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Approach to Pediatric Upper Respiratory Infections
- 1. PediatricUpper Respiratory Infections SHRS PA IssuesAcross the Lifespan Fall 2019
- 2. SondraL. Baumcratz, PA-C Children’s Hospital of Pittsburgh General Academic Pediatrics
- 4. Objectives Lecture 1 Know the anatomy of the pediatric Upper Respiratory System Name the normal flora of the respiratory tract, and understand their role in disease State the effect of routine vaccination against normal flora in terms of incidence of invasive disease Lecture 2 Know the features of PRIMARY infections with common respiratory pathogens List the benefits of knowing the differences between viral presentations. Understand the role of vaccination in prevention of primary infection Lecture 3 Recognize SECONDARY respiratory tract infections due to overgrowth or invasion of normal flora Know the most common overgrowth conditions, and their locations Recognize the red flags that indicate invasive respiratory disease OBJECTIVES
- 9. The Nasopharyngeal Niche Direct colonization occurs shortly after birth and develops over the first months and years of life. S. pneumo, H. flu, M. catharrhalis most abundant Neisseria, Diphtheroids, Fusobacterium Possibly Mycoplasma, though this is not yet established Occasionally Strep Pyogenes The microbiome of the upper respiratory tract appears to be influenced by the host genetic background, age, and factors that determine environmental exposure, such as social status, antibiotic use, vaccination, season, smoking, and the pattern of social contacts, such as day care attendance or number of siblings A rich, complex, and interactive ecology
- 10. So do these make us sick or not? Normal nasopharyngeal flora, by definition, live in the nasopharyngeal niche. Their presence as colonizers is a prerequisite for the occasional OVERGROWTH and/or INVASION of the body. DISRUPTION of the homeostatic mechanisms by PRIMARY infection with viruses (or occasionally, non- commensal bacteria) is the factor that allows this overgrowth and/or invasion.
- 11. MAJOR LEAGUE STREP PNEUMO • OM • Sinusitis • Pneumonia • Bacteremia • Meningitis HAEMOPHILUS INFLUENZAE • OM • Sinusitis • Pneumonia • Bacteremia • Meningitis • Subtype b • epiglottitis MORAXELLA CATARRHALIS • OM • Sinusitis • Pneumonia • Not terribly invasive- bacteremia and meningitis rare MOSTABUNDANT, MOST FREQUENT OVERGROWERS/INVADERSWHEN ABLE
- 12. Minor Leagues Neisseria Meningitidis • Meningitis • Sepsis • Rapidly deadly Diphtheria • Toxin producing • Pseudomembrane Rarer, but still deadly
- 13. Effect of Vaccination Numberofcasesper100,000 population Current Vaccine Initial vaccine Pre-vaccine S. Pneumo Hib Diphtheria Meningococcus 9 1 0.1 12.5 22 15 0.3 24.3 59 150 0.7 Current Vaccine Initial vaccine Pre-vaccine
- 14. SUMMARY: Anatomy of the upper respiratory space How it’s different for kids What the normal flora is What the source of the flora is How vaccination has changed the flora Implication of vaccination conversion of carriage to disease NEXT UP: what are the common primary infections of the URT, how to distinguish them from each other Why it matters that you be able to distinguish them Role of vaccination in prevention ofTHOSE diseases
- 16. Primary infections by respiratory viruses and bacteria Lecture 2
- 17. Objectives Lecture 2 Know the distinguishing features of primary infections with common respiratory pathogens State the reasons why distinguishing various pathogens is important Understand the role of vaccination in prevention of primary infection Lecture 3 Recall that infection with respiratory pathogens predisposes to overgrowth and invasion of normal flora, causing secondary disease Recognize respiratory tract infections due to overgrowth and/or invasion of normal flora, now the most common locations Recognize Red-Flag features that indicate invasive disease
- 18. PRIMARY INFECTION CASE 1 Rhinovirus: the model for the common cold A 15 month-old presents to your office with 4 days of rhinorrhea, initially clear, now yellow-green and cloudy wet sounding cough fever on days 1-3, to 100.9, now resolved she denies n/v/d or dyspnea, though the nasal congestion forces her to stop bottle feeds and interferes with comfort sucking. She is interactive, plays at home, still drinking enough to have 4-5 wet diapers a day. On exam, she is afebrile, well appearing, with thick yellow nasal discharge. The throat is erythematous without tonsillar exudates. The ears are normal.The lungs are clear, without evidence of increased work of breathing. There are no rashes. A/P: Viral URI. Nasal saline,Tylenol for pain. Expect spontaneous resolution in 7-14 days. RTC for temp >100.4, worsening breathing, or persistence past 14 days.
