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Blackwell
Publishing 5amir 5. Shah
Blueprints Q&A Step 2 and
NEW! Index
In an effort to answer a need for high yield review books for the
elective rotations, Blackwell Publishing now brings you Blueprints>
BLUEPRINTS
in pocket size.
These new Blueprints> provide the essential content needed Pediatric
Infectious
during the shorter rotations. They will also prOVide the basic
content needed for USMLE Steps 2 and 3, or if you were unable
to fit in the rotation, these new pocket-sized Blueprints> are just
what you need.
Each book will focus on the high yield essential content for
the most commonly encountered problems of the specialty.
Diseases
Each book features these special appendices:
Blueprints Dermatology
Blueprints Urology
Blueprints Pediatric Infectious Diseases
Blueprints Ophthalmology
Samir S. Shah, MD
Blueprints Plastic Surgery
Instructor, Department of Pediatrics
Blueprints Orthopedics
ne
Blueprints Hematology and Oncology University of Pennsylvania School of Medici
General Pediatrics
Blueprints Anesthesiology Fellow, Divisions of Infectious Diseases and
Blueprints Infectious Diseases The Children's Hospital of Philadelphia
Philadelphia, PA
fl)
Blackwell
Publishing
© 2005 by Blackwell Publishing
ISBN: 1-4051-0402-3
�
Blueprints pediatric infectIous diseases / I edited by] Samlr S. Shah.-I st ed.
Q)
X
p.; cm. - (Blueprints)
v
Includes index.
"
RJ401.B584 2005
61 8. 22'9--ac22
2004013358
A catalogue record for this title i, available from the British Library
Notice: The indications and dosages of all drugs in this book have been rec
ommended in the medical literature and conform to the practices of the gen
eral community. The medications described do not necessarily have specific
approval by the Food and Drug Administration for use 10 the diseases and
dosages for which they are recommended. The package insert for each drug
should be consulted for use and dosage as approved by the FDA. Because
standards for usage change, it is advisable to keep abreast of revised
recommendations, particularly those concerning new drugs.
The publisher's policy is to use permanent paper from mills that operate a
sustainable forestry policy, and which has been manufactured from pulp
processed using acid-free and elementary chlorine-free practices. Furthermore,
the publisher ensures that the text paper and cover board used have met
acceptable envIronmental accreditation standards.
Contributors .................................................... xii
Reviewers ..................................................... xviii
Foreword ....................................................... xix
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx
Acknowledgments .............................................. xxi
Abbreviations .................................................. xxii
84
....
- Endophthalmitis . . . . .... ..
. . .. 33
. . . . . . . . . . . . . . . . . . . . . . . . . . . .., - Cholangitis . . .. . . .. . . . . . . . . .. .. . . . . . ... . . .. . . . . . . . . . . . . . . 88
o
-Orbital and Periorbital Cellulitis ........................... 35 c:
v
Chapter 12: Genitourinary Tract Infections . . . . . . . . . . . . . . . 90
Chapter 7: Central Nervous System Infections ....... .....38 Ron Keren, MD, MPH and David Rubin, MD, MSCE
Jeffrey M. Bergelson, MD -Urinary Tract Infections . . . . .... . . . . . . . .... . . . . . . . .. ... . 90
. . .
- Subdural Empyema and Epidural Abscess ... . . . . . . . . .. . . . .43 - Infectious Diseases in the Sexually Abused Child . . ... . . 96 . . . .
"
o
Susmita Pati, MD MPH, Nicholas Tsarouhas, MD, -Cellulitis . . 100
.ll:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
- Bronchiolitis . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 -Central Venous Catheter-Related Infections . . . . . . . . . . . . 114 . . .
Chapter 16: Trauma-Related Infections • • • . . • • • • • • • • • • • • 119 Chapter 22: Inherited Immune Deficiencies • • • • • • • . • • • • • 170
Reza J. Daugherty, MD, and Dennis R.Durbin, MD, MSCE Timothy Andrews, MD and Elena Elizabeth Perez, MD, PhD
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .227
-Pulmonary Infections . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . 157
- Gastrointestinal Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
xviii xix
"
books. These new pocket-sized Blueprints will be invaluable for Without them, this accomplishment would not be possible.
those students who need to know the essentials of a clinical area There is not enough space to list you all by name but know that
but were unable to take the rotation. Students in physician assis I consider learning from you a privilege. Marie Egan, Victor Morris,
tant, nurse practitioner, and osteopath programs will find these Patrick Gallagher, Stephen Ludwig, Bill Schwartz, and Istvan Seri
books meet their needs for the clinical specialties. deserve special recognition for sharing their wisdom and experi
Feedback from student reviewers gave high praise for this ence as I embark on my career.
addition to the Blueprints brand. Each of these new books was Beverly Copland and Selene Steneck, my editors at Blackwell
developed to be read in a short time period and to address the basics Publishing, demonstrated remarkable enthusiasm and extraordi
needed dunng a particular clinical rotation. Please see the Series nary patience as this book developed. My thanks also extend to
Page for a list of the books that will soon be in your bookstore. the staff members at Blackwell Publishing who contributed to
the production, marketing, and distribution of this book.
My family has provided unwavering support for all of my
projects. I cannot find words sufficient to express my apprecia
tion. Finally, I offer my thanks to my friends and colleagues who
have supported, counseled, and nurtured me during this time.
You have my heartfelt gratitude.
"
�
it -Samir S. Shah, M.D.
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xx
xxi
Abbreviations • xxiii
Mac+ Growth on MacConkey agar (as opposed to ., SDA Strand displacement amplification
0
blood agar) " SE Southeast
MBC Minimal bactericidal concentration v seg Segmented
MCT Mother-child transmission SHEA Society for Healthcare Epidemiology in America
MHA-TP Microhemagglutination for Treponema pallidum SIRS Systemic inflammatory response syndrome
MIC Minimal inhibitory concentration SLV St. Louis encephalitis virus
MMR Measles-mumps-rubella (vaccine) SPACE Serratia, Pseudomonas, Acinetobacter, Citrobacter,
MRI Magnetic resonance imaging and Enterobacter species
MRSA Methicillin-resistant Staphylococcus aurem SPN Streptococcus pneumoniae
MSSA Methicillin-sensitive Staphylococcus aurem ss Single stranded
N/A Not applicable (no form of this disease exists) 1\ STD Sexually transmitted disease
NASBA Nucleic acid sequence-based amplification >.
0.
TB Tuberculosis
NBT Nitroblue tetrazolium TIG Tetanus immune globulin
,:
NP Nasopharyngeal x
0 TMA Transcription-mediated amplification
...
0.
NSAID Nonsteroidal anti-inflammatory drug TMP-SMX Trimethoprim-su Ifamethoxazole
..
NTM Nontuberculous mycobacteria " TNF-a. Tumor necrosis factor-a.
O&P Ova and parasite "l: TRAPS Tumor necrosis factor receptor-associated periodic
OB Occult bacteremia � syndrome (formerly Hibernian fever)
01 Opportunistic infections 2 TSS Toxic shock syndrome
OM Otitis media '" TT Tube thoracostomy
:s:
u
OME Otitis media with effusion 0. UA Urinalysis
Q)
PBP Penicillin-binding proteins III
x
URI Upper respiratory infection
'"
0
PCN Penicillin UTI Urinary tract infection
I
PCP Pneumocystis carini; pneumonia '"
Q VAERS Vaccine Adverse Event Reporting System
'"
PCR Polymerase chain reaction I<i VATS Video-assisted thoracoscopy
Q)
"l:
PE Progressive encephalopathy VCUG Voiding cystourethrogram
:s:
PEP Postexposure prophalaxis VDRL Venereal Disease Research Laboratory
'"
x
PFAPA Periodic fever, aphthous stomatitis, pharyngitis, '" VEE Venezuelan encephalitis
u
and cervical adentitis v VHF Viral hemorrhagic fevers
PFGE Pulsed-field electrophoresis VL Viral load
xxvi Blueprints Urology
VP Ventriculoperitoneal
VSD Ventricular septal defect
VUR Vesicoureteral reflux
VZIG Varicella-zoster immune globulin
VZV Varicella-zoster virus
WB Western blot
1\
WBC White blood cell count Karin L. McGowan, PhD, F(AAM) and Deborah Blecker Shelly, MS
WEE Western equine encephalitis virus
WNV West Nile virus
XLA X-linked agammaglobulinemia BACTERIA
Q)
:r:
v
1\
Microscopy/Direct Examinotion (Table 1-1)
• Gram stain: Bacteria stain differently based on cell wall
composition
- Gram positive: Stain purple/blue; Gram negative: Stain
recl/pink
Damaged or incomplete cell walls (i.e., Mycoplasma,
Ureaplasma) and those with lipids (e.g., Mycobacteria) will
not stain; Nocardia and some fungi stain unpredictably
• Acid-fast stains
- Auramine-rhodamine (fluorescent): Used for rapid screen
ing; most sensitive
- Ziehl-Neelsen and Kinyoun (nonfluorescent): Detection of
acid-fast bacteria (Mycobacteria)
- Modified Kinyoun (nonfluorescent): Detection of weakly
acid-fast bacteria (i.e. , Nocardia, Rhodococcus, Tsukamurella)
Culture Media
• Routine culture media
- Blood agar: Supports growth of most common bacteria
except Haemophilus, Neisseria spp.; can determine hemolysis
on blood agar plate
- Chocolate agar: Haemuphilus, Neisseria spp.
- MacConkey and eosin-methylene blue (EMB) agar:
Selective and differential for gastrointestinal organisms
(enterics) only. Also differentiates lactose fermenters
(Escherichia coli, Klebsiella, Enterobacter) from non-lactose
fermenters (Salmonella, Shigella, Pseudomonas)
• Specialized culture media is needed for the following organisms
that do no grow on routine media: Burdetella spp., Legionella
spp., Escherichia coli 0157:H7, Campylobacter spp. , and Yersinia
spp.
2 • Blueprint!? Pediatric Infectious Diseases Ch. 1: Diagnostic M icro biology • 3
LA TABLE 1-1 Correlations of Staining Result � TABLE 1-2 Examples of Di rect Specimen
with Possible Organisms Diagnostic Testing
Catalase-pOSitive, gram-positive Staphylococcus,Micrococcus,Aerococcus Bartonella hense/ae IFA; sensitivity 95%, specificity 95%
cocci 1\
BordeteJla pertussis peR (new gold standard), DFA
Catalase-negative, gram-positive Streptococcus, Enterococcus, Abiotrophia, Chlamydia trachomatis EIA for antigen; DFA, LCR, PCR; DNA probe
coed Leuconostoc, Pediococcus,GemeJla, Clostridium difficile Toxin A and B detection
Aerococcus,Lactococcus,Globimtella
Clostridium botuln
i um Toxin detection (stool)
Nonbranching, catalase-positive, Bacillus,listeria, Corynebacter
f.coli 0157 EIA for Shiga toxin;peak 2-3 weeks after initial infection
gram-positive bacilli Turicella
Q) Legionella pneumophila DFA; Urine antigen test detects L pneumophila serogroup 1
Nonbranching, catalase-negative, Erysipelothrx
i , Lactobacillus,A
(sensitivity 80%)
:r:
gram-positive bacilli Lactobacillus, Gardnerella v
1\ Mycoplasma pneumoniae PeR
Branching or partially acid-fast Nocardia,Streptomyces,Rhodococcus,
gram-positive bacilli Neisseria gonorrhoeae LCR; DNA probe
Oerskovia, TsukamureJla, Gardona,Rathia
Emerobacteriaceae,Acinetobacter, Streptococcus pneumoniae Antigen testing (urine);tests positive in vaccinated
Gram-negative bacilli and
children
coccobacilli (Mac +, oxidase negative) Chryseomanas, Flavimonas, Stenotrophomanas
Streptococcus pyogenes Rapid Streptococcus antigen, DNA hybridization,
Gram-negative bacilli and Pseudomonas,Burkholderia,Ralstonia,
agglutination (ASO)
coccobacilli (Mac +, oxidase +) Achromobacter group, Ochrobactrum,
Chryseobacterium, AkaJigenes,Bordetella (excl.
B. pertussis), Comamonas, Vibrio,Aeromonas,
Plesiomonas, Chromobacterium
atmospheric requirements (aerobic, anaerobic, CO2); plus use
Gram-negative bacilli and Moraxella, elongated Neisseria,Eikenella of spot tests: oxidase, catalase, indole, etc.
coccobacilli (Mac -, oxidase +) corrodens,Pasteurella,Actinobacillus,Kinge/la,
• Commercial systems: Rapid (4 hour) or overnight; automated
Cardiobocteru
i m, Capnocyrophaga
or nonautomated; substrate utilization, enzyme production,
Gram-negative bacilli and Haemophilus
carbohydrate fermentation; biochemical reactions converted to
coccobacilli (Mac -, oxidase variable)
a code compared with large database
• Other: Latex agglutination tests (Staphylococcus aureus, Campy·
lobacter jejuni, Salmonella/Shigella), serotyping of Haelllophilus
• Nonculture tests are usually better for detecting the following
in/
f uenzae
organisms: Brucella, Corynebacterium diphtheriae, Coccidioides
A, B, C, X, Y, Z, W135); Salmonella and Shigella for outbreaks
immitis, Streptobacillus, Francisella tularensis, Bartonella, Afipia,
and vaccine efficacy; gas-liquid chromatography, long-chain
Helicubacter, Chlamydia, Rickettsia, Ehrlichia, Coxiella, Myco
fatty acid analysis, ribotyping or pulsed-field gel electrophore
plasma, Ureapiasma, Trepunema, Borrelia
sis comparing nucleic acids
Direct Specimen Diagnostic Testing
Identification Methods for Mycobacteria
• Direct testing of clinical specimen by detection of antigen,
• Culture on Lowenstein-Jensen media: Examine growth charac
DNA, or antibody (Table 1-2)
teristics (rate, pigment production) plus biochemical testing
Particularly useful for detection of nonculturable, fastidious,
•
• Typical growth rates: M. tuberculosis: 3 to 4 weeks; M. atrium
slowly growing organisms
illtracellulare complex: 2 weeks; rapidly growing nontubercu
• Considerations: 1) interfering substances such as hlood may
lous mycobacteria (e.g., M. abscesslls, M. fortl/itl/lIl, M. chelonae,
affect result; 2) may represent nonviable organism
M. smegmatis): $7 days
Conventional Bacterial Identification Methods • Nucleic acid probes for culture confirmation: Generally for I'vI.
• Conventional: Phenotypic approach observing macroscopic tuberculosis and M. al'iulll complex (M. allium, M. intracellulare)
morphology on culture media (hemolysis, non-lactose fer • DNA sequencing: Generally used for other species (i.e., M.
menter, etc.); microscopic staining characteristics (pairs, chains); kansasii, M. gordonae)
4 • Blueprints Pediatric Infectious Diseases Ch. 1: Diagnostic Microbiology • 5
Guidelines Cutaneous/Superficial
• Greater volume of blood inoculated yields higher sensitivity • Candida spp.: Cutaneous, mucocutaneous, and nail infections;
and faster detection normal skin flora
6 • Blueprints Pediatric Infectious Diseases Ch. 1: Diagnostic Microbiology • 7
• Malassezia furfur (tinea versicolor): Normal skin flora in fat • Cryptococcus neofonnans: Inhaled from pigeon droppings; causes
rich areas; causes pityriasis versicolor and seborrheic dermatitis pneumonia and meningitis in human immunodeficiency virus
when density becomes too high (HIV) and organ transplantation patients; large dose can infect
• Exophiala wemeckii (tinea nigra): Black rings on skin a normal host
• Dermatophytes ("ringworm"): Skin/hair/nail infections from • Fusarium spp.: Leukemia and bone marrow transplantation
molds Microsporulll spp., Trichophyton spp., Epidermophyton. patients at highest risk
1\
Caused by contact with spores via animals or people • Malassezia furfur: Receiving intravenous lipids is a major risk
factor, seen mostly in neonates
Subcutaneous
• Sporotrichosis (Sporothrix schenkii): Chronic subcutaneous
fungal infection that invades regional lymphatics, caused by
traumatic inoculation with rose thorns Microscopy/Direct Examination
Endemic/Systemic Mycoses
Some commonly used fungal stains discussed below.
