Neonatal Infections & Meningitis

Neonatal Infections (0-3 Months)

• Common pathogens include Group B Strep, E. coli, and Listeria ("Bell").
• Suspect pneumonia or meningitis in neonates.
• Treatment involves ampicillin and gentamicin to cover common pathogens.
• Hospitalization for workup is required for neonates under 28 days with a fever.

CSF Findings

• Bacterial meningitis shows elevated protein, decreased glucose, and elevated WBCs (neutrophil predominant).
• Viral meningitis shows normal glucose, elevated protein, and elevated WBCs (lymphocyte predominant).
• Fungal meningitis shows low glucose and lymphocyte predominance, more common in immunocompromised individuals.
• TB meningitis displays lymphocyte predominance and low glucose.
• Cryptococcus neoformans (in AIDS patients) is diagnosed via positive India ink stain and treated with amphotericin.
• TB meningitis may show basilar enhancement on brain imaging.
• HSV meningitis often involves the temporal lobe and causes seizures.

Sinusitis

• Most cases are viral, requiring supportive care.
• Bacterial sinusitis is indicated by symptoms worsening after a week and purulent nasal discharge.
• Treat bacterial sinusitis with amoxicillin, covering Strep pneumo, H. flu, and Moraxella.
• Bacterial sinusitis can irritate cranial nerves (III, IV, V1, V2, VI).
• Blurry or double vision can be associated with bacterial sinusitis.
• Diagnosis of exclusion (cough, runny nose, sore throat, no fever) with supportive care

Diphtheria

• Characterized by pharyngitis with a gray leathery plaque.
• Typically seen in unvaccinated children.
• Treat with diphtheria antitoxin.

Acute Otitis Media (AOM)

• Otoscopy reveals bulging, erythema, pain, and a stiff tympanic membrane.
• Presents with fever and ear pain.
• Diagnosis is based on otoscopy findings.
• Treat with amoxicillin.

Otitis Externa

• Involves inflammation of the ear canal with a normal tympanic membrane.
• Pain increases with ear pulling.
• Pseudomonas is the most common causative organism.
• Treat with antibiotic ear drops.

Otitis Media with Effusion

• Characterized by serous drainage in the middle ear without infection.
• Otoscopy shows fluid bubbles behind the tympanic membrane.
• No treatment is typically required.

Cervical Lymphadenitis

• Presents as an erythematous, painful, swollen lymph node.
• Commonly caused by Staph aureus.
• Treat with a first-generation cephalosporin or penicillin.

Parotitis

• Bilateral parotitis is likely mumps.
  • Mumps is viral and preventable by the MMR vaccine, causing meningitis, pancreatitis, and orchitis.
• Unilateral parotitis is likely Staph aureus.

Impetigo

• Identified by honey-crusted lesions, often around the mouth.
• Highly contagious.
• Treat with mupirocin.

Erysipelas vs. Cellulitis

• Erysipelas:
  • Has a rapid onset (1 day).
  • Displays well-demarcated borders.
  • Involves dermal lymphatic infection.
• Cellulitis:
  • Increases indolently over days.
  • Has indistinct borders.
  • Involves dermis infection.
• Both are commonly caused by Strep pyogenes.
• Treat with cephalosporin or penicillin.

Necrotizing Fasciitis

• Causes severe pain out of proportion to the wound.
• Common causes include Strep pyogenes and Clostridium perfringens.
• Crepitus suggests C. perfringens.

Scarlet Fever

• Defined by strep throat with a sandpaper rash.
• Rash starts on the trunk and spreads to the limbs.

Post-Streptococcal Glomerulonephritis (PSGN) vs. IgA Nephropathy

• PSGN:
  • Occurs 2 weeks after strep throat.
  • Presents with cola-colored urine (hematuria).
  • Timing is key for diagnosis.
• IgA Nephropathy:
  • Occurs within 3-5 days of an upper respiratory infection.
  • Presents with hematuria.
  • Timing is key for diagnosis.

