Pediatric Infectious Diseases Robert Danoff DO, MS, FACOFP Frankford Hospitals Top to bottom review…. · From Lice in the hair to blisters on their feet! · Ear, nose, throat · Respiratory infections · GI · Dermal Infections · Common Viral Infections · Their identification · Their Treatment Lice · Parasites that infest the head, body and pubic area · A whole group of people now who are professional “ Nit pickers!” Not kidding Lice: Pediculus Humanus · Spread by close person to person contact · Life cycle is Nit Nymph Adult · Adult is the size of a pinhead, is rusty color and clings to hair Lice · Treatment: Permethrin 1% cream rinse applied to clean dry hair and left on for 10 min. Repeat in 1 wk · OR Ovide applied to dry hair for 8-14 hours then rinse · OR a professional Nit picker in conjunction with the above. They use special fine tooth combs through every strand of hair. It’s costly though $330.00 for 3 sessions!!!!! The Eyes Have It! Conjunctivitis · Etiology – Acute conjunctivitis usually a bacterial or viral infection – Characterized by a rapid onset – Several days duration – Common bacterial causes · · · · · Nontypable H. influenza S. pnuemoniae M. catarrhalis N. gonorrhoeae P. aeruginosa – Incubation 24-72 hours Conjunctivitis – Common viral causes: · · · · Adenoviruses Coxsackieviruses Enteroviruses Herpes simplex – Incubation 1-14 days · Epidemiology – Common in young children, especially if in contact with other children with conjunctivitis. – Predisposing factors for bacterial infection include · · · · Nasolacrimal duct obstruction Sinus disease Ear infection Allergic children who rub their eyes frequently – Allergic · Seasonal, itchy, bilateral chemosis Conjunctivitis · Clinical Manifestations – Symptoms include · · · · · Redness Discharge Matted eyelids Mild photophobia Foreign body sensation – Physical examination findings include · Chemosis · Injection of the conjunctiva · Edema of the eyelids Conjunctivitis · Diagnosis – Cultures are not routinely obtained because bacterial conjunctivitis is usually self-limited or responds quickly to antibiotic treatment. · Treatment for bacteria – Topical quinolone solution – Trimethoprim-polymyxin B solution – Sulfacetamide 10% solution – Erythromycin ointment Conjunctivitis · Treatment for viral – Self limited · Treatment for allergic – Antihistamine, topical anti-inflammatory, cromalyn The Ears Have It ? Acute Otitis Media · Etiology – Arises as a complication preceding viral respiratory infection – Secretions and inflammation cause occlusion – Effusion fertile media for microbial growth – Rapid growth leads to infection Acute Otitis Media · Etiology – Suppurative infection of the middle ear cavity – Common bacterial pathogens achieve access through blocked eustachian tube (infection, pharyngitis, or hypertrophied adenoids) – Air trapping → negative pressure → bacterial reflux – Bacterial reflux + obstructed flow → effusion Acute Otitis Media – Common bacterial pathogens are · · · · S. pnuemoniae Nontypable H. influenza M. catarrhalis Group A streptococus – Sterile effusions occur in approximately 20% of cases Acute Otitis Media · Epidemiology – One third of office visits to primary care. – The peak incidence - second 6 months of life. – By the first birthday, 62% of children experience at least one episode. – Few first episodes after 18 months Acute Otitis Media – – – – – – More common in boys Lower socioeconomic status Seasonal disease (distinct peak in January and February) Corresponds to the rhinovirus, RSV, and influenza seasons Is less common from July to September Major risk factors for acute otitis media are · · · · · · · Young age Bottle feeding Drinking a bottle in bed Parental history Sibling history Second hand smoke Daycare Acute Otitis Media · Clinical Manifestations – Symptoms often nonspecific, may include: · · · · · · Fever Irritability Poor feeding Otalgia Otorrhea Signs of a common cold Acute Otitis Media · Diagnosis – Pneumatic otoscopy – standard for clinical diagnosis – tympanic membrane is characterized by hyperemia – Can be pink, white or yellow with bulging – Poor mobility with negative or positive pressure Acute Otitis Media – The light reflex is lost - middle ear structures are obscured – A hole in the tympanic membrane or purulent drainage confirms perforation. – Bullae maybe present on the lateral aspect Acute Otitis Media · Acute · Chronic – Definition · Recent · Usually abrupt · Signs of acute illness – Fever – Pain – URI · Middle ear inflammation · Middle ear effusion – Definition · Presence of effusion without any other signs and symptoms of acute illness Acute Otitis Media · Treatment Recommendations – Infants younger than 6 months should receive antibiotics – Children 6 months to 2 years should receive antibiotics if the diagnosis is certain · Diagnosis uncertain observation period 48 to 72 hours with analgesics and follow up – Children 2 years and older should receive antibiotics if diagnosis is certain or illness severe · Observation period an option Acute Otitis Media · Treatment – Amoxicillin – First line therapy – Second line therapy · · · · Amoxicillin-clavulanate Cefuroxime axetil Cefdinir ceftriaxone Say Aah! Pharyngitis · Etiology – Caused by many infectious agents · Most common bacterial – – – – Group A streptococci (Strep pyogenes) Group C beta hemolytic streptococcus Group G streptococci Neisseria gonorrhoeae · Most common viral – – – – – – – – – – Rhinovirus Adenovirus Influenza A and B Parainfluenza Coxsackievirus Coronavirus Echovirus Herpes simplex virus EBV CMV Pharyngitis · Diagnosis – The challenge is to distinguish pharyngitis caused by group A streptococci from pharyngitis caused by nonstreptococcal organisms – Throat culture is the diagnostic “gold standard” – Rapid streptococcal antigen tests Pharyngitis · Epidemiology – Relatively uncommon before 2 to 3 years of age – Increased incidence school-age children – Decreased incidence in late adolescence and adulthood – Occurs throughout the year in temperate climates – Peaks during the winter and spring – Easily spreads to siblings and classmates Pharyngitis · Clinical Manifestations – Inflammation of pharyngitis causes · Cough · Sore throat · Dysphagia – Onset often rapid and associated with · · · · · · Prominent sore throat Moderate to high fever Headache Nausea Vomiting Abdominal pain Pharyngitis – Typical, florid case · Pharynx is distinctly red · Tonsils are enlarged, with a yellow, blood-tinged exudate · Petechiae or doughnut-shaped lesions on the soft palate and posterior pharynx may be present · Uvula may be red, stippled, and swollen · Anterior cervical lymph nodes are tender and enlarged Pharyngitis · Treatment – Untreated most episodes of streptococcal pharyngitis resolve – Antimicrobial therapy accelerates clinical recovery by 12-24 hours – Major benefit of antimicrobial therapy is the prevention of acute rheumatic fever – Penicillin given orally three or four times daily for a full 10 days MRSA · Keep this in mind with any dermal infection! · Cutaneous abscesses that are stubborn, and require special treatment MRSA · Should culture every abscess to R/O MRSA · Important to differentiate due to different treatment protocol, and need for nasal and body eradication MRSA · Must I & D if needed, · Iodoform packing and dressing’s with bactroban topically · Treatment is bactrim or clindamycin PO in children. Can use Doxy in children over 8 y/o · Bad infections can require IV medication and hospitalization · Contagious to others in household MRSA Eradication · Culture Nares · Consider culturing groin area in adolescents and adults · Bactroban intranasal with q tip BID for 7 days for everyone in house hold to eradicate colonization · “ Hibiclens” in shower BID for a period of 2-3 weeks to eradicate colonized areas on body Rotavirus · Electron micrograph of rotavirus. I’m Thirsty! · Baby being feed oral rehydration. Rotavirus · Etiology – Invades the epithelium and damages villi of the upper small intestine – In severe cases involves the entire small bowel and colon – Vomiting may last 3 to 4 days, and diarrhea may last 7 to 10 days – Dehydration is common in younger children – Primary infection with rotavirus in infancy may cause moderate to severe disease but is less severe later in life Rotavirus · Epidemiology – Occurs in both developed and developing countries – Peaks in the winter each year – Highest rate of illness occurs in children 3-24 months of age – Fecal oral route is the major mechanism of transmission Rotavirus · Clinical Manifestation – – – – – Fever (low grade) Lethargy Abdominal pain Dehydration Diarrhea is characterized by watery stools, with no blood or mucus – Stools may be odorless or foul-smelling – Vomiting may be present – Dehydration may be prominent Rotavirus · Diagnosis – CBC – BMP – UA for specific gravity as an indicator of hydration status – Stool specimens – Stool cultures Rotavirus · Treatment – Most infectious causes of diarrhea in children are self-limited – Correcting dehydration and electrolyte deficits Rotavirus · Prevention – Hand washing – Diaper changing – Water purification – Vaccines · RotaTeq – pentavalent RV5 (ages 2, 4, 6 mths) · Rotarix – RV1 (2 mths and 4 mths) QUICK QUIZ? · Rotavirus invades which portion of our