Acquired through inhalation or inoculation of spores; all are • Giemsa: Best for visualization of fungi seen in bone marrow
dimorphic, meaning they exist in more than one physical form aspirate specimens and blood smears (e.g., H. capSl/latum and
(mold, yeast, spherule); most localized to an endemic zone. Most P. mameffei)
occur as primary pulmonary infections with rare dissemination • Gomori methenamine silver (GMS): Most popular pathology
(central nervous system, skin, bone, lymph nodes, viscera), except stain for visualizing yeast or hyphae in tissue; excellent for
in immunocompromised hosts and very young children. Pnellmocystis carinii
• Gram stain: Detects Candida spp.
• Blastomyces dermatitidis: Southeastern United States as far
• Modified acid-fast bacillus (modified AFB): Performed directly
north as Norfolk, VA; Ohio, Mississippi, Missouri, and Arkansas
river valleys on specimens and on colonies from culture; Nocardia spp. are
• Coccidioides immitis: California, Arizona, New Mexico, Texas, positive, Actinomyces and Streptomyces are negative
Mexico, South America Potassium hydroxide (KOH) 10%: Most popular stain to
demonstrate fungi in hair, skin, and nail specimens
• Histoplasma capsula tum: Ohio; Missouri; Mississippi river val
leys; Lancaster County, PA; New York State; southern Canada; Identification Methods for Fungi
Central and South America • Molds:
• Paracoccidioides brasiliensis: Central and South America Aspergillus: Septate 45° angle branching hyphae on histology;
• Penicillium mameffei: Cambodia, southern China, Indonesia, Zygomycetes: nOllseptate 90° angle branching hyphae on his
Laos, Malaysia, Thailand, and Vietnam tology
• Sporothrix schmkii: Worldwide Aspergillus: Characteristic conidiophores (from biopsy speci
_
Opportunistic Fungi
men) are usually present within 48 hours on Sabouraud dex
In theory, any yeast or mold can cause systemic disease in a com trose or brain-heart infusion agar. In contrast to candidiasis,
promised host; the most commonly seen yeasts and molds are blood cultures almost never positive in invasive aspergillosis
listed here. With some groups of molds and the filamentous bacteria
(Nocardia, Streptomyces, Actinomyces) biochemical tests
• Candida spp.: C albimns and C parapsilusis most common; identifY an isolate; such testing can take from 2 to 10 days
cause many types of infections, including dissemination to heart, Extent to whIch a mold should be identified (genus vs. genus
lung, liver, spleen, and kidney after catheter-related fungemia and species) depends on site of isolation and immune status
• Aspergillus spp.: Ubiquitous in environment; cause disease of the host
(especially in sinuses and lungs) in cases of prolonged neu • Yeast:
tropenia, bone marrow and solid organ transplantation, and - Pseudohyphae on Gram stain of surface lesions or aspirated
neutrophil dysfunction (e.g., chronic granulomatous disease) fluids or GMS stain of biopsy specimens suggests C albicans
• Zygomycetes (Mucor, Absidia, Rhizopus): Diabetics and im Microscopically, examine yeast for presence of capsule by
munosuppressed receiving steroids at highest risk India ink (C neoformans)
8 • Blueprints Pediatric Infectious Diseases Ch. 1: Diagnostic Mic robiology • 9
• Trematodes (flukes): come in intestinal, liver, lung, and blood • AFB and modified acid-fast stains: Cryprosporidium, Cye/o-
forms spora, Isospora, Microsporidia
Intestinal: Fasciolopsis buski, Echinostoma ilocanum, Hetero • Silver stains: P. carinii
phyes heterophyes, Metagonimus yokogawai; acquired by in • Hematoxylin-based stains: Microfilariae
gestion of infected raw/undercooked water chestnuts, bamboo • Hematoxylin-eosin: Acanthamoeba, E. hisrolytica, Trichinella
shoots, mollusks, or freshwater fish "
spiralis, or Trypanosoma cruzi in muscle
Liver and lung: Clonorchis sinensis, Opisthorchis viverrini, • Calcofluor white stain: Naegleria, Acanthamoeba, P. carinii
Fasciola hepatica (liver) , Paragonimus spp. (lung); acquired • Trichrome or iron hematoxylin: Intestinal tract specimens
by ingesting infected raw fish or water plants • Modified trichrome: Microsporidia
Blood: Schistosoma mansoni, S. meiwngi, S. haematobium, • Fluorescent antibody reagents (direct and indirect): Giardia
S. intercalatum; acquired when the microscopic cercariaI lamblia, P. carinii, C. paroum
form liberated from fresh water snails penetrates human skin "
x Antigen and Antibody Detection
v
Arthropods (Medically Important) "
• Antigen and metabolite detection (rapid tests): Designed to
An enormous group that cannot be thoroughly covered in this detect organisms of high incidence not to replace traditional
text. Medically important arthropods transmit disease to humans O&P if you are looking for the unusual
either by serving as vectors in another parasite's life cycle or by - Antigen tests commonly used for C. parvum; G. lamblia,
causing disease directly through their bites (e.g., Anopheles mos E. histolytica, and P lasmodium spp. (result but must be sup
quito transmits malaria). plemented with smears for percent parasitemia; poor at
detecting mixed infections)
• Antibody detection: Requires acute and convalescent specimens
- Commonly used for diagnosis of Babesia microti (in conjunc
tion with Wright-stained blood smears), Echinococclls granu
Morphologic Identification: Ova and Parasite (O&P) Examination
losus (hepatic cysts more likely to elicit antibody response
• Most parasites still identified by their macroscopic and micro that pulmonary cysts), E. hisrolytica (useful for extraintesti
scopic morphology nal infection; positive in 70% with amebic liver abscess),
• O&P consists of three separate parts: Stool is I) grossly exam Leishmania spp. (antibodies detected during infection in
ined for worms and worm segments; 2) concentrated to maxi 95% of immunocompetent patients and 50% of HIV
mize finding ova and larvae; and 3) stained to maximize finding patients), microfUariae (elevated IgG4 levels indicate active
intestinal protozoa infection), T. canis, T. gondii, T. spiralis, T. cruzi
..
Routine O&P does not include Cye/ospora and Microsporidia x
a
- Sputum: Examined microscopically to detect migrating .ll:
larvae of A. lumbricoides, hookworm, and Strongyloides; pro ..
I')
tozoa E. hisrolytica, Cryptosporidium parol/Ill, P. carinii (now
classified as a fungus); eggs of Paragonimus and Echinococcus
- Blood, bone marrow: Examined microscopically to detect
P lasmodium spp., Babesia spp., Tty panosoma spp., and
Leishmania spp.
Laboratory should be notified at the time the specimen is
submitted when Acanthamoeba or Naegleria are suspected
in CSF
Polymerase chain reaction used for Toxoplasma gondii
Microscopy/Direct Examination
• Giemsa stain: Best stain for all blood parasites and microfilaria,
Acanthamoeba, Naeg/eria, Microsporidia, Toxoplasma, P. carinii
Ch. 2: Diagnostic Virology • 13
6 2 copies and II
Cell Culture Systems Cytology Viral CPE Examination of Papanicolaou-, low 1-2h
" hematoxylin-eosin-, or
Conventional live virus Inoculation of specimens High- Days-
Wright-Giemsa-stained
tube into culture tubes containing moderate weeks "
I<i exfoliated cells for direct
human or animal cell '"
"I
0 detection of viral-induced
monolayers; growth of virus
§' cellular changes
with observation of viral- '"
" Histology Viral CPE, Hematoxylin-eosin stain Moderate- 1-2d
induced morphologic "I
• Molecular amplification methods (e.g., PCR) are extremely envelopes, are quite labile outside their natural host. When im
sensitive and are now the tests of choice for detecting many mediate transport is not possible, specimens should be kept
viruses; quantitative measures of viral nucleic acids (e.g., for refrigerated or on wet ice. If delays of 24 to 48 hours are antic
CM\', EBV, BK, HCV, HBV, HIV) provide useful information ipated, rapidly freeze the specimen to -700C and transport to
about disease progression, prognosis, transmission, therapeutic the laboratory on dry ice. In general, specimens for viral diag
response, and development of drug resistance in chronically " nosis should never be stored at room temperature or frozen at
infected immunocompromised hosts -20nc
• Electron microscopy offers the main advantage of speed when • Swabs are used for collecting specimens from dermal, rectal, res
doing negative staining of liquid samples (i.e., examining stools piratory, and ocular sites. Plastic- or metal-shafted swabs with
for viral agents of gastroenteritis); major limitations include the rayon, Dacron, cotton, or polyester tips should be used; calcium
high cost of the instrument, the requirement for specialized alginate or wood-shafted swabs are inhibitory to some viruses.
expertise, and the overall lack of sensitivity and specificity. This • All swab and tissue specimens should be placed in viral trans
procedure is seldom available in clinical virology laboratories in port medium immediately after collection.
the United States • Urine, stool, cerebrospinal fluid, and other body fluid specimens
• Direct cytologic or histologic examination of stained clinical Q)
.-<
should be submitted to the laboratory in sterile, leak-proof con
<II
material is one of the fastest and oldest methods for detecting III tainers. Do not dilute these specimens in viral transport
'"
viruses. The tests are relatively insensitive in comparison with o medium.
....
direct antigen or nucleic acid detection methods. Specificity is ., • Whole blood specimens should be collected in a suitable anti
o
also low; for example, Tzanck preparations are limited by their so: coagulant such as EDTA, sodium heparin, sodium citrate, or
v
ineffectiveness in distinguishing herpes simplex virus from acid citrate dextrose. EDTA is currently the preferred anticoag
varicella-zoster virus infections. The sensitivity of histologic ulant for most viral studies that require plasma or white blood
staining can be increased somewhat by using immunohisto cells for testing.
chemical or in situ hybridization techniques • Specimens for nucleic acid testing (i.e., PCR) should be col
• Serological assays provide an indirect diagnostic approach by lected and transported in such a manner as to ensure the sta
detecting Viral-specific antibody responses. Detection of virus bility and amplification of the nucleic acids. This is particularly
specific IgM or a seroconversion from a negative to a positive true when collecting and transporting specimens to detect
IgG antibody response can be diagnotic of primary infection. RNA viruses; RNA is a very unstable molecule and is
Detection of virus-specific IgG in a single serum specimen extremely susceptible to degradation by RNases that are ubiq
indicates past exposure or vaccination. Negative antibody uitous in the environment.
titers may exclude viral infection. ..
x • For serological assays, blood should be collected without the
o
,g: use of anticoagulants or preservatives. A single serum specimen
Specimen Collecting and Handling .. is required to determine the immune status of an individual or
"
for the detection of virus-specific IgM antibody. With few
f��Y�!��J?��9 -:-'����
_ ______________________________________________________________
exceptions, paired serum specimens, collected 10-14 days
• Collect specimens as close to clinical onset as possible. Acute apart, are required for the diagnosis of current or recent viral
viral infections are self-limited and cleared within the first 5 to '" infections when specimens are tested for virus-specific IgG
:s:
o
10 days of illness. Therefore, nothing is gained by a delay in antibody.
It
taking a specimen. However, duration of viral shedding varies III
X
• When submitting specimens to the laboratory, the specimen
o
depending on the virus, the host immune status, the anatomic '" container should be labeled with the patient's full name, the
I
site or source of the specimen, and whether there is systemic ,\l<II medical record number or other unique identifier, and date and
or local involvement � time of collection. Each specimen should be accompanied by a
"l
• Virus recovery may be enhanced by collecting multiple speci requisition slip containing the same information as on the
:s:
mens from different body sites x specimen as well as the suspected clinical diagnosis.
<II
'"
• Transport specimens to the laboratory as quickly as possible o
1
GAS/GBS ++ ++ ++ ++ ++ ++ ++ ++ ++ ++ +
SPN + ++ ++ + + + ++ + ++ ++ +
Enterococcus + ++ ++ ++
S. aureus ++ ++ ++ ++ ++ ++ ++ +
MRSA ++ +
Moraxellal + ++ + ++ ++ ++ ++ +
H. inf/uenzae n
_2 ?"
E. colil + +3 + ++ ++ ++
w
K. pneumoniae J>
SPACE +' ++ ++ �
Salmonella + + + + ++ ++ ++
3'
;:; .
Anaerobes ++ ++ a
cr
(mouth) �
Anaerobes ++ J>
<.C
rtl
(gut) ::J
...
(Continued) '"
�
""
""
MRSA + + ++ ++
S-
it
Moraxe/lal + + ++ ++ ++ ++ ++ + "
....
H. influenzae 0'
t:
'"
E.caIiIK. + + ++ ++ ++ ++ ++
pneumoniae
9.
_6 ro
SPACE ++ ++ ++ ++ ++ Oi
'"
ro
Salmonella + + + ++ ++ ++ '"
Anaerobes ++ ++ ++ ++ ++ +9 ++ +
(mouth)
Anaerobes (gut) ++ + ++ ++ ++ +9 +
- No or very poor activity against the organism;+ May use if sensitivity testing permits;++ Potential first-line agent
1 First- and second-generation cephalosporins have very poor CNS penetration. 21 5% to 50% of E. cali sensitive to ampicillinl I J 3096 to 60% of E. (ali and Klebsiella species sensitive to 1" generation
cephalosporinsl14 Poor activity vs. P. oeruginosal 15 Ticarcillin-clavulanate and piperacillin-tazobactam II 6 OK to use for urinary tract infections (except for P. aeruqinosa)1 11 OK for synergy but not as
monotherapyl18 Piperacillin-tazobactam more effective than ticarcillin-clavulanate vs. enterococcill 9 Cipro has no anaerobic activity; Levofloxacin covers mouth anaerobes; newer generation quinolones
cover both mouth and gut anaerobes.
Theoklis E. Zaoutis, MD
Polyenes
• Mechanism of actiun: Binds to the sterol ergosterol in the
fungal cell membrane and causes changes in cell permeability
leading to cell lysis and death
• Mechanism of resistance: Intnnsic (prim ary) or acquired (sec
ondary) resistance. Intrinsic observed prior to drug exposure
while acquired develops upon exposure to the antifungal
agent. Resistance is most commonly associated with altered
membrane lipids, particularly ergosterol. Another possible
mechanism of resistance is mediated by increased catalase
activity
• Available agents: Nystatin; amphotericin B; lipid formulations
of amphotericin B (amphotericin B lipid complex, ampho
tericin B cholesteryl sulfate, liposomal amphotericin B)
Azoles
• Mechanism of a cti o n : Inhi bits cytochrome P-450 enzymes
used in the synthesis of the fungal cell membrane
• Mechanism of resistance: Resistance to azoles can develop by
several different mechanisms, including decreased membrane
permeability, altered membrane sterols, active efflux, altered or
overproduced target enzyme, and compensatory mutations in
the desaturase enzyme. The category of DDS (dose dependent
susceptible) has been created for azoles to characterize isolates
with intermediate resistance that can be inhibited hy higher
doses of drug. DDS isolates may be treated successfully with
12 mglkg/d of fluconazole
23
24 • Blueprints Pediatric Infectious Diseases
Flucytosine
• Mechanism of action: Inhibits RNA and DNA synthesis
• Mechanism of resistance: Mechanisms of resIstance to flucyto
sine (S-fluorocytosine, S-FC) can also be intrinsic or acquired.
