Severe Childhood Diseases

Disease Processes

Michael Dick, MD, FAAP

FUO

Fever of Unknown Origin

Definition
> 38 C (100.4 F) for 14 days
Major Etiologies
Infection
Malignancy
Connective Tissue Diseases
Physical Exam
Nutritional status, sweating, conjunctivitis, pharyngitis, sinuses, skin bullae, ophthalmologic exam, muscle/bone palpation, rectal exam
Historical data
Factitious (Munchausen’s by proxy), family dysautotonia, "systemic symptoms" (fever, chills, weight loss, night sweats etc)

FUO continued

Diagnosis
  • Level 1
  • CBC, ESR, UA, Urine Culture, CXR, Liver function tests, Renal Disease Battery (Lytes, BUN, Cr, Ca, phos, Mg) Aerobic and Anaerobic cultures, VDRL/RPR, ANA, RF, Compliment, skin tests
  • Level 2
  • Specific cultures and serology, bone marrow, specific imaging
  • Level 3
  • More extensive imaging, complex tests, biopsies, therapeutic trials
Treatment
Withhold antibiotics when possible
Except neutropenic patients – special protocols

Sepsis

Definitions
  • Bacteremia: recovery of viable bacteria from the bloodstream
  • Sepsis: Toxic Bacteremia

Risk Factors Age Immunodeficiency Specific Disease States (i.e. malignancy) Instrumentation / Devices Manifestations Blood pressure (hypotension) Tachycardia DIC (purpura/bleeding) Temperature (Fever or hypothermia) Alteration of CNS status Skin perfusion, decreased capillary refill, other lesions

Sepsis Continued

Diagnosis
  • Cultures and Indirect Serology
  • Nonbacterial Infections or Bacterial Toxins
  • RMSF (Rocky Mountain Spotted Fever), TSS (Toxic Shock Syndrome), Leptospirosis, Yersinia, Lyme, TB, Tularemia, Malaria, Viral (enteroviral, HSV), Fungal (Candidiasis, Cryptococcosis)
  • Noninfectious
  • Anaphylaxis, ingestions, envenomations, hemorrhage, volvulus, vasculitis (ie Kawasaki’s)
Treatment
Antibiotics (gram positive, gram negative, anaerobic)
Antifungal or Antivirals
Supportive measures: chronotropes, inotropes, deep access etc
Steroids, naloxone, anti-endotoxin antibodies, anti-tumor necrosis factor antibodies and other cytokines

Osteomyelitis

(3-12 years, males)

Etiology
  • Staph aureus, HIB, strep (group B in neonates)
  • Special situations
  • Sickle Cell – Salmonella
  • Animal bite – Pasturella
  • Punture wound through sneakers – Pseudomonas
  • Vertebra – Brucella
Pathology
Hematogenous
Contiguous
Direct innoculation
Manifectations
After infancy usually involves a single bone
Acute
Subacute / Chronic
Psedoparalysis
Diagnosis
ESR, Quantitative CRP, Blood Culture (60%), aspirate
Treatment
Semisythetic penicillin initially
Follow acute phase reactants
Consider switch to oral antibiotics
Surgical drainage / debridement

Septic Arthritis

Etiology
Staph, HIB, Meningococcal, GC
Pathology
  • Hematogenous, contiguous, direct innoculation
  • Spread by epiphyseal bridging vessels
  • Manifestations
  • Rubor, tumor, dolor, calor, pain on positioning
  • Diagnosis
  • ESR, Quant CRP, Blood culture (85%), Aspirate (30%), synovial biopsy
  • Differential
  • Toxic synovitis – s/p URI with nonspecific inflammation (male, 3-6 years, ESR < 40)
  • Treatment
  • 2-3 weeks IV antibiotics (<< GC, >> hip)