- 19. PRIMARY INFECTION CASE 1 Uncomplicated Rhinovirus: features Rhinovirus: incubation 3-4 days nasal congestion, clear to cloudy, then clear again inflamed throat cough low grade fever at onset of illness, resolves. overall well-appearing. Po maintained, UOP maintained. no rashes self resolves over 1-2 weeks Sometimes: Thick yellow mucus backs up into eustacian tubes and produces bulging of theTM. This is otitis media. Inhalation of virus to the lower respiratory tract results in inflammation , wheezing, or viral pneumonia. This STILL should self-resolve over 1-2 weeks, though you’d want to check the baby again in a couple of days, and give really good follow up instructions to the family, so they recognize worsening.AAP red book 2018-2021
- 20. Other Primary infections: howdo theydiffer? Viruses •RSV •Coxsackie •Parvovirus B19 •Parainfluenza •Roseola Bacteria •S. Pyogenees •B. Pertussis Vaccine PreventableViruses •Influenza •Varicella •Measles •Mumps •Rubella This Photo by Unknown Author is licensed under CC BY-SA-NC This Photo by Unknown Author is licensed under CC BY-NC This Photo by Unknown Author is licensed under CC BY
- 21. Why should I care? Occasionally, treatment IS different Allows guidance as to expected course Allows avoidance of antibiotics Allows surveillance for expected complications Allows reporting of reportable diseases
- 22. Baby/ toddler/child with cold symptoms AND… respiratory distress and crunching crackles high fever and sores/ulcers on the throat, hands, feet, and buttocks Few days of fever who develops a pink, flat rash as the fever resolves a high fever followed rapidly by a barking cough Fever and cold sxs last week. Now has a lacy rash and very red cheeks
- 24. Baby/ toddler/child with cold symptoms AND… rapid onset high fever, HA, chills, myalgia, dry cough, n/v/d fever, myalgia, generalized blisters, some new, some crusting over. fever, rash starting on the face, rash inside the mouth fever, HA, myalgia, with rapid parotid swelling mild sxs fever, prominent LAD, and rash
- 26. PRIMARY INFECTION Primary Bacterial Infections Rapid onset high fever, sore throat, swollen glands, WITHOUT cold sxs Fever, URI with weeks of lingering cough and post-tussive emesis Neonate with conjunctivitis and cough
- 28. Vaccine hits and misses current initial vaccine Pre Vaccine 0 500000 1000000 1500000 2000000 2500000 3000000 3500000 4000000 MMR Pertussis Varicella Influenza ChartTitle current initial vaccine Pre Vaccine
- 29. Vaccine hits and misses current initial vaccine Pre Vaccine 0 5000000 10000000 15000000 20000000 25000000 30000000 35000000 40000000 MMR Pertussis Varicella Influenza ChartTitle current initial vaccine Pre Vaccine
- 30. Summary Cold sxs are the most common reason for seeking medical care other virus variations have distinguishing features that set them apart distinguishing features allow for more precise assessment, planning, and reporting vaccines are great but not perfect (and you gotta get them if you want them to work) Up next: bacterial illness can complicate simple viral illness OM and sinusitis most common invasive disease is still deadly how to recognize invasive disease
- 31. Secondary infections: overgrowth and/or invasion by normal flora Lecture 3
- 32. Objectives Lecture 3 Recognize SECONDARY respiratory tract infections due to overgrowth or invasion of normal flora Know the most common overgrowth conditions, and their locations Recognize the red flags that indicate invasive respiratory disease
- 33. Secondary Infections Sinusitis • Orbital Cellulitis Otitis Media • Mastoiditis *Tonsillitis • Deep Neck Infections
- 34. Sinusitis (overgrowth) Sinusitis Clinicians should make a presumptive diagnosis of acute bacterial sinusitis when a child with an acute URI presents with the following: Persistent illness, ie, nasal discharge (of any quality) or daytime cough or both lasting more than 10 days without improvement; OR Worsening course, ie, worsening or new onset of nasal discharge, daytime cough, or fever after initial improvement; OR Severe onset, ie, concurrent fever (temperature ≥39°C/102.2°F) and purulent nasal discharge for at least 3 consecutive days (Evidence Quality: B; Recommendation)
- 35. Sinusitis and Orbital Cellulitis (invasive) Orbital cellulitis • 90% extension of sinusitis, esp ethmoid • Findings result from pressure in the orbit: pain, ptosis, restriction of motility (diplopia) etc • Don’t call it peri-orbital unless you can document a clear hx of skin injury prior to onset • Immediate referral to ophthy for imaging decisionmaking • Medical vs surgical
- 38. Otitis Media (overgrowth) OM • Follows URI Fever, worsening, pain at expected END of viral illness • Describe theTM • Translucent or opaque (this is opaque) • Bulging, neutral, reatracted (this is bulging) • Purulent or clear effusion (this is purulent) YOU’VE GOTTA HAVE ALL THREETO CALL IT AN EAR INFECTION.
