13                                                   Serious illnesses                                                   •...
212      SERIOUS ILLNESSES                                                       •     A rubbing noise (friction rub) hear...
SERIOUS ILLNESSES    21313-6 How is acute rheumatic fever treated?         which records the monthly injections. Careful  ...
214     SERIOUS ILLNESSESChildren with chronic rheumatic heart disease                  and complement to form immune comp...
SERIOUS ILLNESSES    21513-15 What are the complications of acute              13-17 How can acute glomerulonephritisglome...
216      SERIOUS ILLNESSES      is, therefore, often difficult to make an                                                 ...
SERIOUS ILLNESSES   217meningitidis). Meningococcus is transmitted          13-28 How is meningococcal infectionfrom perso...
218      SERIOUS ILLNESSES•     Neck stiffness. It is painful if the patient     and antibiotics can be stopped once the r...
SERIOUS ILLNESSES   219has prevented most cases of haemophilus                        13-37 What are the clinical features...
220      SERIOUS ILLNESSESof management steps is required. Treating            the blood leading to a very high blood gluc...
SERIOUS ILLNESSES    221•     Hypoglycaemia                                    abnormal neurological signs after the child...
222   SERIOUS ILLNESSES  NOTE Less common malignancies in children          2. What are the other major criteria?  include...
SERIOUS ILLNESSES   2231. What is the probable diagnosis?                  that he has a fine rash which reminds her of   ...
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Child Healthcare: Serious illnesses


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Child Healthcare addresses all the common and important clinical problems in children, including:immunisation history and examination growth and nutrition acute and chronic infections parasites skin conditions difficulties in the home and society.

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Child Healthcare: Serious illnesses

  1. 1. 13 Serious illnesses • Acute rheumatic fever Objectives • Acute glomerulonephritis • Septicaemia, especially meningococcal When you have completed this unit you septicaemia should be able to: • Meningitis • Diagnose and manage acute • Pyelonephritis rheumatic fever. Some serious illnesses, such as pneumonia and • Diagnose and manage acute typhoid, are discussed in other units. glomerulonephritis. • Diagnose and manage septicemia and meningitis. • Diagnose and manage pyleonephritis. ACUTE RHEUMATIC FEVER • Diagnose and refer children with diabetes or epilepsy. • List the warning signs of childhood 13-2 What is acute rheumatic fever? cancer. Acute rheumatic fever is the most common cause of acquired heart disease in children, especially in poor, overcrowded communities.INTRODUCTION It is a complication of pharyngitis (a throat infection) caused by Streptococcus bacteria. An unusual immune response by the body13-1 What serious bacterial infections are to this bacterial infection damages the joints,seen in children? heart and other tissues of the body. The exactThese are illnesses which can result in death if mechanism whereby this happens is still notthey are not correctly managed. Every effort fully understood. Acute rheumatic fever ismust be made to prevent them, recognise them usually seen in children aged 5 to 15 years.early and treat them correctly. Many serious NOTE Many strains of Group A beta haemolyticillnesses which are rarely seen in children in Streptococcus can cause rheumatic fever which isdeveloped countries, are still major problems in a multisystem disease affecting the heart, joints,poor communities with overcrowding. skin and brain. Recent studies suggest that skin infections (impetigo) may also cause rheumaticImportant serious illnesses include: fever.
