Pediatric Hypertension: Risk Factors & Evaluation

Risk Factors for Pediatric Hypertension

• Pediatric hypertension affects more males (15%-19%) than females (7%-12%).
• Hypertension prevalence is higher in Hispanic and African American children.
• Obesity, sedentary lifestyles, and stress are increasingly associated with hypertension in children.
• Secondary hypertension is more common in children under 6 years, often with significant or severe hypertension levels.
• Renovascular or parenchymal renal diseases are the primary cause of secondary, severe hypertension.
• Other causes of secondary hypertension include coarctation of the aorta, endocrine disorders, Williams syndrome, neurofibromatosis, tuberous sclerosis, certain drugs, and central nervous system tumors.
• Primary hypertension is more likely to occur after 10 years of age.
• Neonates with hypertension are usually severely ill, displaying neurologic, cardiac, and renal symptoms.

Cardiovascular Evaluation in Pediatric Patients

• Cardiac evaluation includes reviewing family, maternal, fetal, neonatal, and infant medical history, as well as growth and development.
• Physical assessment should be age-appropriate, flexible, and thorough, adapting to ensure the patient's comfort and needs are met.
• Heart rate, respiratory rate, and blood pressure vary significantly throughout childhood.
• Heart rates should be assessed through auscultation for rate and rhythm variations.
• Increased heart rate may indicate excitement, anxiety, hyperthyroidism, heart disease, anemia, or fever.
• Irregular heart rate can be caused by normal sinus arrhythmia, which is more common in children than adults.
• Pulses should be palpated in the upper and lower extremities to evaluate character and variation between sites.
• A bounding pulse may signal PDA or aortic insufficiency, while weak or thready pulses may indicate CHF or an obstructive lesion, like severe aortic stenosis.
• Strong brachial pulses with weak or absent femoral pulses may indicate coarctation of the aorta.
• Annual blood pressure monitoring should begin at age 3 for healthy children and adolescents.
• Blood pressure should be checked at every appointment for individuals with obesity, kidney disease, diabetes, or known aortic arch disease.
• Manual blood pressure assessment with a sphygmomanometer is preferred.
• Primary care providers should check blood pressure in younger children if heart disease is suspected.
• Always use a blood pressure cuff appropriate for the child's size.
• Cuff width should be two-thirds the length of the upper arm, measured from the axilla to the antecubital space.
• An inappropriately sized cuff can cause erroneous readings.
• Cuff sizes of 3, 5, 7, 12, and 18 cm should be available.
• Initial evaluation should include blood pressure assessment in all four extremities, which should read equal.
• Leg pressure should be slightly higher (10–20 mm Hg) in a child who walks.
• Lower extremity pressure should be measured with the stethoscope over the popliteal artery.
• If blood pressure is higher than the 90th percentile, recheck it two more times and average the last two readings.

Respiratory Rate Evaluation

• Respiratory system evaluation includes assessing the respiratory rate, respiratory effort, and breath sounds.
• Evaluating respiratory rate should be done during a calm time for the child/infant.
• A respiratory rate greater than 40 breaths/min in a young child or 60 breaths/min in a newborn warrants further evaluation.
• Infants with CHD may be happily tachypneic without other signs of distress.

Cholesterol Screening in Pediatric Patients

• Screening should be considered by age 2 if hypercholesterolemia or early CVD is present in the family history.
• Selective screening is performed on children/adolescents over 2 years with overweight/obesity, hypertension, or diabetes as individual or family risk factors.
• Universal screening with fasting lipid profile or nonfasting non-HDL cholesterol testing should be done between ages 9 and 11 and again after puberty.
• Fasting lipid profiles should be obtained on two separate occasions and results averaged.
• Between 12 and 16 years, screening can be inaccurate due to decreased lipid synthesis during puberty.