Intrinsic resistance is seen in Candida glabrata. Resistance may
be due to the deficiency or lack of enzymes implicated in the
metabolism of S-FC or may be due to deregulation of the
pyrimidine biosynthetic pathway. Rapid development of resist
ance limits the usefulness of S-FC as a single agent and it
should be used in combination with other antifungal agents
• Available agents: S-fluorocytosine (S-FC)
Echinocandins
• Mechanism of action: Cyclic lipopeptide structure that inhibits
l.3-J3-o-glucan synthase. Glucan is the major component of the
fungal cell wall
• Mechanism of resistance: Mechanisms of resistance to echino
candins have not been well defined
• Available agents: Caspofungin; micafungin*
Allylamines
• Mechanism of action: Inhibits squalene epoxidase, an enzyme
in the synthetic pathway of the fungal cell membrane
• Available agents: Terhinafine; naftifine
Griseofulvin
• Mechanism of action: Unknown. The drug is deposited in keratin
precursor cells and becomes bound to newly formed keratin,
thereby preventing invasion by fungi
• Available agents: Griseofulvin (derived from Penicillium)
i'J
U1
26 • Blueprints Pediatric Infectious Diseases
\ll
c
(1)
Adenovirus (MV EBV Enterovirus HBV HeV HHV-6 HSV Influenza A Influenza B Parainfluenza RSV VZV �
"'.
"
Acyclovir + ++ ++ '"
"tJ
Amantadine ++ I1l
a.
Cidofovir + + + + +
+ ++
§'
;:;.
Famciclovir
Foscarnet ++ + + + + + + + S"
+ +
rt
Ganciclovir + ++ ++ + �
lamivudine ++ o·
<:
++ ++
'"
Oseltamivir
0
Penciclovir ++ + v;.
I1l
+ e.I
Pleconaril '"
b ro
Ribavirin + + + + + ++ '"
Rimantadine ++
Zanamivir ++ ++
- Nottested or no known activity; + susceptible based on in vitro testing; ++ commonly used for therapy,
• Chlamydia trachomatis (8 .2/1 000 live births) most common in b Spe<imen must contain conjunctival celis. not exudate alone.
industrialized nations
• Etiologic agents and age of onset: Silver nitrate chemical conjunc
tivitis(I day); Neisseria gO/lorr/weae (3 to 5 days); C. trachomatis
Additional Studies (Table 6-1)
(5 to 14 days); herpes simplex virus (HSV) (5 to 30 days); bacte
ria (5 to 14 days; Staphylococcus aureus, Streptococcus pile lImo Differential Diagnosis
niae, viridans group streptococci, Haemophilus inf/uenzae, • Birth trauma, corneal abrasion, foreign body, nasolacrimal duct
Escherichia coli, P aeruginosa) obstruction, dacryocystitis, congenital glaucoma
Pathogenesis
Management (Table 6-2)
• Thret' mechanisms of infection • [n cases of chlamydial or gonococcal conjunctivitis, the mother
Retrograde spread of organisms to fetal conjunctiva/cornea and her sexual partner requirt' evaluation and treatment for
after premature membrane rupture sexually transmitted diseases
Direct contact with infected genital secretions during vagi
nal delivery Complications
- Direct contact with infected caregivers after birth
• Chemical: None
30
32 • Blueprints Pediatric Infectious Diseases Ch.6:0phthalmologic Infections • 33
• Pathogenesis
TABLE 6-2 Treatment for Ophthalmia Neonatorum
• Direct contact with infected secretions (hand-eye contact)
Etiologic Agent Systemic Treatment Topical Treatment • Organisms infiltrate conjunctival epithelium
Chemical None None
• History/Physical Examination
N. gononhoeae Ceftriaxonex 1 dose Hourly saline lavage until
"
Altemative: IV cefotaxime no further discharge • Red eye, tearing, discharge, foreign hody sensation, itchll1g,
x 7days crusting of eyelids
C trachomatis Erythromycin PO Erythromycin or sulfa • Conjunctival injection, discharge, papillae, edema (chemosis),
x 2-3 weeks ophthalmic ointment or follicles (lymphoid hyperplasia)
Herpes simplex virus" Acydovir x 10 days - Trifluorot hymidine '" • Subconjunctival hemorrhages
1%q 2hx7days ::i
Q)
- Altemative: Vidarabine 3% x
• Additional Studies
ointment 5/dayx 7days v
"
Bacteria None - Erythromycin or gentamicin
• Mild conjunctivitis, diagnosis is made based on history and
ointment
Q)
'""' physical examination
'"
III • Acute severe, recurrent, or chronic conjunctivitis with poor
"
• Duratioll of therapy longer for associated (entral nervous system or disseminated infection. o response to therapy, perform cultures
....
-IJ
o
s:: • Differential Diagnosis
V
• Blepharoconjunctivitis, allergic conjunctivitis, foreign body,
• P aeroginosa: Corneal ulceration or perforation; sepsis or
trauma, chemical irritation, drug reaction, nasolacrimal duct
meningitis in 40% of premature infants with P aeruginosa con
obstruction, iritis, episcleritis, or scleritis
junctivitis
• HSV: Chorioretinitis, cataracts, corneal scarring
Management
• Etiology
• Complications
• Usually bacterial, only 20% of cases are viral • Dry eyes, subconjunctival scarring, keratitis, and entropion
• Common causes:
- Bacterial: H. injluellzae, S. pneumoniae, N. g01wrrhoeae, Moraxella
catarrhalis, S. aureus, Haemophilus aegyptius
� ���ph�h� I ���!�
_ _. _ _ _ _ _ _ _________.. _ ..___________________________________ _ _ _ _ _ _ _ _ __
• Exogenous endophthalmitis: Direct inoculation through surgi Orbital and Periorbital Cellulitis
cal or accidental trauma
• Endogenous endophthalmitis: Hematogenous spread from dis • Periorbital (preseptal) cellulitis: Infection of the skin and soft
tant infection tissues anterior to the orbital septum
• Orbital cellulitis: Infection of the tissues posterior to the
History/Physical Examination orbital septum
• Eye pain and redness, blurred vision, strabismus, recent trauma Epidemiology/Risk Factors
or surgery
• Periorbital cellulitis: Trauma, skin infection, chalazion, dacry
• Reduced visual acuity, conjunctival injection, chemosis, vitritis,
ocystitis, upper respiratory infection
retinal periphlebitis, uveitis, hypopyon, leukocoria
• Orbital cellulitis: Chronic sinusitis, trauma, systemic infection
• Obtain aqueous and vitreous specimens by aspiration with an • Periorbital cellulitis: S. aureus, S. pnellnlUniae, H. injlueuzae
automated suction catheter • Orbital cellulitis: S. aurells, S. plleullloniae, Streptococcus pyo
• Send for bacterial, fungal, and viral cultures and Gram and genes , anaerobic cocci, Prevotella spp., Fusobacterium spp. ,
giemsa stains Veillollella spp.
• Older children have an increased prevalence of anaerobes
Differential Diagnosis
• Few cases of H. illjluenzae since the introduction of the
H. injluenzae type B vaccine
• Severe uveitis, retinoblastoma, neuroblastoma, Langerhans cell
• Fungal orbital cellulitis (mucormycosis) is uncommon; occurs
histiocytosis, leukemia, lymphoma, metastatic tumor in patients with ketoacidosis or immunosuppression
Management • Pathogenesis
• Extrapolated from adult experience due to the paucity of pub • Periorbital cellulitis: Direct spread from nearby skin or lacrimal
lished pediatric reports drainage system via the puncta
36 • Blueprints Pediatric Infectious Diseases Ch.6:0phthalmologic Infections • 37
• 75% to 85% of cases of orbital cellulitis are related to sinusitis - CT scan of the orbits to detect abscess or foreign body
• Factors predisposing to orbital extension of sinusitis - Culture results should be used to tailor antibiotic therapy
- Natural bony dehiscences Oamina papyracea) exist in walls - Gram stain and culture of surgical specimen (when avail-
of ethmoid and sphenoid sinuses able)
- Valveless orbital veins allow communication via blood flow - Indications for surgery:
of sinuses and orbits A
- Ophthalmoplegia with visual loss
- Subperiosteal abscess, globe displacement, or intraconal
• History involvement with disease progression after 24 hours of
• Red or swollen eyelids, headache, periorbital skin trauma, antibiotic therapy
chronic sinus infection, upper respiratory infection
• Complications
• Physical Examination OJ • Ocular sequelae: Compressive optic neuropathy, extraocular
:c
• Periorbital cellulitis: Eyelid edema and erythema. mild con v muscle scarring, neurotropic or ulcerative keratitis, secondary
A glaucoma, septic optic neuritis or uveitis. thromboembolic retinal
junctival injection, normal extraocular movements, periorbital
skin trauma OJ disease
....
"
• Orbital cellulitis: Eyelid edema and erythema, proptosis, papil " • Intracranial sequelae: Brain or epidural/subdural abscess, cav
... ernous sinus thrombosis, meningitis
lary disturbances, restricted extraocular movements, decreased
.;:
visual acuity ....,
o
c
'" Additional Studies v
• Blood cultures
• Evaluation of cases presenting with orbital signs:
- Orbital CT scan to evaluate for abscess or subperiosteal
elevation
- Cultures of blood and sinus aspirates (when possible)
• Differential Diagnosis
• Periorbital cellulitis: Allergic reaction, trauma, angioneurotic
edema, thyroid-related eye disease
• Orbital cellulitis: Orbital trauma, rhabdomyosarcoma, rup
tured dermoid cyst, carotid cavernous fistula, thyroid eye
disease
• Management
• Periorbital cellulitis:
- Hospitalize children under age 2 for IV antibiotics (ampicillin
sulbactam or cefotaxime JV)
- Consider PO antibiotics in children younger than 2 years
(amoxicillin-clavulanate, clindamycin)
If nO improvement after 24 hours or if apparent worsening,
obtain CT scan of the orbits
• Orbital cellulitis:
- Hospitalize all children for IV antibiotics (ampicillin-sulbactam
IV). Other options: Cefotaxime, cefuroxime, ceftriaxone,
clindamycin, or ticarcillin-clavulanate
Ch. 7: Central Nervous System Infections • 39
.
TABLE 7-1 Common Causes of Meningitis by Age
Neonates 6 weeks-Adulthood
• Inflammation of the meninges surrounding the brain a Haemophilus influenzae type b meningitis is unusual in the neonate.
"
x , Herpes simplex eocephalitis should be considered in newborns with aseptic meningitis.
V
Epidemiology A
TABLE 7-2 Cerebrospinal Fluid Evaluation TABLE 7-3 Definitive Therapy for MeningitisQ
Bacterial Neutrophils: low 0 High Positive Group B Streptococcus Penicillin ± gentamicin 2-3wk
lOOs-lOOOs E.cofi Cefotaxime or imipenem/meropenem 3-6wk
Viral Mononuclear: Normal Slightly Negative 1\
Streptococcus pneumoniae If sensitive to penicillin: penicillin lO-14d
hundreds increased If sensitive to cefotaxime, resistant to
TB Mononuclear; low High Negative penicillin:cefotaxime
hundreds If resistant to cefotaxime and penicillin,
Cryptococcal Mononuclear: low Normal Negative but sensitive to vancomycin:
few-1OOs or high cefotaxime + vancomycin ± rifampin
Para meningeal Mononuclear:few Normal High Negative Neisseria meningitidis Penicillin (or cefotaxime)b 7d
Haemophifus influenzae Ampicillin (if sensitive) or cefotaxime 7d
o Less than 50% serum glucose.
Listeria Ampicillin ± gentamicin 2-3wk
Alternative: TMP-SMX
(or ceftriaxone). For cephalosporin-allergic patients, consider • Herpes simplex virus (HSV) encephalitis: In neonates, perina
ciprofloxacin, meropenem, or rifampin. tal acquisition usually after primary maternal genital infection
- Definitive (Table 7-3) (see Chapter 17). In older children, HSV encephalitis is most
- Add coverage-but don't reduce it-based on Gram stain results commonly associated with reactivation
42 • Blueprints Pediatric Infectious Diseases Ch. 7: Central Nervous System Infections • 43
• Viral encephalitis often transmitted by mosquitoes (may be • Magnetic resonance imagl' may show focal involvement or evi
associated with outbreaks of illness in animal populations) dence of demyelination
• Postinfectious encephalitis often occurs after relatively minor - HSV in adult typically affects temporal lobe
respiratory infections (including mycoplasma) and sometimes • Electroencephalogram may show evidence of focality
after vaccinations • Arbovirus serology, including West Nile virus
• Cat scratch encephalitis after contact with kittens • Tuberculin skin testing (PPD)
A
• Cysticercosis, caused by the pork tapeworm, is common out • Cat scratch serology and PCR if suspected
side the United States; patients present with seizures
Differential Diagnosis
• Risk Factors
• Bacterial meningitis typically causes neutrophilic pleocytosis;
• Most patients have no predisposing illness viral meningitis usually does not cause marked CNS dysfunc
"
x tion
III Etiology V • Vasculitis; tumor; genetic and metabolic causes of cerebral
A
• Viruses: Herpes simplex, insect-borne (Eastern and Western dysfunction
equine, California, La Crosse, West Nile, Japanese), rabies,
enteroviruses, varicella, Epstein-Barr virus, others Management
• Bacteria: Mycobacterium tuberculosis, Bartonella henselae (cat • Acyclovir for possible HSV encephalitis
scratch), Listeria monocytogenes (in immunocompromised - In neonates: 60 mg/kg/d, divided into three doses, for
patients) 21 days
• Parasites: Toxoplasma gondii (in immunocompromised), In children and adults: 1500 mg/m2, divided 1I1to three
Cysticercus doses, for 14 to 21 days
• Specific therapies for most other viruses are not available
• Pathogenesis
• Steroids for documented demyelinating illness
• Viral mfection of the brain parenchyma causes cellular damage • Control of seizures
and provokes inflammatory response
• Postinfectious encephalitis is believed to be immune mediated • Complications
• Patients with viral encephalitis may have good recovery or may
History
have persistent cognitive and motor defects
• Fever, headache, altered mental status, convulsions HSY, Eastern equine encephalitis often have poor prognosis
• Ask about mosquito and animal bites, bat exposure, travel, - Cat-scratch encephalitis has good prognosis
exposure to tuberculosis, recent vaccinations
• Physical Examination
• Neurologic exam: Focality makes HSV more likely. Extremity
weakness suggests West Nile virus • Intracranial infection may be confined to the spaces between
• General exam: Evidence of systemic illness. Local adenopathy the dura and the inner table of the skull or spinal column
may suggest cat-scratch disease (epidural abscess), or between the meninges and dura (sub
dural empyema)
Additional Studies
- After tr auma or neurosurgery: vancomycin plus ceft azidime • Empiric antibiotics: Intravenous vancomycin (± intrathecal
- Adjust once culture r esults are known gentamici n); if severely ill, add intr ave nous br oad gram
- Prolonged treatment (more than 6 weeks) often necessary negative coverage as well
- CSF penetration poor in the absence of inflammation
• Complications - Intrathecal vancomycin administration may be necessary if
• Seizures; cerebral herniation; rupture into ventricles may cause A response is poor
acute decompensation - Some centers use oral trimethoprim-sulfamethoxazole
(TMP-SMX) plus rifampin
• Longer treatment may be necessary for frank meningitis,
Ventricular Shunt Infections
abscess, or cellulitis
• Etiology
" • Complications
• Common: S. epidermidis "
V • S hunt infections generally resolve with appropriate therapy
• Less common: Propionibacterium aCTIes, S. aureus, enteric gram A
negative bacilli • Some patients suffer repeated infections
" • Distal infection (e.g., peritonitis) may occur
• Rare: Candida species ....