  2. 2. 212 SERIOUS ILLNESSES • A rubbing noise (friction rub) heard Rheumatic fever is the most common cause of on auscultation, which indicates an acquired heart disease in children in developing inflammation of the pericardium countries. (pericarditis)13-3 What are the clinical features of acute 13-5 How is the clinical diagnosis of acuterheumatic fever? rheumatic fever made?Acute rheumatic fever develops 2–3 weeks By documenting a Streptococcal infection plusafter a Streptococcal pharyngitis. The classical 2 major or 1 major and 2 minor criteria.features of acute rheumatic fever are: The major criteria are:• Fever • Flitting polyarthritis• A ‘flitting’ polyarthritis. Pain, redness and • Carditis swelling (arthritis) of a number of joints • Erythema marginatum (polyarthritis) where the arthritis moves • Nodules within days from joint to joint (flitting). • Chorea Usually the large joints (elbows, knees) are involved. The minor criteria are:• Carditis • Fever• Eythema marginatum. A short-lived • Arthralgia (joint pain only) without erythematous (pink) rash which forms arthritis irregular patterns on the trunk. • Blood tests indicating inflammation, i.e.• Subcutaneous nodules. Small, non tender raised erythrocyte sedimentation rate lumps under the skin over the elbows, (ESR), raised C reactive protein (CRP) or a knuckles, wrists, knees and spine. leucocytosis (raised white cell count)• Chorea. Usually seen in girls who become • An abnormal electrocardiogram (ECG) clumsy and very emotional with unusual especially a prolonged PR interval (do not jerky movements. Their handwriting use this minor criteria if carditis is used as deteriorates and they have difficulty a major criteria) doing up buttons due to the abnormal movements. Chorea may only appear NOTE These are the modified Duckett-Jones months after the throat infection. criteria. A Streptcoccal infection is documented by a positive throat culture or a raisedChildren with acute rheumatic fever do not antistreptolysin O titre. A blood culture is usefulnecessarily develop all the classical signs. The to exclude bacterial endocarditis which should berash, subcutaneous nodules and chorea are less considered in any child with fever and a murmur.common signs of acute rheumatic fever. Two minor criteria are needed to diagnose acute rheumatic fever in a child with establised rheumatic heart disease.13-4 What are the signs of carditis? Always suspect acute rheumatic fever in anCarditis is an inflammation of the heart. The unwell child older than 3 years who presentsheart muscle, valves and pericardium are with fever, tachycardia and shortness of breathinvolved. The signs of carditis are: or painful joints.• A heart murmur due to inflammation or damage to one or more heart valves Strict clinical criteria are used to diagnose acute• Tachycardia, especially when resting or asleep. Signs of heart failure may develop rheumatic fever. (e.g. shortness of breath).• An enlarged heart seen on chest X-ray
  3. 3. SERIOUS ILLNESSES 21313-6 How is acute rheumatic fever treated? which records the monthly injections. Careful follow up is essential.1. Bed rest until all signs of acute rheumatic fever have disappeared and the resting heart rate is normal. All children with 13-9 What are the possible outcomes of acute rheumatic fever should be admitted acute rheumatic fever? to hospital if possible Acute rheumatic fever should resolve in 42. Amoxycillin 10 mg/kg 6 hourly orally for weeks. Some children recover completely 10 days or a single dose of benzathine while others are left with permanent damage penicillin 1.2 million units intramuscularly. to their hearts. Acute rheumatic fever tends to3. Aspirin for symptomatic relief of fever and recur and the risk of permanent heart damage joint pain. Acute rheumatic fever is one (rheumatic heart disease) increases with each of the very few indication for aspirin in acute attack. Every effort must therefore be children. made to prevent repeat attacks.4. Observe closely for signs of heart failure. One or more attacks of acute rheumatic fever can cause permanent damage to one or more13-7 How can the first attack of acute heart valves. This is called chronic rheumaticrheumatic fever be prevented? heart disease. Leaking of the mitral valveIt is difficult to know if an acute sore throat (mitral incompetence) or narrowing of theis due to a virus or Streptococcus. Therefore, mitral valve (mitral stenosis) are the mostantibiotics should be given to all children common permanent valve defects. Damageunder 15 years who have a fever and sore to a valve or damage to the heart muscle canthroat (pharyngitis) without the signs of a cause heart failure.common cold, i.e. blocked nose and nasaldischarge. Oral penicillin, amoxycillin Every effort must be made to prevent repeatedor erythromycin for 5 days are needed.However, it is also important that antibiotics attacks of acute rheumatic fever.are not given to all children with a viralupper respiratory tract infections such as the 13-10 What are the features of chroniccommon cold or influenza. rheumatic heart disease?With the more frequent use of antibiotics, These children are often underweight andacute rheumatic fever has become uncommon have delayed developmental milestones duein wealthy countries. to their heart disease. Their schooling may be interrupted. On examination they have13-8 How can repeated attacks of acute signs of leaking (incompetent) or narrowedrheumatic fever be prevented? (stenotic) heart valves. They may also have signs of heart failure.Repeated attacks of acute rheumatic fever canbe prevented in children, who have previously These children are at great risk of developingsuffered one or more attacks, by giving infective endocarditis after dental proceduresbenzathine penicillin (Bicillin LA) 1.2 million (bacteria enter the blood stream and then stickunits intramuscularly every 4 weeks (600 000 to the heart values where they cause infectionunits if the child weighs less than 30 kg). This and damage). The dentist should give a dose ofmust be continued until adulthood when prophylactic antibiotic before the procedure.it should be reviewed. As the injections are NOTE A large single oral dose of amoxycillin orpainful, the child and family must understand clindamycin an hour before dental extractionthat it is most important to prevent ongoing reduces the risk of bacterial endocarditis onheart damage. The mother should keep a card damaged valves.
