30-Infectious-Diseases-Bitnun-slides.pdf

Infectious diseases pre- exam torture session Ari Bitnun, MD MSc FRCPC [email protected] Conflict of interest Dr. Bitnun has no actual or potential conflict of interest in relation to the content of this presentation Outline Congenital infections Infection in neonates and infants < 90 days Co...

Infectious diseases pre- exam torture session Ari Bitnun, MD MSc FRCPC [email protected] Conflict of interest Dr. Bitnun has no actual or potential conflict of interest in relation to the content of this presentation Outline Congenital infections Infection in neonates and infants < 90 days Common pediatric infections Tuberculosis HIV Exposures, infection control and daycare issues Golden rules Be safe ◦ Don’t miss a life-threatening condition ◦ Approach the situation as you would in practice (if you think its an emergency treat it as such) Be reasonable ◦ Use common sense, don’t look for Zebra’s ◦ If the question seems simple, it probably is just that CPS statements are gospel ◦ In case of differences between Red Book and CPS statement always follow the latter Congenit al infections Question Newborn with maculopapular rash, microcephaly, chorioretinitis, hepatosplenomegaly, bony changes. Most likely diagnosis? a. Toxoplasmosis b. Rubella c. CMV d. Syphilis e. HIV Early onset manifestations System Manifestations General Prematurity, IUGR, FTT Mucocutaneous Snuffles, maculopapular rash followed by desquamation, blistering and crusting, condyloma lata Reticuloendothelial Hepatosplenomegaly, lymphadenopathy Hematologic Coomb’s negative hemolytic anemia, thrombocytopenia Skeletal Pseudoparalysis, osteochondritis, diaphyseal periostitis, deminiralization/destruction of proximal tibia metaphysis, osteitis Neurologic Aseptic meningitis, hydrocephalus, cranial nerve palsy Periosteal reaction Radiolucent defects Question Mom diagnosed with syphilis week 32 of pregnancy, RPR 1:128. Given single dose IM penicillin after which RPR drops to 1:64. Infant has normal physical exam; RPR 1:64. Management? a. No treatment as mom was appropriately treated b. Full workup including LP; give 10 days of IV penicillin regardless of workup findings c. Full workup including LP; 10 days of IV penicillin if workup abnormal d. Full workup including LP; single dose IM penicillin if workup abnormal When to evaluate an infant for congenital syphilis Infant has signs and symptoms of congenital syphilis Mother not treated or treatment not adequately documented Mother treated with non-penicillin regimen Mother treated within 30 days of child’s birth Less than 4-fold drop in mothers non-treponemal titer or not assessed or documented Mother had relapse or re-infection after treatment https://cps.ca/documents/position/congenital-syphilis, 2021 Red Book Evaluation of the infant with suspected congenital syphilis Physical exam Skeletal survey (long bones) ◦ Stigmata ◦ (ophthalmology, audiology Syphilis serology assessments) ◦ Non-treponemal ◦ Treponemal CBC, (LFT’s) Direct detection Lumbar puncture * ◦ PCR ◦ CSF WBC count ◦ (Darkfield microscopy) ◦ CSF protein ◦ (Direct fluourescent Ab) ◦ Treponemal and non-treponemal ◦ Placental tissue, umbilical cord, serologic tests lesion exudate https://cps.ca/en/documents/position/congenital-syphilis Treatment and follow-up Aqueous crystalline penicillin G intravenously for 10 days is the preferred treatment for suspected or proven congenital syphilis regardless of age at diagnosis Newborns at risk who are receiving IV ampicillin and cefotaxime for R/O sepsis, should still receive 10 days of penicillin Close follow-up required ◦ Serologic follow-up for all cases ◦ Repeat long bone x-rays not routinely needed if appropriately treated ◦ Repeat LP (if initial abnormal) not always needed if clinically well and RPR in blood becomes negative https://cps.ca/en/documents/position/congenital-syphilis Follow-up Baseline concurrent RPR in mother and newborn is ideal When to expect sero-reversion in uninfected infants ◦ RPR usually negative by 3 – 6 months ◦ Treponemal tests usually negative by 12 months For infants with reactive RPR at birth, repeat testing to document decline over time ◦ Typically – birth, (6 weeks), 3 – 4 months, 6 months, 12 months ◦ Varies slightly by risk category (see table 3 in CPS statement). https://cps.ca/en/documents/position/congenital-syphilis Case presentation Term infant. Growth parameters at 5th percentile. Mild splenomegaly. What infection in the mother is most likely to cause this? a. Toxoplasmosis b. Rubella c. CMV d. Varicella zoster virus e. HIV Picture from - Arch Pediatr Adolesc Med 2007;161(11):1102-3  Most common congenital infection (0.3 – 1.2% of newborns) Congenita Most congenital CMV follows non-primary maternal CMV l CMV infection (infection with new strain, endogenous reactivation) One in 5 children develops permanent sequelae (SNHL most common) Most common cause of acquired hearing loss in childhood Hearing loss can develop late (after normal newborn hearing screen) Early detection and treatment improves hearing and developmental outcomes Clinical manifestations System Clinical features General IUGR, prematurity Skin Petechiae, purpura, echymoses, jaundice Hematopoietic Thrombocytopenia, anemia, splenomegaly Hepatobiliary Hyperbilirubinemia, elevated ALT, hepatomegaly CNS Microcephaly, seizures, periventricular calcifications Eye Chorioretinitis, strabismus, optic atrophy, microphthalmia Ear Sensorineural hearing loss Ophthalmologic & Neuroimaging abnormalities in severe congenital CMV Lissencephaly b White matter hyperintensity Periventricular calcifications Polymicrogyria Question You receive a report of a positive CMV test on an infant who is 2 months old. Thrombocytopenia at birth, now resolved. Asymptomatic. What is the most important thing to do? a. MRI head b. Ultrasound Head c. Hearing screen d. Initiate treatment with IV ganciclovir e. Initiate treatment with oral valganciclovir Neurocognitive sequelae Combined data from 10 studies (n=271) Symptomatic (n=19) ◦ Any deficit 57.9% (n=11) ◦ Isolated hearing impairment 15.8% (n=3) ◦ Isolated neurocognitive deficit 15.8% (n=3) ◦ Hearing & neurocognitive deficits 26.3% (n=5) Asymptomatic (n=252) ◦ Any deficit (one death) 13.9% (n=35) ◦ Isolated hearing impairment 9.1% (n=23) ◦ Isolated neurocognitive deficit 3.6% (n=9) ◦ Hearing & neurocognitive deficits 0.4% (n=1) Rev Med Virology 2007;17:355-63 Question Newborn with IUGR, petechial rash with thrombocytopenia, unilateral hearing loss, positive CMV PCR on urine. What to do? a. Reassure and follow-up in 6 months b. Ganciclovir for 2 weeks