Presentation on theme: "Core Tutorial in Pediatric Infectious Diseases for Third Year Medical Students Infectious Disease Emergencies."— Presentation transcript:
1 Core Tutorial in Pediatric Infectious Diseases for Third Year Medical Students Infectious Disease Emergencies
2 How would you evaluate this patient? A sixteen-year-old girl presents with fever and lower abdominal pain but denies urinary urgency or frequency. She is sexually active and uses condoms infrequently.
3 How would you evaluate this patient? A sixteen-month-old presents with a history of nasal discharge for the past week presents with a swollen, red eye and fevers to 1030 F.
4 Learning ObjectivesBe able to recognize an infectious disease emergencyUnderstand the age-appropriate approach to diagnosis and initial management of infectious disease emergenciesBe familiar with various agents with bioterrorism potential
5 Bacteremia and SepsisBacteremia = Presence of pathogenic bacteria in the blood of mildly or moderately ill childIncidence peak at age 6 to 18 monthsSee “Fever” tutorial for complete discussion of work-up and managementSepsis = Bacteremia with serious systemic illnessPathogensbirth to 2 months: Group B Streptococcus, E. coliolder infants: Strep. pneumoniae, N. meningitidis, Group A Streptococcus, S. aureus, SalmonellaRisk factorsneoplasia, immunodeficiency syndromes, immunosuppressive therapy, asplenia, sickle cell disease
6 Sepsis Signs and Symptoms Work-up Treatment fever, tachycardia, tachypnea, hypotension, metabolic acidosis, thrombocytopenia, leukocytosis (leukopenia with overwhelming infection)Work-upCBCblood culturecoagulation studies, electrolytes, LFT’s, BUN and creatinineTreatmentfluids, vasopressors; close monitoring in ICUage < 2 months: ampicillin and gentamicin or cefotaximeage > 2 months ceftriaxone or cefotaxime +/- vancomycin
7 Meningococcemia Neisseria meningitidis Peak incidence is first year of life, 40% in age < 5 yrsRisk factors include overcrowding, poverty, cigarette smoke exposure, prior respiratory infection, congenital impairment of phagocytosisTransmission by respiratory droplets, close direct contactEndotoxin (lipopolysaccharide) causes endothelial damage, systemic inflammatory responseCan progress from asymptomatic to death within hours
8 Meningococcemia, con’t Signs and symptomsFever, headache, myalgiasAltered mental status , high fever or hypothermia, tachypnea, hypotensionPetechial rash progressing to purpura may begin as macules, maculopapules, or urticariaCase fatality rate > 40%Work-upCulture blood, CSF, skin lesionsCSF antigen testing (latex agglutination)
9 Meningococcemia, con’t TreatmentPenicillin G if susceptible (most are but start with third generation cephalosporin until sensitivities are known)Supportive carePreventionchemoprophylaxis of contactsrifampin, ceftriaxone, ciprofloxacinvaccineA/C/Y/W135
10 Meningitis Incidence peak at age 6 to 24 months Cerebrospinal fluid normal values vary with ageMeningeal signs (neck stiffness, Kernig’s sign and Brudzinski’s sign) may be absent in young infantsMost common bacterial pathogens vary with age:Neonate: Group B Strep, E. coli, L. monocytogenesOlder infants and children: S. pneumoniae, N. meningitidis, H. influenzae
11 Meningitis, con’tColonization (nasopharynx) resulting in bacteremia can lead to hematogenous seeding of meninges; also can have direct extension from a parameningeal focus (i.e., sinusitis)Work-upCBC, electrolytes, BUN, creatinine, glucose, coagulation studiesblood cultureCSF analysis: cell counts, protein, glucose, gram stain and culture,ManagementABC’s, monitoringsupportive careage < 1 month: ampicillin and cefotaximeage > 1 month; vancomycin and ceftriaxone or cefotaxime
12 Other CNS Infections Encephalitis viral, bacterial, post-infectious, non-infectioustreatment depends on etiologySubdural empyemaimmediate surgical drainageBrain abscessantibiotics, steroidsmanagement of elevated intracranial pressurefrequently requires surgical drainageOrbital cellulitisI.V. antibiotics and frequent evaluation by ophthalmologist with consideration of surgical drainage
13 EpiglottitisCommon etiology was H. influenzae type b prior to the introduction of vaccineOther etiologies: Strep. pneumoniae, Strep. pyogenes, Staph. aureusIncidence was highest in age 3 to 6 years but with vaccine incidence has declined dramaticallyPresentation is toxic-appearing child with fever, drooling, stridor, tachycardia, tachypnea, and a preference for sitting up leaning forwardThis is a true emergency and can progress rapidly to complete airway obstruction especially if the child is disturbedIf epiglottitis is suspected priority is control of the airway before any other intervention or diagnostic evaluation
14 Epiglottitis, con’tInfection leads to edema of epiglottis, spreads to aryepiglottic folds, arytenoids, and entire supraglottic larynxWork-up and treatment after securing airwayWork-upWBC (leukocytosis with left shift)blood cultureepiglottis culturelateral neck film (“thumb sign”)Treatmentceftriaxone or cefotaximeclose observation in ICU
15 Bacterial TracheitisBacterial complication of viral laryngotracheobronchitisPathogens: Staph aureus, Strep pyogenes, H. influenzae, Strep pneumoniae; rarely M. catarrhalis, anaerobesAs viral infection wanes, abrupt worsening of symptoms with new fever and stridorToxic-appearing, agitatedPriority is establishment of an artificial airwayWork-up and management: see Epiglottitis