'"
"
...
• Pathogenesis .B
....,
• Bacteria of low virulence colonize the skin. Shunts may become o
c
contaminated at the time of placement v
• History
• Fever, shunt dysfunction, redness of skin overlying shunt,
abdominal symptoms
• Physical Examination
• Look for signs of increased intracranial pressure, meningeal
inflammation, inflammation along the path of shunt, peri
toneal signs
• Additional Studies
• Aspirate shunt fluid: Culture and Gram stain; mild pleocyt osis
may occur without infection
• MRI or cr to rule out abscess if response to therapy is delayed
• Differential Diagnosis
• Shunt infection may mimic shunt dysfunction without infection
• Management
• Combined medical and surgical treatment:
1) Remove shunt, insert intraventricular drain
2) Treat with antibiotics until cultures are negative
3) Replace shunt and treat several days more
(h.B: Upper Respiratory Tract Infections • 49
II Additional Studies
• GAS rapid antigen detection studies: Sensitivity greater than
1\
Susmita Pati, MD, MPH, Nicholas Tsarouhas, MD,
80%; specificity greater than 95%
• GAS culture: "Gold standard"; recommended when rapid stud
and Samir S. Shah, MD
ies are negative
• "Monospot" (hete rophile antibody) test: EBV diagnosis, but
not reliable if patient is younger than 5 years
�_���y'�9����
_ _ ___________________________________________________________________________
• EBV titers: "Gold standard"; necessary to diagnose E BV in chil
Q)
Epidemiology x dren younger than 5 years
V
• Atypical lymphocytosis and mild thrombocytopenia: Classic
• Generally in children older than 3 years. Peaks in late winter! 1\
CBC findings with EBV
early spring Q)
....
'"
"
III Differential Diagnosis
II Risk Factors ...
.;: • Stomatitis, peritonsillar or retropharyngeal abscess, dental
• Day care attendance; crowded living conditions ....,
o abscess
c
v
II Etiology
II Management
• Bacterial: Group A Streptococcus (GAS), Group C and G strep • GAS: 1) Penicillin V (first-line oral agent); 2) benzathine peni
tococci, Arcanobacterium haemo/yticllm , Neisseria gonorrhoeae, cillin (single 1M injection obviates compliance issues); 3)
Corynebacterium diphtheriae, Mycoplasma pneumoniae amoxicilIin (common, practical alternative to oral penicillin);
• Viral: Adenovirus, Epstein-Barr virus (E BV), influenza, parain 4) other options include clindamycin, cepha\ osporins, and
fluenza, enteroviruses macrolides
• Most cases viral but 15-20% due to GAS • N. gonorrhoeae: 1M ce ftriaxone (one dose)
• EBV: 1) supportive care; 2) avoid contact sports until
Pathogenesis splenomegaly resolves; and 3) steroids if impending airway
• Inhalation of organisms in large droplets or by direct contact obstruction from tonsillar enlargement
with respiratory secretions
• Incubati on period is 2 to 5 days for GAS pharyngitis and 28 to II Complications
42 days for E BV • GAS infections: 1) Suppurative (peritonsillar or retropharyngeal
abscess, cervical lymphadenitis); 2) nonsuppurative including
History rheumatic fever (prevented if therapy started within 9 days of
• Fever, thr oat pain, trouble swallowing, hoarseness, refusal to eat symptom onset) and glomerulonephritis (therapy does not
• GA S: Headache, abdomi nal pain alter risk)
II Physical Examination
• Peritonsillar abscess: Usually occurs in adolescents but occa • CT scan or ultrasound: Differentiate peritonsillar cellulitis
sionally in younger children. from peritonsillar abscess
• Retropharyngeal abscess: Usually in children younger than 5
Retropharyngeal Abscess
years, as these nodes atrophy and disappear later in childhood
1\
• Lateral neck X-ray: Initial diagnostic study of choice; suspect
.. Etiology
abscess if, at level of C2/C3, the prevertebral soft-tissue space
is more than half the adjacent vertebral body diameter
• Most common: GAS; a-hemolytic streptococci; oral anaer • CT scan: Confirms diagnosis, delineates extent, and distin
obes; Staphylococcus aureus guishes abscess from cellulitis
• Pathogenesis
II Differential Diagnosis
• Peritonsillar abscess: Infectious tonsillopharyngitis progresses
from cellulitis to abscess • Stridor: Croup, tracheitis, epiglottitis, foreign body, angioedema,
• Retropharyngeal abscess: Lymphatics drain nasopharynx/ cystic hygroma (infected)
posterior sinuses/adenoids • Torticollis: Pharyngitis, cervical adenitis, vertebral osteomyelitis,
- Purulent infections in these regions spread to retropharynx Lemierre syndrome
by lymphatic drainage. • Retropharyngeal mass: Neoplasm, hemangioma, ectopic thy
Retropharyngeal lymph node inflammation followed by roid, congenital myxedema, lymphadenopathy (e.g., Kawasaki
necrosis leads to abscess disease, histiocytosis)
- Rarely, infection caused by penetrating neck injury or exten
sion of cervical osteomyelitis a Management
Peritonsillar Abscess
iIII History
• Otorhinolaryngology consultation
• Fever, sore throat, dysphagia, drooling, refusal to eat • Drain true abscesses via either needle aspiration or surgical
• Peritonsillar abscess: Also trismus, muffled ("hot-potato") incision
voice, unilateral neck or ear pain • First-line antibiotic therapy: Intravenous penicillin
• Retropharyngeal abscess: Also neck pain or stiffness • Alternative antibiotic therapy: Clindamycin, oxacillin, cefa
zolin, or ampicillin-sulbactam
- Physical Examination
• Antibiotic course: 1 0-14 days. Oral antibiotics when fever!
Peritonsillar Abscess peritonsillar swelling subside
• Unilateral peritonsillar fullness; uvular deviation; bulging of
posterior superior soft palate; palpable fluctuance of palatal Retropharyngeal Abscess
swelling • Antibiotics, otorhinolaryngology consultation, and, in most
• Erythematous and edematous pharynx, enlarged and exuda cases, operative drainage
tive tonsils, cervical adenopathy • If CT reveals inflammatory changes (phlegmon) but no clear
• Occasionally torticollis abscess, treat with antibiotics and consider repeat imaging in
24 to 72 hours if insufficient clinical improvement
Retropharyngeal Abscess
• First-line antibiotics: Ampicillin-sulbactam
• Neck pain especially with extension; head maintained in neu
• Alternative: Cefotaxime plus metronidazole or monotherapy
tral position; torticollis
with clindamycin (especially if high MRSA prevalence)
• Occasionally meningismus or stridor (less than 5%)
• GAS throat studies: Often positive (see "Pharyngitis") Peritonsillar or Retropharyngeal Abscess
• Gram stain and culture of aspirate specimen from abscess • Upper airway obstruction, dehydration
S2 • Blueprints Pediatric Infectious Diseases Ch. 8: Upper Respiratory Tract Infections • S3
• Differential Diagnosis • Otitis media (OM): Inflammation of mucosa lining the middle
• Infectious: Acute epiglottitis; retropharyngeallperitonsillar ear
abscess; bacterial tracheitis; infectiOUS mononucleosis; laryngeal - Acute otitis media (AOM): Acute middle ear inflammation
diphtheria with local or systemic illness
54 • Blueprints Pediatric Infectious Diseases Ch. 8: Upper Respiratory Tract Infections • 55
- Recurrent AOM: Less than three episodes in 6 months, or iii Differential Diagnosis
four or more episodes in 1 year • Retained foreign body, otitis extern a, traumatic tympanic
- Chronic suppurative OM: Purulent drainage from perfo membrane perforation, pharyngitis with referred pain, basilar
rated tympanic membrane more than 6 weeks skull fracture, tumors
• Epidemiology
" • Management
• 90% of children have at least one episode of AOM by 2 years
• AOM (Based on AAP recommendations. PediatriCS 2004;
of age; 50% have three or more episodes by age 3 . Incidence
1 1 3 : 1 45 1 - 1 465)
greatest between 6 and 1 8 months of age.
- Pain control with acetaminophen or ibuprofen. In children
• Risk Factors
older than 5 years consider topical benzocaine
- For age less than 2 years and for those with severe otalgia or
• Congenital: Craniofacial anomaly; immunodefiCiency; dys Q)
" fever �39°C, treat with antibiotics (see below)
functional cilia; male sex v
- For age older than or equal to 2 years, consider initial obser
"
• Acquired: Allergy; bottle-feeding; day caTe attendance; siblings; vation without antibiotics if illness is not severe or diagnosis
tobacco smoke exposure is uncertain. Then treat if no improvement within 48-72
• Risk of recurrent AOM is higher if the first episode occurs at hours. (If observation option exercised, ensure follow-up
age 6 months or younger and availability of antibiotics if necessary.)
First-line therapy: High-dose amoxicillin (90 mg/kg/d)
• Etiology
- Duration of therapy: 5 days but treat 10 days if child
• S. pneumoniae (35% to 48%); Nontypeable H. influenzae (20% younger than 2 years or with underlying medical conditions,
to 29%); Moraxella catarrhalis ( 1 2% to 23%); GAS (less than recurrent AOM, or chronic suppurative OM
5%); S. aureus (less than 5%) - Alternative for treatment failure, amoxicillin allergy, and
• Viruses cause 1 0% to 40% of middle ear effusions in AOM recurrent AOM: Amoxicillin-clavulanate (high dose) or
• Chronic suppurative OM: Mixed flora including Pseudomonas cefuroxime, cefdinir, clindamycin, ceftriaxone, or azithromycin
aeruginosa and S. aureus • Recurrent AOM
- Treat as above followed by prophylaxis with sulfisoxazole or
Pathogenesis amoxicillin for 3 to 6 months
• Eustachian tube dysfunction caused by viral URI or other fac • Asymptomatic middle ear effusions routinely follow AOM
tors (see "Risk Factors") ..
(not considered treatment failure)
"
• Tube dysfunction leads to negative middle ear pressure; middle o - 40% at 1 month after AOM; 20% at 2 months; and 1 0% at
ear fluid accumulates; bacterial infection follows .ll: 3 months
..
I') - Effusions usually sterile so antibiottc management of OME
History/Physical Examination not recommended
• Ear pain, pulling at ear, otorrhea, fever, crying, sleep disturbance • Chronic suppurative OM
• Examination of tympanic membrane: 1 ) Decreased mobility - 7 to 1 4 days of ototopical antibiotics; consider oral antibi
by pneumatiC otoscopy; 2) red or yellow color; 3) bulging or otics as for AOM
thickened ; 4) poorly visualized landmarks; 5) dull light reflex; • Indications for tympanostomy tubes: 1 ) Chronic OME (more
6) perforation with drainage than 3 months) and associated conductive hearing loss greater
than 1 5 dB; 2) failed chemoprophylaxis for recurrent AOM; 3)
• Additional Studies
tympanic membrane retraction with ossicular erosion or
cholesteatoma formation.
• Tympanometry confirms middle ear effusion when pneumatic
otoscopy is impossible
iii Complications
• Indications for tympanocentesis: 1 ) Relieve severe pain; 2)
confirm pathogens in neonates or immunocompromised chil • Middle ear: Cholesteatoma, conductive hearing loss, facial nerve
dren; 3) failed antibiotic therapy; 4) treatment for mastoiditis paralysis, ossicular damage, tympanic membrane perforation
56 • Blueprints Pediatric Infectious Diseases (h.8: Upper Respiratory Tract Infections • 57
• Acute mastoiditis
- Myringotomy to drain middle ear and mastoid and to obtain
����()J��!!�
_ _ __________________________________________________________ _________________
1\
culture data
• Infection of mastoid air cell system (with or without bone Parenteral antibiotic treatment (cefotaxime, ceftriaxone, or
destruction) caused by middle ear suppuration. May be acute ampicillin-sulbactam)
or chronic (symptoms more than 6 weeks) - Mastoidectomy if fever and otalgia persist for more than 48
'" hours or if infection progresses
�
• Epidemiology/Risk Factors Q) • Chronic mastoiditis
J:
- Antibiotic therapy as above plus myringotomy and mas
• Usually age less than 5 years v
1\ toidectomy
• Risk factors: Viral infections, ciliary dysfunction, and immun
Q)
odeficiency ...,
'" l1li Complications
III
'" • Meningitis, epidural or subdural abscess, otogenic extradural
• Etiology ....