c. Valganciclovir for 4 weeks d. Valganciclovir for 6 months  CPS statement disease severity grading Asymptomatic ± SNHL ◦ No clinical or laboratory abnormalities consistent with cCMV Mildly symptomatic ± SNHL ◦ 1 or 2 isolated, transient, mild features of cCMV without chorioretinitis or CNS involvement (e.g., mild transaminitis, transient thrombocytopenia) Moderate-to-severely symptomatic ± SNHL ◦ CNS disease: microcephaly, seizures, positive CSF CMV PCR, abnormal head imaging ◦ Chorioretinitis ◦ Multisystem disease (≥ 3 organ/systems involved) with significant non-transient laboratory values (e.g., hepatosplenomegaly, IUGR and moderate-to-severe hepatitis and moderate-to-severe thrombocytopenia) ◦ Severe single organ disease https://cps.ca/documents/position/update-on-congenital-cytomegalovirus-infection-prenatal-prevention-newborn-diagnosis-and-management  CPS statement recommendations Who should be referred to infectious diseases ◦ Confirmed symptomatic congenital CMV ◦ Congenital CMV with SNHL even if asymptomatic ◦ Probable cases may be considered (Table 4) Who should be treated ◦ CNS disease ◦ Chorioretinitis ◦ Severe single (Table 4 footnote) or multi-organ disease https://cps.ca/documents/position/update-on-congenital-cytomegalovirus-infection-prenatal-prevention-newborn-diagnosis-and-management Infections in neonates & infants < 90 days old Question 37-week gestation newborn, GBS negative mother. Membranes ruptured x20 hours before delivery. Intrapartum fever. Ampicillin 5 hours prior to delivery. Newborn appears well. Management? a. Routine care, discharge at 24 hours b. Observe closely with vital signs every 3-4 hours for 24-48 hrs; consider CBC 4 hours after birth c. Observe closely with vital signs every 3-4 hours for 48 hrs; do CBC and blood culture at birth d. Investigate promptly, full sepsis workup, empiric antibiotic coverage Risk factors for early-onset sepsis in term neonates Maternal intrapartum GBS colonization during current pregnancy GBS bacteriuria during current pregnancy Previous infant with invasive GBS disease Prolonged rupture of membranes (≥ 18 hours) Maternal fever (≥ 38.0oC) http://www.cps.ca/en/documents/position/management-infant-sepsis Approach to well appearing term newborns at risk of early-onset sepsis GBS status Other risk Adequate IAP Recommendation factors Positive No Yes Routine care No Close observation § Yes Irrespective Individualized care ‡ ¥ Negative/unknown No - Routine care 1 Yes Routine care No Close observation § ≥2* Irrespective Individualize care ‡ ¥ § Examine at birth, observe 24-48 hrs (vital signs q3-4h), reassess & counsel pre-discharge ‡ At minimum, observe 24-48 hrs (vital signs q3-4H), reassess and counsel pre-discharge ¥ Consider CBC after 4 hrs * Or chorioamnionitis = maternal temperature >38oC plus two of uterine tenderness, maternal or fetal tachycardia, foul/purulent amniotic fluid, maternal leukocytosis http://www.cps.ca/en/documents/position/management-infant-sepsis http://www.cps.ca/en/documents/position/management-infant-sepsis Question 7-week-old infant with fever. Looks generally well. CBC shows a WBC count of 24 x 109/L (70% PMN’s, 25% lymphocytes, 5% bands), procalcitonin 2.0 ng/mL. Best management? a. Blood, urine and CSF cultures; start ampicillin plus cefotaxime b. Blood, urine and CSF cultures; start ceftriaxone plus vancomycin c. Blood, urine and CSF cultures; no antibiotics pending culture results d. Blood and urine cultures; start ceftriaxone pending culture results Low risk criteria for febrile infants ECARN prediction rule 1) Urinalysis negative for leukocyte esterase, nitrite, and pyuria (≤5WBC/hpf) 2) ANC ≤4090/μL 3) PCT ≤1.71 ng/mL Step-by-Step method 1) Well-appearing 2) 22 to 90 days old 3) Urinalysis negative for leucocytes 4) PCT 3 mo. Streptococcus pneumoniae Ceftriaxone + vancomycin Neisseria meningitidis Haemophilus influenzae type b https://www.cps.ca/en/documents/position/management-of-bacterial-meningitis Acute bacterial meningitis – steroids (non-neonatal meningitis) When to consider ◦ Presumptive Haemophilus influenzae (gram negative coccobacilli) ◦ Presumptive Streptococcus pneumoniae (gram positive diplococci) Dosing and timing ◦ Dexamethasone 0.6 mg/kg/day in 4 divided dose for 4 days ◦ Immediately before, concomitant with, or within 4 h of administering the first dose of antimicrobials ◦ Discontinue if organism not identified within 48 hours (e.g., culture negative) https://www.cps.ca/en/documents/position/management-of-bacterial-meningitis Question 5-year-old unimmunized male confirmed to have Haemophilus influenzae type b meningitis. Has 3 siblings aged 3, 6 and 16 years who are also unvaccinated. Who should receive rifampin prophylaxis? a. No prophylaxis indicated b. All household contacts c. All household contacts and exposed healthcare workers d. Only the 3-year-old sibling Prophylaxis for household contacts Haemophilus influenzae type b ◦ Rifampin is preferred option ◦ Indications (index case or household members) ◦ Child < 12 months of age (who has not completed primary Hib series) ◦ At least one child < 4 years who is unimmunized or incompletely immunized ◦ Immunocompromised child of any age ◦ Index cases < 2 years of age should receive prophylaxis if treated with anything other than ceftriaxone or cefotaxime Neisseria meningitidis ◦ All household contacts ◦ Meningococcal vaccine should also be given according to strain https://www.cps.ca/en/documents/position/management-of-bacterial-meningitis Question Three-year-old child with fever and limp for one day. Tender over distal femur. Which is most sensitive for diagnosis of osteomyelitis? a. Plain x-ray b. Bone scan c. Magnetic resonance imaging d. Needle aspiration of affected site Question 10-year-old boy with tibial osteomyelitis confirmed on MRI. CRP and ESR raised. What is the best treatment? a. IV cefotaxime b. IV cloxacillin c. IV cefuroxime d. IV cefazolin Acute osteoarticular infections Staphylococcus aureus and Kingella kingae are the most common pathogens ◦ In children > 4 years Kingella kingae is uncommon MRI most sensitive and specific non-invasive test Antibiotic treatment ◦ IV cefazolin empirically (unless suspect MRSA) ◦ Switch to oral when clinically improved, CRP decreased, compliance and follow-up assured ◦ If uncomplicated, antibiotic duration 3-4 weeks; 4-6 weeks for septic hip https://www.cps.ca/en/documents/position/osteoarticular-infections-in-children Question For which of the following is a throat swab for group A streptococcus most warranted? a. 2-year-old child with fever, cough and runny nose for 3 days b. 4-year-old child with