Medication Therapy for Pediatric Populations with Cholesterol Issues

• Children under 10 years with homozygous FH with LDL above 400 mg/dL or CVD within the first two decades of life/ status post cardiac transplant should be considered for medication therapy.
• Medication therapy should also be considered for children with LDL ≥190 mg/dL + positive family history, or one high-risk factor/condition, or two moderate risk factors/conditions
• Children 10 and older should be considered for medication therapy if LDL ≥190 mg/dL, LDL ≥160 mg/dL + positive family history, or one high-risk factor/condition, or two moderate risk factors/conditions, or LDL ≥130 mg/dL + two high-risk factors/conditions, or one high-risk factor/condition and two moderate risk factors/conditions, or clinical CVD

Scarlet Fever

• Scarlet fever is caused by erythrogenic toxin.
• It is uncommon in children younger than 3 years old, mostly occurring with pharyngitis and rarely with pyoderma, skin, or wound infection.
• The incubation period is about 3 days (range 1–7 days).
• The symptoms are an abrupt illness with pharyngitis, emesis, headache, chills, and malaise.
• Fever reaches 104°F (40°C).
• The tonsils are erythematous, edematous, and usually exudative.
• The pharynx is inflamed and may be covered with a gray-white exudate.
• The palate, uvula, and petechiae are erythematous and edematous.
• The tongue is usually coated and red, and desquamated coating leaves prominent papillae (strawberry tongue).
• The typical scarlatina rash appears 1 to 5 days after symptom onset.
• The exanthema is red, blanches to pressure, and is finely papular with a sandpaper feel.
• The rash typically begins on the neck, underarms, or groin, and spreads to the trunk and extremities by 24 hours.
• The face may be spared (reddened cheeks with circumoral pallor), but the rash is denser on the neck, axilla, and groin.
• Pastia lines (hyperpigmented linear areas with tiny petechiae) are in the joint folds.
• Severe disease manifests small vesicles (miliary sudamina) on the hands, feet, and abdomen.
• Circumoral pallor and erythematous cheeks are typical.
• The rash fades and desquamates after 3 to 4 days, starting on the face and slowly moving to the trunk and extremities, and may include fingernail margins, palms, and soles
• Pharyngitis and constitutional symptoms resolve in approximately 5 to 7 days (average 3-4 days).

Roseola

• Roseola involves a sudden onset of high fever is 101°F to more than 103°F (38.3°C to more than 39.5°C) for 3 to 7 days, but the child does not seem ill.
• Approximately 20% of all emergency department visits for children with fevers, ages 6 to 12 months are attributed to HHV-6.
• Possible symptoms during high fevers are irritability and malaise.
• Other symptoms include URI signs, cervical and posterior occipital lymphadenopathy, lethargy, infected palpebral conjunctiva, eyelid edema, GI complaints, reddened tympanic membranes, and febrile convulsion (10–15%).
• As fever breaks, diffuse, nonpruritic, discrete, rose-colored maculopapular rash (2 to 3 mm in diameter) fades on pressure and rarely coalesces.
• The roseola exanthema is similar to rubella.
• The rash lasts from hours to 2 to 3 days, begins on the trunk, and spreads centrifugally.
• Rare case of CNS involvement, the anterior fontanelle may bulge.
• Management is supportive. Use acetaminophen if the child is uncomfortable with the fever. There are no practical means of prevention.

Rubella

• Approximately 25% to 50% of rubella infections are subclinical.
• Postnatal disease shows 3 stages:
• Prodrome: Mild fever (101.5°F [38.6°C]), lower Gl upset, pharyngitis, eye pain, arthralgia, malaise, and headache occur for 1 to 5 days before onset of stage 3 and are occasionally missed.
• Lymphadenopathy: Usually begins within 24 hours but can begin as early as 7 days before the rash appears and lasts for more than 1 week. Primary lymph nodes include postauricular, posterior cervical, and posterior occipital. Generalized lymph node involvement and splenomegaly may be noted.
• Rash: Enanthem (Forchheimer spots) may appear before the general rash; consists of small rose-colored to reddish spots on the soft palate alone but is not pathognomonic. Rubella rash (discrete maculopapules that occasionally coalesce) usually first shows on the faces, fades as it spreads caudally during the next 24 hours, and resolves by the third day. The rash may be pruritic without a rash or a fine, bran-like desquamation. In addition their may low-grade fever occur during the eruptive phase and continues for up to 3 days. There is no photophobia; anorexia, headache, and malaise are rare. Exanthems occur less often in adolescents and young adults; they may have more pruritus. A facial acneiform rash is more common in adolescents. Paresthesia and tendonitis may be present,

Rubeola (Measles)