o
brain abscess, lateral sinus thrombosis, or facial nerve palsy
....,
• Acute mastoiditis o
<: • Extension medially to petrous air cells (petrositis)
- Common: S. pneumoniae, S. aureus, S. pyogenes, H. inf/uenzae v • Extension through mastoid tip (sternocleidomastoid abscess,
- Less common: P aeruginosa, Proteus species a.k.a., Bezold abscess)
• Chronic mastoiditis • Extension through digastric groove (digastric triangle abscess,
- S. aureus, P aeruginosa, other gram-negative bacilli, and a.k.a., Citelli abscess)
anaerobes • Retropharyngeal or parapharyngeal abscess
• History/Physical Examination
• Complicates 5% to 1 0% of URIs
• Recent OM, ear discharge, ear pain, hearing loss, or fever III Risk Factors
• Auricle displaced: Downward and outward in infants but • Mucosal swelling: Viral URI, allergic inflammation, cystic
upward and outward in older child fibroSiS, immune disorders, immotile cilia, facial trauma, swim
• Mastoid swelling, tenderness, and erythema; blunted postauric- ming, diving, rhinitis medicamentosa
ular sulcus • Mechanical obstruction: Choanal atresia, deviated septum, nasal
• Drainage fistula may be present polyps, foreign body, tumor, ethmoid bullae, encephalocele
• Tympanic membrane inflamed or perforated
• Chronic mastoiditis: Middle ear granulation tissue or polypoid IlIII Etiology
formations • Acute and subacute sinusitis
Bacterial: 30% to 40% S. pneumoniae; 20% H. inf/uenzae
Additional Studies
(nontypeable); 20% M. catarrhalis
• Contrast-enhanced head CT to define extent of disease - Viral: Adenovirus, parainfluenza, influenza, and rhinovirus
58 • Blueprints Pediatric Infectious Diseases Ch. 8: Upper Respiratory Tract Infections • 59
• Contact with cats (Bartonella henselae, Toxoplasma gondii, • Miscellaneous lymphadenopathy: Kawasaki syndrome, PFAPA,
Pasteurella multocida, Yersinia pestis) or rabbits (Francisella sarcoid, Rosai-Dorfman (sinus histiocytosis with lym
tularensis) phadenopathy), Kikuchi-Fujimoto (histiocytic necrotizing
• Phagocyte defect (e.g., hyper-IgE) lymphadenitis), Kimura disease, Castleman disease (giant
"
• Dental caries predispose to anaerobic infection lymph node hyperplasia)
• CongentiaI: Thyroglossal duct cyst, branchial deft cyst, der
.. Etiology moid cyst, goiter, lymphangioma
• Common: S. aureus, GAS, GBS (neonates) • Malignancy: Lymphoma, neuroblastoma, parotid tumor, rhab
• Less common: B. henselae (cat-scratch), nontuberculous domyosarcoma
mycobacteria (NTM), anaerobes
• Rare: Mycobacterium tuberculosis, T. gondii, F. tularensis, P. mul II! Management
tocida, Y pestis, gram-negative bacilli, Nocardia species • Determine most likely organism based on age, exposure, and
examination
III Pathogenesis
Bacterial Adenitis
• Local infection in lymph node may follow hematogenous
spread of systemic infection or lymphatic drainage of infected • Empiric therapy
area - po: Cephalexin or dicloxacillin (first line), or c1indamycin,
amoxicillin-c1avulanate, cefuroxime, trimethoprim-
II History sulfamethoxazole (TMP-SMX), ciprofloxacin, or linezolid
• Inquire about specific exposures, recent travel, dental prob - IV: oxacillin, cefazolin, c1indamycin, ampicillin-sulbactam,
lems, and systemic symptoms TMP-SMX, or vancomycin
• Inquire about symptoms associated with compression of adja • Consider needle aspiration or incisional drainage if I) not
cent neck structures improved in 2 days; 2) suppuration
8. henselae
II Physical Examination
• Self-limited, resolves over 2 to 4 months
• Bacterial: Unilateral, firm, tender, warm, overlying cellulitis,
• AZithromycin for 5 days decreases lymph node volume more
occasionally fluctuant
than placebo over first month
• B. henselae: Follows scratchlbite by ] to 8 weeks, nontender,
• Antibiotics with in vitro susceptibility include rifampin,
solitary large (more than 4 cm) node, no overlying discol
macrolides, tetracyclines, TMP-SMX, quinolones, and amino
oration or cellulitis, 25% with associated fever
glycosides
• NTM: Gradual enlargement (weeks to months), minimal ten
derness, overlying skin becomes violaceous as nodes soften and NTM
1 0% drain spontaneously through sinus tract to skin • Standard therapy requires surgical resection of affected nodes
• M. tuberculosis: Gradual enlargement, nontender, firm, primary • Incisional drainage not recommended because it may lead to
pulmonary focus in 30% to 70% sinus tract drainage
• Medical management with c1arithromycin, ethambutol, or
II Additional Studies
rifampin rarely successful
• Consider CT or ultrasound of neck to detect suppurative nodes
and extent of infection M. tuberculosis
• B. henselae: Serology (indirect fluorescent antibody) or poly • Isoniazid, rifampin, and pyrazinamide ± ethambutol or strepto
merase chain reaction of serum or lymph node mycin
• NTM: Tuberculin skin test usually 5 to 9 mm
• M. tuberculosis: Tuberculin skin test usually more than I S mm; .. Complications
chest radiographic findings may include hilar adenopathy, cav • Compression of adjacent structures; draining sinus tract; exten
itary lesion, or pleural effusion sion to form deep neck abscess; bacteremia
Ch. 9: lower Respiratory Tract Infections • 63
• Epidemiology v
• Management
"
• Peak occurrence in October through May Q) • Extent of bronchiolar necrosis and speed of regeneration influ
• 80% of infections occur in children younger than 2 years ...
.. ence recovery
III
... • Usually self-limited: 3 to 7 days acute illness with slow recov
• Risk Factors .8
ery (2 weeks)
..,
• Risk factors for severe illness during bronchiolitis: Chronic o
c • 0.5% to I % of patients require hospitalization; of these, 5%
lung disease (CLD); cystic fibrosis; congenital heart disease v previously healthy and 20% high-risk require intubation
(CHD); hematopoietic stem cell or organ transplantation; cel
Relieving Airway Obstruction
lular immune deficits (e.g., 22q1 1 .2 deletion)
• j3-Agonists (nebulized albuterol)
• Etiology - Evidence on efficacy conflicting
- Modest short-term improvement in clinical features but no
• Common: Respiratory syncytial virus (RSV; 70% of cases)
impact on rate or duration of hospitalization
• Less common: Parainfluenza, influenza, adenovirus
• Combined a- and j3-agonists (racemic epinephrine)
• Rare: Human metapneumovirus, Mycoplasma pneumoniae,
rhinovirus - In principle, a-agonist diminishes airway edema/mucous
production and j3-agonist relieves bronchospasm
• Pathogenesis - No large trial but several small trials report conflicting
..
x results
• Virus induces o
- No significant therapeutic benefit with either RSV IVIG or TABLE 9-1 Common Causes of Childhood Pneumonia
palivizumab by Age
- Palivizumab monthly prophylaxis reduces RSV hospitaliza
tions (from 8% to 2%) in children born prior to 32 weeks Neonates 1-3 months 3 months-5 years >5 years
gestation
Group B lower respiratOf)' lower respiratory Mycoplasma
1\ Strept(}(OCCUS viruseso viruses pneumoniae
Complications
:s:
Gram-negative Streptococcus Streptoc(}(CUS Chlamydophila
• Mortality: Less than 0 . 1 % overall but 3% to 5% for those with � enteric bacilli pneumoniae pneumoniae pneumoniae
"
CLD or CHD 0
Cytomegalovirus Chlamydia Haemophilus Streptococcus
• Long term: Asthma more likely but cause/effect unclear g.
" trachomatis influenzae pneumoniae
� Lsteria
i Bardete lla Mycoplasma Influenza
Ql
Acute Pneumonia
-----------------------------------------------------------------------------------------------
x mOfl(}(ytogenes pertussis pneumoniae viruses
v
Herpes simplex StophylOC(}((/./S
1\
• Epidemiology virus aureus
Ql
• Most common in children younger than 2 years .... Strepr(}(OCCUS Ureaplasma
'"
IJ)
• Seven-valent pneumococcal vaccine (Prevnar) reduced Strepto pneumoniae urealyticum
...
0
coccus pneumoniae bacteremic pneumonia by 90% ....
o Includes respiratory syncytial virus, adenovirus, parainfluenza viruses,and influenza viruses.
...,
0
c
II Risk Factors
v
• Etiology
• Chest radiograph (CXR) required for firm diagnosis
- Consider CXR: 1) Young children, 2) uncertain/severe diag
• 30% to 40% bacterial; S. pneumoniae remains most common nosis, 3) failure of therapy, or 4) recurrent infections
(Table 9-1) • Diagnostic clues
- Bacterial: Lobar/segmental consolidation or large pleural
• Pathogenesis
effusion
• Three main mechanisms of infection Staphylococcus aureus: Pneumatoceles (air-filled cavities
- Transient or chronic impairment of normal airway defenses from alveolar rupture)
Inhalation of large aerosol burden " Viral or atypical: Diffuse or bilateral interstitial pattern
- Hematogenous seeding of the lung i:i 1 0% of M. pneumoniae infections lobar, 20% with small
It
..
x bilateral pleural effusions
• History/Physical Examination o
'" • Blood cultures (uncomplicated pneumonia) positive in less
• Fever, cough, labored breathing, chest or abdominal pain, vom �'" than 2% of outpatients but 7% to 10% of hospitalized children
iting, decreased activity • Transthoracic needle aspiration: Microbiologic yield 70% with
• Tachypnea is the most reliable predictor of pneumonia in chil
! culture, polymerase chain reaction (PCR), and immunofluo
:s:
dren: Sensitivity, 50% to 85%; SpeCificity, 70% to 95% x
'"
rescence
• Wheezing with pneumonia usually signifies viral or atypical '"
tJ - Consider if immunodeficient or worsening pneumonia of
cause V unclear cause
• Common findings: • NP cultures correlate poorly with cultures of lung tissue
66 • Blueprints Ped i at ric Infectious Diseases Ch.9: Lower RespiratoryTraa Infeaion s • 67
Or Cf); to delineate anatomy (chest CT) adjust based on blood/pleural fluid culture results
0:
• Send pleural fluid studies (Box 9-] and Table 9-3) - Empiric: Ampicillin-sulbactam or cefotaxime + oxacillin
::i
• Pleural fluid eosinophilia: Parasites, TB, fungi, or hypersensitiv Q) (vancomycin if methicillin-resistant S. aureus prevalent)
x
ity diseases v • Classify pleural effusions based on CXR results
• Consider pleural biopsy to detect tuherculous granulomas " - Size on decubitus CXR
Q)
'""' Small: Less than ] 0 mm
'"
" - Moderate: 1 0 mm or more, but less than half of hemithorax
...
BOX 9-1 Pleural F luid Studies o - Large: Half of hemithorax or more
.....
'"' - Character: Free flowing or loculated
Always o
r:: • Surgical management options to prevent organizing phase and
Cell count v
remove loculationslfibrinous peel
Glucose
- Thoracentesis (needle aspiration)
pH
LDH
- Tube thoracostomy (TT; chest tube) with or without fibri-
Gram stain
nolysis
Add-fast stain - Open decortication or video-assisted thoracoscopy (VATS)
Cultures· with decortication
• Initial surgical management based on size and character of
Sometimes effusion: ] ) Small: No surgical management; 2) Mo de rate:
My<:opIasma PCR Thoracentesis or TT; 3) Large : TT or VATS; 4) Loculated :
Viral antigen immunofluorescence
Open decortication or VATS
Viral culture
• Subsequent management based on detection of empyema: ] )
Total protein
Amylase
I f initial thoracentesis reveals empyema, perform TT; 2) If
Cholesterol inadequate drainage from IT, perform open decortication or
Cytology (to exdude malignancy) VATS
II Additional Studies
� BOX 9-2 Infectious Causes of Pulmonary
Lymphadenopathy • CXR: Detects size and location of mass; detects calcifications;
prompts further imaging (CT or MRI) to define anatomy and
Bacterial extent of disease
My(obacterium tuberculosis • Chest CT: Demonstrates calcium; better for anterior and
Nontuberculous mycobacteria middle mediastinal masses
A
Mycoplosma pneumoniae
• Chest MRI: Does not demonstrate calcium; better for posterior
Bartonella hense/ae "
� mediastinal masses (usually neurogenic origin)
B ordetella pertuss i s 'I
0 • Tuberculin skin testing (PPD)
Yersinia entero(o/i tim 0.
c • Complete blood count findings (e.g., pancytopenia, eosino
Bru(ella spp. '"
Fran(ise11o tularensis � philia) may suggest cause
Q)
"
Fungal IiI1 Differential Diagnosis
v
Histoplasma mpsulatum A
• Chronic inflammation: Bronchiectasis, cystic fibrOSiS, lung
Coccidioides immitis Q)
.... abscess
Paracoc(idioides brasiliensis ..
III • Malignancy: Hodgkin lymphoma, non-Hodgkin lymphoma,
Blastomyces dermatitidis ...
Cryptococcus neoformans
0
....
leukemia
., • Other: Chronic granulomatous disease, Langerhans cell histio
0
Other c cytosis, sarcoidosis. Castleman disease
v
HIV
Epstein-Barr virus II Management
Toxoplasma gondii • Lymph node biopsy if: 1 ) Other tests do not reveal cause; 2)
size increases over 2 weeks or persists for more than 4 weeks;
3) malignancy is suspected
II Pathogenesis
II Complications
• Findings that suggest abnormal mediastinal lymph nodes: I)
Lymph nodes present where none usually seen; 2) size greater • Related to cause of mediastinal adenopathy
than 1 .5 cm; 3) lymph node morphology reveals calcification,
cavitation, caseation. or rim enhancement ..
"
o
II History .ll:
..
I')
• Findings from underlying cause or compression of adjacent
structures. Inquire about:
- Cough, wheeZing, hemoptysis, dysphagia, hematemesis
�
�
- Facial swelling, headaches, epistaxis, tinnitus
Hoarse voice, symptoms of spinal cord compression
• Physical Examination
• Pathogenesis
• Endocarditis: Infection on the endocardial surface of the heart • Key features: Change in heart murmur, new or worsening heart
including the heart valves Q)
x
failure, peripheral septic emboli, or new neurologic findings
• Infections on the endothelial surface of blood vessels may act v
"
as "endocarditis"
Q)
..... BOX 10-1 Symptoms, Signs, and Laboratory Findings
..
'"
Epidemiology Associated with Infective Endocarditis in Children
"
o
• Estimated incidence, 1.7 to 4 cases per 100,000 population per '"
.., Symptoms
year in developed countries o
c Fever
• In children, mostly a complication of congenital heart disease v Malaise
(CHD) Anorexia/weight loss
Heart failure
• Risk Factors Arthralgia
Chest pain
• CHD: Especially tetralogy of Fallot and ventricular septal Neurologic symptoms a
defects Gastrointestinal symptoms
• Surgically repaired CHD using patches, grafts, or artificial
valves Signs
• Others: Mitral valve prolapse; atherosclerosis (adults); intra Fever
venous drug use; indwelling central vascular catheters; rheu Splenomegaly
Petechiae
matic heart disease (once common, now rare)
Embolic phenomenon
New or changed murmur
• Etiology Clubbing
• Bacteria: Viridans streptococci (most common at all ages); Osler nodes
enterococci; Staphylococcus aureus; coagulase-negative staphy Roth spots
Janeway lesions
lococci; hemolytic streptococci, groups A, B (in neonates and
Splinter hemorrhages
elderly), C, G, D Streptococcus; Streptococcus pneumoniae; gram
Conjunctival hemorrhage
negative enteric rods (uncommon); HACEK organisms (Haemo
philus aphrophilus, Actinobacillus actinomycetemcomitans, laboratory Findings
Cardiobacterium hominis, Eikenella corrodens, and Kingella Positive blood rulture
kingae) Elevated ESR
• Fungi: Candida species, Aspergillus species, Cryptococcus neo Anemia
formans Positive rheumatoid factor
• Others: Coxiella burnetii (Q fever), chlamydiae, culture-negative Hematuria
endocarditis
• Sud! as local neurologic deficit and aseptic meningitis.
72
74 • Blueprints Pediatric Infectious Diseases Ch.lO:Cardiac Infections • 75
• Management
'" • Pathogenesis
::i
• Major indications for surgery in patients with endocarditis: 1) Q)
x • Seeding of the pericardium from 1) viral or bacterial blood
Persistent vegetation after systemic embolization; 2) increase v
stream infection; 2) extension of myocarditis as myopericar
in vegetation size after 4 weeks of antimicrobial therapy; 3)
"
ditis; 3) direct extension from contiguous lung infection;
congestive heart failure not responding to medical treatment; '"''"
Q)
4) multifocal spread of bacteremia (other distant foci may
4) periannular extension of infection or abscess; 5) fungal Vl
exist); 5) postsurgical chest infection
...
endocarditis; 6) persistent bacteremia or emboli despite ade o
.... • Inflammation causes fluid accumulation between visceral and
quate antibiotic therapy; 7) unstable prosthesis '"'
o
parietal pericardium
• Take multiple blood cultures (at least three) before antibiotic <:
v
treatment • History
• Empiric antibiotics for the very ill but in subacute disease • Precordial chest pain (difficult to elicit in the very young)
await results of blood cultures • Fever, irritability, and exercise intolerance
• Antibiotic treatment with bactericidal drugs. Preferred regi • Night sweats and hemoptysis in tuberculous pericarditis
mens as follows:
- Viridans streptococci, S. bOllis : Penicillin or ceftriaxone with
or without gentamicin BOX 1 0-2 Causes of Pericarditis
- Enterococci: Penicillin (vancomycin if penicillin resistant)
"
plus gentamicin » Viruses
Po
- Methicillin-susceptible staphylococci: Nafcillin or oxacillin Coxsackie 8"
(vancomycin for methicillin-resistant S. aureus) .:
x
Coxsackie A
0
Staphylococci with prosthetic device or materials: Nafcillin, Po Echoviruses
08<
.,..
