Presented By:
Dr.Fatimah Al Dubisi
Pediatric Infectious Diseases
Head Infection control
Follicular
TonsillitisTonsillitis
Pharyngitis
Pharyngitis, Tonsillitis:
Etiology

Viral: Most Common, important agents : adenoviruses,
coronaviruses, enteroviruses, rhinoviruses, respiratory syncytial virus
[RSV], Epstein-Barr virus [EBV], herpes simplex virus [HSV],
metapneumovirus)

Bacterial : A β hemolytic Streptococcus

Transmission: close contact, and occur most commonly in fall,
winter, and spring.
Clinical Manifestations:

viral
Onset: more gradual, symptoms often include rhinorrhea, cough, and
diarrhea
-
A viral etiology may be also suggested by the presence of
conjunctivitis, coryza, hoarseness, and cough.

The The pharynx is red, and the tonsils will be enlarged if involved.
Classically not covered with exudate.
Clinical Manifestations

Bacterial

Streptococcal pharyngitis : uncommon before 2-3 years.
Peak incidence : early school years, and declines in late adolescence
and adulthood
Onset often rapid, with prominent sore throat (odynophagia) and fever
and chills in the absence of cough. referred otalgia, headache

The pharynx is red, and the tonsils are enlarged and classically
covered with a yellow, blood-tinged exudate, enlarged tender,
cervical nodes
- Can be followed by scarlet fever
Epstein-Barr virus [EBV]
Infectious mononucleosis syndrome
Primary HSV infections
Gingivostomatitis
Primary HSV infections
Primary HSV infections
Enterovirus (Coxsackie virus)
Herpangina
Some specific viral Pharyngitis Patterns:

Adenovirus (pharyngoconjunctival fever), concurrent conjunctivitis and fever

Coxsackie virus(herpangina) small (1-2 mm) grayish vesicles and punched-out ulcers in
the posterior pharynx

EBV (infectious mononucleosis syndrome) prominent tonsillar enlargement with exudate,
cervical lymphadenitis, hepatosplenomegaly, rash, and generalized fatigue

Primary HSV (gingivostomatitis) in young children: high fever and oral ulcers

F. necrophorum (Lemierre syndrome) serious complication, septic thrombophlebitis of
the internal jugular veins with septic pulmonary emboli.
Diagnosis:

Clinical diagnosis.

Strept pharyngitis:

Culture ( Throat swab)

Rabid test
Treatment:

Viral pharyngitis: supportive management

Bacterial Pharyngitis:
Treatment is mainly to prevent possible development acute
rheumatic fever.
1- Medical,Antibiotics:

1st line: Penicillin ( V, Benzathine penicillin, amoxill)

2nd line: Macrolide ( erythromycin, Azithromycin )

Clindamycin
2- Tonsilectomy
Complication of tonsillitis :

Airway obstruction

Peritonsillar Infection

Retropharyngeal Space Infection

Rhumatic fever

Recurrent or Chronic Pharyngotonsillitis
Otitis Media

Peak incidence and prevalence of OM is during the 1st 2 years of life

Most common reason for prescribing antimicrobial drugs

Most common cause of hearing loss in children.

propensity to become chronic and recur.

It can be: - Suppurative ( acute otitis media, AOM ) or
- Nnonsuppurative (secretory OM, or otitis media with
effusion OME).
Epidemiology:

More below 2 years of age

Incidence is greater in boys

Tends to run in families

More in Low Socioeconomic Status

More with Formula Feeding

Incidence increase with Exposure to Tobacco Smoking

Increased incidence with congenital Anomalies ( cleft palate, craniofacial
anomalies)

Risk depends on Vaccination Status
Etiology:

Pathogens predominate:
Streptococcus pneumoniae, nontypeable Haemophilus influenzae, and
Moraxella catarrhalis

Other less frequent pathogens
Group A streptococcus, Staphylococcus aureus, and gram-negative
organisms
EXAMINATION OF THE EARDRUM:

Normal Tympanic membrane
Examination:
Tympanic Membrane Findings:

Findings can include:

Erythema, loss of light reflex .