  4. 4. 214 SERIOUS ILLNESSESChildren with chronic rheumatic heart disease and complement to form immune complexesmust be managed by a special cardiac clinic which are deposited in, and damage, theteam. It is very important that they do not glomeruli.have any further attacks of rheumatic fever.Most children can be managed with drugs 13-13 What are the presenting signs ofto control heart failure but some will require acute glomerulonephritis?cardiac surgery. • Haematuria and proteinuria. There may be obvious blood in the urine seen with13-11 What are the clinical symptoms and the naked eye (dark urine). Markedsigns of heart failure? haematuria looks like dilute Coca Cola.• Tiredness with exhaustion after only a little The red cells can also be seen under the exercise microscope. Haematuria and proteinuria• Shortness of breath and wheezing, can be detected with reagent strips. especially when lying flat • Decreased urine volume (oliguria).• Swelling of the ankles due to oedema In severe cases there may be no urine• An enlarged liver produced (anuria). • Oedema of the face (especially in theThere are many causes of heart failure, morning) and feet (especially in theincluding acute rheumatic fever, chronic evenings)rheumatic heart disease, congenital heart • Hypertensiondisease and severe anaemia. The severity of signs varies widely. In many children the condition is asymptomatic andACUTE would only be diagnosed by testing the urine for blood and protein, or by measuring theGLOMERULONEPHRITIS blood pressure.13-12 What is acute glomerulonephritis? Acute glomerulonephritis usually presents with dark urine, reduced urine output and oedema.It is an acute inflammation of the kidneywhich follows a few weeks after an infection NOTEOedema plus marked proteinuria withoutwith Streptococcus. The infection is usually haematuria suggests nephrotic syndrome.of the skin (i.e. impetigo) but may follow athroat infection (therefore often called acute 13-14 What is the clinical course of acutepost-streptococcal glomerulonephritis). The glomerulonephritis?inflammation of the kidney is the result of anunusual response to the infection by the body’s Most children present with oedema and visibleimmune system. Antibodies produced against haematuria. However, hypertension can occurthe Streptococcus damage the kidney. This is with no oedema and with haematuria onlysimilar to the immune response which results detected on reagent strips.in acute rheumatic fever. Again, the reason for Children usually recover completely. By 2this unusual response is not fully understood. weeks the urine output increases and the NOTE Damage to the glomeruli of both kidneys oedema and hypertension disappear. The urine results in blood and protein leaking into the urine may remain dark (due to blood) for up to 6 and a decrease in urine production. Retained weeks but blood may be detected on reagent fluid causes oedema and fluid overload. Although strips for a few months. there are many causes of glomerulonephritis, acute glomerulonephritis is usually post- It is very important to look for signs of streptococcal. Proteins from specific strains of complications. Group A Streptococcus combine with antibodies
  5. 5. SERIOUS ILLNESSES 21513-15 What are the complications of acute 13-17 How can acute glomerulonephritisglomerulonephritis? be prevented?• Hypertensive encephalopathy which Most cases occur in children over the age of 2 usually presents with headaches, vomiting, years in poor communities where Streptococcal drowsiness and convulsions. This may be infections, especially of the skin are common. the first sign of acute glomerulonephritis. It is important that skin infections are treated• Pulmonary oedema and heart failure due to promptly with local antiseptics (e.g. Savlon). fluid overload. This presents with breathing Scabies, which is often complicated by difficulties, especially when lying down. impetigo, should be treated. Oral penicillin• Acute renal failure with raised serum urea should be given for 5 days if there is extensive and creatinine impetigo. The more frequent use of antibiotics in developed countries has resulted in a13-16 What is the management of a child fall in the number of children with acutewith acute glomerulonephritis? glomerulonephritis (and acute rheumatic fever). However, this is not a reason to give1. Refer the child to hospital if possible. antibiotics to every child with a few patches of2. Oral phenoxymethyl penicillin (penicillin impetigo that can be treated locally. V) 12.5 mg/kg 6 hourly or oral amoxycillin for 10 days to treat the Streptococcal infection.3. Restrict the daily fluid intake to 20 ml/kg SEPTICAEMIA plus the volume of the previous day’s urine output. It is important to keep a careful 13-18 What is septicaemia? check on the fluid intake and output.4. Weigh daily to assess fluid status. Septicaemia is an acute serious illness caused5. Low sodium and low protein diet until the by bacterial infection of the blood. This is urine output increases (diuresis). Bread, often a complication of local infection, such jam, rice, fruit and vegetables with no as pneumonia or pyelonephritis. Septicaemia added salt is a practical diet. may in turn