Adenoviruses
oxacillin, or cefazolin plus rifampin plus gentamicin
InfluenZ<l
"l:
• Complications 5 Ba(teria
• Congestive heart failure, stroke, arrhythmia, metastatic infec 2
Staphykxoc(lJS aUfeus·
tion, and mycotic aneurysms :.'"
0
Hoemophilus influenzoe type b"
Po
Q)
Neisseria meningitidis·
III
Mycoboderium tuberculosis
�!���� ��i���
x
_ _ __ ___________________________________________________________________________ '"
0
I
Q Others
• Infection/inflammation of the pericardium surrounding the '"
III
iii Mycoplasma pneumoniae
Q)
heart and proximal great vessels "l:
Histoplasma copsulotum
:. Coccidioides immitis
x
Epidemiology
•
'"'"
0
Blastomyces dermatitidis
• Retrospective reviews: 211000 to 311000 admissions to chil v
• Most (ommon<3uses In North America.
dren's hospitals
76 • Blueprints Pediatric Infectious Diseases Ch.lO:Cardiac Infections · 77
tamponade
• Inflammatory condition involving the myocardium; peri
cardium and endocardium sometimes involved. Dilated car
• Additional Studies
diomyopathy is a manifestation of chronic myocarditis
• Chest radiograph: Enlarged cardiac silhouette '"
- Send for WBC and differential counts, glucose, protein, and • Certain agents vary geographically: For example, Chagas dis
Q)
cytology '"' ease (South America) and Lyme disease (East and West Coast,
'"
.. Additional Studies
79
80 • Blueprints Pediatric Infectious Diseases Ch. 1 1 : Gastrointestinal Tract Infect io ns • 81
• Noninflammatory: Affects proximal small bowel by entero TABLE 11-1 Antimicrobial Therapy for
toxin adherence. Causes watery diarrhea. Examples: Vibrio Bacterial Enteropathogen s
cholerae, Yenterocolitica
• Inflammatory: Invade GI tract epithelium. May cause dysen Bacteria Indication Antibiotic
tery. Examples: Salmonella and Shigella spp. Aeromonas spp. Prolonged disease TMP-SMX, ciprofloxacin
"
Campylobaeter Severe or systemic infection, Azithromycin, fluoroquino\ones,
.. History
:;: jejuni immunodeficiency erythromycin
'"
• Food- or water-borne illness '"
"I Oostridium Symptomatic, not improving Metronidazole (PO/lV) or oral
Incubation: Less than 6 hours (preformed toxin: S. aureus, B.
_
0
difficile vancomycin orcholestyramine
g.
cereus); 8 to 16 hours (C perfringens, B. cereus); 16 to 96 hours '" Escherichia coli Severe or systemic infection TMP-SMX, f1uoroquinolonesa
"
(Shigella, Salmonella, Vibrio spp., invasive E. coli, C jejuni, Y "I
Ol
SalmOf/eila spp. Age <3 months, Ampicillin, cefotaxime,
enterocolitica, caliciviruses) x
immunodeficiency, ciprofloxacin, azithromycin
• Determine duration of illness, stooling pattern (frequency, v
dissemination
"
volume, blood/mucus), travel and ingestion history (see Shigella Spp. Dysentery Ceftriaxone,azithromycin,
Ol
"Epidemiology/Risk Factors"), hydration status ..,
'" fluoroquinolones,TMP-SMX
III
• Other symptoms: Fever, emesis, abdominal pain, rash, tenesmus Vibrio cholerae Treatment decreases Ciprofloxacin,TMP-SMX,
'"
0
.... illness duration tetracyclines
.. Physical Examination ....
0 Yersinia Sepsis, immunodeficiency Cefotaxime, TMP- SM)(,
s::
• Signs of dehydration: Absence of tears, dry mucous membranes, v
enterocolitica fluoroquinolones
decreased skin turgor, prolonged capillary refill, cool peripheral
skin temperature, diminished pulse volume and elevated rate, Q Antibiotic management off. co/i0157:H7 may inuease risk of hemolytic-uremic syndrome.
an invasive or cytotoxin-producing organism such as Shigella • Fluid and electrolyte replacement; precautions to prevent spread
spp., Salmonella enteritidis, C jejuni, invasive E. coli, C diffi of enteropathogen; specific therapy if indicated (Table 11-1)
cile, Yenterocolitica, Vibrio parahaemolyticus, or Aeromonas
.. Complications
• Stool culture for bacteria (see Chapter 1)
• Consider stool antigen testing for rotavirus, adenovirus, • Extraintestinal manifestations:
Giardia, and Cryptosporidium (also see "Intestinal Parasites") Erythema nodosum (Campylobacter, Salmonella, Yenterocol
itica)
.. Differential Diagnosis - Hemolytic-uremic syndrome (E. coli, Shigella dysenteriae,
• Anatomic (e.g., Hirschsprung enterocolitis, short bowel syn Salmonella typhi, C jejuni)
drome, malrotation) - Reactive arthritis (C difficile, C jejuni, S. dysenteriae, S. enter
• Malabsorption (e.g., celiac disease, fructose intolerance, sucrase itidis, C ovale, Y. enterocolitica)
or lactase deficiency, Shwachman disease, glucose-galactose - Seizures (S. dysenteriae)
transport defect)
• Neoplasms (e.g., neuroblastoma, pheochromocytoma)
� ��������r���������
_ _ _ _ _____________________________________________________________
• Poisoning (e.g., heavy metals, mushrooms, scombroid)
• Endocrinopathy (e.g., thyrotoxicosis, Addison disease) .. Epidemiology/Etiology
• Food allergy (e.g., cow milk or soy protein) See Table 11-2.
82 • Blueprints Pediatric Infectious Diseases Ch. 11: Gastrointestinal Tract Infections • 83
• Risk Factors
TABLE 11-2 Parasitic Intestinal In fections
• Immunocompromised host; immigration from or travel to
Geographk endemic areas
Pa/CIsite Distribution Treatment Aherrlative Therapy • Day care attendance; contact with infected animals
Stomach • Contaminated food or water (including swimming pools)
Anisakissp. Scandinavia,HoUand, Endoscopic or "
Japan, Pacific Coast of surgical larvae • Pathogenesis
"
South America removai �tI • Transmission almost exclusively by fecal-oral route
Smal l intestile 0
• Involvement may vary from asymptomatic carriage to invasive
Giardia Prevalence highest in Metronidazole Tinidazole,mepacrine,
go
'" infection
Iomblia developing world (5 mg/kg TIDx3d) furazolidone, paro- �
(up to 30%) momydn, quinacrine .,
x • History/Physical Examination
B/astocystis Worldwide Metronidazole Furazolidone, v
hominis (20--3S mglkg tinidazole " • Travel and dietary history
divided TIDx 10 d) iii • Abdominal pain, diarrhea, tenesmus, bloating, flatulence
....
Countries with high Nitazoxanide (100- Azithromycin + .. • Fever, emesis, anorexia
CrypfDspo- It)
ridium AIDS prevalence 200 mgBID) (therapy paromomycin ... • Wheezing (Strongylaides stercoralis, As caris lumbricaides)
0
'><
porvum only needed for • Muscle pain or skin rash (Trichinella spiralis)
.,
patients with AIDS) 0
• Pruritis ani (often nocturnal) (Enterobius vermicularis)
t:
Isosporo S. Americ3,Africa, Trimethoprim Pyrimethamine v • Local skin reaction at the site of larvae penetration (S. sterco
belli SE Asia (5mglkg) - (SO-75mgJday)+ mus, Ankylostoma duodenale)
sulfamethoxazole folinic acid • Failure to thrive and growth impairment with chronic infections
(25 rug/kg)BIDx
• Evaluate for dehydration, abdominal obstruction or mass
HOd)
Cydospora Developing countries Same as fot
• Additional Studies
cayetanensis IsosporabeHi
S(rongy/o- Tropics,eastem Albendazole Thiabendazole (25 mgt
• Stool for ova and parasites (see Chapter I): Several not found
ides stereo- Europe, Australia, (400 mgBIDx 3 d), kgBIDx 2-3d ) on standard ova and parasite testing (Cryptosporidium parvum,
"
folis southern US ivermectin (200 ig/ :>. Cyclospora cayetanensis , and Microsporidia species)
0-
kg/dx Hd) • Duodenal aspirate (during endoscopy, or swallowed string test)
,: • Tape test (E. vermicularis)
TrichineJla Worldwide in Mebendazole(200 mg x
0
spiralis communities coo- TIDx3d,followed 0-
... • Mucosal biopsy (G. lamblia, S. stercoralis, C. parvum, Enta
suming pork meat by 400 rug TID x 10 d) E<
moeba histolytica)
"
Ascaris Prevalence highest Albendalole (200- levamisole (5 rug/kg "1: • Enzyme-linked immunosorbent assay (ELISA) for giardiasis,
/umbricoides in developing world 400 mg single dose) single dose), piper- 6 amebiasis, cryptosporidiosis
(roundworm) or mebendazole aline otrate, pyrantel � • Serology for helmintic infections (5. stercoralis, trichinosis)
(500 mg single dose) pamoate '" • Serum eosinophilia
:.
0
Ankylostoma Africa,Asia, Australia, Mebendazole (100 Albendazole (400 mg 0- • Muscle biopsy (T spiralis)
.,
duodenole southem Europe rugBlDx3d) single dose) ..
x
(hookworm) 0
'"
I • Management
Necator Central and South Mebendazole (100 Albendazole (400 mg Q
co
.. See Table 11-2.
americonus America,SE Asia, mgBIDx3d) single dose) IE
.,
(hookworm) I>ddflC "1:
:. • Complications
Taenia Worldwide, more in Praziquantel (5-10 Nic\osamide (50 mg/ x
saginohl Central Africa mg/kg single dose) kg single dose) ..
'" • Hepatic abscess (amebiasis)
0
v • Seizures (Taenia solium)
• Pneumonitis, myocarditis, encephalitis (T spiralis)
84 • Blueprints Pe di atric Infectious Dise ases Ch. 11 : Gastrointestinal Tract Infections • 85
• Intestinal and biliary obstruction, intussusception (A. lumbri- BOX 11-' Causes of Infectious Hepatitis by
coides) Type of Organism
• Iron deficiency anemia (A. duodenale)
• Megaloblastic anemia (DiphyUobothrium latum) Virus
• Rectal prolapse (Trichuris trichiura) HepatitiS virus A. B, C 0, E, G
Cytomegalovirus
1\
Epstein-Barr virus
��p.������ - - -
_____________________________________________ --------- -- ------------------- -
Herpes simplex virus
Adenovirus
• Hepatitis: Clinical or biochemical evidence of hepatic dysfunction Enterovirus
• Classification: Acute (less than 6 months) or chronic (more Coxsackie virus
than 6 months) HIV
., Echovirus
x
• Epidemiology Reovirus
V
1\
• Schistosomiasis is most common cause worldwide (more than
Bacteria
.,
200 million per year) ..... SalmoneikI ryphi (typhoid fever)
"
• Hepatitis B: 0.1% incidence in North America IJ)
Bru(ella melitensis (brucellosis)
...
• Hepatitis C: Prevalence is 1.8% of the general population in the o
....
BartoneHa hense/ae (cat-scratch)
United States, seroprevalence in children 0 to 12 years old is 0.2% .... Borrelia burgdorferi (Lyme disease)
o
c Leptospira interrogans (leptospirosis)
v
• Risk Factors Rickettsia rickettsii
Coxiella burnetii (Q fever)
• Poor hygiene, contaminated water (hepatitis A and E, parasites)
Treponema pal/idus (syphilis)
• Intravenous drug use; sex with an infected person; blood trans
fusion; hemodialysis; medical personnel exposed to blood; Parasite
body piercing and tattooing (hepatitis B and C, HIV) Entomoebo histolytico (amebiasis)
• Maternal-fetal transmission (hepatitis B and C, HIV) Plasmodium spp. (malaria)
Asmris /umbricoides
• Etiology/Pathogenesis (Box 11-1) Echinococws granulosus
Schistosoma spedes
• Cellular hepatocyte damage may occur due to direct cytopathic
Oonorchis sinensis (liver fluke)
effect or, more commonly, due to immune-mediated injury
Fosdola hepatica
Leishmania donovani
• History/Physical Examination
Toxocara canis
• Fever, fatigue, anorexia
• Jaundice, scleral icterus, abdominal pain, pruritus, diarrhea, Fungi
dark urine Candido spedes
• Hepatomegaly (often painful), splenomegaly (with viruses) Hisroplasma capsu/arum
" A5pergil/us species
• Rash (e.g., syphilis, Lyme disease, hepatitis B) � Cryptococcus neoformons
go
.. Cocddioides immitis
• Additional Studies x
o
'" PerriciHium marneffei
,
• Elevated alanine aminotransferase (ALT) or aspartate amino TrichospOfOfJ cutaneum
5l"
transferase (AST)
• ALT (mainly present in the liver) is more specific for liver dis !