Toxic Shock Syndrome

• Staph aureus exotoxin stimulates T cells.
• Often associated with nasal packing or tampon use.
• Presents with septic shock and desquamation of skin.
• Treat with fluids, antibiotics, and removal of the source.

Gastroenteritis

• Rotavirus: Common in winter months, causes vomiting, diarrhea (non-inflammatory).
• Norovirus: Causes non-bloody diarrhea, vomiting, outbreaks in daycares, schools, and cruise ships.

Inflammatory Diarrheas

• Caused by Campylobacter, EHEC, Salmonella, Shigella, Yersinia.
• Presents with bloody diarrhea, WBCs in stool, and potentially fevers.
  • Shigella can cause seizures.
  • Yersinia mimics appendicitis.
  • Campylobacter is associated with raw chicken.
  • Salmonella is linked to reptilian animals and eggshells.
  • EHEC is related to uncooked hamburgers.

Clostridium difficile (C. diff)

• Associated with broad-spectrum antibiotic use.
• An opportunistic infection causing pseudomembranous colitis.
• Treat with oral vancomycin.

Pneumocystis jirovecii

• Affects immunocompromised patients (HIV/AIDS).
• Causes dry cough, fever, diffuse interstitial pulmonary infiltrates.
• Treat with TMP-SMX.

Infectious Mononucleosis

• Caused by Epstein-Barr virus (EBV).
• Transmitted via saliva.
• Symptoms include pharyngitis, posterior cervical lymphadenopathy, and splenomegaly.
• Presents with severe malaise.
• Treatment is supportive.
• Amoxicillin can cause a rash if given.
• Atypical lymphocytes are present on peripheral blood smear.

Measles

• Caused by paramyxovirus, preventable with a vaccine.
• Characterized by the four C's: Cough, coryza, Koplik spots, conjunctivitis.
• Maculopapular rash starts at the head and descends.
• Treat with vitamin A.
• Complications include pneumonia and SSPE.

Rubella

• Rash starts at the top and goes down.
• Lacks the "four C's," but features more joint pain.
• Treatment is supportive.
• Dangerous for pregnant women due to congenital defects (cardiac, cataracts, deafness).

Aspergillus

• Lung infection with eosinophilia.
  • Allergic Bronchopulmonary Aspergillosis (ABPA): Asthma-like symptoms, wheezing, hemoptysis; treat with steroids.
  • Systemic Aspergillus: Hemoptysis, fever, night sweats, weight loss; treat with Voriconazole.
  • Aspergilloma: Fungus ball in upper lobes within a preexisting TB cavity.

Parasitic Infections

• Entamoeba histolytica:
  • Causes right upper quadrant pain, diarrhea.
  • Treat with metronidazole.
• Giardia:
  • Associated with hikers and contaminated water.
  • Presents with greasy, fatty stools.
  • Treat with metronidazole.
• Malaria:
  • Linked to recent travel to Africa, recurrent fevers.
  • Hemolysis markers: Anemia, elevated reticulocyte count, decreased haptoglobin.
  • Transmitted by the Anopheles mosquito.
• Toxoplasma:
  • Contracted from cat feces or undercooked meat.
  • Congenital TORCH infection: Causes chorioretinitis, hydrocephalus, intracranial calcifications.
• Enterobius vermicularis (pinworm):
  • Diagnosed by the Scotch tape test.
  • Treat with albendazole.
• Hookworms (Strongyloides, Ancylostoma, Necator):
  • Transmitted through barefoot contact in sand.
  • Involves lung migration and GI invasion.
  • Causes iron deficiency, eosinophilia.
  • Treat with albendazole.
• Neurocysticercosis:
  • Caused by Taenia solium (pork tapeworm) eggs.
  • Leads to calcifications in the brain and seizures.