result in the spread of infection to6. Furosemide (Lasix) 1 mg/kg orally to help other sites, such as meningitis and osteitis. increase urine output Septicaemia may be caused by either Gram7. Observe the blood pressure every 6 hours. positive bacteria (such as Staphylococcus or8. Check serum urea, creatinine and Streptococcus) or Gram negative bacteria electrolytes to monitor any renal failure. (such as E. coli or Klebsiella). NOTE Severe hypertension can be treated as an NOTE Gram described the method of staining emergency with nifedipine (Adalat) bacteria blue and then dividing them into those 0.25 mg/kg sublingually (under the tongue). bacteria that retained the stain (Gram positive) Convulsions can be stopped with rectal diazepam. and those that lost the stain (Gram negative)Respiratory distress due to pulmonary oedema when exposed to other chemicals. Gram positiveshould be managed with oxygen, furosemide 1 bacteria usually live on the skin and in the upper respiratory tract while Gram negative bacteriamg/kg intravenously, sitting the patient up and normally live in the bowel. Rarely fungi can alsoreferring to hospital urgently. cause septicaemia. NOTE Serum C3 complement is classically markedly reduced. The chest X-ray often shows 13-19 What are the clinical features of an enlarged heart plus features of pulmonary septicaemia? oedema due to fluid retention. Serum Streptococcal antibodies are usually raised. • There may be a local source of infection. • At first the child may feel generally unwell but not have any specific signs. It
  6. 6. 216 SERIOUS ILLNESSES is, therefore, often difficult to make an A blood culture is needed to confirm the clinical early clinical diagnosis of septicaemia. As diagnosis of septaecaemia. the septicaemia becomes worse the child appears seriously ill.• Fever is almost always present. NOTE The C reactive protein (CRP) level may initially be normal but rises after a few hours.• The patient may become shocked (septic shock).• Shock leads to failure of many organs such 13-23 What is the management of as the kidney and lungs. septicaemia? 1. Start antibiotics immediately. Do not wait Children with septicaemia are seriously ill, often for the result of the blood culture. 2. Treat shock if it is present. without an obvious site of infection. 3. Transfer the patient urgently to hospital. Give oxygen during transport.13-20 What is shock? 4. Look for an underlying cause and monitorShock is the failure of normal peripheral for complications such as organ failure.circulation with a fall in blood pressure. The fist choice of antibiotics is either:The heart rate increases and urine output • Benzyl penicillin 50 000 units/kg everyfalls. The skin temperature may be low with 6 hours intravenously (or ampicillin 50shock and the hands and feet often feel cold. mg/kg every 6 hours intravenously) plusThe oxygen saturation may also fall. Most gentamicin 7.5 mg/kg daily (or amikacinimportantly, the capillary filling time is 20 mg/kg daily), given slowly intravenouslyprolonged to over 3 seconds. over 5 minutes. NOTE In early shock the blood pressure may still • Ceftriaxone 80 mg/kg daily intramuscularly be normal (compensated shock) although the or by slow intravenous injection. This is peripheral perfusion is poor. Later the blood very useful in a primary care facility before pressure falls (uncompensated shock). the child is transferred to hospital.13-21 How is the capillary filling time 13-24 What is the treatment of shock?measured? The aim of treatment is to correct theThis is estimated by compressing the skin for blood pressure and improve the peripherala few seconds over the hands, feet or chest, perfusion. A fast intravenous infusion mustwith your finger, to produce blanching (a be started immediately with 20 ml/kg ofpale area). When the pressure of the finger is normal saline or Ringer’s lactate. If the signsremoved, the time it takes for the pink colour to of shock are not corrected, repeat the bolus ofreturn is measured. This is called the capillary intravenous fluid. This will usually correct thefilling time. A normal capillary filling time is shock. Always give oxygen. Urgent transfer to3 seconds or less. hospital is needed. Start treating shock before moving the patient.13-22 How is the clinical diagnosis ofsepticaemia confirmed? Shock must be treated before the patient isWith finding a positive blood culture. Always moved to hospital.take a blood culture before starting treatment.The white cell count may be high at first and 13-25 What is meningococcal septicaemia?later fall. The platelet count may also fall andthe blood clotting factors may be low. This is a serious illness caused by septicaemia due to Meningococcus (i.e. Neisseria
