Pediatric Infectious

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

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Nontypable H. influenza
S. pnuemoniae
M. catarrhalis
N. gonorrhoeae
P. aeruginosa

– Incubation 24-72 hours





Conjunctivitis



– Common viral causes:

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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

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•
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Nasolacrimal duct obstruction
Sinus disease
Ear infection
Allergic children who rub their eyes frequently

– Allergic
• Seasonal, itchy, bilateral chemosis





Conjunctivitis



• Clinical Manifestations
– Symptoms include

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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

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•
•
•


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




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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

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•
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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:

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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

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Amoxicillin-clavulanate

Cefuroxime axetil

Cefdinir

ceftriaxone





Say Aah!





Pharyngitis



• Etiology
– Caused by many infectious agents
• Most common bacterial

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Group A streptococci (Strep pyogenes)
Group C beta hemolytic streptococcus
Group G streptococci
Neisseria gonorrhoeae

• Most common viral

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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

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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

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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