- 42. Tonsillitis (primary and secondary) Tonsillitis Deep neck infections • Abrupt onset • Fever • Exudate • Anterior LAD • Absence of URI sxs Strep tonsillitis • Normal flora • Invades fascial planes and extends • pharynx, larynx, into mediastinumFuso
- 44. DNI features (invasive) Dysphagia (Is the swelling in the way of your swallowing? Watch them drink something. Dysphonia (Is the swelling INTHE WAY of your speech? Listen to their voice) Dyspnea (Is it in the way of your breathing? Is it waking you up?0 Posturing (is the patient repeatedly scooping up the nose, or looking to the ceiling?That’s the ‘sniffing’ position) You can’t see it. They’re saying scary things on history (like the above) but the throat looks normal because it’s lower.
- 46. Summary
Editor's Notes
- This Photo by Unknown Author is licensed under CC BY-NC-ND INTRO MATERIALS, SCOPE OF THE PROBLEM Most common outpatient complaint Here is the overall approach to this concept here. In the middle, there’s a nose. An entire upper respiratory system, in fact. It’s a system of dead end caves, and twists, and turns, and two major cavern entrances, right? The nose, and the mouth. And a teeny, tiny, back door exit at the top of the lacrimal sac that leads to the eye. And there’s normal flora in there. They climb aboard starting in the birth canal, then mom kisses, and grandma kisses, and trips to wal-mart, etc. And grow a whole subterranean host-defense-evading biofilm community in there. That’s normal. Over on the left, sometimes, you catch a cold. Or a strep. Or flu. Or something. This is a pediatric infection module, so think where KIDS get germs. Have you ever spent time in a class of 8 year olds? There’s sniffles, and nose-picking, and eye rubbing, and finger-licking, it’s disgusting. These pathogens enter the body through the nose, or the mouth, and cause various constellations of symptoms. And sometimes you can tell from the constellation what virus it is, and sometimes that’s useful. BUT. There’s still this bacterial ‘underground’ in there. THEY get upset by these viruses, too. The primary infection itself causes disruption of their colony. Now they’re exposed to host defenses, too, so they ramp up invasive mechanisms in order to survive. They increase their numbers. They take advantage of epithelial damage that the viruses cause, and sneak past the barrier and invade. This brings us to the secondary infection box on the right. THESE infections are overgrowth and/or invasion of normal flora that are caused by the disruption of the primary. They occur at the time when you expect that the primary should be resolving. 10 days, 2 weeks of a cold, and you SHOULD be getting better, but you get worse. Or you start getting better for a day or two…..but never make it, and then you’re there with an ear ache, or sinus pressure, or a new fever. Lastly, RARELY, overgrowth gets invasive. Not just filling up the middle ear, or clogging the sinuses. That’s low-hanging fruit. Sometimes, they get ambitious and invade the mastoid. Or the orbit. Or, in the case of tonsillar infections, the peri-tonsillar or retropharyngeal space. These things are immediately dangerous. Life-threatening. Make a HABIT of looking for them, (every kid, every cold) and documenting their absence. And we’re going to go over how to do that. https://emedicine.medscape.com/article/302460-overview
- The videos attached are organized as follows. Lecture 1 We start in the middle, with the normal condition. Point out pediatric anatomical idiosyncrasies, and review the normal flora. Review the success of routine immunization strategies in reducing colonization by virulent strains of normal flora. This Photo by Unknown Author is licensed under CC BY-SA-NC Lecture 2 Review groups of primary infectors: viruses, bacteria (that DON”T normally live there) and give some distinguishing features of those. Review the reasons why it’s important to be able to tell certain illness apart. Demonstrate the success of routine immunization in reducing morbidity and mortality of these. This Photo by Unknown Author is licensed under CC BY-SA Lecture 3 Finally, we present Otitis Media and Sinusitis as OVERGROWTH conditions, give recognition strategies for those, and Remember when I said that every kid with a cold gets an affirmative search for invasive (read: life-threatening) conditions? We’ll review what those are, what and where to look, and what to document. This Photo by Unknown Author is licensed under CC BY There is, as always, a guided note packet for you to organize, process, and manipulate your thoughts.
