A DUTCH GIRL WITH FEVER AND ABDOMINAL PAIN

Else Bijker, Clinical Lecturer Paediatric Infectious Diseases Oxford

Wessex & Thames Valley infection course 6/11/2020

RISK OF ACQUIRING TUBERCULOSIS AFTER CONTACT

What is the chance of this girl being infected by her teacher?

A. <1%

B. 1-10%

C. 10-50%

D. >50%

E. It depends on…

x

IT DEPENDS ON…

1. Infectivity patient (active untreated pulmonary TB, sputum production, smear positivity, cavities, coughing)

2. Extent of exposure (duration and intensity)

3. Susceptibility contact (age, immunity, underlying illness)

Infectious TB patient (in low-endemic country) -->

1.8% of close contacts: active disease

28% infection

DIAGNOSIS OF TUBERCULOSIS IN CHILDREN

• Testing for TB infection

• TST

• Quantiferon/TB-elispot

• Assessing for TB disease

• History & exam

• Chest Xray

• Sputum/gastric aspirate (3x)/ LP, lymph node biopsy -> microscopy, culture and PCR

TUBERCULIN SKIN TEST

What is the definition of a positive TST?

A. Redness 5mm

B. Redness 5mm (>10mm if BCG vaccinated)

C. Induration 5mm

D. Induration 5mm (>10mm if BCG vaccinated)

x

TUBERCULIN SKIN TEST

What is the definition of a positive TST? According to the NICE Guideline.

A. Redness 5mm

B. Redness 5mm (>10mm if BCG vaccinated)

C. Induration 5mm: regardless of previous BCG vaccination

D. Induration 5mm (>10mm if BCG vaccinated)

INTERFERON-GAMMA RELEASE ASSAY

BONUS QUESTION

• Can the Quantiferon test be used in Ankara?

INTERFERON-GAMMA RELEASE ASSAY

PSITTACOSIS / PARROT FEVER

• Systemic zoonosis

• Chlamydophila psittaci

• Exposure to birds, while not always present, is major risk factor

• Incubation 5-14 days

• Wide range in both disease severity and in spectrum of clinical features

• Typically fever, headache, myalgia, and cough; ‘atypical pneumonia’

• Diagnostic testing: serology/PCR

• Treatment: doxycycline/azithromycin

Stewardson & Grayson. Psittacosis. Infect Dis Clin N Am 24 (2010) 7–25

Retrospective single-centre 2010-2019

110 children (0-18 years) with PUO

53 patients (48%): FDG-PET/CT identified cause of fever (e.g. endocarditis (11%), systemic juvenile

idiopathic arthritis (5%), inflammatory bowel disorder (5%))

42 patients (38%), no cause of fever found on FDG-PET/CT

58 out of 110 patients (53%): treatment modifications made after FDG-PET/CT.

• The Netherlands: 452 paediatric scans Jan 2016-Aug2017

• 64 scans (14%): infection or inflammation in differential

diagnosis

• Diagnostic scans: performed after a median of 41 days of

symptoms (IQR 20–128 days)

PET-CT: RADIATION RISK

• +- 21 mSv -> 9 mSv low dose CT (CT +-4/5 of dose, PET 1/5)

• Background radiation dose: 3 mSv/year

150 mSv

• Reactive arthritis

• Acute symmetrical polyarthritis, involving large and small joints

• Associated with active TB (pulmonary, miliary, extrapulmonary)

• Rare

• Resolves after initiation of TB therapy

Kikuchi disease

Kikuchi-Fujimoto disease

Histiocytic necrotizing lymphadenitis

Pathology: histiocytes,

plasmacytoid monocytes, T cells,

necrosis

Most common in young women

in Far East

First reported by Japanese

pathologists Kikuchi and

Fujimoto in 1972

Self-resolving.

For severe cases: steroids, IVIG, chloroquine

PATHOGENESIS

HHV-8

6/26 patients1

1Huh et al. Hum Pathol. 1998. 2Zhang et al. Viral Immunol. 2007.

Parvo B19

87% patients

56% controls2

EBV

12/57 patients PCR+

5/207 IgM+

Auto-immunity T-cells/histiocytes

Pre-disposing genetic

background (HLA

DPA1*01 and DPB1*0202)

???

Upregulation interferon

associated genes - apoptosis

HHV-7, HTLV-1, Toxoplasma,

Yersinia, Giardia, Torque teno virus?

Kikuchi’s

disease

CLINICAL PRESENTATION OF KIKUCHI DISEASE IN CHILDREN

0

10

20

30

40

50

60

70

80

90

100 Most children present with lymphadenopathy and

fever, but a wide range of other symptoms can occur.

Histopathology is crucial to confirm the diagnosis of

Kikuchi disease.

LOCATION OF LYMPHADENOPATHY

Cervical: 96%

Axillary: 4%

Supraclavicular: 2%

Abdominal: 2%

Inguinal: 2%

Generalized: 0.2 %

Not determined 0.1%