Tick-Borne Diseases

• Rocky Mountain Spotted Fever (RMSF):
  • Caused by Rickettsia rickettsii.
  • Rash starts on extremities and moves inward.
  • Can cause hemorrhaging, anemia, thrombocytopenia, and septic shock.
• Ehrlichia:
  • Targets granulocytes, leading to decreased WBCs.
• Anaplasma:
  • Targets granulocytes, leading to decreased WBCs.
• Lyme Disease:
  • Characterized by erythema migrans (target rash).
  • Later symptoms: Bell's palsy, meningitis, arthralgias.
• Babesia:
  • Infects red blood cells, causing hemolysis.

Cat Scratch Disease

• Caused by Bartonella henselae.
• Results in lymphadenitis proximal to the scratch.
• Treat with macrolides or doxycycline.

Tuberculosis (TB)

• Active TB:
  • Presents with night sweats, fever, weight loss, hemoptysis.
  • Treat with RIPE (rifampin, isoniazid, pyrazinamide, ethambutol).
• Latent TB:
  • Positive PPD, normal chest x-ray.
  • Treat with isoniazid for 9 months.

Cardiology

• Fixed split S2: Suspect Atrial septal defect (ASD).
• Coarctation of the Aorta:
  • Treat with prostaglandin E1 to keep PDA open.
  • Repair via surgery or balloon angioplasty.
  • Has an excellent prognosis.
• 100% Oxygen Test:
  • PaO2 doesn't rise: Heart defect.
  • PaO2 rises: Lung problem.
• Transposition of Great Vessels:
  • Aorta and pulmonary artery are switched.
  • Requires arterial switch operation, keep PDA open.
  • Associated with pregestational diabetes.
• Tricuspid Atresia:
  • Tricuspid valve doesn't open.
  • Requires ASD for survival.
  • Unique: Cyanotic heart condition with left ventricular hypertrophy.
• Single S2 Heart Conditions:
  • Transposition of the Great Vessels (loud aorta drowns out pulmonic).
  • Tricuspid Atresia (weak/absent pulmonic valve).
  • Truncus Arteriosus (single vessel, single valve).
• Prophylactic Antibiotics for Dental Surgery needed when:
  • Congenital heart disease, prosthetic heart valves, previous infective endocarditis.
• Complete Heart Block in Fetus:
  • Mother likely has lupus.
• Tetralogy of Fallot:
  • VSD, pulmonic stenosis, overriding aorta, right ventricular hypertrophy.
  • Main murmur: Pulmonic stenosis murmur.
  • Tet spells (crying, exercise): Decreased systemic vascular resistance, right-to-left shunting.
• Squatting helps with Tet spells.
• Any holosystolic or diastolic murmur is pathological and needs an echo.

Pulmonology

• Laryngomalacia:
  • Collapsed larynx cartilage.
  • Causes upper airway obstruction (stridor).
  • Worsens when supine.
• Vascular Ring:
  • Aortic arch anomaly choking trachea.
  • Causes inspiratory AND expiratory stridor.
  • Improves with neck extension.
• Croup:
  • Mostly viral (parainfluenza).
  • Characterized by barking cough, stridor, steeple sign on X-ray.
  • Treated with cool mist, steroids, and racemic epinephrine.
• Bacterial Tracheitis:
  • Caused by Staph aureus.
  • Presents as croup advancing with fever, mucus, and pus in the trachea.

Atelectasis

• Collapsed lung, identified by opacities on chest x-ray.

Bronchiolitis

• Caused by RSV (Respiratory Syncytial Virus).
• Upper respiratory infection progresses to asthma-like presentation.
• Symptoms include wheezing, tachypnea, and crackles.
• X-ray shows hyperinflation and atelectasis.
• Treatment is supportive.
• Strep pneumo, H. flu, Moraxella are the usual bacterial culprits.

Viral Pneumonia

• The number one cause is viral. It presents with interstitial infiltrates with lymphocytes.

Bacterial Pneumonia

• Presents with fever and leukocytosis (neutrophil dominant).
• Lobar consolidation is characteristic.
• Strep pneumo, H. flu and Moraxella can be treated for.

Interstitial Pneumonia

• X-ray shows interstitial infiltrates bilaterally.
• Caused by Mycoplasma, Chlamydia and Legionella.

