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Pediatric Review
Richard Arias, MPAS, PA-C, DFAAPA
June 2014
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Pulmonary Medicine
Bronchiolitis
Cystic Fibrosis
Pneumonia
Tb
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Bronchiolitis
An obstructive pulmonary disease
Attacks infants and young children
Most often caused by RSV infection
Smoking household/crowed conditionsincreases occurrence
Is a clinical diagnosis: prodrome followedby cough, nasal flaring, lethargy, andtachypnea
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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 insuffiencyMedian survival 30 years of age
Persistent pulmonary infections
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Pneumonia
Infection of inflammation of the lung
parenchyma
Most episodes in young children result
from viral infection
A smaller percentage results from bacterial
infection
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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
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Signs & Symptoms
Viral
Prodrome
progresses toSOB,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 feedingelevated WBCS with
PMNS
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CXR
Viral
Patchy broncho-
pneumonia
Bacterial
Consolidation, plural
effusion
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Pneumonia Types
Group Bstrepleading cause ofpneumonia in neonates
Chlalmydia trachomatis is a common causeamong young infants, 2-3mo
Pneumococcus is the most common cause
of bacterial pneumoniaAtypical pneumoniaMycoplasm and
chlamydia pneumonia
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Laboratory Evaluation
Diagnostic Laboratory workup for childrenis extensive
WBC counts are typically high, withpredominance of PMNs in bacterialPneumonia
Typical chest radiographic findings forviral, Mycoplasma, and bacterialpneumonia are distinctive
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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
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Complications
Pleural effusion
Empyema
Lung abscess
Bronchiectasis
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Prognosis
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Tuberculosis
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Etiology
Due to infection by Mycobacterium
tuberculosis, an acid-fast bacillus
Majority of infected persons so not developactive disease
Transmitted from person to person via
respiratory droplets
Highly contagious and difficult to diagnose
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Epidemiology
One of the most common worldwide
causes of infection-related death
In infected, immunocompetent patients, thelifetime risk of developing desease is
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Diagnosis
PPD reaction after 24-48 hours
- 15mm induration is a positive test
PPD reaction positiveobtain 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
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Treatment
TB infection
- INH prophylaxis for 9 months
- Administer vit. B6 to adolescents and
adults to prevent INH-induced neuropathy
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Treatment
TB disease
- begin therapy with INH, rifampin,and
pyrazinamide- Adjust therapy according to drug susceptibility of
isolates from sputum or gastric aspiratespecimens
- Usual duration of RX is 6mo or until repeatspecimens are negative
- Direct-observed therapy by healthcare worker toensue compliance
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Prognosis/Clinical Course
Treatment is complicated by the need for
multiple drugs over a prolonged time
Strict infection-control measures arenecessary
Up to 3 million deaths occur annually
worldwide
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Pediatric Cardiology
Aortic stenosis
Pulmonic stenosis
Aortic coarctation
Left to right shunt lesions
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Aortic Stenosis
5% of all CHD M:F = 4-1
Most asymptomatic
Chest pain, CHF is severeUsually 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
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Pulmonic Stenosis
5-8% of Congenital heart ds
Symptoms vary depending on severity of
the stenosis
Systolic murmur with ejection click
,
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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
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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
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Diagnosis
Fourextremity blood Pressures
EKG:right ventricular hypertrophy in
neonates ; left ventricular hypertrophy inolder child/adolescents
CXR: Variable
Echocardiography (with Doppler) is
diagnostic
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Treatment
Surgical Repair
Neonates with CHF/cardiogenic shock
should be treated medically prior tosurgical repair
Balloon angioplasty
Lifelong bacterial endocarditis prophylaxis
is beneficial
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Left to Right Shunts Lesions
ASD
VSD
PDA
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ASD
Shunting of fully oxygenated blood back
into the lung
Fixed widely split S2
SEM @ LUSB
EKG usually normal
CXR: cardiomegaly, increased pulmonary
markings
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PDA
Bounding pulses
Continuous murmur @ LUSB and
subclavicular area
EKG: normal or LVH
CXR: large LA/LV
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Pediactric GI Illnesses
Pyloric Stenosis
Intusussception
Hirschprungs
Meckels
Anal fissures
Henoch-Schonlein purpura
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Pyloric Stenosis
M>F, spring births