fever, exudate on tonsils and tender anterior cervical adenopathy for 2 days c. 6-year-old with fever, exudate on tonsils and cough for 2 days d. 5-year-old with fever, cough and rash for 2 days Group A streptococcal pharyngitis Group A streptococcal pharyngitis rare in children < 3 years of age Not usually associated with cough, rhinorrhea CENTOR clinical decision rule (only for children aged 3 – 14 years) One point for each characteristic - Exudate or swollen tonsils - Tender or swollen anterior cervical lymph nodes - Fever - No cough If the total score is ≥ 3 do a throat swab; there is a 32% to 56% probability of GAS infection in such cases https://cps.ca/documents/position/group-a-streptococcal Question Six-year-old child with varicella infection presents with fever and progressive lesion on his limb – red with blue hue, increasingly large, exquisitely painful. Antibiotics? a. Piperacillin-tazobactam b. Ceftriaxone + vancomycin c. Penicillin + clindamycin d. Clindamycin + gentamicin Necrotizing fasciitis risk factor assessment Group A streptococcal ◦ Recent pharyngitis, chickenpox Colonization with methicillin resistant Staphylococcus aureus Potential exposure to water-borne pathogens ◦ Aeromonas hydrophilia, Vibrio spp. (V. vulnificus) Clostridial or polymicrobial ◦ Recent GI surgery, abdominal/pelvic focus, pregnancy complications, penetrating trauma https://www.cps.ca/en/documents/position/Invasive-group-A-streptococcal-disease Empiric treatment of necrotizing fasciitis Empiric therapy ◦ β-lactam-β-lactamase inhibitor (piperacillin-tazobactam) or a carbapenem + clindamycin ◦ Add vancomycin if MRSA is concern Otherwise healthy child with no risk factors for pathogens other than S. pyogenes ◦ “Some experts” recommend penicillin G + clindamycin ◦ Consider addition of vancomycin for better S. aureus coverage IVIG for streptococcal toxic shock, severe invasive disease https://www.cps.ca/en/documents/position/Invasive-group-A-streptococcal-disease Chemoprophylaxis for contacts of invasive GAS disease – who? Only for close contacts of confirmed case of severe invasive disease Close contact ◦ Household contacts: spent ≥4 hours/day or 20 hours in total with the case during the previous 7 days ◦ Non-household contacts: Share bed, sexual contacts, direct contact with mucous membranes, oral/nasal secretions, open skin lesions Severe invasive disease ◦ Toxic shock syndrome, soft tissue necrosis, meningitis, pneumonia, other life-threatening conditions https://www.cps.ca/en/documents/position/Invasive-group-A-streptococcal-disease Chemoprophylaxis for contacts of invasive GAS disease – what? First line treatment ◦ Cephalexin 25–50 mg/kg/day (maximum 1 gram/day), 2–4 divided dose, 10 days ◦ Cefadroxil 25 mg/kg/day (maximum 1 gram/day), 2 divided dose, 10 days Second line treatment options ◦ Clarithromycin 15 mg/kg/day (maximum 250 mg BID) divided BID for 10 days ◦ Clindamycin 8-16 mg/kg/day (maximum 600 mg/day) divided 3-4 times a day for 10 days https://www.cps.ca/en/documents/position/Invasive-group-A-streptococcal-disease Question 15-year-old girl with fever, malaise, myalgia, nausea, vomiting and dizziness. Diffuse erythematous macular rash and strawberry tongue. BP 75/40, HR 190, RR 30 and temperature 40C. What is the MOST likely causative organism? a. Staphylococcus aureus b. Rickettsia rickettsii c. Borrelia burgdorferi d. Neisseria meningitidis Staphylococcal toxic shock Clinical features ◦ Fever >38.9°C, hypotension, diffuse erythroderma, desquamation, and dysfunction of ³3 organ systems ◦ Liver, blood, renal, mucous membranes, gastrointestinal, muscular, CNS Isolation of S. aureus not required for diagnosis ◦ Recovered from wound or mucosal sites in 80–90% ◦ Blood cultures positive in minority (~5%) Exclusion of other causes ◦ Sepsis due to other bacteria, rocky mountain spotted fever, leptospirosis, measles Streptococcal toxic shock Hypotension or shock PLUS two or more of the following ◦ Renal impairment ◦ Disseminated intravascular coagulation ◦ Hepatic abnormalities ◦ Adult respiratory distress syndrome ◦ Scarlet fever rash ◦ Soft tissue necrosis Isolation of S. pyogenes from normally sterile body site Other clinical aspects ◦ Focal infection can usually be demonstrated ◦ Varicella zoster virus infection is the major risk factor Question 4-year-old boy with sickle cell disease is admitted with fever. He is hypotensive, grunting and is being transferred to the ICU. Best management? a. Ceftriaxone b. Ceftriaxone plus vancomycin c. Vancomycin plus gentamicin d. Cefuroxime plus vancomycin e. Piperacillin-tazobactam Pathogens in asplenic children Pathogen Comment Streptococcus pneumoniae 50% to 90% of overwhelming post- splenectomy sepsis Haemophilus influenzae type b Now rare due to Hib immunization Neisseria meningitidis Uncommon Capnocytophaga canimorsus Dog saliva exposure Salmonella spp. Reptiles, food & water Preventive interventions for children post-splenectomy Immunizations Prevnar 13 & 23-valent polysaccharide vaccine Quadrivalent meningococcal vaccine & 4CMenB H. Influenzae type b Influenza vaccine, annually S. typhi vaccine pre-travel Household contacts - routine vaccines & annual influenza vaccine Antibiotic 0 – 5 years: amoxicillin 10 mg/k/dose bid prophylaxis > 5 years: Penicillin V 300 mg BID or amoxicillin 250 mg BID Education Caregiver need to be aware that child needs urgent assessment for fever illnesses https://www.cps.ca/en/documents/position/preventing-treating-infections-in-children-with-asplenia Antibiotic prophylaxis Minimum of two years post-splenectomy and for all children 2 partners within past year, serial monogamy ◦ No contraception or only non-barrier contraception ◦ Injection drug use or substance abuse (including alcohol) ◦ Previous STI ◦ Unsafe sexual practices (e.g., exchange of blood, sharing sex toys) ◦ Sex worker, survival sex, street involved, homelessness ◦ Anonymous sex ◦ Sexual assault or abuse https://www.cps.ca/en/documents/position/sexually-transmitted-infections Major pathogens and testing Pathogen Recommended testing Chlamydia trachomatis Nucleic acid amplification test (NAAT) First catch urine or urethra/vaginal/ cervical swab Neisseria gonorrhoeae Nucleic acid amplification test (NAAT) First catch urine or urethra/vaginal/ cervical swab Rectal/pharyngeal swab as appropriate Treponema pallidum Serology HIV Serology Hepatitis B/C Serology https://www.cps.ca/en/documents/position/sexually-transmitted-infections Treatment of uncomplicated gonococcal infection in children Children ³9 years Children < 9 years Anogenital infection (urethra, endocervix, vaginal, rectal) Ceftriaxone 