Chlamydia Pneumonia

• Presents as random zebra-like pneumonia with a staccato cough.
• Associated with eosinophilia.
• Treat with macrolides.

Pertussis

• Virus with a 100-day cough.
• Vomiting after coughing is common.
• Ptosis can occur after holding their breath.
• A 2-week period with nonspecific symptoms, such as a runny nose and coughing, is the prodrome.
• Lasts 4 months, treat the virus with macrolides.

Asthma

• Characterized by coughing, wheezing, and difficulty breathing during exercise.
• Chest X-ray will show hyperinflation.
• Treat with Albuterol using a beta 2 agonist.

Cystic Fibrosis

• The following bacteria can be culprits: <20 years its staph and >20 years if pseudomonas.
• Due to CF Mutation problems in chloride transport. Chloride is needed to add liquid when glands are extraverting.
• Sweat has really salty sweat, due to poor water output.
• Lungs become sticky and dry and mucousy.
• Pancreas release juices is very thick and juices.
• Cannot secrete the pancreatic lipase.
• Treatment: Creati enzymes and good hygiene.

GI

• GERD (gastric esophageal reflux): Acid reflux triggers vagus nerve constriction, causing wheezing.
• Ladd's Bands: Peritoneal adhesion bands squeeze the duodenum in gut volvulus.
• Gut Volvulus: Small intestine doesn't twist 270 degrees counterclockwise and doesn't fall into the abdomen; cecum is in the RUQ.
  • Causes abdominal pain and nausea.
  • Presents with bilious vomiting.
  • Patient is unable to pass gas or move bowels.
  • Diagnosis: Upper GI series.
  • Treatment: NG tube for vomiting relief support.
• Duodenal Atresia: Look for the triple bubble sign. Causes vascular accidents.
• Duodenal Atresia/Double Bubble Sign: Can cause vascular accidents, use or cocaine, duodenal atresia has double bubble + Down syndrome
• Intussusception: Ileum telescopes into itself, causing inflammation and ischemia, leading to tissue sloughing off, bloody stool, leg up to chest, colicky pain. Treatment with air enema.

Meckel's Diverticulum

• Ectopic gastric and pancreatic tissue causes painless bleeding.

Ulcerative Colitis vs. Crohn's Disease

• Rectum is always involved in UC.
• UC is limited to the mucosal layer, UC association with primary sclerosis cholangitis.

Crohn's Disease

• Transmural: associated with pyoderma gangrenosum.
• Premature + Feed Early + Rectal Bleeding = Necrotizing Enterocolitis with Pneumocystis on imaging.

Chronic Glomerular Najar (Crigler-Najjar)

• Deficiency in glucuronyl transferase prevents unconjugated bilirubin from being conjugated.
• Causes unconjugated hyperbilirubinemia, above levels of 1.
• Unconjugated bilirubin can cross barriers and damage basal ganglia, causing kernicterus.

Gilbert Syndrome

• There is an absolute deficiency, and will be apparent when the patient gets sick.
• Only gets slight jaundice when sick.

Dubin-Johnson Syndrome

• Patient can conjugate bilirubin, but cannot release bile from hepatocytes.
• Causes direct hyperbilirubinemia.
• Liver is blackened.

Rotor's Syndrome

• More mild version of Dubin-Johnson, and liver is not blackened.
• Nephrology

Minimal Change Disease in Children

• Proteinuria over 3.5 grams a day, creatine >3.5 protein.
• Loss of albumin through excretion decreases intra-oncotic pressure, causing edema and body swelling.
• Also excretes antithrombin: Gets deficient and risks antibody deficiencies.
• Increases risk of encapsulated organisms, pneumonia: Please Shine My Skis.
• Prone to hyperlipidemia.
• Hypercoagulable with venous thrombosis.
• Treat patients with minimal change syndrome with steroids. Histology finds "effacement of podocytes".