16 Retropharyngeal Abscess Potential space between anterior border of cervical vertebrae and posterior wall of esophagusGroup A Strep, anaerobes, Staph. aureusAge < 4 years more commonFever, toxic-appearance, stridor, drooling, meningismusLateral neck film or CTRisk of airway obstructionTreatment: Clindamycin or penicillin and cefazolin; drainage
17 Septic ArthritisPresentation is systemic illness with fever and refusal to use jointExam reveals warmth, swelling, tenderness, and limited passive range of motionUsual etiology is hematogenous seeding of synovial tissueMay also result from extension of osteomyelitisMost are monoarticularBoys more commonly affected than girlsBacterial etiologies: Staph. aureus, Strep. pneumoniae, Strep. pyogenes, H. influenzae (also Group B Strep and gram-negatives in neonates; N. gonorrheae in adolescents)
18 Septic Arthritis, con’t Work-upCBC (leukocytosis with left shift)ESRjoint fluid analysis (WBC, glucose, culture)blood cultureTreatmenthip: immediate surgical drainageage birth to 2 months: oxacillin and gentamicin2 months to 3 years: cefotaxime, ampicillin/clavulanate3 to 12 years: oxacillinadolescents: ceftriaxone
19 Toxic Shock SyndromeStaphylococcus aureus of phage group I that produces epidermal toxin, toxic shock syndrome toxin-I (TSST-I)Also toxin-producing Streptococcus pyogenesPresenting signs/symptoms: fever, hypotension, erythrodermatous sunburnlike rash with subsequent desquamation of palms and soles, multiorgan system involvement (diarrhea, vomiting, myalgias, azotemia, hepatitis, thrombocytopenia, change in mental status)Treatment includes fluid resuscitation, vasopessors, intensive care monitoring, antibioticsMortality due to cardiac arrhythmias, respiratory failure, bleeding
20 Appendicitis Most common pediatric abdominal surgical emergency Polymicrobial with enteric floraAge > 5 years (peak years)Perforation in one-third of cases; more common in age < 6 yearsMid-abdominal pain initially, then RLQ painFever, anorexia, nausea, vomiting, rebound tendernessPsoas and obturator signsElevated WBCImaging modalities most helpful U/S and CT scan
21 Appendicitis, con’tIV antibiotics directed against gram negatives and anaerobesAntibiotics prior to surgeryComplications: peritonitis, abscess, wound infection, multiorgan failure, hernia, adhesions, death
22 Biological Terrorism Features of a potential bioterrorism event multiple patients with same symptomssevere illness among young, previously healthyunusual organismsunusual antibiotic resistance patternsatypical presentationsunusual patterns of disease (geographic clustering)intelligence informationsick or dead animals or plantsadapted from Annals of Emergency Medicine 1999;34:183-90
24 Biological Terrorism Click to link to the CDC web site on biological terrorism
25 ReferencesFleisher GR and Ludwig S, eds. Textbook of Pediatric Emergency Medicine, Fourth Edition. Lippincott Williams and Wilkins, 2000.Reece RM, ed. Manual of Emergency Pediatrics, Fourth Edition. W. B. Saunders Company, 1992.Centers for Disease Control and Prevention. Biological and chemical terrorism: strategic plan for preparedness and response. Morbidity and Mortality Weekly Report 2000;49(RR-4).Richards CF, et al. Emergency physicians and biological terrorism. Annals of Emergency Medicine 1999;34:
26 Questions for Discussion 1 of 8?Questions for DiscussionA sixteen-year-old girl presents with fever and lower abdominal pain but denies urinary urgency or frequency. She is sexually active and uses condoms infrequently.How would you evaluate this patient?
27 2 of 8?Questions, con’tA sixteen-month-old presents with a history of nasal discharge for the past week presents with a swollen, red eye and fevers to 1030 F.What are you most concerned about?How would you evaluate this patient?
28 3 of 8?Questions, con’tA fourteen-year-old male presents with six hours of severe abdominal pain that is now more right sided. He has had no diarrhea.How would you evaluate this patient?How would your approach differ if the patient were a girl?
29 4 of 8?Questions, con’tA 14-month-old girl presents with the sudden onset of fever and refusal to walk.Discuss your differential diagnosis and evaluation of this child.
30 ? Questions, con’t A five-year-old presents with a swollen, red knee. 5 of 8?Questions, con’tA five-year-old presents with a swollen, red knee.Discuss your differential diagnosis and evaluation of this child.
31 6 of 8?Questions, con’tA three-year-old child presents to the Emergency Department with acute onset of stridor and tachypnea.Discuss your approach to this patient, including important aspects of the history and physical exam, the differential diagnosis, and management principles.
32 7 of 8?Questions, con’tA four-month-old baby presents to the Emergency Department with a fever of 1040 F and petechiae.What is your differential diagnosis?How would you evaluate and manage this patient?
33 Questions, con’t8 of 8?A previously healthy 14-month-old presents to the Emergency Department following 2-3 minutes of generalized, symmetric tonic-clonic movements.Discuss your approach to the following scenarios:(a) The child was sleepy initially but is now awake, alert and easily consoled by her parents. Her temperature is 104 F.(b) The child remains somnolent and appears to have nuchal rigidity.