Diarrhea

Mechanisms
  • Secretory
  • Osmotic
  • Motility
  • Surface area
  • Invasive
Chronic diarrhea
More likely a malabsorption state
Etiologies
Rotavirus
  • Vomiting precedes diarrhea
  • Vaccine
  • More often in winter
E coli
Pathogenic
Toxigenic
Invasive
Adherent
Hemorrhagic (asscociated with HUS)
Salmonella
Milk, eggs, poultry
Avoid antibiotics
Shigella
Shiga toxin
Invasive (hematochezia)
Seizures, Fever
Treat with Septra
Camplobacter
Puppies,seafood
Yersinia
Mesenteric lymphadenopathy
Arthritis, rash, spondyylopathy
Food Poisoning
Salmonella, Staph aureus, C perfringes, C botulinum
Clostridium dificile
Pseudomembranous colitis
Vibrio
Cholera
Seafood
Entamoeba histolytica
Bloody diarrhea then systemic invasion
Giardia
Insidious
Fat malabsorbtion
Cryptosporidium
Day care
Immunocompromised
Unwashed fruit (druplets)

 

Meningitis

Leptomeningeal inflammation

Males 2mo – 2 years

Etiology
  • HIB, pneumococcus, Neisseria, (Staph epi – VP shunts)
Pathogenesis
Hematogenous vs contiguous
Sickle cell and Certain races
Manifestations
Fever, mental status changes, increased ICP
Kernig’s
  • In dorsal decubitus the patient can completely and easily extend the leg, when sitting or lying with the thigh flexed on the abdomen – the leg cannot be extended
  • Brudinskis’s
    • Flexion of the hip results in flexion of the hip and knee
    • Or "Contralateral Sign" passive flexion of the lower limb on one side results in a similar movement will result in the contralateral extremity
  • Diagnosis
  • Spinal fluid for cultures, stains and serology
  • Treatment
  • 10 days antibiotics (except 7 with neisseria)
  • Fluid restriction of not in shock (SIADH)
  • Prophylaxis (also Cipro in adults?)
    • Neisseria – Rifampin max 600mg bid times 2 days
    • HIB – Rifampin max 600mg q am times 4 days

 

  • Prognosis
  • Young age
  • Duration of illness before antibiotics
  • Bacterial load
  • Late seizures
  • Early coma
  • Pneumococcus or gram negative rods
  • Immunocompromised

Aseptic Meningitis (Usually Viral)

"Worst headache in your life"
Fever, exanthem
Etiology
  • 85% enterovirus
  • summer > fall
CSF:
Viral: less wbcs, normal glucose
Granulomatous: High Protein, low glucose (TB)
Specific treatment usually not indicated
Serodiagnosis could decrease summer admissions

Encephalitis

Etoilogy
Arbovirus > enterovirus > HSV/VZ
Postinfectious / postimmunization demylination
Epidemiology
Animal / arthropods
Vectors / resevoirs
Manifestations
Mental status changes
Diagnosis
History
  • Exposures/travel
  • Hypoglycemia
  • Vitamin A intoxication
  • Metabolism
  • Trauma
Spinal fluid
  • RBCs increased
  • Temporal focus for EEG (HSV)
Treatment
Antivirals: especially acyclovir for HSV/VZ
Supportive
Prognosis
Poor for EEE (Eastern Equine Encephalitis) and HSV

Otits Media

Supperative disease 4mo – 2 years

  • Pathogenesis
  • Pneumococcus, nontypeable HIB, moraxella, viral
  • Abnormal anatomy: eustacian tube, adenoids
  • Manifestations
  • Otalgia, fever, diarrhea, anorexia, insomnia
  • Treatment (to avoid complications)
  • Amoxyl 80-100 mg/kg
  • 2nd line
    • Ceftriaxone 50-75 mg/kg times 1-3 doses
    • Zithromax (different molecular mechanisms)
    • Vantin times 5-7 days for low risk groups
    • Ceftin (CDC reccomendations)
    • Augmentin
  • 3rd line
  • Cefzil (expense)
  • Biaxin (taste, expense)
  • Questionable choices
  • Penetration but ? coverage: Suprax, Cedax, Omnipen
  • Lorabid and Ceclor
  • Complications
  • Meningitis uncommon
  • Mastoiditis, cholesteotomas
  • Intracranial: lateral sinus thrombosis
  • Follow up
  • 4-6 weeks > 15 months
  • 2-3 weeks in younger children