  7. 7. SERIOUS ILLNESSES 217meningitidis). Meningococcus is transmitted 13-28 How is meningococcal infectionfrom person to person by droplet spread prevented?(coughing and sneezing). It often causes All those in contact with the patient, includingasymptomatic colonisation of the upper the health staff, should take rifampicin 10respiratory tract only. However, some people mg/kg twice a day for 2 days (5 mg/kg inget a septicaemia, meningitis or both. infants less than 1 month) or ceftriaxone 125Meningococcal infection is more common mg intramuscularly once. This will treat andin overcrowded conditions where epidemics prevent colonisation of the upper respiratorymay occur. tract. All contacts should be closely observed for signs of illness.13-26 What is the typical presentation ofmeningococcal septicaemia? A short-lived vaccine against meningococcus can be used to help end epidemics. Over-The patient presents with the signs of crowding in schools, army camps and crèchessepticaemia. However, a rash also develops. should be avoided.This starts as small red spots on the skin andconjunctivae which rapidly become purpuric(larger pink or purple spots). The spots donot blanch when pressed. The rash becomes MENINGITISvery dark and may become necrotic (ulcerate).Gangrene of the skin may occur. Without 13-29 What is meningitis?early treatment the mortality is high. It is veryimportant to look for a rash in all children It is a serious infection of the meninges (thewho are thought to have septicaemia. membranes covering the brain). Meningitis may be due to a viral or bacterial infection. Bacterial meningitis is usually far more Always look carefully for a rash if a child has a dangerous. Causes of bacterial meningitis diagnosis of possible septicaemia. include both Gram positive and Gram negative bacteria. The most common causes areMany children with meningococcal Pneumococcus (Streptococcus pneumoniae),septicaemia will also have meningococcal Haemophilus (Haemophilus influenzae) andmeningitis. Most will rapidly develop shock. Meningococcus (Neisseria meningitidis). Bacteria usually reach the meninges via the13-27 How is meningococcal septicaemia blood stream. Rarely, infection is by directmanaged? spread, e.g. from mastoiditis. Tuberculosis alsoSimilarly to other types of septicaemia. The causes bacterial meningitis. Fungal meningitischoice of antibiotic is benzyl penicillin or may be seen in children with AIDS.ceftriaxone intravenously. Start antibioticsimmediately as the clinical condition 13-30 What are the symptoms and signs ofdeteriorates rapidly without treatment. meningitis?Do not do a lumber puncture as this is very • Feeling generally unwell with fever. Mostdangerous due to brain swelling and will not children with meningitis rapidly appearalter the choice of initial treatment. Treat shock seriously ill.and move the patient to hospital urgently. • A severe headache, vomiting and photophobia (avoids bright light)Meningococcal infection is a notifiable disease • Irritability, drowsiness, loss ofin South Africa. consciousness and convulsions • Young infants may present with poor feeding, lethargy and apnoea.
  8. 8. 218 SERIOUS ILLNESSES• Neck stiffness. It is painful if the patient and antibiotics can be stopped once the results tries to flex his/her neck so that the chin of the lumbar puncture exclude bacterial touches the chest. It is also painful and meningitis. Tuberculous meningitis also has a difficult if the examiner tries to flex the similar presentation and must be distinguished patient’s neck. Neck stiffness may be absent on lumbar puncture and other investigations. in young children with meningitis.• Infants may have a full (bulging) fontanelle. It is not possible to distinguish between viral and bacterial meningitis on clinical examination alone.The signs of meningitis and septicaemia arevery similar. Both must be suspected in any NOTEIn viral meningitis most cells in the CSF arechild who is seriously ill or unconscious or lymphocytes, the CSF glucose is normal and thewho has a high fever without an obvious cause. Gram stain and culture are negative for bacteria. Headache, fever and vomiting suggest meningitis. 13-33 What is the correct management of bacterial meningitis?13-31 How is the clinical diagnosis of The most important step is to start antibioticsmeningitis confirmed? as soon as possible. If a lumbar puncture cannot be done immediately, it is better toBy obtaining a sample of cerebrospinal fluid start antibiotics before transferring the child(CSF) by lumbar puncture. CSF should be sent to hospital for investigation and furtherto the laboratory for chemistry, microscopic treatment. The sooner the treatment is startedexamination for cells and bacteria, and for the better is the clinical outcome.culture. As many children with meningitis alsohave septicaemia, the bacterial cause can often 1. The first choice of antibiotic is ceftriaxonealso be identified on a blood culture. 100 mg/kg intravenously immediately and then repeatedly daily. In older children the NOTE Do not do a lumbar puncture if there second choice is benzyl penicillin 100 000 is reduced level of consciousness, focal units/kg 6 hourly plus chloramphenicol neurological signs or features of meningococcal meningitis. With bacterial meningitis the CSF 25 mg/kg 6 hourly intravenously (or protein is raised (normal 0.15–0.4 g/l) and the intramuscularly if an intravenous line glucose is low (normal 2–4 mmol/l) with many cannot be started). In neonates the second polymorphonuclear cells. Bacteria may be seen choice is ampicillin and gentamicin. on a stained spun deposit or may be cultured. 2. Convulsions should be stopped. 