- A Tour of the space: If you’re a germ, you’re going to enter here through the nose. You’ve got the mucosa of the nasal cavity, nasopharynyx all the way in the back and that further down that back wall is the OROpharynx, and further down more, is the laryngopharynx /larynx. Theres the epiglottis, which flips back and forth to cover either the trachea or the esophagus (depending on if you’re breathing or swallowing). And this is a sideways picture, so the eustacian tube and the lacrimal apparatus aren’t really visible because theyre coming out at you in the z axis of this shot. This Photo by Unknown Author is licensed under CC BY-SA
- Here’s a view from the front so you can see the relationship between the lacrimal sac and the nose and sinuses. So when I said in the introductory video that there’s a tiny communication between the upper respiratory system and the eye? Here it is. It’s job is to drain the tears from the eye down into the nose, but in this context, the gunk from the nose occasionally backs up into the eye. Beverlyhillssinus.com
- A closer look at the sinuses. So one thing to note about the upper airway anatomy is that, in kids, there really aren’t sinuses yet. There’s the little proto—maxillary sinuses at birth, tiny proto-ethmoid sinuses, but no real development of the sphenoid, or frontal spaces until much later. That becomes important when you try to say a one year old has a sinus infection. It’s complicated. http://www.kids-ent.com/resources/clinical/sinus.jpg
- Another thing that’s different in kids: the shape of the face: and we talked about rhinorrhea backing up into the eustacian tube. This happens to everyone, but in kids, the tube is narrower, so it gets swollen shut more easily, AND, its not angled as steeply, so gravity doesn’t help out as much. (also, babies spend more time horizontal than older kids.) So the younger the child, the more likely that middle ear is to get stuffed full of gunk. So that;s the review of all the nooks and crannies of the upper respiratory system. http://2.bp.blogspot.com/-6K3SB1xuDVA/UprTnHSNhKI/AAAAAAAAAUs/y4bNvo_xX3o/s1600/eustachian_tube_difference.jpg
- So what goes on in this anatomy? Part of the normal condition, is that this space has bacteria in it. It’s exposed to the outside world, and that’s not a sterile space. Colonization happens immediately after birth and continues: Intrauterine environment is sterile. Birth canal: not sterile Nasal suction at birth: maybe sterile Mom and dad’s kisses: not sterile Breast, skin, colostrum: not sterile Bottle nipple, water to mix formula, formula powder: not sterile Air at home, grandma with COPD and sibling with kindergarten-booger kisses, not sterile. And these are the common human commensals.
- So look at this list again. S pneumo, H flu, M. catarrhalis, Diphtheria, Neisseria, Mycoplasma, Strep. These are the bad guys, right? They cause pneumonia, meningitis, diphtheria, meningitis, sepsis, pneumonia, rheumatic fever. These are the guys that make us sick. Now here I am saying, they’re normal, its ecology, they don’t make us sick. What gives? PUNCHLINE IN BOLD https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4760621/ Web2.uwindsor.ca/courses/biology/fackrell/MedMicro/Ref_Shelf/Resptrac/frmain.htm
- Textbook of bacteriology Todar, phd https://www.uptodate.com/contents/moraxella-catarrhalis-infections
- Now this group, I’ve labelled as ‘minor league’ because of their incidence being lower. They’re far deadlier than the more common group, however. And the only reason diphtheria is low incidence is because of routine immunization.
- Vaccines reduce carriage/colonization, and remove the pre-requisite factor for invasion REPEAT THAT Multiple serotypes, and vaccines are targeted to the most invasive, typically which leaves other serotypes the chance to thrive So epidemiology changes over time S Pneumo: Initially, prevaccine era, average 24.3 cases of INVASIVE disease (bacteremia, sepsis, meningitis) per 100,000 people- So these are folks whose normal flora decided to invade and cause disease. Was talking to an attending last week who was practicing in the prevaccine era. Her estimate was 15 admissions for rule-outs A DAY. Every day. Now this number doesn’t look crazy high, especially when you see that diphtheria towering over there. Misleading, though, because in the <2 year old age group, incidence clustered at 145/100,000 Prevnar-7 in 2000 addressed the most common 7 serotypes and incidence of invasive disease decreased to 12.5/100,000 Epidemiology now different; now non vaccine serotypes predominate A19 which is a particularly drug-resistant type now most prevalent Prevnar 13 in 2011, which covers that A19, and incidence again fell, now to 9/100,000 Still expect drift in the future https://cmr.asm.org/content/25/3/409.short Haemophilus influenza subtype b Vaccine against one subtype of H flu only: especially virulent because of the capsule that hides it from host defenses and allows invasion. (so when we say H flu causes OM, or sinus infections, and h flu is normal flora? This USED to be a part of that flora, and now isn’t anymore. It IS the same species, just a particulary hardy and mean little supgroup) Epiglottitis Pre vaccine era, <1986, average incidence was 59/100,000 but again, misleading due to age distribution 0-1 was 40 0-2 was 60 2-4 was 135 4-6 was 180/100,000 Initial vaccine in ‘86 reduced overall incidence to 22/100,00 