projectile vomiting
palpable abd mass
Rx: surgical release of pylorus
DD: formula intolerance
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Intusussception
Most occur in children < 1 year old
intermittent colicky abdominal pain
vomiting (80%0
currant jelly stool (95% of infants/65% of olderchildren)
sausage shaped mass in abdomen (85%)
Dx& Rx:Sonogram / instillation of contrastagents, saline, or air
failure needs surgery
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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 of40-50% of newborn intestinal obstruction
older children: chronic constipation
urge to deficate is rare b/c stools are retained proximal tothe anorectum
DX: absence of plexus ganglion on pathology
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Meckels
Blind omphalomesenteric duct causing an
antimesenteric outpouching of ileum
2:1 male predominancemost are asymptomatic
S&S: painless rectal bleeding, intestinal
obstruction, pain mimicking appendicitis
RX: wide wedge resection of diverticulum
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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
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7/23/2014
Pediatric ID
Meningitis
Rubeola
Rubella
Varicella
Roseola Infantum
Fifths Disease
Herpes Simplex
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contd
Scarlet Fever
Kawasaki
Lyme
Steven Johnson Syndrome
Epiglottitis
Laryngeotracheobronchitis
Pertussis
Fever Without Source
Fever of Unknown Origin
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Meningitis
Bacterial meningitis is especially commonin winter
70% of cases occur in children
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RX:
Hospitalize
Isolate
Bacterial: Third-generation cephalosporin
plus vancomycin
antipyretic
follow-up: hearing, cognitive,
neuromuscular function
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Rubeola (Measles)
Paramyxovirus
winter & spring
spread via droplets
incubation 9-14 days
contagious 7 days after exposure and 5
days after cough
KOPLIK SPOTS
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FOUR Cs
COUGH
CORYZA
CONJUNCTIVITIS / PHOTOPHOBIA
CONFLUENT MACULOPAPULAR
RASH starts centrally & spreads peripherally
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Treatment
Supportive
passive immunoglobulin for
immunocompromisedacute exposure vaccinate within 3
days/after 3 days give gammaglobulin
PREVENTION BY VACCINATIONComplications:pnuemonia, otitis,
encephalitis, myocarditis
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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
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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 inimmunocompromised patients
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Roseola Infantum
Herpes 6
6-18 months old
incubation 7-14 days/ spring & fall
S & S-high fever w/ or w/out febrile seizure forthree days followed by exanthem
edema of eyelids or exudative tonsillitis
Rx: supportive PCN for + throat culture
seizure prevention
Fif h Di
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Fifths Disease
(Erythema Infectiosum)
Parovirus
preschool-school aged children
incubation 7-28 days
S & S nonspecific febrile illness x 1-2 daysfollowed 5-6 days later with a slapped cheekappearance
Rx: supportiveComplications:arthritis,hemolytic anemia,
encephalopathy, pneumonitis
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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
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Rx: PCN
Complications: sinusitis, mastoiditis,
cervical adenitis, osteomyelitis, rheumaticfever, glomerulonephritis.
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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
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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
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Rx: IV human gamma globulin in early
active febrile disease prevents cardiac
complicationssurgery for cardiac stenotic lesions
heparin for anuerysms
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Lyme
Deer tick borne by spirochete Borrelia
burgdorferi
Stage 1: localized erythema migrans, migratorymusculoskeletal 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
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Rx: Stage 1: ampicillin or Doxy
Stage 2: Ceftriaxone (crosses BBB)
Stage 3: Amp/PCN, Ceftriaxone
PREVENT TICK BITES
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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 signRx: oxygen, IV abx (2nd -3rd generation
cephalosporin), protect airway
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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,
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Pertussis
Bordatella pertussis
3 stages:
1. Catarrhal 1-2 weeks rhinorrhea, mild cough, lowgrade fever .
2. Paroxysmal 2-4 weeks forceful cough,
inspiratory whoop, facial redness, bulging eyes,
lacrimation, vomiting 3. Convalescence decreased cough & vomiting
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CXR: perihilar infiltrate
Rx: erythro
prevention by vaccination
Complications: pneumonia, otitis, epistaxis ruptured diapraghm
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Fever Without Source
Pts with fever>100.4, but the source offever is not obvious
20% of childhood fevers have no apparentcause
Commonly seen in children between 1moand 3yrs
Children
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Fever of Unknown Origin
Defined as a prolonged fever >21 days
An explanation for the fever is eventually
found in 90% of casesInfections account for 1/3 of cases
Some patients never have a final DX
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