• Clinical manifestations include:
• Incubation period:There are no specific symptoms.
• Prodromal period: Lasts 4 to 5 days with URI symptoms, low to moderate fever (>101°F [38.3°C]), and cough, coryza, and conjunctivitis (the "three C's" of measles). Koplik spots may occur on the oral mucosa opposite the lower molars. They are small, irregular, bluish-white granules on an erythematous background, last 12 to 15 hours, and are pathognomonic of measles infection. They typically disappear 48 hours before the exanthem appears.
• Rash stage: The rash of unmodified measles usually appears on the third or fourth day of the illness. As the rash appears, the temperature rises, often to 105°F (40.5°C). The rash is maculopapular and first appears behind the ears and on the forehead. Papules enlarge, coalesce, and move progressively downward, engulfing the face, neck, and arms over the next 24 hours. By the end of the second 24 hours, the rash spreads to the back, abdomen, and thighs. As the legs are involved, the face begins to clear. The entire process takes approximately 3 days. Respiratory symptoms are most severe on day 3 of the rash. The more severe the rash, the more severe the illness. It can become hemorrhagic, and this can be fatal because of disseminated intravascular coagulation (DIC). Photophobia generally occurs when the rash begins to spread and worsens. The rash begins to fade after the fourth day. The disease peaks; defervescence occurs. After the rash clears, a residual desquamating light-colored pigmentation occurs, lasting approximately 1 week.

Mononucleosis

• The CBC classically demonstrates lymphocytosis with more than 10% atypical lymphocytes.
• Elevated liver enzymes are typical.
• Monospot and serum heterophile tests are positive in 85% of infected patients older than 4 years old, but often negative in those younger.
• Children older than 4 years usually must be ill for about 2 weeks before seroconverting.
• Viral culture and Epstein-Barr-specific core and capsule antibody testing are usually used for diagnosis when primary screening test results are negative and there is continued suspicion of IMS.
• Depending on the specific EBV antigen system tested, levels are detectable for years after infection.
• Polymerase chain reaction assay for detecting EBV is available and is useful in evaluating if the child is immunocompromised or has a chronic complex medical condition.

Hand, Foot, and Mouth Disease (HFMD)

• Symptoms include low-grade fever.
• Mouth or throat pain (verbal children) or refusal to eat (nonverbal children) are common.
• Prodrome is usually absent.
• Malaise, abdominal pain, diarrhea, and fussiness may occur.
• 25% of patients have enlarged anterior cervical nodes or submandibular nodes.
• Oral manifestations (enanthem) may be small, red papules on the tongue and buccal mucosa progressing to ulcerative vesicles on an erythematous base.
• Exanthem (macular, papular, or vesicular) occurs 1-2 days after oral lesions, is rarely pruritic, and may occur on palms, foot soles, arms, legs, buttocks, fingers, and toes.
• The virus may be detected in stool for 6 weeks or longer after infection.
• Viral shedding from the oropharynx may last up to 4 weeks.

Aphthous Stomatitis

• Pain is severe or burning, starting before the ulcer appears.
• Ulcers are small, round, white, gray, or yellow with a red border.
• They are usually located inside the lips, on the cheeks, or on the tongue.
• The ulcers usually heal in 7 to 14 days, but tend to recur.

Herpetic Gingivostomatitis

• Caused by HSV-1.
• Symptoms include gingivostomatitis with pharyngitis with grouped vesicles on an erythematous base that ulcerate and form white plaques on mucosa, gingiva, tongue, palate, lips, chin, and nasolabial folds; lymphadenopathy and halitosis present.

Vincent's Angina

• This condition is also known as trench mouth.
• It is a progressive, painful infection with ulceration, swelling, and sloughing-off of dead tissue from the mouth and throat due to the spread of infection from the gums.

Kawasaki Disease (Acute Phase)

