Pediatric Review

Richard Arias, MPAS, PA-C, DFAAPA

June 2014
Pulmonary Medicine
Bronchiolitis
Cystic Fibrosis
Pneumonia
Tb



Bronchiolitis
An obstructive pulmonary disease
Attacks infants and young children
Most often caused by RSV infection
Smoking household/crowed conditions
increases occurrence
Is a clinical diagnosis: prodrome followed
by cough, nasal flaring, lethargy, and
tachypnea
Cystic Fibrosis
Most common autosomal recessive illness
Genetic based protein deficit
Predominantly in White Europeans
Manifests in first year
Impact on respiratory tract
90% have pancreatic insuffiency
Median survival 30 years of age
Persistent pulmonary infections
Pneumonia
Infection of inflammation of the lung
parenchyma
Most episodes in young children result
from viral infection
A smaller percentage results from bacterial
infection
Pathophysiology
Organisms that cause viral pneumonia are
also common causes of viral URI
Bacterial causes vary with age of the child
Intracellular organisms such as Chlamydia
trachomatis, M. pneumoniae, cause lower
respiratory tract disease
Signs & Symptoms
Viral
Prodrome
progresses to
SOB,course rhonchi,
nasal flaring,
tachypnea, wheezing
normal or slightly inc.
WBC
Bacterial
acute onset
toxic appearance
pleuritic chest pain,
chills, high fever, fine
rales, poor feeding
elevated WBCS with
PMNS
CXR
Viral
Patchy broncho-
pneumonia


Bacterial
Consolidation, plural
effusion
Pneumonia Types
Group B strep leading cause of
pneumonia in neonates
Chlalmydia trachomatis is a common cause
among young infants, 2-3mo
Pneumococcus is the most common cause
of bacterial pneumonia
Atypical pneumonia Mycoplasm and
chlamydia pneumonia
Laboratory Evaluation
Diagnostic Laboratory workup for children
is extensive
WBC counts are typically high, with
predominance of PMNs in bacterial
Pneumonia
Typical chest radiographic findings for
viral, Mycoplasma, and bacterial
pneumonia are distinctive
Management
Antimicrobial treatment of bacterial
pneumonia is appropriate
Outpatient management is sufficient
Close observation is necessary until
children improve
Decisions regarding hospitalization are
base on severity of sxms
Complications
Pleural effusion
Empyema
Lung abscess
Bronchiectasis
Prognosis
<1% mortality except for staph which is
10-30%
May result in empyema or lung abscess
Tuberculosis
Etiology
Due to infection by Mycobacterium
tuberculosis, an acid-fast bacillus
Majority of infected persons so not develop
active disease
Transmitted from person to person via
respiratory droplets
Highly contagious and difficult to diagnose

Epidemiology
One of the most common worldwide
causes of infection-related death
In infected, immunocompetent patients, the
lifetime risk of developing desease is
<10%
In HIV patients, the annual risk of
developing Tb is 7-10%
Diagnosis
PPD reaction after 24-48 hours
- <5mm induration is a negative test
- >15mm induration is a positive test
PPD reaction positive obtain CXR
TB exposure: PPD is neg. and cxr is neg.
TB infection: PPD is pos. but cxr is neg.
TB disease: PPD and CXR are positive


Treatment
TB infection
- INH prophylaxis for 9 months
- Administer vit. B6 to adolescents and
adults to prevent INH-induced neuropathy

Treatment
TB disease
- begin therapy with INH, rifampin,and
pyrazinamide
- Adjust therapy according to drug susceptibility of
isolates from sputum or gastric aspirate
specimens
- Usual duration of RX is 6mo or until repeat
specimens are negative
- Direct-observed therapy by healthcare worker to
ensue compliance
Prognosis/Clinical Course
Treatment is complicated by the need for
multiple drugs over a prolonged time
Strict infection-control measures are
necessary
Up to 3 million deaths occur annually
worldwide
Pediatric Cardiology
Aortic stenosis
Pulmonic stenosis
Aortic coarctation
Left to right shunt lesions
Aortic Stenosis
5% of all CHD M:F = 4-1
Most asymptomatic
Chest pain, CHF is severe
Usually progressive
PE: normal BP, narrow pulse pressure in
severe AS, ejecton click, 2-4/6 harsh SEM
@RU SB/LUSB w/radiation to neck
EKG and CXR normal in most cases
Pulmonic Stenosis
5-8% of Congenital heart ds
Symptoms vary depending on severity of
the stenosis
Systolic murmur with ejection click
,
Diagnosis
EKG: normal or variable degrees of right
ventricular hypertrophy
CXR: often normal
Echocardiography (with Doppler) is
diagnostic
Coarctation of the Aorta
8-10% of all congenital heart disease
Incidence of 3.2/10,000 live births
2:1 male to female predominance
85% also have a bicuspid aortic valve
May be associated with Turner syndrome
Signs/Symptoms
Symptomatic neonates exhibit evidence of
CHF/cardiogenic shock
Typically have a gallop rhythm
Differential strength of pulses is less
obvious until CHF/shock is treated