Presence of liquid in the middle-ear cavity

Opacity of the membrane

Absence/impairment of memberane mobility.

Perforations

In sever cases: Retraction pockets and Cholesteatoma formation
Treatment:

Adequate analgesic medications (acetaminophen,
ibuprofen)

Pathogenic bacteria cause a large majority of cases,
antibiotics is need in most of the cases
Bronchiolitis
Acute bronchiolitis

It is a viral disease. RSV is responsible for >50% of cases
Other agents:

Parainfluenza ,influenza, and adenovirus.

Older family members are a common source of infection
Pathophysiology picture
Pathophysiology:

Bronchiolar inflammation, edema, mucus, and cellular debris

This will lead to bronchial narrowing and obstruction

Early distal air trapping and overinflation of the chest.

Trapped distal air will be resorbed and the child will develop
atelectasis

Hypoxemia and hypercapnia can develop.
Risk factors for bronchiolitis:

Social history should include an environmental history, any
smokers at home, number of siblings , daycare exposure,

Prematurity

Age <12 weeks.

Underlying comorbidity : Cardiovascular, pulmonary, or
immunologic diseases
Clinical Manifestations:

Usually preceded by exposure to an older contact with a minor
respiratory syndrome within the previous week

Infant 1st develops a mild upper respiratory tract Infection

Diminished appetite and fever of 38.5-39°C

Gradually, respiratory distress ensues
Clinical Manifestations:
Physical Examination:

Signs of respiratory distress:
Tachypnea, increased respiratory effort, nasal flaring, tracheal tugging,
subcostal and
intercostal retractions, and excessive use of accessory
muscles.

Wheezing

Prolonged Expiratory time

Auscultation :crackles or wheezes, with prolongation of the expiratory phase.
-
Diagnosis:
- Mainly Clinical
- Chest radiography can reveal hyperinflated lungs, Peri-Hailer ticking of the Bronchi and patchy atelectasis
- Specific Viral study
Treatment :
- Mainstay of treatment is supportive: Oxygen, hydration, and
suctioning of nasal and oral secretion
CommunityAcquired
Pneumonia
Pneumonia:
Inflammation of the parenchyma of the lungs
Etiology:

Streptococcus pneumoniae

(pneumococcus) is the most common bacterial pathogen in

children 3 wk to 4 yr of age, whereas Mycoplasma pneumoniae

and Chlamydophila pneumoniae are the most frequent pathogens

in children 5 yr and older.
Clinical manifestations:

Viral usually preceded by symptoms of an upper respiratory tract infection.

Temperatures are generally lower in viral than in bacterial pneumonia.

Tachypnea is the most consistent clinical manifestation.

Increased work of breathing.

Severe infection may be accompanied by cyanosis and respiratory fatigue.

Auscultation of the chest: crackles, possible Bronchial breathing and
wheezing,
Clinical manifestations:

Bacterial pneumonia in adults and older children typically begins suddenly with chill, high
fever, cough, and chest pain.

Physical findings:
- Early : diminished breath sounds, scattered crackles over the affected lung field.
- With the development of consolidation or complications such as effusion, empyema,
dullness on percussion, lag in respiratory excursion, bronchial breathing are often occur.

This classical presentation is rarely observed in infants and young children (Prodrome of URT
symptoms followed by Sudden fever, prominent respiratory distress in addition to
generalized non-specific signs and symptoms )
Diagnosis;
Viral pneumonia;
WBC count can be normal or elevated but is usuall not
higher than 20,000/mm3, with a lymphocyte predominance

Chest X Ray:
hyperinflation with bilateral interstitial infiltrates and
peribronchial cuffing
Viral Pneumonia Xray :
Bacterial Pneumonia:
Eelevated WBC count, 15,000-40,000/mm3, and a
predominance of granulocytes