Sinusitis

Development
MESF: maxillary, ethmoid, sphenoid, frontal
Manifestations
Nocturnal cough, purulent rhinorrhea, facial pain
Etiology
Same pathogens as OM
Predisposed: heart disease, immunodeficiencies, intubation, NG tube, dental infection, immotile cilia syndrome
Diagnosis
Sinus CT
Treatment
Prolonged antibiotics, nasal steroids
Surgery – last resort
Saline nasal irrigation, humidity, occasionally decongestants
Complications: osteomyelitis, orbital infections,pott’s puffy tumor

Pharyngitis

Etiology
< 2 years viral
> 5 years Strep
adolescents: mycoplasma
Manifestations
Erythema, edema, exudates, palatal petechiae, cervical lymphadenopathy
Vesiculations / ulcerations: coxsackie / HSV
Conjunctivitis: adenovirus
Diagnosis
ELISA, culture, optical immunoassay

 

  • Complications
  • Rheumatic fever, Scarlet Fever, Glomerulonephritis, peritonsilar and retropharyngeal abscess, Ludwig’s angina, epiglottitis
  • Neutropenic mucositis, autoimmune ulceration, thrush, Kawasaki’s
  • Treatment
  • Reduce symptoms
  • Decrease complications
  • Penicillin, erythromycin

Eye Infections

Preseptal Cellulitis (< 4 years)
Fever, lid swelling, toxic appearing
Orbital cellulitis
Usually a complication of sinusitis
Can progress to Cavernous Sinus Thrombosis
Cranial nerve involvement
Lamina papyracea separates orbit from ethmoids
Symptoms
  • High fever, orbital pain, decreased or painful EOM, chemosis, proptosis, decreased visual acuity

Large Airway Disease

Epiglottitis
3-10 years HIB (typeable – vaccinated against)
Thumb sign (soft tissue neck)
Treatment
  • Nasotracheal intubation
  • Antibiotics
  • Steroids
Emergency potential airway compromise
  • Leaning forward
  • Drooling
Laryngitis
Nearly always viral etiology
Same pathogens as bronchiolitis / croup

 

  • Croup
  • Epidemiology
    • 6 months – 6 years
    • < 5 days in duration
    • usually PIV3 or RSV
  • Manifestations
    • Stridor, retractions
    • Steeple sign – narrowed subglottic space
  • Treatment
    • Racemic epi, epi (rebound phenomenon)
    • Sedation, cool mist, ventilation if fatigue occurs
    • Steroids (controversial) – spasmodic croup
    • Laryngoscopy if < 4 months, prolonged symptoms (>1 week)
  • Tracheiitis (pseudomembranous croup)
  • Severe toxic bacterial infection
  • Usually staph, can be OM pathogens

Bronchiolitis

Epidemiology
  • RSV, PIV3, Influenza A
  • Winter,spring
Manifestations
Tachypnea, wheezing, air trapping, hypoxemia, hypercapnia
Pathology
Airway necrosis, peribronchial inflammation, edema, plugging
Diagnosis
Culture, antigen assay
Differential
GER, CF, CHF, foreign body, rings/slings, tracheomalacia

 

  • Treatment
  • Supportive measures, ventilation
  • Possibly steroids, bronchodialators, antivirals
  • Prognosis
  • Cause/effect: susceptible individuals vs damaged lungs
  • Secondary infections / complications
  • Prevention
  • Initial vaccine made it worse
  • New potential vaccine pending