• Acute Phase: High fever (103-105° F or 39-41° C) for at least 5 days that is unresponsive to antibiotics, Oral mucosal lesions last 1-2 weeks, Perineal rash.
• Possible symptoms: hyperdynamic precordium, tachycardia, gallop rhythm, innocent flow murmur (if anemia present), and depressed myocardial contractility (secondary to myocarditis)
• Can have nontender cervical adenopathy (1.5 cm, unilateral).
• Can have painful rash and edema of the feet.
• Possible myocardial infarction due to perivasculitis and vasculitis.
• May include joint involvement: arthritis or arthralgia.
• Requires 5 days of fever and 4 of the following diagnostic criteria: Edema or erythema of the hands and feet, Conjunctival injection (bilateral bulbar), Cervical lymphadenopathy (node >1.5 cm; unilateral), Rash (nonvesicular and polymorphous): maculopapular, diffuse erythroderma, or resembling erythema multiforme, exudative pharyngitis, diffuse oral erythema, strawberry tongue, and crusting/cracking of lips and mouth.
• Subacute (2-8 weeks after onset)
• Desquamation of palms, feet, periungual area, perineal area; coronary artery aneurysms; joint aches and pains, Acute myocardial infarction.
• Pancarditis, Diarrhea, jaundice, hepatosplenomegaly, Aseptic meningitis, Sterile pyuria.
• Platelet count may rise >106 per mm3, Convalescent (6-8 weeks following onset), Symptoms resolve, Sedimentation rate returns to normal.
• Kawasaki disease is fatal in a small percentage of children with coronary artery problems.

Kawasaki Disease (Management)

• Nonpharmacologic Management: Comfort measures, Bedrest and limited physical activity, Isolation of patients is not necessary, Patient education about disease, treatment, and prognosis.
• Pharmacologic Management: Goal is to reduce inflammation and arterial damage and prevent thrombosis, The main goal of pharmacotherapy is to reduce inflammation and platelet activation. Early and aggressive intervention improves outcomes by:
  • Standard treatment: intravenous immunoglobulin (IVIG) and high-dose aspirin, IVIG administration may shorten the acute phase and decrease the prevalence of coronary artery abnormalities, especially aneurysms) within first 10 days illness.
  • If patient presents with cardiovascular collapse, they are at higher risk of resistance, coronary artery abnormalities, myocardial infarction, and prolonged myocardial dysfunction.
  • Live vaccines should be withheld for at least 11 months after IVIG administration, potential risk of reye syndrome in children.
  • Aspirin dose: 80-100 mg/kg/day in 4 doses; decreased (3-5 mg/kg/day) over next 6-8 weeks.
    • Potential risk of Reye syndrome with aspirin use in children (especially with viral illness); use with caution
    • If coronary aneurysms form, increased doses of aspirin or other antiplatelet agents may be needed
  • Corticosteroids: may be used in patients unresponsive to IVIG standard therapy or in combination with IVIG; use in children is controversial.
  • Immunosuppressants: used in IVIG-resistant cases and in refractory cases with coronary aneurysms. Anticoagulants: use in patients with large aneurysms and high risk for thrombus and may require long-term treatment.

Varicella Infections

• Complications include pyodermas (about 5% incidence), causing serious invasive disease with Streptococcus and Staphylococcus, idiopathic thrombocytopenic purpura (ITP) (1%-2%), and pneumonia (smoking is a risk factor).
• Other complications are: CNS complications (e.g., encephalitis and Reye syndrome) and, rarely, glomerulonephritis, orchitis, hepatitis, toxic shock, osteomyelitis, necrotizing fasciitis, myositis, myocarditis, arthritis, and appendicitis.
• Primary varicella is rarely fatal, and the highest mortality is found in newborns and immunocompromised children.
• Neonatal involvement is directly tied to the timing of the maternal infection.

Eczema

• Treatment strategy:
  • The itch-scratch-itch cycle must be interrupted.
  • Dryness of the skin must be corrected by rehydrating the stratum corneum with lubrication as the first-line therapy to enhance skin moisturization.
  • Moisturizer choice is dependent on the individual, safe, free of additives, and inexpensive.
  • Application of moisturizer should take place soon after bath to decrease transepidermal water loss.
  • Start skin barrier protection at birth as it may be protective against the development of AD.
  • If moisturization does not control the disease, then topical corticosteroid preparations (TCPs) are used. Low-potency corticosteroids for maintenance but higher potency for exacerbations.
  • Use of nonsoap surfactants and synthetic detergents are often recommended but without good supporting evidence. Eliminate any known offending agents (irritants and allergic triggers). Secondary bacterial or viral infections must be treated.
  • American Academy of Dermatology and the AAP published AD guidelines, with similarities between the guidelines.