250 mg IM SD plus Ceftriaxone 50 mg/kg IM (max 250 mg) SD plus Azithromycin 1 g SD Azithromycin 20 mg/kg (max 1 g) SD Cefixime 800 mg PO SD plus Cefixime 8 mg/kg PO BID x 2 doses plus Azithromycin 1 g SD Azithromycin 1 g SD Pharynx Ceftriaxone 250 mg SD plus Ceftriaxone 50 mg/kg IM (max 250 mg) SD plus Azithromycin 1 g SD Azithromycin 20 mg/kg (max 1 g) SD https://www.cps.ca/en/documents/position/sexually-transmitted-infections Selected infectious causes of genital lesions Pathogen Clinical aspects Diagnostic tests HSV Painful vesicular lesions, ulcers PCR on lesion samples Haemophilus ducreyi Painful superficial ulcerating lesions; regional PCR on lesion samples (chanchroid) lymphadenopathy; rare Syphilis Painless papule or ulcerating lesion (chancre); Serology; PCR or dark field regional lymphadenopathy microscopy on lesion samples Chlamydia trachomatis Painless lump or ulcerating lesion; localized NAAT on vaginal or cervical (LGV) lymphadenopathy, fever, fatigue, myalgia swabs or first-void urine * Klebsiella granulomatis Painless, slowly enlarging ulcerative lesion; no Dark-staining Donovan bodies (Donovanosis ǂ) associated lymphadenopathy; rare on tissue samples * In males, first void urine; ǂ Granuloma inguinale Question Well newborn infant of mother with untreated gonorrhea. Next step in management? a. CBC; cultures of conjunctiva, blood, CSF; IV ceftriaxone b. CBC; cultures of conjunctiva, blood; IV ceftriaxone c. Culture of conjunctiva; IM ceftriaxone d. Culture of conjunctiva; treat according to results Neisseria gonorrhoeae – management of exposed infant Well appearing ◦ Conjunctival culture ◦ IM ceftriaxone 50 mg/kg (maximum 125 mg) Unwell ◦ Conjunctival, blood and CSF cultures ◦ Consult ID with established disease (IV ceftriaxone) http://www.cps.ca/en/documents/position/ophthalmia-neonatorum Neisseria gonorrhoeae – clinical aspects Conjunctivitis ◦ Prominent bilateral purulent discharge ◦ Onset usually days 2 – 5 after birth (as late as 3 weeks) ◦ Corneal scarring and blindness if not treated promptly Other manifestations ◦ Scalp abscess ◦ Disseminated disease (< 1% of perinatally exposed newborns) ◦ Septic arthritis (1 – 4 weeks of age) ◦ Bacteremia ◦ Meningitis (uncommon) Sem Pediatr Infect Dis 2005;16:258-270 Question Four-week-old baby has a staccato cough, tachypnea, conjunctivitis. On exam, has diffuse crackles. Xray showed diffuse fine bilateral infiltrate. Most likely diagnosis? a. Chlamydia trachomatis b. Bordetella pertussis c. Ureaplasma urealyticum d. RSV Chlamydia trachomatis Risk of disease if mother untreated ◦ 30% to 50% risk of conjunctivitis ◦ 10% to 20% risk of pneumonia Management of exposed infant ◦ Antibiotic prophylaxis not recommended (due to risk of pyloric stenosis) ◦ Close clinical follow-up ◦ PCR testing recommended if develop symptoms ◦ Treat if PCR testing is positive https://www.cps.ca/en/documents/position/ophthalmia-neonatorum Question 5-year-old child, recently immigrated from east Africa. Fever 39.1oC, HR 130, RR 30. Withdraws to pain, otherwise not rousable. Scleral icterus, hepatosplenomegaly. What investigation? a. Hemoglobin electrophoresis b. Blood smear c. MRI brain d. Blood culture Fever in the returned traveler Ask yourself 4 questions ◦ Is travel related? ◦ Is it infectious? ◦ Is it potentially fatal? ◦ Does it pose a public health risk? Acute medical emergencies ◦ Malaria ◦ Typhoid fever ◦ Meningococcemia ◦ Viral hemorrhagic fevers Prolonged fever of delayed onset – consider TB, brucellosis, leishmaniasis, typhoid fever etc. Travel history Travel details: Destinations, dates, timing of symptom onset Setting: Rural vs. urban, living conditions, altitude, season (rainy, dry) Activities: VFR or professional, community involvement, environments Potential exposures: Food (unpasteurized dairy, meat, seafood); water (drinking, swimming, washing); sick contacts; insect bites (especially mosquitos, ticks); animal bites or other animal exposures; sexual encounters Pre-travel preparation: Vaccinations (routine, recommended, required), malaria prophylaxis (compliance), personal protective equipment (clothing, insect nets, repellant) Medical care: Health care contacts, medications received while travelling and since return https://www.cps.ca/en/documents/position/fever-in-the-returning-child-traveller Tuberculosis Who should be screened Children with suspected active TB disease Contacts of known case of active TB Children travelling or residing for more than 3 months in a region with high TB prevalence Children < 15 years of age new to Canada from countries with high TB incidence within the last 2 years Children with known risk factors for progression to disease (e.g., immune compromised) https://kidsnewtocanada.ca/conditions/tuberculosis How should you screen/investigate? Screening of asymptomatic, at risk children ◦ Screening for TB infection ◦ Tuberculin skin test ◦ Interferon g release assays ◦ Chest x-ray to assess for pulmonary disease At risk & compatible symptoms or CXR abnormalities ◦ Microbiologic sampling ◦ Three sputum, induced sputum or gastric aspirate samples (gastric aspirates in early AM before arising) ◦ Bronchoalveolar lavage (no more sensitive than sputum) Interpreting tuberculin skin test results Positive skin test Negative skin test Mycobacterium tuberculosis Incorrect technique infection Active M. tuberculosis disease Non-tuberculous mycobacteria Immunodeficiency states infection Corticosteroids BCG in past Young age Malnutrition Incorrect technique (measurement) Viral infections (measles, varicella, influenza) Live attenuated vaccines (measles) Interferon g release assays (QuantiFERON-TB Gold in-Tube & T-spot.TB) T-cell release of IFN- in response to M. tuberculosis (ESAT-6, CFP-1) Advantages ◦ More specific for M. tuberculosis than TST ◦ Doesn’t cross react with BCG and most non-tuberculous mycobacteria (exceptions – M. marinum, M. kansasii, (M. szulgai, M. flavescens) ◦ Does not require follow-up visit in 48-72 hours ◦ Most useful for diagnosis of LTBI in BCG recipients Important limitations ◦ Cannot distinguish LTBI from active TB ◦ Like TST, can be negative in active TB disease, immunocompromised hosts https://www.cpsp.cps.ca/uploads/publications/RA-tuberculosis.pdf https://www.linksmedicus.com/news/canadian-tuberculosis-standards-8th-edition/ Question Two-year-old boy exposed to a suspected case of pulmonary TB in the home. Clinically well, TST negative, CXR normal. Which is most appropriate? a. Symptom reassessment and TST in 2 months time b. Initiate 6-month course of isoniazid, rifampin, pyrazinamide and ethambutol c. Two-month