Pneumonia

Definition
Inflammation and consolidation
Lobar, Consolidation, Interstitial
Etiology
Viral most common
Bacterial < 10 – 30%
Neonate: Group B strep, gram negatives)
4-16 weeks: Staph Aureus, HIB, Strep pneumo
Older: strep pneumo and less staph
Adolescent: mycoplasma
Manifestations
Viral: bronchopneumonia
Bacterial: lobar
Diagnosis
Sputum culture negative
  • CXR not always positive when dehydrated
Hospitalization
Respiratory distress
Poor response to oral antibiotics
Vomiting / poor compliance
> 1 lobe involvement
immunosuppression
underlying cardiopulmonary disease
abscess
pneumatocele
empyema

Urinary Tract Infections

Manifestations
Unexplained fever @ any age
Neonate: changes in feeding, FTT, diarrhea, vomiting, fever, jaundice
Older: urgency, dysuria, frequency, abdominal pain
Diagnosis
Culture: suprapubic, cath, "clean catch"
Indicative: leukocytes, RBCs, enzymes
Localizing to upper pole: IF, TNF, beta 2 microglobulin, LDH
Predisposing factors
Short female urethra
Urinary stasis
VU reflux
Certain adherant organisms
Treatment
Cystitis 3-7 days
Pyelonephritis: formerly though 14 days IV, now oral
Follow up
Surveillance cultures
Abdominal ultrasound, VCUG
  • UTI in any male
  • UTI in the 1st year of life
  • Pyelonephritis
  • Recurrent UTI in a female

Hepatitis

Etiology
HAV,HBV,HCV,HDV ETC, herpesviruses, enteroviruses
Manifestations
Prodrome: anorexia, nausea, vomiting, malaise,anorexia
Immune complex disease, urticaria, arthritis
Jaundice (15-20x LFT elevation), tender hepatomegaly
Diagnosis
Serology, culture, PCR, histology, autoimmune markers
Treatment
Passive / Active immunization
Interferon, immunomodulators, steroids
Blood products, diuretics, antacids
Nutrition (ammonia production), Vitamin K, TPN
Orthotopic transplant

STDs

Gonorrhea
Gram negative diplococci,
PID/concominant infection
Hematogenous spread / arthritis
Perihepatitis
Emerging resistance
Chlamydia
More cervicitis/urethritis
"Reiter’s syndrome"
Female infertility
Lymphogranuloma venerum
Neonatal conjunctivitis
Neonatal pneumonia
Trichomonas
Not all cases sexually transmitted
Vaginosis
Gardernella
Clue cells
"Fishy order" – "whiff test"
Moniliasis
Candida albicans
Predisposed by BCP, pregnancy, obesity, steroids, DM
Herpes (HSV2)
Primary > secondary severity
Latency in scral root ganglia
Shed 10-14 days, heal 16-20 days, recurrances 5-8 year

 

  • Condyloma accuminata
  • HPV
  • Associated with Kaposi’s Sarcoma
  • HIV
  • retrovirus
  • Syphillis
  • Trepnema pallidum
  • Congenital / acquired through abuse
  • 4 stages
  • Serologic diagnosis
  • Easily treated in early stages
  • Jarish-Herxheimer reaction

Lyme’s Disease

Etoilogy
Borrelia borgdorferi (spirochete)
Tick borne (Ixodes sp)
Manifestations
  • Stage 1 (3-32 days)
  • ECM: erythema chrnonicum migrans
  • Systemic symptoms
  • Stage 2 (< 5 weeks)
  • Cardiac (dysrhythmia)
  • NEUROLOGIC (protean)
  • Stage 3
  • Arthritis

 

  • Diagnosis
  • ESR, decreased compliment, false positive VDRL
  • Cryoglobulins, immune complexes
  • Treament
  • Stage 1 oral tetracycline
  • Later: penicillin, tertacycline, ceftraixone

Group B Streptococcal Disease

Neonatal forms
Early (6 hours): respiratory distress
Late onset: meningitis
Clinical features
Indistinguishable from primary pulmonary / cardiac disease
Ground glass pulmonary appearance
Pathology
Pulmonary hypertension, hemorrhage, WBC sheets with / without bacteria
Treatment
Synergy between amp/gent