3. Paracetamol and tepid sponging can be13-32 Is it easy to tell clinically whether used to lower the temperature.meningitis in a child is due to a bacterial or 4. Always look for signs of shock and excludeviral infection? hypoglycaemia. 5. The patient must be transferred urgently toNo. Therefore, all cases of clinical meningitis hospital.must initially be managed as if they arebacterial meningitis until the cause of themeningitis is identified. However, children with Antibiotics must be started as soon as possible if aviral meningitis are often not as severely ill as clinical diagnosis of bacterial meningitis is made.children with bacterial meningitis. Only thefindings on the lumbar puncture enable one to 13-34 Can meningitis be prevented?tell whether the infection is viral or bacterial. The introduction of immunisation againstChildren with viral meningitis usually improve Haemophilus influenzae into the routinerapidly after a lumbar puncture and have fewer schedule at 6, 10 and 14 weeks after birthcomplications. The management is supportive
  9. 9. SERIOUS ILLNESSES 219has prevented most cases of haemophilus 13-37 What are the clinical features of ameningitis. The promise of new vaccines urinary tract infection?against Pneumococcus and Meningococcus Often the symptoms are non-specific and,will hopefully also prevent these causes of therefore, the diagnosis is frequently missed.meningitis. Fever, dysuria (pain or discomfort whenAll those in contact with a patient with passing urine), frequency (passing frequentmeningococcal meningitis or septicaemia small amounts of urine) and abdominalshould be given rifampicin or ceftriaxone or back pain are common presentingprophylaxis. complaints. A high fever and vomiting suggests pyelonephritis rather than a mild13-35 What are the complications of form of urinary tract infection.meningitis? 13-38 How is the clinical diagnosis of aAbout 25% of children with bacterial urinary tract infection confirmed?meningitis will die and about 25% of thesurvivors will have permanent brain damage It is very important to get a clean specimen ofsuch as: urine. A midstream urine or clean catch sample (urine collected after the child has already• Cerebral palsy started passing urine), a sample collected• Intellectual impairment by passing a catheter into the bladder under• Nerve deafness aseptic methods or a suprapubic aspiration• Hydrocephalus (best done with ultrasonography) are by far• Epilepsy the best methods. Using a urine bag is very inaccurate and is should be avoided if possible.PYELONEPHRITIS Leukocytes, nitrites and protein, and sometimes blood, are typical findings when the urine is tested with a reagent strip. It is13-36 What is pyelonephritis? probably not a urinary tract infection if the reagent strip test on a sample of freshly passedPyelonephritis is a bacterial infection of the urine is completely normal, i.e. negative forkidney and the most serious form of urinary protein, nitrite, blood and leucocyte esterase.tract infection. If not diagnosed and treatedearly, repeated attacks of pyelonephritis can Pus cells are usually present on a spun depositlead to permanent kidney damage resulting in of urine.hypertension and renal failure. The only accurate way to confirm a urinaryE. coli (Escherichia coli) is usually the bacteria tract infection is a positive culture when thecausing a urinary tract infection. Most urine has been collected correctly. More thancommonly the infection is mild and only 100 000 bacteria/ml on a clean catch urine,affects the bladder (cystitis). Less commonly, more than 1 000 bacteria/ml on a catheterthe infection spreads up the ureters to affect specimen or any bacteria on a suprapubicthe kidney (pyelonephritis). Pyelonephritis sample is abnormal.may be secondary to a renal tract abnormality It is very important to make an accuratethat causes an obstruction to the normal diagnosis and not simply send a urine bagflow of urine. This increases the chance that sample to the laboratory. A normal urine baginfection will spread to one or both kidneys. result will exclude a urinary tract infection but NOTE Vesico-ureteric reflux, hydronephrosis and a positive result may simply be due to skin or posterior urethra valves increase the chances that stool contamination. A confirmed diagnosis is a urinary tract infection will result in pyelonephritis. also important because it indicates that a series
  10. 10. 220 SERIOUS ILLNESSESof management steps is required. Treating the blood leading to a very high blood glucosea presumed urinary tract infection without concentration. Diabetes, if not well controlled,confirming the diagnosis is bad practice. may result in severe complications and even death. Therefore, it is important to diagnose diabetes as soon as possible. It is important to collect a clean specimen of urine to make an accurate diagnosis before 13-42 What are the presenting symptoms starting treatment. and signs of diabetes? • Passing frequent, large amounts of urine13-39 How should a urinary tract infection (polyuria). The child may start to bed-wetbe managed? again after being dry for months or years.1. Once the urine sample has been collected, • Drinking a lot of water a course