course of isoniazid and vitamin B6, followed by repeat TST d. Initiate 9-month course of isoniazid and vitamin B6 now Management of the well exposed child with normal CXR < 5 years of age ◦ Baseline TST negative ◦ Initiate window prophylaxis ◦ Repeat TST at 8 – 10 weeks post-contact, if negative stop prophylaxis, if positive complete full prophylaxis course ◦ Baseline TST positive ◦ Prescribe full course of prophylaxis ≥ 5 years of age ◦ Prescribe prophylaxis only if baseline or 8-10 week post-contact TST is positive https://cps.ca/documents/position/approaches-to-detecting-tuberculosis-in-children-and-youth Age at infection Disease manifestation Risk of disease < 12 months No disease 50% Pulmonary disease 30-40% Meningitis or miliary disease 10-20% 12-23 months No disease 70-80% Pulmonary disease 10-20% Meningitis or miliary disease 2-5% 2-4 years No disease 95% Pulmonary disease 5% Meningitis or miliary disease 0.5% 5-10 years No disease 98% Pulmonary disease 2% Meningitis or miliary disease 1000 copies/mL Infant feeding ◦ Exclusive formula feeding is the preferred recommendation in Canada ◦ Breast feeding is acceptable for mothers with optimal adherence and consistent virologic suppression (need pediatric HIV expert input) https://jammi.utpjournals.press/doi/full/10.3138/jammi-2022-11-03, Can J Infect Dis Med Microbiol 2014;25(2):75-77 https://cps.ca/en/documents/position/reducing-perinatal-infection-risk-in-newborns-of-mothers-who-received-inadequate-prenatal-care Management issues in HIV exposed infants Finalizing HIV status ◦ Exclusion of HIV requires 2 separate negative PCR tests taken at 1-2 and 4-6 months of age ◦ HIV infection confirmed by positive PCR x2 prior to 18 months or reactive serology after 18-24 months Anemia, neutropenia most common adverse effects of zidovudine Can J Infect Dis Med Microbiol 2014;25(2):75-77 General management issues for HIV- infected children Well controlled children are “almost” immunologically normal ◦ Increased risk of pneumococcal disease ◦ Vaccine responses not as good as healthy children ◦ Management of acute illnesses as for uninfected children Assessment of HIV infected child in ER ◦ Clinical status ◦ Immunologic status (CD4 count & CD4 percent) ◦ Virologic status (viral load) ◦ Antiretroviral therapy and adherence Immunizations in HIV-infected children Should receive all routine childhood vaccines Live virus vaccines ◦ MMR should be given in absence of severe immune compromise (immunologic category C) ◦ VZV vaccine should be considered in asymptomatic children with CD4 percentage > 25% ◦ BCG & oral polio vaccine contraindicated in developed countries Other vaccine ◦ Annual influenza vaccine ◦ Polysaccharide pneumococcal vaccine (after Prevnar 13) ◦ Conjugate meningococcal vaccines (Men-C-ACYW, 4CMen B) Exposures, infection control & day-care issues Question A 7-year-old boy stepped on a discarded needed while walking barefoot on the beach. He was bleeding. He was previously vaccinated against hepatitis B. Initial management? a. Given hepatitis B vaccine and immune globulin b. Give hepatitis B immune globulin c. Send testing for anti-hepatitis B surface antigen d. Reassure as previously vaccinated  HBV vaccination status Fully vaccinated Not fully vaccinated HBsAb (STAT) ǂ HBsAb & HBsAg (STAT) § HBsAb (+) If HBsAb (-), do HBsAg Both (-) HBsAb (+) HBsAg (+) No HBIG HBsAg (-) HBsAg (+) HBIG Complete Refer or & vaccine vaccine HBIG vaccine series & Refer vaccine § If results not available within 48 hours, give HBIG immediately, ǂ If results not available within 48 hours, give vaccine dose vaccine as soon as possible within 7 days of incident https://www.cps.ca/en/documents/position/needle-stick-injuries-in-the-community HIV post exposure prophylaxis Recommended if all of the following present ◦ Source considered likely to have HIV ◦ Needle/syringe with visible blood ◦ Blood may have been injected HIV PEP considerations ◦ Within 72 hours of exposure ◦ Regimens ◦ Tenofovir + emtricitabine + raltegravir or dolutegravir if ≥12 years and ≥35 kg ◦ Zidovudine + lamivudine + lopinavir/r for young children (this option almost guarantees failure….) https://www.cps.ca/en/documents/position/needle-stick-injuries-in-the-community Question Six-month-old infant of HCV seropositive mother. Infant serology non-reactive? a. Measure HCV RNA by PCR b. Repeat HCV serology in 6 months c. Liver biopsy d. No further testing needed HCV – risk factors for HCV infection Being born to a mother with HCV infection Injection, intranasal, or inhalational drug use with shared equipment Sexual assault victims Exposure to non-sterile medical, dental or personal service equipment (unsafe tattooing) Being born or having lived in high prevalence regions of the world https://cps.ca/en/documents/position/the-management-of-hepatitis-c-virus HCV – vertical transmission & infant management issues Transmission risk ◦ Average risk ~6% ◦ Risk factors include HIV co-infection, higher HCV viral load, elevated ALT, cirrhosis Mode of delivery ◦ No evidence to support routine elective Cesarean section ◦ Should avoid invasive procedures (scalp electrodes etc.) Breastfeeding ◦ No evidence of transmission via breast-milk ◦ Cannot completely exclude possibility of transmission Testing of exposed infant ◦ HCV serology at 12 to 18 months ◦ RNA after 2 months selectively (follow-up concerns; parental anxiety) https://cps.ca/en/documents/position/the-management-of-hepatitis-c-virus Interpreting HCV test results of an infant born to HCV seropositive mother Age HCV antibody HCV RNA Interpretation < 2 mo Reactive Not detected Too early to interpret RNA PCR result as child may not yet be viremic if infected perinatally ≥ 2 mo Reactive Detected HCV infection is present; between 20% and 30% of infants will clear the infection by 2 to 3 years of age 2 to 17 mo Reactive Not detected As sensitivity of HCV RNA PCR may be 5 x104 CFU/mL) ◦ Clean catch (> 105 CFU/mL) ◦ (Suprapubic aspiration) (any growth) Bag specimens are notoriously unreliable ◦ Good negative predictive value ◦ High false positive rate (~65%) Presumptive diagnosis (urinalysis, microscopy) ◦ Microscopy (presence of bacteria, WBC) ◦ Urinalysis (leukocyte esterase, nitrite) https://www.cps.ca/en/documents/position/urinary-tract-infections-in-children UTI – imaging Renal and bladder ultrasound recommended after first febrile UTI in children < 2 years of age Voiding cystourethrography (VCUG) is not usually indicated after first febrile UTI Indications for VCUG ◦ Recurrent febrile UTI ◦ Ultrasound evidence of “selected” renal abnormalities or obstruction, or high-grade