:s:
ease than AST x
" • Serologic tests for hepatitis viruses (Table 11-3)
• Elevated bilirubin, alkaline phosphatase, and y-glutamyltrans '"
tJ
ferase (GGT) suggest cholestasis V
• Abdominal ultrasound of the liver, biliary tree, and spleen to
• Liver synthetic function: Serum albumin level, prothrombin diagnose anatomic abnormalities
time (PT) and partial thromboplastin time (PTf) • Percutaneous liver biopsy may be required for diagnosis
86 • Blueprints Pediatric Infectious Diseases Ch. 1 1 : Gastrointestinal Tract Infections • 87
HepatitisD HDVAg + + ::i • Risk factors: Appendicitis; chronic renal failure (occurs in up to
HDVIgM +
Q)
x 17% of patients with nephrotic syndrome); liver failure; peri
HDVlgG + v toneal dialysis; ventriculoperitoneal (VP) shunt
"
Hepatitis E HEAg + N/A • Also occurs in 2% to 17% of processes that perforate intestine
HElgM + N/A Q)
'"' (e.g., trauma, necrotizing enterocolitis, volvulus)
'"
HDVPCR + N/A "
...
o
.... • Etiology
-IJ
o
s:: • Common: Streptococcus pneumoniae (previously healthy chil
• Differential Diagnosis
V dren), S. aureus (dialysis catheters, VP shunts), gram-negative
enteric bacilli (cirrhosis), coagulase-negative staphylococci
• Cholecystitis, drug/toxin-induced, autoimmune hepatitis, Wilson
(VP shunts)
disease, a)-antitrypsin deficiency, inborn metabolic errors, scle
• Less common: Candida spp., Neisseria meningitidis, Haemo
rosing cholangitis, hepatic malignancy, vascular disorders (e.g.,
philus influenzae type b (unimmunized)
Budd-Chiari), others (Crohn)
• Management • Pathogenesis
• Antibiotic treatment of bacterial, parasitic, and fungal hepatitis • Primary SBP: Hematogenous or lymphatic spread to peri
depends on the individual organism and severity of disease toneum
• Most viral hepatitides are self-limited (e.g., CMV, Epstein • Secondary bacterial peritonitis: Intestinal perforation
Barr, hepatitis A and E)
• Hepatitis B and C may progress to chronic hepatitis and require
• History/Physical Examination
specific therapy to minimize complications
• 10% of patients are entirely asymptomatic
- Hepatitis B: Subcutaneous interferon-a ( three times a week
• Acute febrile illness (50% to 80%). generalized abdominal pain
for 4 to 6 months), or oral lamivudine
• Rebound tenderness, decreased bowel sounds. diarrhea, hypo
- Hepatitis C: Pegylated interferon. and oral ribavirin
tension
• Complications
• Chronic hepatitis B and C: Cirrhosis, portal hypertension, and • Additional Studies
hepatocellular carcinoma (1.5 cases per ]00 patients with cir Paracentesis:
rhosis). Fulminant hepatitis in 5% with hepatitis B and D • Free air. blood. or bile suggest intestinal perforation
coinfection • WBCs in peritoneal flUid greater than 250/mm3 support the
• Ascariasis, schistosomiasis, fascioliasis: Abscess or biliary diagnosis of peritonitis (often more than 30001mm3)
obstruction • In secondary bacterial peritonitis. ascitic fluid analysis usually
• Echinococcosis: Hydatid cyst formation, anaphylaxis with cyst reveals: Total protein greater than] giL; lactate greater than 25
rupture mgldL; Glucose less than 50 mg/dL
88 • Blueprints Pediatric Infectious Diseases Ch. 1 1: Gastrointestinal Tract Infections • 89
'"
otics o
....
• Elevated transaminases or bilirubin from baseline
- Repeat paracentesis may be indicated after 48 hours to ., • Alkaline phosphatase or GGT commonly are elevated
o
ensure waning WBC count. If WBC count remains elevated so: • Blood cultures positive in approximately 50%
v
or organisms continue to be cultured, suspect antibiotic • Bile or hepatic (via biopsy) cultures usually positive
resistant organisms or secondary bacterial peritonitis.
• Secondary bacterial peritonitis: Surgical intervention to resolve • Differential Diagnosis
underlying cause of abdominal infection • Esophagitis, gastritis, gastroesophageal reflux, cholecystitis, pan
creatitis, appendicitis, Fitz-Hugh-Curtis syndrome. pneumonia
iii Complications
• Mortality: 30% to 40%; probability of primary SB P recurrence III Management
at one year is 70%; respiratory compromise may occur due to • Empiric antibiotics: Ampicillin-sulbactam with or without
secondary to diaphragmatic spasm and abdominal rigidity aminoglycoside or cefotaxime plus metronidazole
- Alternative regimens: Ticarcillin-clavulanate; carbapenems;
..
x
ciprofloxacin plus metronidazole.
9!�I��gi��� __ ___________________________________________________________________________
�
o
:s:
x
• Etiology <II
'"
U
to 30% of cases)
Ch. 12: Genitourinary Tract Infections • 91
(ommon
Ecalio
Proteus Spp.b
" Klebsiella spp.
Ron Keren, MD, MPH and David Rubin, MD, MSCE
P. aeruginosa
:;: Enterococcus spp.
'"
'"
"I 5. saprophyticus
0
g-
o: Less(ommon
<:
• Urinary tract infection (UT I): Infection of the bladder (cystitis, "I Group B streptococci
lower tract) or kidneys (pyelonephritis, upper tract) Q)
x 5almooe/1a spp.
v Shigella spp.
" Campy/abaeter spp.
• Epidemiology
Q)
• Prevalence in febrile children without fever source: Ages 2 to ,..,
'" Rare
"
24 months 5%=
... H. influenzQe type b
0
Gender is an important variable in those older than 3 ..... Anaerobes
months (e.g., prevalence at ages 12 to 24 months: boys =
-IJ
0 Fungi
"
1.9%; girls 8.1%)
=
v
M. tuberculosis
Protozoa
• Risk Factors/ Etiology (Box 12-1) Adenovirus
• Pathogenesis
• GI bacteria colonize periurethral mucosa (mediated by host of pyelonephritis have bacteria isolated from kidneys by
and bacterial adhesion factors) and then ascend to bladder and ureteral catheterization.
kidneys • Meatal erythema or abnormalities, costovertebral angle or
• VUR (present in 30% to 50% with UTI) increases risk of suprapubic tenderness
pyelonephritis
• Additional Studies (Table 12-1)
• History/Physical Examination • Urine dipstick positive (dipstick positive if :?: trace leukocyte
• Infants: Fever, irritability, decreased feeding/activity, vomiting, esterase or positive nitrite): Sensitivity 80%; specificity 97%
= =
urine
• School age: Dysuria, frequency, urgency, hesitancy, hematuria , • Differential Diagnosis
back/abdominal pain • Urethritis, vaginitis, cervicitis, prostatitis, foreign body, nephro
• Fever in a child with a positive urine culture reliably identifies lithiasis, renal abscess, vaginovesical fistula, enterovesical fistula
pyelonephritis (sensitivity 84%, specificity 92%)
= =
• Etiology
than 1 year) ; perinephric abscess or stones; renal scarring caus • Palpable renal mass (5% of cases, mostly infants), scoliosis with
ing hypertension and end-stage renal disease splinting of affected side, pain on bending to contralateral side
94 • Blueprint6 Pediatric Infectious Diseases Ch. 12: GenitourinaryTract Infections • 95
• Additional Studies • Increased risk: Young age, multiple partners, history of STD,
• ESR and peripheral WBC count: Elevated in 90% intrauterine device use
• Urinalysis: Microscopic pyuria • Decreased risk: Barrier contraceptive, vaginal spermicide
• Cultures: Blood (positive in 35% of cases); urine (positive in
50% of cases) • Etiology
space; rupture into abdominal or pulmonary space; hematoge • Cervical culture for N. gonorrhoeae and C. trachomatis
nous spread to other sites • Nucleic acid amplification (rapid detection with PCRJLCR)
"
techniques replacing culture as tests of choice
� • Consider testing for other STDs including HIV and syphilis
go
..
• Exclude pregnancy (including ectopic)
x
• Pelvic inflammatory disease (PID): Ascending spread of o
'"
• AbdominaVpelvic ultrasound: Fluid-filled/thick fallopian tubes;
tubo-ovarian abscess
microorganisms up the genitourinary tract. Distinguish PID �'"
from uncomplicated cervicitis (vaginal discharge and cervical
findings without abdominal pain)
! • Differential Diagnosis
:s:
III Etiology
• N. gonorrhoeae, C. trachomatis, herpes simplex virus (HSV ) ,
HIV, syphilis, hepatitis B or C, Trichomonas vaginalis, human
papilloma virus (HPV)
Ch.13:Skin and Soft-Tissue Infections 99
Bullous
• Superficial, thin-walled, fluid-filled lesion of varying size sur
rounded by erythematous base
1\
• May be single or clustered; may become purulent
Laura Gomez, MD and Stephen C. Eppes, MD
• Main sites: Face, extremities, perineum, and periumbilical area
V
• Bullous form characterized by single or clustered bullae • Differential Diagnosis
1\
Ql
Nonbu//ous
• Epidemiology ....
'" • Nonbullous form: Contact dermatitis, viral (herpes simplex,
.,
• Mainly in infants and young children (usually ages 2 to 5 years) ...
o
varicella), fungal (dermatophytes), scabies (all may become
• Can affect adolescents sporadically or in epidemics ...
secondarily impetiginized)
....
• More than 70% of infections are nonbullous type o
c
Bullous
v
• Neonates: Epidermolysis bullosa; bullous mastocytosis; her
Risk Factors
petic infection; scalded skin syndrome; group B streptococcal
• Breaks in skin associated with wounds, HSY, angular chelitis,
infection; congenital syphilis
insect bites, abrasions • Older children: Insect bites; burns; erythema multiforme;
chronic bullous dermatitis of childhood; bullous pemphigoid
• Etiology
98
100 • Blueprint5 Pediatric Infectious Diseases Ch. 13: Skin and Soft-Tissue Infections • 101
Cellulitis • Management
...,
abscess with perianal cellulitis)
o
• Three mechanisms of infection: I) Local wound infection (most c
• Differential Diagnosis x
'"
• History/Physical Examination
'"
tJ
• Deep venous thrombosis; ruptured baker's cyst; erythema • Preceding history of trauma, wound, irritation, hot tub use
V
nodosum; insect bites; septic arthritis; osteomyelitis • Pustules commonly found on extremities, buttocks, or scalp
102 • Blueprints Pediatric Infectious Diseases Ch. 13: Skin and Soft-Tissue Infections • 103
• Folliculitis: Discrete, dome-shaped pustule with an erythema • Risk factors: Immunodeficiency, neutropenia, surgery, varicella,
tous base, systemic symptoms rare penetrating injury
• Furuncle: Tender, erythematous, fluctuant, firm mass; predilec
tion for areas exposed to friction • Etiology
• Carbuncle: Swollen, erythematous, deep, painful mass; fever • Type I: Mixed aerobic (5. aureus, gram-negative enteric organ
more likely isms, and P aeruginosa) and anaerobic (Peptostreptococcus,
1\
Bacteroides fragilis) infections
• Additional Studies • Type II: Group A Streptococcus (GAS) (most common)
• Gram stain and culture of purulent material
II Pathogenesis
'"
• Differential Diagnosis � • Following trauma, surgery, or other conditions, skin becomes
• Folliculitis may resemble papulovesicular diseases (e.g., herpes
Q)
x
portal of entry for GAS infection
zoster, insect bites) V • Hematogenous translocation of GAS from the throat to site of
1\ blunt trauma or muscle strain
• Insect or spider bites may mimic skin abscess with surrounding
cellulitis • Pyrogenic exotoxins from GAS strains lead to cytokine pro
duction and tissue damage
• Infection spreads along fascial planes, eventually producing
• Management
myonecrosis and gangrene
• Local measures: Warm compresses
• For furuncles and carbuncles, surgical drainage may be neces • History/Physical Examination
sary
• Antecedent wound or varicella; fever and prostration
• First line: Penicillinase-resistant antibiotic such as dicloxacillin
• Erythema, edema, and tenderness with pain disproportionate to
or first-generation cephalosporin. Alternative: Clindamycin
physical findings
(especially in areas with high MRSA prevalence) or macrolides
• Overlying skin may develop blebs, bullae, and necrosis
• Fever, malaise, myalgias, anorexia may occur during first 24
II Complications
hours
• Frequent recurrences with some strains: • Systemic complication due to shock and metabolic abnormali
- Prophylaxis against recurrences involves eradication of ties may occur in advanced cases
staphylococcal colonization
For example. combining topical bacitracin, nasal mupirocin, • Additional Studies
and oral antistaphylococcal penicillin (or clindamycin) plus
• CT or MRI of involved area allows assessment of extent of
rifampin, and chlorhexidine baths (for 3 to 7 days)
tissue involvement
• Recurrent skin abscesses should prompt search for phagocyte
• Blood cultures and cultures of skin/soft tissue lesions
defect (see Chapter 22)
• Direct surgical exploration allows definitive diagnosis and cul
tures
��!���I�I�gJ:=�_�!�����
_ ___________________________________________________________
• Differential Diagnosis
• Complications
Q)
• One third to one half of cases occur in children younger than 2
...
.. years
.,
... • 9 0% are monoarticular; large joints (knee> hip > ankle>
.::: elbow) most common overall
...,
o
c
• Lyme affects knee in 90%; Neisseria gonorrhoeae affects distal
v joints (hands, wrists, knees)
• History
• Physical Examination
tissue;
4) signs and symptoms fail to improve within 48 hours
(clinical improvement is usuaJly seen before radiographic
improvement); 5) chronic osteomyelitis
• CRP usually peaks on second day of appropriate therapy and nor
malizes at 7 to 9 days. ESR typically peaks at 5 to 7 days and nor
malizes by 3 to 4 weeks after initiation of appropriate therapy "
• Epidemiology/Risk Factors
• Pathogenesis
111
112 • Blueprint5 Pediatric Infectious Diseases Ch. 15: Bloodstream Infections • 113
Neonates
• Differential Diagnosis
Group B Streptococcus
Escherichia coli • Metabolic/endocrine: Adrenal insufficiency, electrolyte distur
Klebsiella 5pp 1\ bances, dehydration, diabetes insipidus, diabetes mellitus,
Enterococcus spp inborn errors of metabolism
Listeria monocytogenes • Also, GI (volvulus, intussusception, hemorrhage); neurologic
Viruses' (intoxication, intracranial hemorrhage); Kawasaki; Stevens
Johnson; hemolytic-uremic syndrome
Infants/Older ChUdren
Streptococcus pneumoniae • Management
Q)
Neisseria meningitidis :r:
Group A Streptococcus v • Specific antibiotic therapy depends on the source of the infec
1\ tion (e.g., meningitis, pneumonia; see specific topics for details
Staphylo(oc(IJS aureus
Hoemoph/lus inf/uenzoeb Q) of directed therapy)
...
..
., • Empiric treatment:
Nosocomial ...
Neonate (early-onset sepsis): Ampicillin + aminoglycoside
Coagulase-negative staphylococci
.:::
'"' or cefotaxime (consider adding acyclovir if herpes simplex
fnteroboder spp. o
c: virus suspected)
Pseudomonas oeruginosa v
Neonate (nosocomial sepsis): Vancomycin + aminoglyco
Enteric gram-negative rods
side + ceftazidime
Candido spp.