of antibiotics must be started, • Weight loss and tiredness usually oral nalidixic acid 10 mg/kg 6 • Collapse (shock), dehydration, loss of hourly for 7 days in children older than 3 consciousness (diabetic coma) and fast months. breathing (due to metabolic acidosis). This2. In younger infants and any child with is a life-threatening emergency. a clinical diagnosis of pyelonephritis, The diagnosis of diabetes must be suspected if a intravenous cefuroxime or intramuscular very high blood glucose concentration is found, ceftriaxone is indicated. using reagent strips. All children with suspected3. All children with a proven urinary diabetes must be referred urgently to hospital. tract infection must be referred for An intravenous infusion with normal saline investigation. Usually an ultrasound must be started before transferring a child with examination is done. Other special diabetic coma. Later the clinical diagnosis of investigations may also be needed. diabetes must be confirmed with a glucose tolerance test. Children with diabetes usually need daily injections of insulin for life to controlOTHER BACTERIAL their diabetes.INFECTIONS Diabetes usually presents with tiredness, weight loss and polyuria.13-40 What serious bacterial infections areless common?• Osteitis (bacterial infection of bone) CONVULSIONS• Septic arthritis (bacterial infection of a joint)• Mastoiditis (bacterial infection of the 13-43 What are convulsions? mastoid bone behind the ear) Convulsions (fits) present with a sudden onset of abnormal movements and an altered level of consciousness due to abnormal brain activity.DIABETES Convulsions have many different causes and may present in a wide variety of ways. Important causes are:13-41 What is diabetes? • EpilepsyDiabetes is due to inadequate amounts of • High feverinsulin being produced by the pancreas. As a • Meningitisresult, the body cannot remove glucose from
  11. 11. SERIOUS ILLNESSES 221• Hypoglycaemia abnormal neurological signs after the child• Cerebral cysticercosis (brain cysts caused recovers from the convulsion. by the pig tapeworm) Management is to lower the fever and reassureAll children with convulsions must be urgently the parents. Given paracetamol (Panado) whentransferred to hospital for investigation, the child is ill to keep the temperature normal.to establish the cause, and start correct Do not use aspirin. Children usually outgrowmanagement. febrile convulsions. Oral anticonvulsants are usually not used to prevent febrile convulsions.Before moving a child with convulsions,make sure the airway is open and give NOTE If the child is over 18 months, has a typicaloxygen. Always measure the blood glucose repeat febrile convulsion and there are noconcentration with a reagent strip and correct meningeal signs, a lumbar puncture is not needed.any hypoglycaemia. Cool the child if thetemperature is very high. 13-46 What is epilepsy? Children with epilepsy have repeated13-44 How are convulsions stopped? generalised convulsions. There is usually noAlways look very carefully for the cause and obvious cause, and they are well betweentreat this if possible. If a fit last longer than 5 convulsions. The diagnosis is usually basedminutes it can be usually be stopped with one on the history. Epilepsy often starts at pubertyof the following: and can be controlled (prevented) with oral anticonvulsants. All children with epilepsy• A single dose of rectal diazepam (Valium) should be referred to a neurological clinic for 0.5 mg/kg. Intravenous diazepam may assessment and initial management. Long- cause apnoea unless given very slowly. term management can be supervised from a• Phenobarbitone 15 mg/kg intravenously or primary care clinic. intramuscularly. This is safe.• Phenytoin 15 mg/kg by slow intravenous injection can also be used. Never give CANCER phenytoin intramuscularly, as it damages the tissues locally. NOTE Lorazepam 0.1 mg/kg intravenously is 13-47 Are malignancies common in very effective at stopping a convulsion. Buccal children? midazolam 0.1 to 0.2 mg/kg is also effective. Malignancies (‘cancers’) are not common in children. However, it is important to Any convulsion lasting longer than 5 minutes know the warning symptoms and signs of should be stopped. childhood malignancy as many childhood malignancies are curable if they are diagnosed and treated early.13-45 What are febrile convulsions?These are generalised convulsions caused bya high temperature. Often there is an obvious Malignancy in children often has a goodcause of the fever, e.g. upper respiratory tract prognosis if diagnosed and treated early.infection. The child is usually between 6months and 5 years old and there may be a 13-48 What malignancies occur in children?family history of febrile convulsions. Some • Leukaemiachildren have febrile convulsions whenever • Lymphomathey have a viral infection with a high fever. • Brain cancerUsually the convulsion does not last longer • Kidney cancer (Wilm’s tumour)than 15 minutes and there are no other