vesicoureteral reflux https://www.cps.ca/en/documents/position/urinary-tract-infections-in-children UTI – antibiotic treatment Majority can be managed with oral antibiotics ◦ Cephalosporin, amoxicillin-clavulanate, TMP SMX Indication for parenteral therapy ◦ Toxic appearance ◦ Unable to retain oral intake (including medications) ◦ Immunocompromised host (selectively) ◦ Ampicillin + gentamicin (other options as well) Antibiotic therapy should be given for 7-10 days Antibiotic prophylaxis not routinely recommended after first febrile UTI https://www.cps.ca/en/documents/position/urinary-tract-infections-in-children Question 5-month-old previously healthy girl, fever and irritability for 3 days. Catheter-obtained urine shows bacteria, WBC > 50/HPF, nitrite +ve. Given cefixime. Culture – E. coli > 108/L. Resistant to amp, Septra, cephalosporins; sensitive to cipro, gent. NEXT step in management? a. Admit for IV gentamicin b. Start on PO ciprofloxacin c. Start on PO nitrofurantoin d. Repeat urinalysis and culture Question 5-month-old previously healthy girl, fever and irritability for 3 days. Catheter-obtained urine shows bacteria, WBC > 50/HPF, nitrite +ve. Given cefixime. Culture – E. coli > 108/L. Resistant to amp, Septra, cephalosporins; sensitive to cipro, gent. NEXT step in management? “If the child is now asymptomatic, one approach would be to repeat the urinalysis and a. urine Admit culture for IVand change therapy only if results are suggestive of a persistent gentamicin UTI, keeping in mind that even a repeat positive urine culture may be b. Start on PO contaminated. ciprofloxacin If the child remains symptomatic, urinalysis and urine culture should bec.repeated Start onandPOthe nitrofurantoin antimicrobial modified pending results.” d. Repeat urinalysis and culture https://www.cps.ca/en/documents/position/urinary-tract-infections-in-children Question Child with grade IV VUR has completed treatment for her second UTI. The organism was resistant to TMP SMX and nitrofurantoin. You are thinking about starting prophylaxis – what do you start? a. Amoxicillin b. Cefixime c. TMP SMX d. Ciprofloxacin e. No prophylaxis Question Child with grade IV VUR has completed treatment for her second UTI. The organism was resistant to TMP SMX and nitrofurantoin. You are thinking about starting prophylaxis – what do you start? a. Amoxicillin b. Cefixime c. TMP SMX d. Ciprofloxacin e. No prophylaxis UTI – antibiotic prophylaxis Prophylaxis not recommended for grade I-III VUR ◦ May be considered for grades IV-V VUR If given prophylaxis should be reassessed after 3-6 months Antibiotic choices ◦ TMP SMX, nitrofurantoin are the recommended first line agents ◦ If child has UTI due to organism resistant to these – consider stopping prophylaxis ◦ Broader spectrum agents not recommended due to risk of infection with highly resistant organisms http://www.cps.ca/en/documents/position/prophylactic-antibiotics-recurrent-urinary-tract-infections Question A term newborn infants mother’s hepatitis B status is unknown. Which of the following is the best course of action? a. Give HBIG and first dose of vaccine immediately b. Send maternal HBsAg test; if (+) give HBV vaccine and HBIG, if (-) no intervention c. Send maternal HBsAg STAT: if result available within 12 hours of birth can await result, if (+) give HBV vaccine and HBIG, if (-) no intervention d. If maternal history suggests she is not at risk for hepatitis B infection reassurance is all that is needed Question A term newborn infants mother’s hepatitis B status is unknown. Which of the following is the best course of action? a. Give HBIG and first dose of vaccine immediately b. Send maternal HBsAg test; if (+) give HBV vaccine and HBIG, if (-) no intervention c. Send maternal HBsAg STAT: if result available within 12 hours of birth can await result, if (+) give HBV vaccine and HBIG, if (-) no intervention d. If maternal history suggests she is not at risk for hepatitis B infection reassurance is all that is needed  HBsAg positive mother HBIG and HB vaccine within 12 hours of birth HB vaccine at 1 and 6 months ‡ HBsAg & anti-HBs at 9-12 months (at least 4 weeks after last vaccine dose) HBsAg- HBsAb+ (protective) HBsAg- HBsAb- (< 10mIU/mL) HBsAg+ Nil else Revaccinate Refer ‡ Infants < 2.0 kg at birth: 4 dose schedule recommended (0, 1, 2 & 6 months http://www.phac-aspc.gc.ca/publicat/cig-gci/p04-hepb-eng.php  Maternal HBsAg status unknown Stat HBsAg on mother Results available within 12 hours Yes No Mother HBsAg -ve Mother HBsAg +ve Administer HBV vaccine Consider HBIG § No intervention HBV vaccine & HBIG § HBIG should also be given if the mother is a chronic carrier; can be delayed for up to 7 days in term infants http://www.phac-aspc.gc.ca/publicat/cig-gci/p04-hepb-eng.php Question Baby born to mother who is hepatitis B surface antigen reactive. Given HBIG at birth and vaccine at birth, 1 month and 6 months. At 9 months he is well – most likely serologic pattern? a. HBeAg+, HBcAg+, HBsAg+, HBaAb+, HBsAb+ b. HBeAg-, HBcAg-, HBsAg+, HBcAb+, HBsAb+ c. HBeAg-, HBcAg-, HBsAg-, HBcAb+, HBsAb+ d. HBeAg-, HBcAg-, HBsAg-, HBcAb+, HBsAb- Question Baby born to mother who is hepatitis B surface antigen reactive. Given HBIG at birth and vaccine at birth, 1 month and 6 months. At 9 months he is well – most likely serologic pattern? a. HBeAg+, HBcAg+, HBsAg+, HBaAb+, HBsAb+ b. HBeAg-, HBcAg-, HBsAg+, HBcAb+, HBsAb+ c. HBeAg-, HBcAg-, HBsAg-, HBcAb+, HBsAb+ d. HBeAg-, HBcAg-, HBsAg-, HBcAb+, HBsAb- Question Two-year-old fully immunized girl falls in playground, deep laceration to arm. Wound cleaned and sutured. Which is correct? a. Tetanus toxoid b. Tetanus toxoid and tetanus immune globulin c. Antibiotic prophylaxis d. Nothing Question Two-year-old fully immunized girl falls in playground, deep laceration to arm. Wound cleaned and sutured. Which is correct? a. Tetanus toxoid b. Tetanus toxoid and tetanus immune globulin c. Antibiotic prophylaxis d. Nothing Tetanus exposure prophylaxis Tetanus toxoid Clean minor wounds All other wounds § history DTaP, Tdap or Td TIG DTaP, Tdap or Td TIG < 3 or unknown Yes No Yes Yes ≥3 No if < 10 years since No No if < 5 years since last No last tetanus dose tetanus dose Yes if ≥ 10 years since No Yes if ≥ 5 years since last No last tetanus dose tetanus dose § Such as wounds contaminated with dirt, feces, soil or saliva (animal bites); puncture wounds; avulsions; wounds resulting from missiles, crushing, burn or frostbite DTaP if < 7 years, Tdap preferred over Td for under-immunized children ≥ 7 years who have not previously received Tdap 2021 Red Book 