but didn’t work well under 2 yoa Intro of new product in 1990 reduced invasive disease (including epiglottitis) to 1/100,000 https://www.cdc.gov/vaccines/pubs/pinkbook/hib.html Diphtheria 5% pre-vaccination colonization rate, so not a lot of people carried it, but it was enough to serve as reservoir for disease URI sxs plus thick, leathery membrane over the throat that obstructed the airway Toxin producing as well Fatality rates approach 15-20% Incidence in 1920: 150/100,000 Post vaccine : 0. actually in 2011, two cases nation-wide, so 2/whatever the entire US population was then. https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/dip.pdf Meningitis mixed results The case-fatality ratio of meningococcal disease is 10% to 15%, even with appropriate antibiotic therapy. The case-fatality ratio of meningococcEMIA is up to 40%. As many as 20% of survivors have permanent sequelae, such as hearing loss, neurologic damage, or loss of a limb. Lower prevalence: pre-vaccine era was 0.53/100,000: carriage rate about 8% in one study of military recruits prior to vaccination (2016) Canada began vaccinating against serotype C in 2000, which probably affected US incidence also (herd immunity) US vaccine, serotypes ACYW in 2005, age 12 and 16 Men B added to ‘at risk’ populations (crowding, dorms, chronically ill) US Incidence now 0.11/100,000 https://www.cdc.gov/vaccines/pubs/pinkbook/mening.html#neisseria https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5139924/ BOTTOM LINE: VACCINATION HAS CHANGED THE ECOLOGY OF THE NORMAL FLORA TO REDUCE INVASIVE DISEASE CLINICAL IMPLICATION: VACCINATED KIDS ARE GOING TO HAVE DIFFERENT NORMAL THAN UNVACCINATED KIDS AND YOU NEED TO BE ABLE TO RECOGNIZE WHICH NORMAL YOU MIGHT BE DEALING WITH https://www.ncbi.nlm.nih.gov/pubmed/20001736/ https://www.cdc.gov/meningococcal/clinical-info.html https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3667932/
- So now we understand the normal condition: the anatomy, the biome, where the biome comes from, and the effect of vaccines on the biome But then life happens. And you catch a cold. This next section reviews a bunch of common respiratory pathogens, and hopefully gives you a couple ways to get them straight inside your head.
- Keyword: ‘DISTINGUISHING FEATURE’ So these guys all cause cold sxs to some degree. We’ll use rhinovirus as our model. Then I’ll point out some variations from the rhino model that should tip you off to the fact that it’s a different kind of germ.
- Rhinovirus as reference model. So every other virus we talk about is going to be compared to this. This is URI vulgaris. A couple notes; Fever is common in the first couple days of illness. In the toddler-preschool group, even up to 3 or 4 days. As long as the child 1. doesn’t meet work-up criteria otherwise (see fever module) AND 2. They appear well, AND 3. Theres obviously URI sxs (ie…a ‘source’) then kids get fevers. Not a big deal. she DENIES dyspnea. The lungs are clear and there is no increased work of breathing. She denies n/v/d. There are no observable fluid losses, and PO/UO are maintained. She is interactive. Variations from this are not a common cold.
- Notes here: Otitis Media indicated fluid in the middle ear. It doesn’t indicate the TYPE of fluid. And its common to get clear effusions, cloudy effusions, retraction of the TM, all of which are just ’congestion,’ and do not represent progression of disease.
- So that’s the common cold. If Rhinovirus is the index/benchmark disease, lets talk about how other viruses are a little bit different. And there are bacterial primaries, too. And vaccine preventable viruses that you shouldn’t see, but will. I’m trying to simplify it a little bit so there’s a minimized number of things to remember. So when we study these OTHER cold viruses, you only need to know one or two things about it. Interject here: Kids can get up to ten of these a season sometimes. TEN. A SEASON. As long as they come and go (resolve in between episodes) and the kid stays well (recall sick-not-sick), it just means they’re exposed to a lot. Day care kids? All. The. Time. So the way I’d like you to approach these is this: Kid has something that looks like a cold. Maybe a fever, come nasal congestion, some cough, etc. Then there’s something a little weird-a rash, or a barking noise or a duration of illness… That one weird thing is going to be the DISTINGUISHING FEATURE that allows you to recognize a differing pattern. So what’s off for each of these? We’ll go group by group.
- But first these are all viruses, then, by definition, they’re going to self-resolve, and it shouldn’t matter if I can tell them apart, right? Treatment for croup is different for that of rhinovirus Family instructions may be different. “This is Parvovirus, or Fifth’s disease. You don’t need to do anything, it will go away by itself.” vs “Don’t be surprised if this takes a long time. Kids will wheeze for months sometimes after RSV” ”It DOES look like scarlet fever, but it isn’t. Antibiotics are the wrong treatment.” ”Sometimes kids get pneumonia after the flu. Let’s have you come back the day after tomorrow just to check the O2 again, listen to the lungs, and make sure that there’s nothing different.” “This looks like hand-foot-mouth disease. It’s really painful, and they sometimes refuse to drink, so you have to be really careful to control pain and watch for dehydration.” Measles, mumps, chicken pox.