  12. 12. 222 SERIOUS ILLNESSES NOTE Less common malignancies in children 2. What are the other major criteria? include liver and bone cancer, retinoblastoma (eye), rhabdomyosarcoma (muscle) and germ A rash (erythema marginatum), subcutaneous cell tumours. nodules and chorea. Only 2 major criteria are needed to make the diagnosis of acute13-49 What are the warning signs of rheumatic fever.malignancy in children? 3. What is the likely cause of the sore throat?1. Pallor and bleeding2. Aching bones or joints, especially waking A streptococcal infection. the child at night; backache3. Unexplained weight loss, fever or fatigue 4. Which signs suggests that this child has4. Persistent, unexplained lymphadenopathy carditis?5. Abdominal masses A heart murmur, tachycardia and enlarged6. Lumps in the neck, testes or limbs heart.7. Eye changes: white pupil, sudden squint or loss of vision, bulging eyeball8. Neurological symptoms or signs: 5. What is the management of acute headaches, early morning vomiting, rheumatic fever? unsteady gait, cranial palsies, change in The child should be referred to hospital. behaviour With bed rest, antibiotics (oral amoxycillinChildren presenting with any of these warning for 10 days or a single dose of intramuscular(danger) symptoms or signs must be urgently benzythine penicillin) and aspirin the acutereferred for an expert opinion. rheumatic fever usually recovers within 4 weeks. It is important to look for signs of heart failure.CASE STUDY 1 6. What is the danger of repeated attacks of acute rheumatic fever?A 5-year-old child presents with a fever anda one-week history of pain and swelling of It may result in chronic rheumatic heart diseasethe knees and elbows. Over the past few days with damaged heart valves. Rheumatic feverthe pain has moved from joint to joint. On is the most common cause of acquired heartexamination the child is unwell with arthritis disease in poor, overcrowded communities.of both knees. The heart rate is noted to be110 beats per minute. A soft murmur is heard 7. How can repeated attacks of acutewhen her heart is examined. The heart appears rheumatic fever be prevented?enlarged on a chest X-ray. On questioning themother says the child had a sore throat a few With 4 weekly intramuscular injections ofweeks back. benzathine penicillin.1. What is your clinical diagnosis? CASE STUDY 2Acute rheumatic fever. The child has 2 majorcriteria (polyarthritis and carditis) and one A 3-year-old child has had a swollen face andminor criteria (fever). There is also a history of dark urine for the past 24 hours. There area sore throat. numerous areas of impetigo on his legs. The mother says he is very short of breath when he lies down.
  13. 13. SERIOUS ILLNESSES 2231. What is the probable diagnosis? that he has a fine rash which reminds her of purpura. The child is fully conscious with noAcute glomerulonephritis. neck stiffness.2. Why does he have dark urine and a 1. What is the likely diagnosis?swollen face. The child has the clinical signs of septicaemia.The dark urine is probably due to the presenceof blood. Haematuria can be confirmed withreagent strips. His swollen face is due to 2. Why is the blood pressure low?fluid overload as a result of decreased urine The low blood pressure, fast pulse and coldproduction. hands, in spite of a fever, indicate that the child is shocked. This is often seen in patients with3. What is the cause of this condition? septicaemia.The streptococcal skin infection (impetigo).This is an unusual immune response to 3. What does a capillary filling time of 8Streptococcus where antibodies damage the seconds mean?kidney. It is abnormally long, as the pink colour should return to a blanched (pale compressed area)4. How is this condition prevented? area of skin within 3 seconds. The long capillary filling time confirms that the child is shocked.By preventing or treating impetigo. Usually,local treatment is adequate. An oral antibioticshould be given with widespread impetigo. 4. Why is there a rash? A fine pink or purpuric rash strongly suggests5. Why is this child short of breath? that the septicaemia is due to Meningococcus. This is an extremely serious condition.Due to fluid overload. The most seriouscomplications of acute glomerulonephritis are: 5. How is the diagnosis of septicaemia• Severe hypertension resulting in confirmed? encephalopathy• Pulmonary oedema and cardiac failure due By finding a positive blood culture. to fluid overload• Acute renal failure 6. Do you think the child has meningitis? There are no signs of meningitis.6. What is the management of the fluid However, meningitis is very common withoverload? meningococcal septicaemia.Reduced fluid intake, a low salt diet andfurosemide. These children should be 7. What is the correct management ofmanaged in hospital. septicaemia with shock? Take a blood culture and start a fast intravenous infusion with normal saline orCASE STUDY 3 Ringer’s lactate. Immediately start antibiotics. Benzyl penicillin or ampicillin plus gentamicinA severely ill child is brought to the clinic. He or amikacin would be the antibiotichas a high temperature without an obvious combination of choice. Do not perform acause. His heart rate is fast, blood pressure low lumbar puncture. The child should be movedand hands feel cold. The capillary filling time to hospital as soon as possible.over the chest is 8 seconds. The nurse notices