750-755, https://www.canada.ca/en/public-health/services/canadian-immunization-guide.html Question A young boy is walking down the street. Suddenly a stray dog, unprovoked, bites him. What do you do? a. Give rabies vaccine b. Given rabies vaccine and immune globulin c. Quarantine the dog; if shows signs of rabies – give prophylaxis d. Sacrifice the dog; if pathologic evidence of rabies – give prophylaxis Question A young boy is walking down the street. Suddenly a stray dog, unprovoked, bites him. What do you do? a. Give rabies vaccine b. Given rabies vaccine and immune globulin c. Quarantine the dog; if shows signs of rabies – give prophylaxis d. Sacrifice the dog; if pathologic evidence of rabies – give prophylaxis Question Two-year-old girl bitten by dog in playground. Open wound on right thumb. Fully immunized. What are five things you would do in her management? ◦ Explore, clean (soap & water), irrigate (saline) & debride ◦ X-ray if concerned about fracture ◦ Wound closure – controversial; hand wounds often left open ◦ Antibiotic prophylaxis (amoxicillin-clavulanate for 5 days) ◦ Rabies immune globulin into wound ◦ Initiate rabies vaccination series (5 doses) ◦ Notify public health ◦ Advise elevation of the hand first 48 to 72 hours Question Family vacationing in cottage country, staying in cabin. A dead bat is found in the cabin one morning. No history of bite or direct contact of any kind by the bat. What do you do? a. Give rabies prophylaxis b. Give prophylaxis if bat shown to be rabid c. No need for prophylaxis as no history of bite or scratch d. No need for prophylaxis as bats do not carry rabies Question Family vacationing in cottage country, staying in cabin. A dead bat is found in the cabin one morning. No history of bite or direct contact of any kind by the bat. What do you do? a. Give rabies prophylaxis b. Give prophylaxis if bat shown to be rabid c. No need for prophylaxis as no history of bite or scratch d. No need for prophylaxis as bats do not carry rabies Bats and post-exposure rabies prophylaxis Clearly indicated ◦ There has been direct contact with a bat AND ◦ A bite, scratch, or saliva exposure into a wound or mucous membrane cannot be ruled out Clearly not indicated ◦ A bite, scratch, or saliva exposure into a wound or mucous membrane can be ruled out Difficult scenarios… ◦ Direct contact of bat with clothing of young child where possibility of bite or scratch cannot be excluded ◦ Bat found in room where individual who is unable to provide reliable history was sleeping Canadian immunization guide (http://www.phac-aspc.gc.ca/publicat/cig-gci/p04-rabi-rage-eng.php), CCDR November 2009;35:ACS-7 Animal species Condition of animal at exposure Management of exposed Dog, cat, ferret Healthy and available for 10 days Local wound care observation Initiate RIG and vaccine if animal shows signs of rabies Rabid or suspected rabid; unknown or Local wound care escaped Initiate RIG and vaccine Skunk, fox, coyote, Regard as rapid Local wound care raccoon, other Initiate RIG and vaccine carnivores Bat Direct contact & bite, scratch or saliva Local wound care exposure to wound or mucous Initiate RIG and vaccine membrane cannot be ruled out No obvious contact No prophylaxis indicated Livestock, rodents, Consider individually; consult public health lagomorphs Bites of squirrels, chipmunks, rats, mice, hamsters, gerbils, other rodents, rabbits and hares may warrant post-exposure prophylaxis if behaviour is highly unusual Canadian immunization guide (http://www.phac-aspc.gc.ca/publicat/cig-gci/p04-rabi-rage-eng.php), CCDR November 2009;35:ACS-7 Management of possible rabies exposure Notify public health Handling of animal ◦ Domestic animal can be observed 10 days for signs of rabies; if develop – animal euthanatized and tested ◦ If wild animal – euthanize and test immediately Rabies immune globulin ◦ 20 IU/kg; as much as possible should be infiltrated into wound ◦ Remainder can be given IM Rabies vaccine (Human diploid cell vaccine) ◦ Four (or five) doses of vaccine days 1, 3, 7, 14, (28) ◦ Intramuscular injection Canadian immunization guide (http://www.phac-aspc.gc.ca/publicat/cig-gci/p04-rabi-rage-eng.php), CCDR November 2009;35:ACS-7 Close contact exposure prophylaxis (selected conditions) Pathogen Recommended prophylaxis Reference H. influenzae type b Rifampin x4 days Red Book p. 348-50 N. meningitidis Rifampin x2 days Red Book (ceftriaxone, ciprofloxacin, azithromycin) p. 522-3 S. pyogenes Cephalexin CPS (invasive disease) (macrolide, clindamycin) statement B. pertussis Azithromycin x5 days, erythromycin x14 days, Red Book (clarithromycin) p. 582-4 Measles § IG within 6 days of exposure Red Book IVIG is alternative option p. 506-12 Rubella § Generally none; IG may be considered in pregnancy if Red Book termination not an option p. 651-2 § MMR vaccine within 72 hours may be of benefit; contraindicated in pregnancy Question A young child is bitten by a cat. Started on amoxicillin- clavulanate. Returns to ER with increasing redness and swelling. What should you do? a. IV vancomycin and ceftriaxone b. IV piperacillin-tazobactam c. IV cloxacillin (or cefazolin) d. Refer for surgical debridement Question Dad and son have recurrent pinworms despite being treated with oral mebendazole. What is the best treatment option? a. Treat all family members with one dose of albendazole b. Treat all family members with mebendazole now and again at 14 and 28 days c. Treat son and dad with one dose of pyrantel pamoate d. Treat son and dad with pyrantel pamoate now and at 14 and 28 days Question Dad and son have recurrent pinworms despite being treated with oral mebendazole. What is the best treatment option? a. Treat all family members with one dose of albendazole b. Treat all family members with mebendazole now and again at 14 and 28 days c. Treat son and dad with one dose of pyrantel pamoate d. Treat son and dad with pyrantel pamoate now and at 14 and 28 days Treating all family members is recommended. However, usually 2 doses each at baseline and in 2 weeks Enterobius vermicularis tips For recurrent bouts treat entire family ◦ Mebendazole, albendazole or pyrantel pamoate ◦ Two dose regimen, baseline and 2 weeks later Prevention measures to consider concurrent with treatment ◦ Frequent hand washing ◦ Clipping of fingernails ◦ Bathing in the morning ◦ Wash linen frequently ◦ Use onesie for young children to prevent perianal touching https://caringforkids.cps.ca/handouts/health-conditions-and-treatments/pinworms Question 2-year-old previously healthy child with history of malaise and cough, new onset diffuse erythematous rash, with bullae involving