Diagnosis
Four extremity blood Pressures
EKG:right ventricular hypertrophy in
neonates ; left ventricular hypertrophy in
older child/adolescents
CXR: Variable
Echocardiography (with Doppler) is
diagnostic
Treatment
Surgical Repair
Neonates with CHF/cardiogenic shock
should be treated medically prior to
surgical repair
Balloon angioplasty
Lifelong bacterial endocarditis prophylaxis
is beneficial
Left to Right Shunts Lesions
ASD
VSD
PDA
ASD
Shunting of fully oxygenated blood back
into the lung
Fixed widely split S2
SEM @ LUSB
EKG usually normal
CXR: cardiomegaly, increased pulmonary
markings
VSD
Magnitude of shunt depends on systemic
pressure and vascular resistance
Thrill palpated @ LLSB
Widely split S2 w/holosystolic murmur
@LLSB
EKG: normal or LVH if large deficit
CXR: cardiomegaly, increased pulmonary
markings

PDA
Bounding pulses
Continuous murmur @ LUSB and
subclavicular area
EKG: normal or LVH
CXR: large LA/LV
Pediactric GI Illnesses
Pyloric Stenosis
Intusussception
Hirschprungs
Meckels
Anal fissures
Henoch-Schonlein purpura

Pyloric Stenosis
M>F, spring births
projectile vomiting
palpable abd mass
Rx: surgical release of pylorus
DD: formula intolerance


Intusussception
Most occur in children < 1 year old
intermittent colicky abdominal pain
vomiting (80%0
currant jelly stool (95% of infants/65% of older
children)
sausage shaped mass in abdomen (85%)
Dx& Rx:Sonogram / instillation of contrast
agents, saline, or air
failure needs surgery
Hirschprungs
Congenital aganglionic megacolon
assoc w/ Downs and other congenital
anomaliesM:F=4:1
newborn DX: failure to pass meconium in first 48 hours
followed by abd distention & bilious vomiting. Cause of
40-50% of newborn intestinal obstruction
older children: chronic constipation
urge to deficate is rare b/c stools are retained proximal to
the anorectum
DX: absence of plexus ganglion on pathology
Meckels
Blind omphalomesenteric duct causing an
antimesenteric outpouching of ileum
2:1 male predominance
most are asymptomatic
S&S: painless rectal bleeding, intestinal
obstruction, pain mimicking appendicitis
RX: wide wedge resection of diverticulum
Anal Fissures
Perianal fissures are the most common
cause of massive bright blood per rectum
in children
usually caused by passing large hard stool
or straining
cystic fibrosis or parasitic infections must
be ruled out
Henoch - Schonlein Purpura
Most common vasculitis in children
immunoglobulin IgA mediated
etiology unknown
purpuritic rash on lower extremities and
buttocks
abdominal pain most common complaint
7/23/2014
Pediatric ID
Meningitis
Rubeola
Rubella
Varicella
Roseola Infantum
Fifths Disease
Herpes Simplex


contd
Scarlet Fever
Kawasaki
Lyme
Steven Johnson Syndrome
Epiglottitis
Laryngeotracheobronchitis
Pertussis
Fever Without Source
Fever of Unknown Origin



Meningitis
Bacterial meningitis is especially common
in winter
70% of cases occur in children <2 yrs of
age
Neisseria gonorrhoeae: Peak ages 6-12
months and teens
Viral Meningitis is more common in spring
and summer
RX:
Hospitalize
Isolate
Bacterial: Third-generation cephalosporin
plus vancomycin
antipyretic
follow-up: hearing, cognitive,
neuromuscular function
Rubeola (Measles)
Paramyxovirus
winter & spring
spread via droplets
incubation 9-14 days
contagious 7 days after exposure and 5
days after cough
KOPLIK SPOTS
FOUR Cs
COUGH
CORYZA
CONJUNCTIVITIS / PHOTOPHOBIA
CONFLUENT MACULOPAPULAR
RASH
starts centrally & spreads peripherally
Treatment
Supportive
passive immunoglobulin for
immunocompromised
acute exposure vaccinate within 3
days/after 3 days give gammaglobulin
PREVENTION BY VACCINATION
Complications:pnuemonia, otitis,
encephalitis, myocarditis
Rubella (German Measles)
Rubivirus
incubation 14-21 days
no prodromemild coryza, fever
conjunctivitis without photophobia
suboccipital and postauricular adenopathy
Forschmyer spots on palate
maculopapular rash central to periphery
Rx: supportive
passive immune globulins
Complications: congenital rubella produces
congenital heart disease, mental
retardation, deafness, encephalitis
most risk in first trimester
Varicella (Chicken Pox)
Herpes virus -varicella
January - May/5-9 year olds
incubation 14-21 days
contagious 1 day prior and five days after rash
appears or is crusted
S & S: prodrome of fever, URI, pruritis
lesion stages: maculopapular-vesicles-pustules-
crusting
Recurs as herpes zoster
See giant cell on microscopy of vesicle
Rx: supportive
Caladryl
prevent scratching
avoid ASA
Vidarabine for varicella pneumonia
IV Acyclovir for pneumonia in
immunocompromised patients
Roseola Infantum
Herpes 6
6-18 months old
incubation 7-14 days/ spring & fall
S & S-high fever w/ or w/out febrile seizure for
three days followed by exanthem
edema of eyelids or exudative tonsillitis
Rx: supportive
PCN for + throat culture
seizure prevention
Fifths Disease
(Erythema Infectiosum)
Parovirus
preschool-school aged children
incubation 7-28 days
S & S nonspecific febrile illness x 1-2 days
followed 5-6 days later with a slapped cheek
appearance
Rx: supportive
Complications:arthritis,hemolytic anemia,
encephalopathy, pneumonitis
Herpes Simplex
Herpes virus hominus (different than herpangina
caused by Coxsackie)
close body contact/break in skin
virus carried in latent stage
S & S: vesicular lesion
Tzanck stain-multinuclear giant cells &
intranuclear inclusions
RX: supportive, C-section if neonatal herpes risk
topical acyclovir
Scarlet Fever
Staph-no exanthem
Strep-no exanthem
incubation 1-7 days
S & S: days 1-2: fever, sore throat, sandpaper rash
days 2-3: white strawberry tongue
days 5-6; strawberry red tongue, petechial lesions
on pharynx 7 tonsils

