Pediatrics - Childhood Diseases

Roseola infantum is caused by ______ and is also called exanthem subitum.

human herpesvirus 6,

Roseola maculopapular rash course of travel?

Central to lateral spread Start on trunk, then head and neck, then extremities

Decreased movement and pain of the affected limb, fevers/chills, fatigue, and point tenderness raise concern for __, though newborns may have non-specific symptoms.

osteomyelitis

nErythema Infectiosum

"Fifth's Disease" Mild viral illness of children usually aged from 3-12 years old but can affect any age

(Organism) is the most common bacterial cause of pharyngitis. Cause

(Organism) Streptococcus pyogenes is the most common bacterial cause of pharyngitis.

Gonococcal arthritis may present in two forms:

Gonococcal arthritis may present in two forms: asymmetric polyarthritis, often with tenosynovitis and dermatitis, usually in the knee or wrist; or purulent monoarthritis.

Rubeola

14 day measles

Measle how many vaccines neededimmunity?

2 vaccines ~ usually give lifelong immunity Children. CDC recommends all children get two doses of MMR (measles-mumps-rubella) vaccine, starting with the first dose at 12 through 15 months of age, and the second dose at 4 through 6 years of age. Children can receive the second dose earlier as long as it is at least 28 days after the first dose.

**what are the symptoms of measles?

3 C + fever, 2 - 3 days later -> **kolpik's spot (last 28 - 45 hrs), and rash (3 - 5 days) Starting symptoms are the 3 C's + Fever nCough (Dry, Hacking) nCoryza (Runny Nose) nConjunctivitis (Red watery eyes) n2-3 days after start of symptoms Koplik's Spots appear inside mouth Koplik's Spots are pathognomonic Adenovirus can have 3 C as well

Clinical Manifestations A _____ murmur is heard in babies with neonatal rubella.

A continuous machine-like murmur is heard in babies with neonatal rubella.

Scarlet fever manifestation?

Acute onset - fever, vomiting, headache, sore throat, chills, hyperemic tonsils, exudates Enanthem - petechial like rash on palate - red punctate finely popular near the intertriginous area) sandpaper feel to skin Strawberry tongue - white coating with red edematous papillae Face flushed with circumoral pallor

Complication Adult vs child, who has worse manifestation?

Adult, less prevalent so doctors might not detect it. Complications - adults - 60% arthropathy especially wrist, knee, ankle, hand resolves in few weeks Parent of the kid with fifth disease developes Bad joint pain, fever, headache, disease, they have the fifth disease !

Tx for osteomyelitis?

Always IV Abx, ALWAYS IV Abx for 6-8 weeks (Clinda/Vanco) clindamycin cover both staph and strep (may cover MRSA but not as well as Vanco) OR vancomycin Changes to sensitive s/p c/s. Orthopedics- debridement, abscess drainage if needed

Etiology What is the cause of erythema infectiosum?

Caused by Parvovirus B 19

what not to give for viral infection?

Aspirin!!! NO ASPIRIN (In viral illness may cause Reyes Syndrome) Reyes syndrome - A rare but serious condition that causes confusion, swelling in the brain, and liver damage. Children recovering from a viral infection such as chickenpox or flu or who have a metabolic disorder are most at risk, especially if they've been taking aspirin. Early symptoms include diarrhea, rapid breathing, vomiting, and severe fatigue. Symptoms such as confusion, seizures, and loss of consciousness need emergency treatment. There's no specific treatment for Reye's syndrome beyond supportive care and aggressive monitoring for complications.

What may CBC tell you about roseola?

CBC may show lymphocytosis

Workup for osteomyelitis?

CBC ~ bacterial infection check ~ leukocytosis with left shift (neutrophilia) ESR/CRP ~ inflammation marker ~ unspecific Blood culture if conserve bacteremia Wound cs of the site for identification (since usually osteomyelitis happen to perforated skin)

Workup for septic arthritis?

CBC, CRP, ESR, Blood Cx MRI > Xray Gold Standard- Joint aspiration Synovial Fluid with 50-100K WBCs Culture fluid for Organism

_____ . is a yeast associated with osteomyelitis in patients with intravenous drug use. Save to queue

Candida spp

What is the cause of measles or so-called rubeola?

Childhood viral illness - Paramyxovirus of the genus Morbillivirus The paramyxoviruses, including the measles virus, are all RNA viruses (with/without) with an envelope.

Measles Diagnosis How do you test for measles?

Clinical diagnosis nHistory and Physical - Rubeola antibody testing- IGM + in acute illness

Clinical Manifestations _____is a disease that presents in neonates with the classical triad of cataracts, deafness, and patent ductus arteriosus (cardiac manifestation).

Congenital Rubella is a disease that presents in neonates with the classical triad of cataracts, deafness, and patent ductus arteriosus.