Chest X Ray:
lobar consolidation, pleural effusion, empyema.
Bacterial Pneumonia
X Ray :
Consolidation :
Consolidation with pleural
effusion :
Patchy infiltrate
Treatment:

Well Patient :
Out patient management; Antipyratic and Abx if required ( Amoxill or
cephalosporin, Macrolide if Atypical Pneumonia is suspected )

Ill Patient:
- Admission
- Supportive mangament ( Oxygen, Hydarion)
- Iv Abx ( Cephalosporin or Macrolide if Atypical Pneumonia is
suspected )
Tuberculosis
Picture of mycobacterium
Etiology:

Causative organism: Mycobacterium Tuberculosis

Aerobes, non–spore-forming, nonmotile, pleomorphic,
weakly gram-positive

curved rods

Slowly growing organism , takes 3-6 wk
Definitions:
Tuberculosis Disease:
There are signs and symptoms or radiographic changes .
Latent tuberculosis infection (LTBI)
A reactive tuberculin skin test (TST) and the absence of clinical and
radiographic manifestations.
Definitions… Cont.
Reactivation tuberculosis
Rare in children, common among adolescents and young adults. There is
infiltrate or cavity in the apex of the upper lobes.
Pathophysiology of TB :

Transmission; Airborne.

Children with tuberculosis rarely infect other children or adults.
Because: no. of Tubercle bacilli in their secretions is few only
and cough is often absent or week that it lacks the force
required to suspend infectious. Also absence of cavitary
lesions ( adult Type TB, Opened TB)

Children and adolescents with adult-type cavitary or
endobronchial pulmonary tuberculosis can transmit the
organism.

The lung is the portal of entry in >98% of cases.

The hilar lymph nodes usually are involved (The primary complex)

(The primary complex)
combination of a parenchymal pulmonary lesion and a corresponding lymph
node site
The parenchymal

portion of the primary complex often heals completely by fibrosis

or calcification after undergoing caseous necrosis and encapsulation
Clinical manifestations of the 1st organism exposure (
primary infection):

Majority of children with tuberculosis infection develop no signs or
symptoms at any time

Occasionally: low-grade fever and mild cough

rarely marked by high fever, cough, malaise, and flulike
symptoms that resolve within 1 wk.
What happens after first exposure to the organism ?
1-Patient will have a Latent infection :
infection under control, Normal CXRay:
2- Patient will have the Diseases
Pulmonary TB
- Silent with only Ghon’s complex( incidental finding chest xray)
- Development of Local pathology: collapse-consolidation orsegmental lesion,Formation of
fistula Local hyperinflation or emphysema
Cont..
Primary Progressive TB;
Bad progressive lung injury with sever manfistation clinically ( more in infant and
immunecompromzed )
2- Extrapulmonay (Lymphohematogenous spread):
Disseminated Tuberculosis metastatic foci in many organs.( CNS,Cutaneous
Disease,Bone and Joint Disease,Gastrointestinal Disease, Genitourinary Disease)
3- Reactivation of old Primary infection:
When body immunity suppressed for any reason.
Diagnosis:
History:
Possible exposure to an adult with or at high risk for infectious pulmonary
tuberculosis is the most crucial risk factor for children.
Tuberculin Skin Testing (Mantoux TST, PPD);
- Delayed-type hypersensitivity (DTH)
- The amount of induration in response to the test measured by a trained
person 48-72 hr after administration.
Treatment;
General principle: Combination of drugs are used to effect a relatively rapid
cure and prevent the emergence of secondary drug resistance during
therapy
The standard therapy of intrathoracic tuberculosis (pulmonary disease and/or
hilar lymphadenopathy)

6 mo regimen of isoniazid and rifampin supplemented in the 1st 2 mo of
treatment by pyrazinamide and ethambutol

Prolonged treatment courses are need in CNS, bone, and joint infection.
Prevention:
Bacille Calmette-Guérin Vaccination (BCG)

Strain of M. bovis

Intradermal injection

Life attenuated ( contra-indicated in immune compromised)