Recommended Interventions for Control of AD

• Teach patients to bathe daily in lukewarm water for 5-10 minutes, limit soaps and shampoos to dye-free, fragrance-free, and hypoallergenic products. Pat skin dry afterwards and apply emollients within 3 minutes to seal in and reduce transepidermal water loss.
• In moderate to severe eczema, use twice weekly dilute bleach baths to prevent secondary infections. After bathing, wet wrap therapy, with emollients and topical steroids, can help to prevent flares in moderate to severe AD.
• Emollients are high lipid, low water content moisturizers and are an essential element of daily prevention of AD flares. Chronic emollient use helps to retain and replenish skin moisture, lengthens the time between flares, and reduces flare.
• Choice of moisturizer can be left to the patient's preference; however, patients should be educated that ointments have the highest concentration of lipids followed by creams and then lotions. Moisturizers should be applied one to twice a day.
• In infants with a family history of AD, several randomized clinical trials have demonstrated the utility of emollients alone as primary prevention for AD.
• Topical TCPs are a mainstay of therapy for flares and reduce inflammation and pruritus.
• Most children with AD are controlled with twice-daily application for 2 weeks then doing twice-weekly application of a low-dose TCP for up to 4 months once the lesions are quiet to treat a defect in skin that can be treated using an intermittent approach.
• Gels penetrate well and are somewhat more drying, so they are effective for acute weeping or vesicular lesions.
• Ointments are generally stronger than all other types of preparations and provide occlusion which are beneficial in the management of dry, lichenified, or plaque-like areas but may occlude eccrine ducts and lead to sweating.
• Apply the amount of steroid using an fingertip method with strip of cream from the distal interphalangeal joint to the top of the adult finger and apply a thin layer of TCP to affected areas twice a day. TCP formulations may require only once a day application. When applied over large areas of dermatitis or if for occlusion the possibility of significant systemic absorption is greatly increased in young children.
• There are classes of steroids with class 1 being very high potency to class 7 being the lowest potency. Caution is needed when applying steroids to the face/neck and skin folds because the skin is thinner and there is higher risk of systemic absorption. Tapering of the strength of the steroids should occur only once the outbreak is fully controlled.
• The child is then switched to twice-weekly application of a low-dose topical corticosteroid TCS at areas of outbreak to reduce the relapse. Baseline moisturizing skin care should continues to reduce inflammation.
• Phosphodiesterase-4 acts as a mediator in the conversion of cyclic adenosine monophosphate (cAMP) into AMP. In patients with AD, low cAMP levels and high phosphodiesterase (PDE) activity causes inflammatory hyperreactivity. Crisaborole (Eucrisa), a topical PDE-4 inhibitor, is an alternative choice in mild to moderate disease. Common adverse events include burning and stinging or worsening of AD.
• TCIs are second-line therapy for both acute and chronic AD and are considered steroid-sparing agents. Tacrolimus 0.03% and pimecrolimus 1% are approved for use in children ≥2 years and have black box warnings for higher rate of lymphoma.
• Common and main side effects are itching, stinging, or burning, which starts 5 minutes to an hour after application lasting a week. Use sun protection.

Therapies Utilized to Combat Impetigo

• Prescription emollient devices improve the skin's hydration barrier are available by prescription and are used twice a day. Topical antimicrobials and antiseptics can be used if the immune dysregulation in AD results in a tendency for S. aureus to colonize the skin in AD, as well as viral infection, including herpes simplex. Reduction of colonization with staphylococcus, as well as treatment of infection, may be equally as important.
• The use of bleach baths in conjunction with intranasal topical mupirocin for 3 months may be helpful and should be carefully evaluated for children with recurrent infection.
• Systemic Immunomodulating agents like cyclosporine, azathioprine, mycophenolate mofetil [MMF], and systemic corticosteroids in patients with severe/refractory AD/
• Dupilumab is is a targeted biologic and is now approved for the treatment of AD approved for infants 6 months and older with moderate to severe AD
• Emphasis is placed on nonpharmacologic therapy and skin lubrication/ moisture from emollient use

Environmental and Dietary Management

• Decreasing environmental humidity, eliminating known or suspected offending agents, avoiding nonbreathable fabrics, preventing overheating and overdressing, avoiding chlorine, turpentine, harsh soaps, fabric softeners, fragrances, and bleach, minimizing allergenic agents, and controling house dust mites can be helpful.
• In infants, whey-protein partially hydrolyzed infant formula is not hypoallergenic and should not be given to infants who have milk allergy. Dietary restriction done based on history of food allergy after food allergy. Found pre- and probiotics make small differnces for quality of life.
• Most children can be help successfully treated by most PCPs. Children who are not responsive should be seeen by PD derm.