HUS (Hemolytic Uremic Syndrome)

• From undercooked beef that causes EHEC - inflammatory bloody diarrhea.
• If patient is given fluoroquinolones, then develops HUS.
• Presents with Fever, Anemia, Thrombocytopenia, Renal failure.
• If uremia occurs, treat with dialysis.
• Dialysis will occur if the kidney is having platelet dysfunction with uremia.

Alport Syndrome

• Presents with hematuria and deafness.

RTA (Renal Tubular Acidosis)

• Type 1 (distal):
  • Defect in H+ excretion causing a stone.
• Type 2 (proximal):
  • Defect in HCO3- reabsorption causes acidosis.
• Type 4 (hypoaldosteronism):
  • Hypoaldosteronism leads to hyperkalemia, hyponatremia, and hypertension. Only one is hyperkalemia.

Urethral Valve

• Posterior Urethral Valve only happens in boys.
• The baby can't urinate in utero as a fetus.
• Treat with surgery.

Neurology

• Spinal Muscular Atrophy (Werdnig-Hoffmann):
  • Causes destruction of lower motor neurons, hyporeflexia, fasciculations
• Botulism affects the muscular skeletal GI and the heart rate everything.
  • Caused by Ach Treatment with Bot immunoglobulin.

Dandy-Walker Malformation (DWM)

• No cerebellum, the enlarged fourth ventricle blocks CSF circulation, leads to ICP symptoms, nausea projective vomiting.
• CT HEAD before Lumbar puncture unless fontanelles are open.

Tuberous Sclerosis Complex (TSC)

• Ash Leaves: Leaf-shaped white birthmarks on the skin that are visualized with Woods Lamp.
• Shagreen Patches: Rough, raised patches of skin typically on the back or flanks.
• Heart Rhabdomyosarcoma: A benign heart tremor commonly found in children with TSC that can cause cardiac conduction issues.
• Lung hamartomas.
• Epilepsy, as a result of the of Cortical Tubers are present.
• Angiomyolipomas
• Facial angiomas.
• Treat with ACTH.

Headaches

• A migraine headache with:
  • Pulsatile
  • One-Day Duration
  • Unilateral
  • Nausea
• Treat initially with Tylenol or sumatriptan (5HT 1B/1D agonist).

Guillain-Barré Syndrome (GBS)

• Ascending paralysis, symptoms begin in the feet. The primary risk for these patients is respiratory paralysis, which is related to damage to the diaphragm, causing difficulty with breathing. Check vital capacity.
• CSF Cytologic dissociation
• Treat with IVIG or Plasmapheresis.

Muscular Dystrophy

• Duchenne's is more early onset.
• Muscles replaced with fibroblasts and lipid.
• Dystrophin is missing.
• Hypertrophic calves, Gower's sign (use of hands to "walk up" legs when standing.).

Von Willebrand Disease

• Low vWF
• Increased bleeding time and PTT.

Wiskott-Aldrich Syndrome

• WATER (Wiskott-Aldrich Thrombocytopenia, Eczema, Recurrent infections).
• Thrombocytopenia
• Eczema
• Recurrent infections.

Wilms Tumor

• Wilms Tumor (nephroblastoma), does not cross the abdominal midline, with the tumor capsule.

Neuroblastoma (NB)

• Does cross midline
• Has hyper catecholaminemia.

VACTERL association

• Helps remember anal atresia, you must remember Doctor with Anal atresia with cardiac defects.

Hodgkin Lymphoma

B symptoms: Fever, night sweats, weight loss.

Ewing Sarcoma

• Onion skin appearance with the small round blue cells.

Celiac Disease (CD)

• Associated with IgA anti-endomysial, anti-tissue transglutaminase antibodies

Severe Combined Immunodeficiency (SCID)

• Low T cells, B cells, antibodies.
• Needs Monthly IVIG PCP Prophylaxis.

Ataxia-Telangiectasia (A-T)

• Low IgA.

Bruton's Agammaglobulinemia

• Low B cells, no antibodies.

Chronic Granulomatous Disease (CGD)

• NADPH oxidase deficient.
• Lead Deficiency: Delayed falling off of the umbilical cord. Impaired wound healing, no pus, Leukocytosis.