- So. Five cases here, some little things are different. These are grouped together because they’re common, and there’s no vaccine available. Cold sxs with distress : bronchiolitis, usually RSV, and RSV is in the first 2 years of life. The crunching sound is the distinguishing factor BUT these babies can get really sick. REALLLLLYYY sick. Respiratory distress, viral pneumonia, albuterol doesn’t help, steroids don’t help, nothing helps. Predisposes to asthma later; lung irritability lasts for months to years No vaccine, but for at-risk kids (preemies) SYNAGIS is a $2000/dose IgG that provides passive immunity once a month for the season (Nov thru Apr) High fever with sores: Coxsackie, causing hand, foot, and mouth disease Two phenotypes: high fever, myalgia, n/v/d and sores Last 5-6 years of so, much milder systemically, just the sores and some congestion Highest risk is refusal to feed due to pain, and dehydration Rash with a HISTORY of URI: Fifth disease Cold sxs last week,. Unremarkable, bright red slapped-cheek and ”lacy, reticulated” rash. Looks almost mottled, but pink, not blue High fever, 12 hours later, barking: croup “When I put him to bed he was fine, then he woke up in the middle of the night with a 103 and this NOISE” It’s FAST. Most grandmas recognize the noise, and send the kid out in the cold to soothe the cough. Complication: stridor and swelling/obstruction Decadron, cool mist, avoid agitation, recheck frequently. Fever without a source, now fever gone and rash evolves: roseola. This happened to my daughter. At 15 months. Fever without a source (103.9) x 3 days, hx UTI, sent to the ED for urine cath and blood cultures, empiric abx for pyelo. 48 hours later when the fever broke, the rash developed, and I got a call from primary care that said the urine and blood cultures were negative and I could stop the abx. All are viral. All have URI sxs at some point. All self resolve. But recognizing the pattern helps with several things: Bronchiolitis, hand foot and mouth, and croup can all be deadly, either via respiratory failure or dehydration. Recognizing them is crucial so that you also know to make a search for sequelae you wouldn’t normally worry about. Same goes for rashes. Many are harmless (Fifth’s disease, Roseola). Some are reportable (see the vaccine-preventable section) and some indicate bacterial illness (see strep throat.) Knowing the patterns allows you to treat the patient and the public properly
- RSV https://www.youtube.com/watch?v=jQXQfPWKu3Y Hand, Foot, and Mouth This Photo by Unknown Author is licensed under CC BY-ND Fifth’s disease (erythema infectiosum) https://www.drugs.com/health-guide/images/205860.jpg http://classconnection.s3.amazonaws.com/243/flashcards/2526243/jpeg/erythema_infectiosum_21359236791381.jpeg 4. Croup https://www.youtube.com/watch?v=s7qomuX0Gjw 5. Roseola https://i.ytimg.com/vi/xodiG7aYIUg/hqdefault.jpg
- Group 2. These are vaccine-preventable viruses. This is different from the vaccines against the normal bacteria above, because we’re not reducing carriage or colonization of virulent strains. Here, vaccination serves to prime the immune system for immediate response in case of exposure. In theory, these should be very rare. They aren’t. https://www.uptodate.com/contents/mumps?search=mumps&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H9
- Influenza. No joke, these kids are horizontal and crying. This Photo by Unknown Author is licensed under CC BY-NC-ND Chicken pox. lesions are herpetiform and in differing stages of development This Photo by Unknown Author is licensed under CC BY-SA Measles koplick spots, rash face outward https://www.atsu.edu/faculty/chamberlain/images/Koplik_spots.jpg https://healthjade.com/wp-content/uploads/2018/02/measles-conjunctivitis.jpg, http://2.bp.blogspot.com/_cJ96NqGzvK0/S7pqD_PW9-I/AAAAAAAAAHc/TBpyBZ54TSw/s320/measles+rash.jpg Mumps (big fat parotid) Vaccines aren’t perfect, even when you get them. https://larrybrownsports.com/wp-content/uploads/2014/12/Sidney-Crosby-mumps.jpg Unilateral or bilateral. Orchitis, oophoritis, does resolve. Does not seem to be any relationship to ultimate fertility. Rubeola German measles, 3 day measles, Rashes look very similar Disease is really mild and may not come to your attention, even. If pregnant? Significant Birth defects https://illnessee.com/contents/videos_screenshots/0/212/source/10.jpg
- Strep Throat Tonsillar infection, so no rhinorrhea or cough unless they happen to have both. In reality, inflammation causes discharge, and swollen tonsils act on the cough/gag reflex in the throat. Treatment prevents rheumatic sequelae Not in under 3’s (they DO get infection, but not typically rheumatic complications) Bordetella Pertussis (Whooping Cough) Vaccine preventable (Tdap at 2m ,4m, 6m,15m and 4y) Booster at 11, once in adulthood if around unvaccinated newborns (dads and grandmas, for example) If female, boost during every pregnancy, even if otherwise within 10 years. Chlamydia trachomatis Neonatal exposure route? Conjunctivitis presents usually within the first week of life Up to 30% of babies with chlamydial conjunctivitis will have co-occurring pneumonia (think how they got it) so confirmed chlamydial conjunctivitis gets oral erythro Oral erythro predisposes to pyloric stenosis, so risk/benefit if you’re unsure https://www.uptodate.com/contents/gonococcal-infection-in-the-newborn?topicRef=4993&source=see_link#H14