Congenital rubella vs infant rubella, which one has worse manifestation?

Congenital rubella

A child born with a blueberry muffin sign, what do you think?

Congenital rubella syndrome

What is the difference on skin rash for roseola and measle?

Measles is macular lesion** Roseola is Maculopapular rash Measle happens after 3 - 5 days after symptom (3Cs + fever + koplik spot) Roseola happens after fever resolves. (No 3Cs)

_____ is the most common cause of gram-negative osteomyelitis in sexually active young adults.

Neisseria gonorrhoeae

______ is an infection involving the dermis and superficial lymphatics, usually from Streptococcus pyogenes infection. Cause

Erysipelas is an infection involving the dermis and superficial lymphatics, usually from Streptococcus pyogenes infection.

Clinical presentation ___ is a cutaneous complication of parvovirus B19 infection that presents with a "slapped cheeks" rash in children.

Erythema Infectiosum is a cutaneous complication of parvovirus B19 infection that presents with a "slapped cheeks" rash in children.

Patho _____ is the pathological process responsible for causing the "blueberry muffin" rash of rubella.

Extramedullary hematopoiesis is the pathological process responsible for causing the "blueberry muffin" rash of rubella.

What may be a complication of roseola?

Febrile seizures due to high spike fever

Clinical presentation What is the manifestation of fifth disease or erythema Infectiosum?

First Phase - livid erythema on cheeks - SLAPPED CHEEKS!!!! Low grade fever, nasal congestion, headache Second Phase - Red lacy rash on rest of body (esp. extensor surface arms, torso and legs) May last from 4-21 days, Self resolving

First-line treatment for osteomyelitis is .___

First-line treatment for osteomyelitis is IV antibiotics.

Rubella Clinical Presentation What is a manifestation of rubella? Rash spread pattern?

Frequently missed Similar spread as measles (spread from top to bottom) RASH!!! - Starts with the appearance of rash on faceàtrunksàlimbs Rash fades after 3 days ( "3-day measles") Mild flu-like symptoms Tender occipital and posterior auricular lymph nodes may have Forcheimers sign- small red papules on the soft palate (sometimes!)

Rubella (Bella is nice lady)

German measles Mild viral illness that has a constitutional symptom that last 1 - 3 days then resolve. Beola is a boy, not nice~ mild sxs Bella is girl and is nice ~more sxs

____ is a rare respiratory disease, seen after measles, that happens in the immunosuppressed. complication

Giant cell pneumonia is a rare respiratory disease, seen after measles, that happens in the immunosuppressed.

____ is the most common cause of infectious septic arthritis in young sexually active adults.

Neisseria gonorrhoeae is the most common cause of infectious septic arthritis in young sexually active adults.

Infectivity of measles/rubeola?

Highly contagious - contagious from 4 days before rash, until 4 days after rash resolution (10 - 14 days)

______ causes a disease of infants that presents with a high fever followed a few days later by asymptomatic rose colored maculopapular rash.

Human herpesvirus 6 causes a disease of infants that presents with a high fever followed a few days later by asymptomatic rose colored maculopapular rash.

Tx for septic arthritis?

IV Abx Ortho- Joint wash out if necessary debridement, abscess drainage (joint aspiration)(because joint is walled off)

How to you check for immunity?

IgG measles

Measles Diagnosis To check acute measles, what test?

IgM measle

Tell me about the course of manifestation for roseola?

Incubation period - 7 -10 days Sudden onset of high fever (1-5 days) with no other clinical findings while febrile, Temperature normalizes, then rash develops. Typical age- 6 months-4 years Diagnose are made retrospectively - *tell probably viral, self-limiting. If not better 3 - 5 days, come back for re-evaluation. Usually, with in 5 days fever will break and rash will happen.

blueberry muffin sign

Indicate rubella blue red macules at birth on head, neck, trunk or extremities (within 24 hrs)

septic arthritis

Invasion of a joint by an infectious purulent agent leading to arthritis

Normally, synovial fluid contains less than _____cells/µL WBC

Normally, synovial fluid contains less than 200 cells/µL WBC

Joints affected by septic arthritis have purulent synovial fluid, white blood cell count greater than ___/mm3, and elevated erythrocyte sedimentation rate and C-reactive protein.

Joints affected by septic arthritis have purulent synovial fluid, white blood cell count greater than 50,000/mm3, and elevated erythrocyte sedimentation rate and C-reactive protein.

What is pathognomonic of measle (skin manifestation)?

