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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

– Definition

· Recent

· Usually abrupt

· Signs of acute illness

– Fever

– Pain

– URI

· Middle ear inflammation

· Middle ear effusion

· Chronic

– 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

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