- Strep Throat https://media.sciencephoto.com/image/c0234294/800wm/C0234294-Scarlet_fever.jpghttps://i.pinimg.com/736x/79/4c/49/794c49f18f6d3c671f8fb9b41c0efdb1.jpg http://intranet.tdmu.edu.ua/data/kafedra/internal/vnutrmed2/classes_stud/en/med/lik/ptn/Internal%20medicine/5%20course/13.%20Rheumatic%20heart%20disease,%20Infective%20endocarditis.files/image006.png Bordetella Pertussis (Whooping Cough) Vaccine preventable (Tdap at 2m ,4m, 6m,15m and 4y) Booster at 11, once in adulthood if around unvaccinated newborns (dads and grandmas, for example) If female, boost during every pregnancy, even if otherwise within 10 years. https://www.youtube.com/watch?v=S3oZrMGDMMw Chlamydia trachomatis Neonatal exposure route? Conjunctivitis presents usually within the first week of life Up to 30% of babies with chlamydial conjunctivitis will have co-occurring pneumonia (think how they got it) so confirmed chlamydial conjunctivitis gets oral erythro Oral erythro predisposes to pyloric stenosis, so risk/benefit if you’re unsure https://www.uptodate.com/contents/chlamydia-trachomatis-infections-in-the-newborn#H5
- Measles: 500 000 REPORTED CASES estimate infected at 3-4 million Vaccine worked well initially (26,000 cases) then in early 1990’s there was a resurgence to 56000/yr Second dose of vaccine became required current state: 971 cases in the US as of May 30, 2019 which is more than any of the last 25 years (and this is only the first 5 months) https://www.cdc.gov/media/releases/2019/p0530-us-measles-2019.html Whooping Cough so this looks a little weird, right? With the INCREASE in cases with the newer vaccine? DTP initial product: big P denotes’ whole cell’ seizures, neurological complications Dtap now used, which is acellular pertussis, but it doesn’t work as well Boosters at 11-12, during each pregnancy if you’re a girl, and for dads and grandparents when a new baby is born. Chicken pox https://www.cdc.gov/chickenpox/surveillance/monitoring-varicella.html https://www.cdc.gov/pertussis/surv-reporting.html https://fortune.com/2018/01/19/flu-shot-history/ http://thenationshealth.aphapublications.org/content/47/9/E45
- Measles: 500 000 REPORTED CASES estimate infected at 3-4 million Vaccine worked well initially (26,000 cases) then in early 1990’s there was a resurgence to 56000/yr Second dose of vaccine became required current state: 971 cases in the US as of May 30, 2019 which is more than any of the last 25 years (and this is only the first 5 months) https://www.cdc.gov/media/releases/2019/p0530-us-measles-2019.html Whooping Cough so this looks a little weird, right? With the INCREASE in cases with the newer vaccine? DTP initial product: big P denotes’ whole cell’ seizures, neurological complications Dtap now used, which is acellular pertussis, but it doesn’t work as well Boosters at 11-12, during each pregnancy if you’re a girl, and for dads and grandparents when a new baby is born. Chicken pox https://www.cdc.gov/chickenpox/surveillance/monitoring-varicella.html https://www.cdc.gov/pertussis/surv-reporting.html Influenza Civilian vaccine available in 1945 <50% of eligible people get it Efficacy 40-60% 40 000 000flu cases last year (2018-19) https://fortune.com/2018/01/19/flu-shot-history/ http://thenationshealth.aphapublications.org/content/47/9/E45https://www.cdc.gov/flu/about/burden/preliminary-in-season-estimates.htm
- So its time to put both of these ideas together. So let’s say you’ve got a kid with a cold, or the flu, or any other of the viruses in the above lecture. What’s happening in there?
- So here are some common conditions you’ll see in the office: Sinusitis and OM are overgrowth conditions, of course, caused by disruption of the normal flora by a URI. (or anything that changes the environment) Tonsillitis has a little asterisk here because it’s can be either a primary (like with strep) or it can be a secondary (like with fuso.) All of these have a potential to invade into dangerous spaces and cause life threatening complications. And those are the bulleted points listed here. OC is an invasion from the ethmoid or maxillary sinus into the orbit; mastoiditis is actually an osteomyelitis of the cranium. The term “deep neck infection” may be new, but represents tracking of a tonsillar or peri tonsillar infection between the facial planes of the pharynx and larynx, causing, FIRST, systemic infection, but second, compression of the airway. All of these complications require hospitalization, specialist management, and at least consideration of surgicalmanagement.