Complications and Prognosis

• Secondary skin infections are a frequent complication of AD, Lichenification which is secondary skine change. keratoconus are complications
• Appropriate treatment allows AD to generally be controlled and symtpoms to become less severe
• Self-image problems may be the main issuse with AD.

Asthma Classifications

• Asthma is diagnosed in all degrees of severity with the use of NHLBI Classifications, and management of different catagories

Asthma: Diagnostic Evaluation

• Key to diagnostic eval is presence of respiratory symptoms such as a Dyspnea, cough, wheezing, chest tightness, variable expiratory airflow obstruction

Dry Poweder Inhaler

• A "dry powder inhaler" DPI is a type of asthma medication delivery device that contains a dry powder form of the medicine, which is released into the lungs when the user takes a deep, fast breath in; essentially, the user's breath activates the medication delivery, unlike other inhalers that use a propellant to push the medicine out.
• unlike a metered dose inhaler requires no button, and technique in crucial
• Benefits are that it easier, and diffrent brands are used

Blood Pressure

• Screening of blood pressure and physical examination notating: -Body issues especially overweight (body mass index [BMI]), poor growth (height, weight), or signs of metabolic syndrome and note edema, pallor, flushing, or skin lesions suggestive of tuberous sclerosis, systemic lupus erythematosus, or neurofibromatosis -Note what is upper and lower extremity central pulses and optic fundi abnormalities
• Diagnotistics study is to look for causes of HTN at Stage 1 or 2
• Lab eval are primary/ individual
• Follow the recommendation is found for elevated BP

Elevated BP

• At least two follow-up BP measurements should be taken within 1 to 2 months of the initial reading to determine whether a high reading is a single, isolated event. If subsequent readings fall to less than the 95th percentile, the child should continue with routine BP checks during annual visits.
• HTN secondary to overweight can be as serious as HTN secondary to other organic disease and should be treated as such.
• If the BP elevation persists, provide referral to a nephrologist or cardiologist experienced in using antihypertensive agents in pediatric patients and manage through this process

Myocarditis in PEDS

• Myocarditis is a rare inflammatory illness of the muscular walls of the heart and is viral.
• Infants (may manifest intrauterine exposure): Fever, irritability or listlessness, pallor episodes, diaphoresis, tachypnea or respiratory distress, poor appetite, and vomiting.
• Children and adolescents: Recent flu-like or gastrointestinal viral illness (10-14 days previously), lethargy, low-grade fever, pallor, decreased appetite, abdominal pain, exercise intolerance, rashes, palpitations, and respiratory distress (late finding).
• Pallor, mild cyanosis, and cool and mottled skin can be the presentation
• Diagnose ECG, heart studies, and cultures/ peformed
• Treat by keeping patient at rest with diuretics, ACE inhibitors, and carvedilol.

Congestive Heart Failure

• CHF is a progressive clinical and pathophysiologic syndrome found in many individuals with heart problems. The symptoms vary with age of the patient and the root cardiac problem. Besides functional changes, CHF is marked by cardiac neurohormonal and molecular changes.
• Pediatric CHF can be caused by congenital malformations leading to ventricular dysfunction, pressure, or volume overload. CHF also occurs in individuals with structurally normal hearts and is caused by cardiomyopathy, arrhythmias, ischemia, toxins, or infections.
• The largest group of pediatric patients with CHF are those with excessive left-to-right shunting through unrepaired congenital defects. CHF is somewhat of a misnomer in these cases because the myocardium generally responds quite well to the challenge of excessive blood volume for a long time, and cardiac output remains adequate.
• Follow treatment steps of: -Electrolyte and fluid imbalances, -Increase contractility, and -decrease cardiac afterload."

Impetigo

• Treat in acute setting washing with soap/water but note if MRSA if present with chlorhexidene
• Topical/ Systemix therapy may be needed
• The is the need to assess the family
• MOA:
• FDA indicatino and side effects are listed.

Mellouscum contagiosum

• This is more common in kids more, seen and face mucosa
• Dx Clinical
• Treat is more what fits child and family.
• Usually resovles with time
• can caused by cat Scratch

Mosquito-borne infections

• They are many diff, but they share simular charateristic.
• West nile Virus
• patient have signs of meningitis . can be found after mosquitos are around
• there are no vaccines so treatment aims
• dengue and HIV etc, all fall int to the catagory