mucous membranes. Started on amoxicillin 7 days prior for respiratory illness. Nikolsky sign positive. Diagnosis? a. Staphylococcal scalded skin syndrome b. Toxic epidermal necrolysis c. Bullous pemphigoid d. Scarlet fever Question 2-year-old previously healthy child with history of malaise and cough, new onset diffuse erythematous rash, with bullae involving mucous membranes. Started on amoxicillin 7 days prior for respiratory illness. Nikolsky sign positive. Diagnosis? a. Staphylococcal scalded skin syndrome b. Toxic epidermal necrolysis c. Bullous pemphigoid d. Scarlet fever SSSS - mucosal surfaces not involved, Nikolsky sign positive in both SSSS and TEN Pediatr Emer Care 2016;32: 472–478 Question 7-year-old previously healthy boy with 2-day history of mouth sores and rash preceded 1 week earlier by fever and cough. Given amoxicillin and acetaminophen. Most likely diagnosis? a. Herpes simplex virus b. Amoxicillin related c. Acetaminophen related d. Mycoplasma pneumoniae Question 7-year-old previously healthy boy with 2-day history of mouth sores and rash preceded 1 week earlier by fever and cough. Given amoxicillin and acetaminophen. Most likely diagnosis? a. Herpes simplex virus b. Amoxicillin related c. Acetaminophen related d. Mycoplasma pneumoniae Question Child had URTI symptoms treated with amoxicillin and acetaminophen. Subsequent development of mucocutaneous rash. Most likely etiology? a. Herpes simplex virus b. Amoxicillin related c. Acetaminophen related d. Mycoplasma pneumoniae Question Child had URTI symptoms treated with amoxicillin and acetaminophen. Subsequent development of mucocutaneous rash. Most likely etiology? a. Herpes simplex virus b. Amoxicillin related c. Acetaminophen related d. Mycoplasma pneumoniae Question 16-year-old unwell for 5 days. Oral ulcers and target-like rash. Most likely etiology? a. Varicella zoster virus b. Creatine c. NSAIDs d. Mycoplasma pneumoniae Question 16-year-old unwell for 5 days. Oral ulcers and target-like rash. Most likely etiology? a. Varicella zoster virus b. Creatine c. NSAIDs d. Mycoplasma pneumoniae In my view there is insufficient information provided to answer this question Medications associated with SJS/TEN Highest risk ◦ Allopurinol ◦ Sulfonamides, sulfasalazine ◦ Anticonvulsants (carbamazepine, lamotrigine, phenobarbital, phenytoin etc.) ◦ Antiretroviral medications (nevirapine) ◦ NSAIDs (oxicam) Lower risk ◦ Antibiotics (aminopenicillins, cephalosporins, quinolones, tetracyclines, macrolides) ◦ Antidepressants (sertraline) ◦ NSAIDs (diclofenac) Case reports ◦ Acetaminophen, corticosteroids, other NSAIDs, acetazolaminde etc. Arch Dis Child 2013;98:998–1003 Question 12-year-old on infliximab for ulcerative colitis presents with fever, malaise, cough, pleuritic chest pain. CXR shows left-sided infiltrate and ipsilateral hilar adenopathy. Family has chicken coop in back yard. Which test will reveal the diagnosis a. Blood culture b. Mycoplasma pneumoniae PCR c. Histoplasma capsulatum serology d. Anti-Aspergillus serum IgE Question 12-year-old on infliximab for ulcerative colitis presents with fever, malaise, cough, pleuritic chest pain. CXR shows left-sided infiltrate and ipsilateral hilar adenopathy. Family has chicken coop in back yard. Which test will reveal the diagnosis a. Blood culture b. Mycoplasma pneumoniae PCR c. Histoplasma capsulatum serology d. Anti-Aspergillus serum IgE Question 3-year-old with fever, anorexia, fatigue and abdominal pain. Was on uncle’s farm and drank unpasteurized goat milk. Splenomegaly on physical examination. Blood culture growing gram negative coccobacilli. a. Brucellosis b. Tularemia c. Bartonellosis d. Listeriosis Question 3-year-old with fever, anorexia, fatigue and abdominal pain. Was on uncle’s farm and drank unpasteurized goat milk. Splenomegaly on physical examination. Blood culture growing gram negative coccobacilli. a. Brucellosis b. Tularemia c. Bartonellosis d. Listeriosis Question 14-year-old girl who recently got ear piercing. Ear lobe is erythematous and swollen. Who do you treat with? a. IV cefazolin b. IV clindamycin c. IV piperacillin-tazobactam d. PO cephalexin Question 14-year-old girl who recently got ear piercing. Ear lobe is erythematous and swollen. Who do you treat with? a. IV cefazolin b. IV clindamycin c. IV piperacillin-tazobactam d. PO cephalexin Most common pathogens are Pseudomonas aeruginosa followed by Staphylococcus aureus Laryngoscope, 125:1827–1834, 2015 Question Child with unilateral facial weakness, and vesicles in ear canal. Best management a. Acyclovir b. Steroids c. Acyclovir + steroids d. No effective treatment Question Child with unilateral facial weakness, and vesicles in ear canal. Best management a. Acyclovir b. Steroids c. Acyclovir + steroids d. No effective treatment Facial nerve palsy in children Idiopathic (Bell’s palsy) ◦ HSV suggested as possible important cause Infection related ◦ Otitis media ◦ Lyme disease ◦ Varicella zoster virus (Ramsay Hunt syndrome) Tumors ◦ Cholesteatoma ◦ Facial nerve schwannoma ◦ Vestibular schwannoma, meningioma etc Clin Pediatr 2010;49(5):411-7 Treatment Bells palsy ◦ Corticosteroids shown to improve outcome ◦ No benefit to antiviral therapy Ramsay Hunt syndrome ◦ ~5% of facial nerve palsy cases in one review ◦ Worse prognosis ◦ Antiviral + corticosteroids (no conclusive data) Clin Pediatr 2010;49(5):411-7, Arch Dis Child Educ Ed 2012;97:82-5, Cochrane rev (2010) Ann Nwurol 2000;48:254-6, Ped Neurol 2015;52:554-5, Am Fam Physician 2013;88:771-2 Question Previously healthy 6-year-old male with right sided parotitis and upper respiratory symptoms suggestive of viral illnesss. Two prior similar episodes. Salivary swab growing viridans group streptococci. Cause? a. Bacterial parotitis b. Viral parotitis c. Parotid salivary duct stone d. Juvenile recurrent parotitis Question Previously healthy 6-year-old male with right sided parotitis and upper respiratory symptoms suggestive of viral illnesss. Two prior similar episodes. Salivary swab growing viridans group streptococci. Cause? a. Bacterial parotitis b. Viral parotitis c. Parotid salivary duct stone d. Juvenile recurrent parotitis Parotitis differential diagnosis Suppurative parotitis ◦ S. aureus most common; often polymicrobial ◦ Uncommon in children ◦ Sudden onset pain, erythema, tenderness; fever Non-suppurative parotitis ◦ Juvenile recurrent parotitis (non-obstructive, most common in prepubertal males, conservative management) ◦ Chronic recurrent parotitis (often obstructive) ◦ Viral infections ◦ Mumps and other viral infection (EBV, enteroviruses, HSV, adenovirus, etc.) ◦ HIV (chronic)