- So we are framing these bacterial conditions as secondary, complications of the common cold, et al. So in the context that a kid had cold sxs in the last 1 or 2 weeks, and now you year THIS story, you should suspect an overgrowth condition. Heres the aap dx criteria. note: with a URI WITHOUT improvement double sickening Subset: Sinusitis diagnostic criteria: https://pediatrics.aappublications.org/content/132/1/e262 https://posterng.netkey.at/esr/viewing/index.php?module=viewimage&task=&mediafile_id=298377&201001250933.gif
- Invasion: Here’s a CT of a normal orbit. And you can see the sinus labeled, but imagine if that sinus fills up with pus. Where is it going to invade to? University of Iowa case: (link below) child with URI and facial/eyelid swelling in this case, she had diplopia. Which should have been a red flag to the PCP, but wasn’t started on amoxicillin worsened despite amox and was sent to ophthy https://webeye.ophth.uiowa.edu/eyeforum/cases/103-Pediatric-Orbital-Cellulitis.htm https://posterng.netkey.at/esr/viewing/index.php?module=viewimage&task=&mediafile_id=298377&201001250933.gif
- Now she doesn’t look too bad, does she? It’s not a crazy amount of swelling, she’s clearly well-appearing, what should make you suspect that she’s in trouble? Orbital : invasion from sinuses, and she had a sinus infection Peri-orbital is a skin infection, usually from injury. Bug bite, scratch, etc. ASK. Diplopia: indicates ROM problem, which is intraorbital Proptosis (here, 2 mm, which is hardly appreciable, but this is a good way to check for it.
- So even though she looks very unimpressive, this is what is going on inside there. SO you should elicit the history, and then document: NO diplopia, NO propotosis, NO facial erythema
- https://pediatrics.aappublications.org/content/131/3/e964 http://me.hawkelibrary.com/albums/album04/Mastoiditis.jpg https://maaentblog.files.wordpress.com/2017/06/mastoid-surgery-for-ear.jpg
- Complications of om, especially chronic or recurrent (and why we send for tubes) Osteo of the mastoid, which is part of the cranium Extension to the brain, cord, facial nerve palsy, bacteremia and sepsis Historical features: chronic OM, persistent otorrhea, fever This picture shows the overlying cellulitis, and you can’t appreciate it from this picture so much, but the swelling also causes the pinna to push forward, https://pedsinreview.aappublications.org/content/35/2/94 https://apps.nhslothian.scot/refhelp/ENTPaediatric/MastoiditisPaeds http://me.hawkelibrary.com/albums/album04/Mastoiditis.jpg https://maaentblog.files.wordpress.com/2017/06/mastoid-surgery-for-ear.jpg
- And that’s easier to see in this picture here. https://therustedpansy.wordpress.com/2016/02/28/acute-mastoiditis-our-life-and-death-experience/
- Treatment Culture, blood cultures, Surgical revision, iv abx, ASK: (in all OM cases) pain behind the ear LOOK: swelling, erythema, tenderness, DOCUMENT NEGATIVES CONSIDER: documenting supple neck and facial symmetry https://emedicine.medscape.com/article/966099-treatment https://www.wikidoc.org/index.php/Mastoiditis_CT
- https://jcm.asm.org/content/56/12/e00487-18 And this is what can happen when it invades. (I picked the most dramatic example I could find Obviously, I you get a positive strep result, you’re going to treat. But what if your strep is negative? How do you decide which people need abx so they don’t have THIS on their hands? CENTOR CRITERIA 1. fever 2. exudative tonsils 3. anterior LAD 4. absence of cough For 3 or 4 criteria, even if rapid strep negative, treat. (and send the culture) For 2 criteria, culture and wait For 1 criteria, it’s likely viral. Obviously if you have a unilateral tonsillar of soft tissue exam, you’re going to treat. A note about cough. the textbook definition of strep includes the absence of cough, but in reality: you’ve got stuff swelling and touching, and inflaming the throat. So. Also. Look at this person’s position on the lateral. This is the ‘sniffing’ position that helps them open the airway when you’ve got a big old abscess in the way.
- So . How do you suspect this? These people need CT scans, IV abx and steroids, and an ENT consult. DOCUMENT pertinent negatives: NO dysphagia, NO dyspnea, NORMAL voice.
- This is shot via endotracheal cameral. You can clearly see the bulge there, but it’s normal tissue color due to it being BEHIND the tracheal wall. Happy pimple popping!
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