Koplik's spot Grayish-white spots on erythematous background, usually on inside of buccal mucosa opposite 1st and 2nd upper molar Koplik's spots are a prodromic viral enanthem of measles manifesting two to three days before the measles rash itself. They are characterized as clustered, white lesions on the buccal mucosa and are pathognomonic for measles. The textbook description of Koplik spots is ulcerated mucosal lesions marked by necrosis, neutrophilic exudate, and neovascularization. They are described as appearing like "grains of salt on a reddish background", and often fade as the maculopapular rash develops. As well as their diagnostic significance they are important in the control of outbreaks. Their appearance, in context of a diagnosed case, before they reach maximum infectivity, permits isolation of the contacts and greatly aids control of this highly infectious disease.

What does this patient have?

LAce rash Second phase of erythema Infectiosum

Generally, _____ is ideal for evaluation of acute and chronic osteomyelitis.

MRI X-Ray- 2 weeks until changes are seen (2 weeks s/p infection) TOO LATE

Measles Rash

Macular rash! Appears usually about 3-5 days after start of symptoms Starts at the highest fever spikes (104-105) Isolated erythematous macular lesions start at hair line and behind ear Spreads downward from head to toe Progresses in swollen confluent macular lesions As rash disappears leaves behind a reddish/brownish stained appearance on skin

What is the rash characteristic for roseola?

Maculopapular rash! Not just macular rash like measles (rubeola)

sxs ______ is a virus that affects unimmunized children and presents with a rash that is preceded by cough, coryza, conjunctivitis and Koplik spots on the buccal mucosa.

Measles virus is a virus that affects unimmunized children and presents with a rash that is preceded by cough, coryza, conjunctivitis and Koplik spots on the buccal mucosa.

Epidemiology of scarlet fever?

Most common - 6-12 years of age More common in temperate climates especially in cold weather Tropical climate - skin infections (impetigo)

_____ caused by transient bacteremia is most common in children.

Osteomyelitis

______ is a bone disorder defined as the infection of bone marrow and bone.

Osteomyelitis

Class Topics

Osteomyelitis Septic Arthritis Roseola Infantum ~ six disease Rubeola Rubella Fifth disease ~ erythema infectiosum Scarlet Fever Varicella Zoster Virus (HHV 3) Infectious Mononucleosis Mump

___ is a virus that can cause erythrocyte aplasia and rheumatoid arthritis-like symptoms.

Parvovirus B19 is a virus that can cause erythrocyte aplasia and rheumatoid arthritis-like symptoms.

___ usually causes a mild rash in children, but can also cause hydrops fetalis in pregnant women as well as polyarthropathy syndrome and severe anemia in adults.

Parvovirus usually causes a mild rash in children, but can also cause hydrops fetalis in pregnant women as well as polyarthropathy syndrome and severe anemia in adults.

____ is a form of chronic osteomyelitis commonly involving the lumbar vertebrae and caused by (pathogen) Mycobacterium tuberculosis.

Pott disease

_____ is a form of chronic osteomyelitis commonly involving the lumbar vertebrae and caused by Mycobacterium tuberculosis.

Pott disease Pott disease is tuberculosis of the spine, usually due to haematogenous spread from other sites, often the lungs. The lower thoracic and upper lumbar vertebrae areas of the spine are most often affected. It causes a kind of tuberculous arthritis of the intervertebral joints.

Complication Who has the worse consequences of erythema Infectiosum?

Preggo, sicklers, immuncompromised. ---- nIn Pregnant Women nInfection in 1st trimester linked to hydrops fetalis nSpontaneous Miscarriage nIn Sickle Cell nInfection can precipitate an aplastic crisis nImmuncompromised nHigh rate of compliacations

What are complications of measles?

Primary - Pneumonia - viral interstitial (from measles itself) Secondary - pneumo, strep, h. flu, staph Reactivation - exacerbation of TB Myocarditis Encephalitis SSPE - subacute sclerosing pan encephalitis (progressive fatal neurologic disease)

Clinical Manifestations _____is a viral infection that presents with postauricular lymphadenopathy and a fine rash that begins on the head and moves down.

Rubella is a viral infection that presents with a postauricular lymphadenopathy and a fine rash that begins on the head and moves down.

_____is an infective disorder that was formerly known as German measles.

Rubella is an infective disorder that was formerly known as German measles.

Diagnosis _____ is the togavirus that causes a blueberry muffin rash in neonates.

Rubella is the togavirus that causes a blueberry muffin rash in neonates.

Tx roseola?

Roseola Treament Fever Control Tylenol Ibuprofen (if >6 moths) NO ASPIRIN (In viral illness may cause Reyes Syndrome) Encourage hydration Parent education/ Reassurance Will resolve on its own

Congenital rubella

Rubella Congenital rubella - isolated from the nasopharynx, stool, blood, urine. CSF up to 18 months after delivery Clinical Manifestations: Incubation - 14-21 days triad = cataracts, deafness, cardiac manifestations

Diagnosis _____and cytomegalovirus are two infections that are associated with a "blueberry muffin" rash.