intestinal tract? – Large intestine – Colon – Upper small intestine – Lower small intestine – All of the above KFC Chickenpox (Varicella) · Etiology – Varicella-zoster (VZV) is a herpesvirus – Humans are the only source of infection Chickenpox · Epidemiology – Person to person – Occurs by direct contact with varicella or zoster and respiratory secretions – Most common during late winter and early spring – Most reported cases occur between the ages of 5 and 9 years – Congenital varicella syndrome risk is about 2%, and is greatest in the first trimester – Incubation 10 to 21 days after contact – Cases most contagious 2 days before the rash appears, until 5 days after new lesions stop erupting Chickenpox · Clinical Manifestation – Rash has multiple stages – Starts on the trunk, followed by head, face, then extremities – The appearance of a typical rash that occurs in successive crops of macules, papules, and vesicles is distinctive · Diagnosis – Immunofluorescence of the vesicular fluid – Culture of the vesicular fluid – PCR of any tissue of vesicular fluid Chickenpox · Treatment – Acyclovir, vidarabine, famvir, foscarnet – Acyclovir is the drug of choice for children – Acetominophen may be used to control fever – NO ASPIRIN – Immunization · Varicella · MMRV ???? Impetigo · Etiology – Superficial skin infection involving almost any part of the body – Two forms: bullous and nonbullous – Bullous always S. aureus – Nonbullous predominantly S. aureus but may also be A B-hemolytic streptococcus Impetigo · Epidemiology – Warm temperature – High humidity – Associated with socioeconomic disadvantage, especially crowding – Most common bacterial skin infection in children – Rare under 2 years of age; most common between 2 and 7 years of age Impetigo · Clinical Manifestation – Bullous: transparent bullae that rupture easily, leaving a rim surrounding a shallow ulcer; normal surrounding skin; regional adenopathy rare – Nonbullous: papule or vesicle progression to a honey-crusted plaque; erythema of surrounding skin; regional adenopathy common Impetigo · Diagnosis – Clinical diagnosis · Treatment – First line: cephalexin 50 mg/kg/d in two divided doses – Topical · Bactraban · Altabax QUICK QUIZ? · What age group is most susceptible to impetigo? – 1 – 2 years – 2- 7 years – 6- 10 years – 7-11 years Forgot the Sunscreen? Roseola · Etiology – A common illness in preschool aged children characterized by fever lasting 3 to 7 days followed by rapid defervescence and the appearance of a blanching maculopapular rash lasting only 1 to 2 days – Major cause appears to be human herpesvirus 6 (HHV6) – Human herpesvirus 7 (HHV7) may also play a role Roseola · Epidemiology – Occurs throughout the year – Commonly affects children 3 months to 4 years – The peak age 7 to 13 months – 90% of cases occur in the first 2 years of life – Affects males and females equally – Incubation period is 5 to 15 days Roseola · Clinical Manifestation – Rash appears as fever disappears and last 1 to 2 days – Cough – Coryza – Children remain alert and are not ill appearing – Eyelid edema has been noted – Lymphadenopathy Roseola · Diagnosis – Clinical – History very important (telltale rash) – Can check blood test · Treatment – Supportive care Hand Foot Mouth Disease · Enterovirus family · Coxsackie virus A16 infection MCC · Sores in mouth with associated blisters on hands and feet classically · May only have sores in mouth on exam in a lot of cases Hand Foot Mouth · Can’t catch it from animals! · Mostly in children under 10 yo · Spread to other children through hand contamination · 3-7 day incubation period Hand Foot Mouth · Exam shows ulcers or blisters in the pharynx, lips and or tongue · Fevers, loss of appetite, headache · Supportive treatment. Control fever, good hydration · Has a benign course QUESTION? · Predisposing factors for bacterial conjunctivitis include all except? A. Nasolacromal duct obstruction B. Sinusitis C. Asthmatic bronchitis D. Otitis media E. Allergic conjunctivitis QUESTION? · A diagnosis of acute otitis media includes all of the following except? A. Fever B. Middle ear effusion without pain C. Middle ear inflammation D. Recent onset E. Otalgia QUESTION? · Below what age is streptococcus pharyngitis rarely seen? A. 2-3 years B. 4-5 years C. 5-6 years D. 6-7 years E. 7-8 years QUESTION? · Which virus appears to be the major cause of Roseola? A. Enterovirus B. Parainfluenza virus C. Human herpes virus D. Adenovirus E. Eptein barr virus QUESTION? · During which trimester of pregnancy is varicella of primary concern? A. Second B. First C. Third D. All the above E. Not a concern for pregnant women