Typically supportive
- Fever reduction
- Rarely acyclovir may be recommended (20 mg/kg/dose, maximum 800 mg/dose) given as 4 doses/day for 5)
- Prognosis
- Most individuals fully recover
- VZV remains dormant along nerve roots Herpes Zoster
- Vaccinate patients
-
Coxsackie Etiology
- hand foot and mouth dz
- Viral illness caused by Enteroviruses
- Transmission primarily by respiratory droplet contact
- feco-oral contact in developing countries
- Usually self-limited
-
Coxsackie Clinical Manifestations
- 4- to 6-day incubation period, development of odynophagia, sore throat, malaise, and fever
- Often hx of exposure
- 1 to 2 days p symptom onset oral lesions appear
- 75% of cases sill have concomitant skin lesions
- Typically on the hands and feet
-
Coxsackie Treatment and prognosis
- Palliative therapy
- Hydration
- Magic Mouthwash
- IV fluids for dehydration
- Prognosis
- Rare cases of central nervous system or cardiac involvement
-
Pneumonia etiology, neonates, 3 wk-30 mo, 4 mo- 4yr, 5 yr
- neo- group B strep, e coli, gram neg
- 3wk-3 mo- RSV, Parainflu, influ, S .Pneumo
- 4mo-4yr- RSV, Parainflu, influ, S .Pneumo
- 5yr- M. pneumoniae, S. pneumoniae, Chlamydophila pneumoniae, H. influenzae
-
Pneumonia RF
- M, Lower socioeconomic
- School-age children
- Lung/ heart Dz
- Sickle cell disease
- Neuromuscular disorders
- Gastrointestinal disorders (eg, GERD, tracheoesophageal fistula)
- Congenital and acquired immunodeficiency disorders
- Exposure to cigarette Smoking
-
Pneumonia Clinical Manifestations
- Fever: Bacterial>viral pneumonia
- Tachypnea is the most consistent clinical manifestation of pneumonia
- Resp distress
- It is often not possible to distinguish viral pneumonia clinically from disease caused by Mycoplasma and other bacterial pathogens.
- Bacterial pneumonia in adults and older children typically begins suddenly with a shaking chill followed by a high fever, cough, and chest pain.
-
Pneumonia Bacterial-outpatient therapy
- Amoxicillin
- Atypical organism: Macrolide (Zithromax)
- C. pneumoniae, Mycoplasma pneumoniae
- admit if less than 6 mo, or in distress
-
pneumonia Bacterial-in-patient therapy
- 3rd generation cephalosporin (ceftriaxone)
- If evidence of staphylococcal pneumonia Vancomycin
-
pneumonia prognosis
- Most pt’s improve 48-96 h of treatment
- No improvement should raise concern for:
- Empyema
- bacterial resistance
- nonbacterial etiologies such as viruses and aspiration of foreign bodies or food
- bronchial obstruction from endobronchial lesions, foreign body, or mucous plugs
- pre-existing diseases such as immunodeficiencies
-
RSV Epidemiology
- Peak age 2-6 months
- Late fall early Spring
- M>F (1.5-1)
- Viral shedding 5-7 d
- spread to the upper respiratory tract by contact with infective secretions
-
RSV S/S
- Bronchiolitis, cough, wheezing, and respiratory distress (retractions) Clinical findings include hyperexpansion of the lungs, (Seen on CXR)
- Hypoxemia and hypercapnia
- Interstitial infiltrates, often with areas of pulmonary collapse
- The duration of acute illness is often 10 to 14 days.
-
RSV W/U
- Labs-Rapid RSV
- Other labs not typically helpful
- CXR-peri-bronchial cuffing
- Hyperexpansion
-
Measles Etiology
- Caused by Morbillivirus
- Spread though respiratory droplets
- Infectious from 3 days before to up to 4-6 days after the onset of rash.
- Decreased prevalence secondary to vaccine
- ~100 cases/year in the US
-
Vaccine MMR timing and phases
- MMR given at 12-15 months95% effective
- Second dose confers 99% immunity
- incubation period- 8-12 days
- prodromal illness-Virus shedding begins
- exanthematous phase-antibody production begins
- recovery
-
Measles Clinical Manifestations
- high fever
- Prominent exanthem
- Cough
- Coryza
- Conjunctivitis
- Koplik spotspathognomonic sign of measles occurs 1 to 4 days prior to the onset of the rash
-
Measles Treatment
- Supportive
- Antipyretics
- Hydration
- Ventilator support in pneumonia
-
Measles Prognosis
- 2/1,000 fatalities
- Pneumonia and encephalitis were complications in most of the fatal cases
- immunodeficiency conditions were identified in 14-16% of deaths.
-
Mumps Etiology
- Rubulavirus
- winter and spring months
- respiratory droplets
- <300/annually
-
Mumps Clinical Manifestations
- Symptoms begin 16-18 d p exposure
- Mumps virus targets the salivary glands, central nervous system, pancreas, testes
- Effects to a lesser extent, thyroid, ovaries, heart, kidneys, liver, and joint synovia
- fever, headache, vomiting, and achiness.
- Parotitis may be unilateral and can be bilateral in about 70% of cases
-
mumps Treatment Prognosis
- Prevention-MMR
- Reducing the pain associated with mumps
- Hydration
- Antipyretics
- prog- Excellent
- Rare deaths have occurred secondary to encephalitis
-
Rubella (German measles or 3-day measles)Etiology
- Rubivirus
- Incubation-2-3 weeks
- Viral shedding from the nasopharynx begins about 10 days after infection and may continue up to 2 wk following onset of the rash
- The period of highest communicability is from 5 days before to 6 days after the appearance of the rash.