Rx: PCN
Complications: sinusitis, mastoiditis,
cervical adenitis, osteomyelitis, rheumatic
fever, glomerulonephritis.
Kawasaki
Occurs sporadically or in epidemics
etiology unknown
S & S: irritability, altered mental status, cough,
vomiting, diarrhea, abd pain, fever, bilateral
conjunctivitis
*****cardiac manifestations
10-40 % coronary vasculitis--dilated or aneurysmal arteries
Diagnostic Criteria
Fever lasting at least five days
4 of 5 of the following:
bilateral nonpurulent conjunctival injection
oropharyngeal mucosa changes-infected pharynx,
infected lips, strawberry tongue
changes of peripheral extremities-edema/erythema of
hands or feet,desquamation
rash-truncal/nonvesicular
cervical lymphadenopathy
Rx: IV human gamma globulin in early
active febrile disease prevents cardiac
complications
surgery for cardiac stenotic lesions
heparin for anuerysms
Lyme
Deer tick borne by spirochete Borrelia
burgdorferi
Stage 1: localized erythema migrans, migratory
musculoskeletal pains
Stage 2: disseminated disease in un Rx pts
causing CNS, CV and MS system involvement
Stage 3: persistent infection causing progressive
arthritis, depression , intellectual impairment
Rx: Stage 1: ampicillin or Doxy
Stage 2: Ceftriaxone (crosses BBB)
Stage 3: Amp/PCN, Ceftriaxone

PREVENT TICK BITES
Steven Johnson Syndrome
Erythema Multiforma Exudatum major
drug rxn i.e. INH, PCN, anticonvulsants
S & S: fever, rash (target or iris lesions
appearing at mucocutaneous junction
Rx: ophtho consult for corneal ulcer
supportive, Abx for secondary infections,
10% mortality 20% recurrence
Epiglottis
H. flu type B, Strep group B, Staph
2-7 yo, all year long, rare recurrence
S & S: fever, sore throat, dyspnea, resp.
distress, prostration, dysphagia, drooling,
stridor, brassy cough, toxic
Soft tissue neck x-ray: thumb sign
Rx: oxygen, IV abx (2nd -3rd generation
cephalosporin), protect airway
Laryngotracheobronchitis
Parainfluenzae type 1 & 3
most common viral form of croup
8 months - 5 years old, wintertime
S & S: prodromal URI, inspiratory stridor,
barking cough,
CXR: steeple sign
Rx: steam, cool mist,
Pertussis
Bordatella pertussis
3 stages:
1. Catarrhal 1-2 weeks rhinorrhea, mild cough, low
grade fever .
2. Paroxysmal 2-4 weeks forceful cough,
inspiratory whoop, facial redness, bulging eyes,
lacrimation, vomiting
3. Convalescence decreased cough & vomiting
CXR: perihilar infiltrate
Rx: erythro
prevention by vaccination
Complications: pneumonia, otitis, epistaxis
ruptured diapraghm
Fever Without Source
Pts with fever>100.4, but the source of
fever is not obvious
20% of childhood fevers have no apparent
cause
Commonly seen in children between 1mo
and 3yrs
Children <3mo are a greaer risk of serious
bacterial infections
Fever of Unknown Origin
Defined as a prolonged fever >21 days
An explanation for the fever is eventually
found in 90% of cases
Infections account for 1/3 of cases
Some patients never have a final DX