Rubella and cytomegalovirus are two infections that are associated with a "blueberry muffin" rash.

Clinical Manifestations _____ causes a maculopapular type of facial rash that starts desquamating when it moves to the trunk, and does not coalesce.

Rubella causes a maculopapular type of facial rash that starts desquamating when it moves to the trunk and does not coalesce. Rubeola is a macular rash!~

Transmission Rubella is transmitted via _____

Rubella is transmitted via respiratory droplets. Virus in nasopharyngeal secretions, blood, urine, feces 7 days prior to, during and 7 days after rash Congenital rubella - isolated from nasopharynx, stool, blood, urine. CSF up to 18 months after delivery

Clinical Manifestations Rubella virus causes (mild/severe) _____disease in neonates.

Rubella virus causes (mild/severe) severe disease in neonates.

Clinical Manifestations Rubella virus causes a (mild/severe) _____infection in children.

Rubella virus causes a (mild/severe) mild infection in children.

What are s/s of osteomyelitis?

Rubor, dolor, calor, tumor Fever •Decreased use of extremity / Inability to bear weight

S/S septic arthritis?

Signs and Symptoms Rapid onset of joint pain Redness, Warmth and Swelling overlying joint Fever Usually monoarticular (one joint only) Decreased ROM joint Inability to bear weight

MCC of osteomyelitis - In normal people? In people with sickle cell disease?

Staph #1 (MRSA!), Strep, Salmonella in sicklers (people with sickle cell disease)

While _____ is the most common cause of osteomyelitis in newborns overall, two other bacterial species, Escherichia coli and Group B Streptococcus, are somewhat unique causes in newborns to watch for.

Staphylococcus aureus

____ is the most common cause of septic arthritis in children and adults.

Staphylococcus aureus Staphylococcus aureus is the most common cause of septic arthritis in children and adults.

Staphylococcus aureus and ___- are the most common causes of both impetigo and cellulitis. Cause

Staphylococcus aureus and Streptococcus pyogenes are the most common causes of both impetigo and cellulitis.

Scarlet fever

Streptococcal infection that produces an erythrogenic toxin GABS - 55 immunogenically distinct types

Streptococci like Streptococcus pyogenes (do/do not) ____ contain endotoxin in their cell membranes. characteristic

Streptococci like Streptococcus pyogenes (do/do not) do not contain endotoxin in their cell membranes.

____. is the second most common cause of septic arthritis after S. aureus.

Streptococci spp. is the second most common cause of septic arthritis after S. aureus.

Cause _____ is the causative organism of scarlet fever.

Streptococcus pyogenes is the causative organism of scarlet fever.

____ is a lethal complication of measles that involves chronic inflammation of the entire brain complication

Subacute sclerosing panencephalitis is a lethal complication of measles that involves chronic inflammation of the entire brain Sxs (Personality change, seizure, myoclonus, ataxia, coma) Diagnosis- widespread cortical dysfunction on EEG hx: had measels prior to age 2

___is indicated as treatment for osteomyelitis that has not responded to antimicrobial treatment.

Surgery is indicated as treatment for osteomyelitis that has not responded to antimicrobial treatment.

Prevention The MMR vaccine is a (killed/live attenuated) ____ vaccine that can be given to patients with HIV but no signs of immunodeficiency.

The MMR vaccine is a (killed/live attenuated) live attenuated vaccine that can be given to patients with HIV but no signs of immunodeficiency.

The ____is the joint most commonly affected by septic arthritis; affected joints appear swollen, red, and painful.

The knee is the joint most commonly affected by septic arthritis; affected joints appear swollen, red, and painful.

Osteomyelitis caused by open-wound bacteremia from fractures, surgery, and puncture wounds is most common in (children/adults) .

adults

Osteomyelitis is conclusively diagnosed by __ cultures.

blood or bone biopsy

Osteomyelitis caused by transient bacteremia is most common in (children/adults) _____ .

children

Osteomyelitis usually arises through hematogenous spread of bacteria to the bone ____- in adults.

epiphysis

Osteomyelitis usually arises through _____ spread of bacteria to the bone metaphysis (children) or epiphysis (adults).

hematogenous

Patients with osteomyelitis commonly have a (high/low) C-reactive protein and erythrocyte sedimentation rate.

high

transmission of erythema infectiosum

highly contagious -respiratory droplet

Osteomyelitis

inflammation of bone and bone marrow

Osteomyelitis usually arises through hematogenous spread of bacteria to the bone __in children.

metaphysis

Measles Treatment

nSupportive nPrevention!! (MMR Vaccine)

Face flushed with circumoral pallor

sign of scarlet fever

What is forcheimer sign and who has it?

small red papules on the soft palate (sometimes!) German measles (bella) patient has it

What are congenital traid for congenital rubella syndrome?

triad = cataracts, deafness, cardiac manifestations