-
Rubella Risk Factors
- Mild disease not easily discernible from other viral infections
- Rash similar to Measles
-
Rubella trmt prognosis
- supportive
- vaccine
- prog-Thrombocytopenia
- Arthritis
- Encephalitis
- headache, seizures, confusion, coma, focal neurologic signs, and ataxia.
-
Congenital Rubella Syndrome Characterized by
- cataracts
- congenital heart disease
- rubella infections
- hearing loss
- microcephaly
-
Roseola Etiology
- Roseola is caused by human herpesvirus-6 (HHV-6)
- incubation period 5 and 15 days p exposure
-
Roseola Prevalence
- Roseola is a benign viral illness found in infants and characterized by high fevers, followed by a rash
- one third of all infants develop roseola before the age of 2 yr (peaks between 6-9 months)
- 90% of children older than 2 yr of age are seropositive for the virus
- There is no predilection for gender or time of year
-
Roseola clinical manifest
- Fever up to 104° F lasting 3 to 5 days
- runny nose, irritability, fatigue
- rash appears within 48 hr of defervescence and typically fades away within 48 hr
- maculopapular rash that blanches when palpated
- Anorexia
- Seizures
- Cervical adenopathy
-
Roseola Treatment
- Supportive care
- Hydrate-PO fluids
- Tylenol/Motrin PRN
-
Roseola Complications
- Febrile seizures most common complication
- Meningitis
- Encephalitis
- Pneumonitis
- Hepatitis
-
Pharygitis Etiology
- Viruses
- adenoviruses, coronaviruses, enteroviruses, rhinoviruses, respiratory syncytial virus [RSV]
- Bacteria
- Group A β-hemolytic streptococcus
- group C streptococcus
-
Pharygitis Prevalence
- Commonly occurs in close contact
- Fall>winter> spring
- Relatively uncommon before 2-3 yr of age
- Peak incidence in the early school years, and declines in late adolescence and adulthood
-
Pharyngitis clin manifest
- rapid onset of streptococcal pharyngitis is often
- sore throat and fever
- absence of cough
- Headache and gastrointestinal symptoms (abdominal pain, vomiting)
- tonsils a yellow, blood-tinged exudate.
- petechiae or “doughnut” lesions on the soft palate and posterior pharynx,
- anterior cervical lymph nodes are enlarged and tender
- RashScarlitina AKAScarlet Fever
-
Pertussis etiology
- Highly contagious, acute respiratory illness caused by Bordetella pertussis
- Gram-negative coccobacillus
-
Pertussis Transmission-virulence
- Respiratory droplets
- Invades local respiratory epithelium by:
- Tracheal cytotoxins
- Dermonecrotic toxin
- Incubation period after exposure 7-10 days
-
pertussis phases and symptoms
- Catarrhal phase Lasts 1-2 weeks non specific symptoms
- Paroxysmal phase- 2nd week- Hallmark symptomparoxysmal cough
- Convalescent phase- Gradual reduction in frequency and severity of cough
-
pertussis dx
- bacterial culture- affected by abx use
- PCR- not affected
-
pertussis trmt
- 80-90% of patients will improve without treatment
- Tx early does hasten recovery especially in the Catarrhal phase
- Tx later in the disease may not hasten recovery BUT will reduce spread
- Azithromycin (Zithromax)
- Clarithromycin
- Trimethoprim-sulfamethoxazole (Bactrim)
-
pertussis mc complication
pneumonia- primary or secondary bacterial infx
-
kawasaki dz S/S
- Fever M/C symptom
- Mucous membrane findings are seen in approximately 90 percent of cases
- ocular changes in >75 percent
- cervical lymphadenopathy in 25 to 70 percent
- Extremity changes-late in dz
-
kawasaki dz Risk Factors
- greatest in children who live in East Asia or are of Asian ancestry
- Typically kids < 5
- M>F
-
kawasaki Etiology
- Vasculitis of Unknown origin
- THEORY-Possible Immunologic response
- Affects medium-sized arteries
- fatalities that occur within the first two weeks of fever onset and may represent an innate immune response
-
kawasaki dz labs
- Increased ESR
- Increased platelets
- +/- leukocytosis
- normocytic, normochromic anemia
-
kawasaki diagnosis
- fever lasting ≥five days PLUS at least 4 of the 5:
- Bilateral Conjunctival injection
- Oral mucous membrane changes
- -injected or fissured lips
- -injected pharynx
- -strawberry tongue
- Peripheral extremity changes
- palms or soles, edema of hands or feet (acute phase), and periungual desquamation (convalescent phase)
- Polymorphous rash
- Cervical lymphadenopathy (at least one lymph node >1.5 cm in diameter)
-
kawasaki Tx
IVIG within the first 10 days of illness reduces the prevalence of coronary artery aneurysms fivefold
-
moro reflex
dropping baby abduct limbs
-
babinski
toe fans out, big toe doraflex
-
parachute reflex
stick arms out
-
walk reflex
try and walk if stand up
-
root reflex
strok cheek turn
-
-
pastia lines
petechiae in antecubital crease
-
babkin reflex
both arms held down neck extends and turns
-
still murmor
innocent louder when supine 2-7 yo
-
adrenarc
early sexual maturation
-
protoporphyrin
see elevated levels in fe deficiency
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