Staphylococcus ClureuS - Child (previously healthy): Cefotaxime or ceftriaxone, con
sider vancomycin (consider adding doxycycline in tick
'Espedally herpes simplex virus and enteroviruses (e.g.,coxsad<ie virus and echovirus). endemic areas)
b If unirTmmized. - Child (nosocomial sepsis): Vancomycin + gram-negative
coverage taking into account hospital resistance patterns
(consider aminoglycosides, third-generation cephalosporins,
• History/Physical Examination
extended-spectrum penicillins, or carbapenems)
• Fever, comorbidities, immunodeficiency, immunosuppressive Alter therapy based on patient comorbidities, local resist
medications, immunization status, travel, animal exposure, ance patterns, culture results and susceptibility testing (see
instrumentation Chapter 3 for spectrum of antimicrobial agents)
• Assess respiratory and hemodynamic stability and detect • Recombinant activated protein C (rhAPC; Xigris):
potential infection sources - Up to 80% of children and adults with severe sepsis develop
• Common findings in sepsis: Hyper- or hypothermia, tachycar acquired protein C deficiency (associated with shock and
dia, hypotension, tachypnea, pallor, evidence of altered organ death) during sepsis-induced coagulopathy.
perfusion, ecthyma, petechiae or purpura Proposed mechanism of action: 1) Antithrombotic (inacti
• Additional findings: Cyanosis, oliguria , jaundice, congestive vates factors Va and VIlla);2) profibrinolytic (inactivates
heart failure plasminogen activator-I); 3) anti-inflammatory (inhibits
thrombin and cytokine formation)
• Additional Studies
In adults, 19.4% reduction in relative risk of mortality. One
• Age and localizing signs direct initial workup (examination less additional life was saved for every1 6 patients treated. Patients
reliable in infants) at high risk of bleeding excluded from study
- LeukocytOSiS or leukopenia, thrombocytopenia - Sparse data in children but trials ongoing
Respiratory alkalosis, lactic acidosis
- Cultures of blood, urine, and CSF (if stable) • Complications
- Elevated PT, PTT, fibrinogen split products, and D dimer • Multiple organ dysfunction; death rate ranges from 5% to 50%
1 14 • BlueprintB Pediatric Infectious Diseases Ch. 1 5: Bloodstream Infections • 115
• Pathogenesis
TABLE 15-1 Approach to Management of Uncomplicated
Central Venous Catheter-Related Infection • S. aureus strains can produce exotoxin (TSS toxin-I) and
enterotoxins
D uration • S. pyogenes strains can produce at least one of five pyrogenic
Organism (days)" Comments exotoxins
CoNS 10-14 May r etain (V( unless dini�1 deterioration or persisting 1\
or relapsing bacteremia. If catheter removed, may shorter • History/Physical Examination
duration oftreatment to 5-7 days
• Major criteria (all required): 1) Fever (greater than 38.9°C); 2)
S.aureus 14 Remove (V(; If ed1oc:ardiogram reveals vegetations,treat
for 4-6 weeks
diffuse macular erythrodermatous rash that desquamates 1 to
'" 2 weeks after disease onset. Can localize to the trunk, extremi
fntel'OOJccus 10-14 Usuallytreated with combination of vancomydn,ampidlin, :'i ties, or perineum; 3) hypotension
or peniollin plus an aminoglyroside Q)
I: • Minor criteria (any three): Vomiting, diarrhea, liver dysfunc
GNR 10-14 (onsider cve removal for persistent positive cultures v
or clinical deterioration 1\
tion, renal dysfunction, respiratory dysfunction (including
ARDS), CNS changes, mucous membrane inflammation
Candida spp. 14 Remove (VCConsi�r evaluation for dissemination Q)
..., (hyperemia of the pharynx, tongue, and conjunctiva), and
'"
Mycobacteria Unclear Remove catheter. If peripheral blood cultures positive, may III
... muscle abnormalities (including myocarditis)
require more than 6 weeks of treatment o
.... • S. au reus more commonly associated with profuse diarrhea and
" foreign body at site of infection. S. pyogenes more commonly
• Duration oftl1erapy va� depending on presence of(omplication� and s� underlying o
<:
disease(onditions.Optil11i!l duration oftherapy has not been established in children.
v associated with localized soft-tissue infection (e.g., cellulitis,
Recommendalionsi!re extrapolated from adult data. necrotizing fasciitis)
• Additional Studies
- Fluconazole may be used if the organism is susceptible. • CBC with differential (leukocytosis or leukopenia, anemia, and
- Evaluation includes routine ophthalmologic exam. For per- thrombocytopenia)
sistently positive cultures, consider echocardiogram, abdom • Blood culture positive for S. aureus in less than 5% of infected
inal ultrasound or cr; and head cr
patients
• Complications • Cultures of foreign bodies and abscesses
• Throat rapid antigen test and culture for S. pyogenes
• Endocarditis, septic thrombosis, tunnel infections, and metasta ..
• S. aureus colonization screens can be performed but are not
I:
tic seeding o
2: necessary
• If complications occur, antimicrobial duration may have to be .. • Increased ASO or antiDNAase B 4 to 6 weeks after infection
I')
extended or changed may confirm diagnosis
• Other findings: Hyponatremia. hypokalemia. hypocalcemia,
!�?!��_�.����.�y'��!���_____._________...._______________ ..-_.._---_...._ .._- hyperbilirubinemia (75%), elevated creatinine kinase (60%;
rhabdomyolysis)
• Toxic shock syndrome (TSS): An acute febrile illness primarily
• Urinanalysis: Sterile pyuria, myoglobinuria, red blood cell casts
caused by bacterial exotoxins. Patients with features of TSS
• Imaging to detect focal infection: CXR, abdominal CT, bone
but not meeting criteria (see "Physical Examination") can have
scan, or extremity MRI
a toxin-mediated process that is generally less severe
• 1 0-20 cases per 1 00,000 population • Infectious: Meningococcemia, Rocky Mountain spotted fever,
ehrlichiosis, measles, staphylococcal scalded skin syndrome,
• Risk Factors/Etiology
scarlet fever, leptospirosis
• Menstruation and tampon use (Staphylncoccus aureus); varicella • Noninfectious: Kawasaki, systemic lupus erythematosus,
(S. pyogenes) Stevens-Johnson syndrome
1 18 • Blueprints Pediatric Infectious Diseases
• Management
• Etiology
• Pathogenesis
Eo
:r: • Breaks in skin and mucosal barriers allow pathogens to gain entry
o
• Devitalized tissue harbors pathogens not accessible to the
.g;
Eo immune system
OJ
• Major trauma impairs humoral and cellular immunity
119
1 20 • Blueprinte Pediatric Infectious Diseases Ch. 1 6:Trauma-Related Infections · 121
.. Management
Lacerations
.. Epidemiology
• Minor lacerations: Topical antimicrobial agents: Bacitracin or
"triple antibiotic"; PO/IV antibiotic prophylaxis not usually • Bites most commonly occur by dogs (80% to 90%), cats (5% to
required 1 5%), and humans (5%)
• Tetanus immunization: Admimster if patient received less than 1\ • Frequency of infection: Dog bite (2% to 20%); human bite
three doses of toxoid or unknown immunization status (10% to 50%); cat bite (30% to 50%)
- Tetanus immunization not required for 1 ) clean minor wounds • High risk of rabies from bats (most common), raccoons, skunks,
and three previous doses of toxoid less than 1 0 years before; 2) foxes, and coyotes
all other wounds and three previous doses of toxoid less • Low risk of rabies from small rodents and lagomorphs
than 5 years ago
• Tetanus immune globulin (TIC): Administer if contaminated Q) .. Risk Factors
:r:
wound and immunization status uncertain or less than three v • Risk factors for infection from bite wounds: 1) Location on
1\
previous doses of toxoid hand/foot; 2) treatment delay more than 1 2 hours; 3) closed
- TIC not required for 1) clean minor wounds regardless of fist punch to human mouth; 4) puncture wounds; 5) crush
immunization status; 2) all other wounds and three previous injury; 6) immunosuppression; 7) cat bites
doses of toxoid • Risk factors for rabies: l) Unprovoked attack, 2) high-risk
animal (see "Epidemiology'), 3) unimmunized dog or cat, 4)
Major Trauma unusual animal behavior
• Associated lacerations as above; antibiotic prophylaxis (Table
1 6-2). .. Etiology
Basilar skuU fracture Generally not required • Document type of animal, health of animal, provoked or
Facial fracture Cefazolin unprovoked attack
Penetrating brain injury Ceftriaxone • Determine if history of immunosuppression, asplenia, and
after clenched fist injury (E. corrodens); anxiety, dysphagia, and • Risk Factors
seizures (rabies)
• Full-thickness burns; more than 25% body surface area (BSA)
• Management affected; smoke inhalation; prolonged hospitalization; indwel
ling catheters; extremes of age; hyperglycemia
General
• If infection present, obtain anaerobic and aerobic cultures. If A • Etiology
fever, culture blood
• Infections frequently polymicrobial
• High-pressure irrigation, except for puncture wounds; debride
devitalized tissue • Wound infection: S. aureus, Pseudomonas aemginosa, group A
Streptococcus, Enterobacter spp., Klebsiella spp., Enterococcus
• Tetanus immunization as with other minor wounds. Role of
HIV prophylaxis unclear spp., Acinetobacter spp.
• Bloodstream infection: Coagulase-negative staphylococci, S.
"
Antibiotics :r: aureus, P aeruginosa, group A Streptococcus, Klebsiella spp.
v
• Indications for antibiotic prophylaxis: I) Puncture wounds, 2) A • Pneumonia: Streptococcus pneumoniae, S. aureus (usually in
bites on face or hand, 3) cat bite, 4) devitalized tissue,S) crush ventilated patients)
injury, 6) immunocompromised patient • Urinary tract infections: P aeruginosa, Escherichia coli (usually
• Prophylactic antibiotic choice: Amoxicillin-c1avulanate for with urinary catheters)
5 days
Alternate: TMP-SMX and c1indamycin; cefotaxime; or • Pathogenesis
ceftriaxone • Significant burn injury leads to loss of normally protective skin
Rabies barrier, decreased production of interferon-y, immunoglobu
• Dogs and cats (if dog/cat unable to be observed, consult local lins, and phagocytes, poor opsonic and bactericidal activity, and
public health official) increased anergy to antigens
• Colonization of burn wounds occurs by spread of normal skin
- If healthy, observe for 10 days: Immunize patient if animal
develops rabies flora, translocation of gut flora, and nosocomial acquisition
- If signs/symptoms of rabies: Immunize patient plus rabies
• History/Physical Examination
immune globulin (RIG)
• Other animals: Consider sacrifice to test brain tissue for rabies • Local: Edema, erythema, discoloration, or necrosis around
For high-risk animals, rabies immunization and RIG unless wound edge; unexpectedly rapid eschar separation; hemor
animal tests negative .. rhage under subeschar tissue; purulent exudates
:r:
o
For low-risk animals, no specific prophylaxis • Systemic: Fever; hypothermia; hypotension; altered mentation
�
• Use either rabies human diploid cell vaccine (HDCV) or pri ..
OJ
mary chick embryo cell vaccine. PreViously unimmunized • Additional Studies
patients require doses on days 0, 3, 7, 14, and 28, whereas those • Histology (biopsy specimen): Bacteria, thrombosis or necrosis,
with prior immunization only require doses on days 0 and 3 intense inflammation
• Microbiology (biopsy specimen): Quantitative Gram stain and
• Complications
culture (more than lOS colonies per gram of tissue suggests
• Cellulitis, tenosynovitis, septic arthritis/osteomyelitis, sepsis, infection)
meningitis, endocarditis • Blood cultures positive in 50% with systemic signs of infection
�I!'����I!!f����,!!��gJ�����
- - _ _ _ ______________________________________________ • Management
• Prevention
Epidemiology
Clean wound and debride necrotic tissue immediately
• Burn victims: One third to one half are pediatric patients Dressings: Sterile gauze with elastic wrap, cadaveric allo
• Incidence density of approximately 50 infections per 1000 graft, porcine xenograft, or synthetic materials (e.g., Transcyte,
hospital days Biobrane, etc.).
124 • Blueprints Pediatric Infectious Diseases
• Additional Studies
• Chorionic villus, amniotic fluid, and cord blood sampling allow
in utero diagnosis
• Blood: IgM (toxoplasma, rubella), RPR (syphilis), hepatitis B
surface antigen
• CSF: DNA PCR (enterovirus, HSV), Venereal Disease Research
Laboratory (VDRL; syphilis)
• Skin lesions: DFA (HSV, varicella), dark field (syphilis)
• Viral culture: Conjunctiva (HSV), mouth (HSV, enterovirus),
rectum (HSV, enterovirus), urine (CMV)
• Radiography of long bones (rubella, syphilis) or head CT (CMV,
toxoplasmosis)
• Ophthalmologic exam (toxoplasmosis, rubella, CMV, HSV,
syphilis, varicella)
• Hearing screen (rubella, CMV, toxoplasmosis)
• Other studies: Liver function tests, CBC
125
126 • Blueprints Pediatric Infectious Diseases Ch.17:Congenital/Perinatal lnfections • 127
• Pathogenesis
• Epidemiology
• Infected cat then sheds oocysts in stool. Maternal infection • U.S. epidemic during I 990s. Improved prenatal care contribu
occurs by ingestion of stool oocysts or undercooked meat con ted to declining rates
taining cysts • Incidence by race: African American> Hispanic> white
• Congenital infection occurs via transplacental transmission.
Risk of transmission during a primary infection is 40% • Risk Factors
• STD risk factors including HIV infection and multiple anony
• History/Physical Examination (also see "Risk Factors")
mous sexual partners
• Premature delivery (25% to 50% of affected infants) or sym
metric intrauterine growth retardation (IUGR) .. • Etiology
x
• In 70% to 90% of infants disease is asymptomatic at birth, but o
� • Caused by Treponema pallidum, a fastidious and motile spiro
if symptomatic Fever, seizures, jaundice, hydrocephalus, lym .. chete
phadenopathy, hepatosplenomegaly, petechial/maculopapular "
rash .. Pathogenesis
• Transmitted hematogenously (most cases) or via direct contact
• Additional Studies
with infected mucocutaneous lesions during delivery
• Neuroimaging: Hydro-/microcephaly; diffuse, intraparenchy- • Rate of transmission is 60% to 90% during untreated primary
mal calcifications or secondary maternal syphilis but decreases to 10% to 30% in
• Ophthalmologic exam: Chorioretinitis latent syphilis
• Hearing screen: Sensorineural hearing loss
• CSF: Elevated protein and/or pleocytosis .. History/Physical Examination
• Blood: Indirect hyperbilirubinemia, pancytopenia " • Untreated or inadequately treated maternal infection: Pregnancy
x complicated by spontaneous abortion, hydrops fetalis, enlarged
'"
'"
.. Diagnosis u placenta, and/or premature delivery
y
• Neonatal IgM- or IgA-specific serum antibodies or persistently • Subdivided into early (symptoms within the first 2 years of
positive IgG titers life) and late (more than 2 years) disease. Early manifestations
128 • Blueprints Pediatric Infectious Diseases Ch.17: CongenitallPerinatallnfections • 129
are due to active infection and inflammation whereas late • Neonatal evaluation should then include quantitative nontre
manifestations are a consequence of scars induced by initial ponemal and treponemal serologic tests
lesions of early congenital syphilis. Most with early syphilis • Treat infant with aqueous crystalline or procaine PCN G for 10
diagnosed at 3 to 8 weeks of life days if I) physical, laboratory, or radiographic evidence of
• Early disease: Low birth weight, failure to thrive, hydro infection; 2) positive dark-field test; 3) reactive CSF VORL; or
cephalus, mucocutaneous bullous leSions, bloody rhinitis 1\ 4) infant's serum titers are fourfold greater than mother's
("snuffles"), respiratory distress, generalized lymphadenopa • Serologic testing in treated neonates should be performed at 2,
thy, hepatosplenomegaly, edema, osteochondritis, fever, and 4, 6, and 12 months with titers undetectable by 6 months of
jaundice age. If titers fail to decline or are present at 1 year, treat with
• Late disease: Frontal bossing, saddle nose, scaphoid scapulas, aqueous crystalline PCN G for 10 to 14 days.
saber shins (anterior bOWing), mulberry molars (multicuspid
'"
first molars) , Hutchinson teeth (peg-shaped upper incisors), x • Complications
rhagades (linear scars from corners of mouth), seizures V
• Intrauterine death in 25% of pregnancies in mothers with early
1\
syphilis who have not received treatment. If live born, 25% to
• Additional Studies '"
.... 30% die in the newborn period
'"
'"
• Radiography: "Celery stick" pattern of distal long bones (periosteal ...
• Survivors: Sensorineural deafness, blindness, retardation, and
o
reaction/osteitis); diffuse pulmonary infiltrates (pneumonia .... facial deformities
alba) ...
o
"
• Neuroirnaging: Optic atrophy on MRI v
• Hearing screen: Sensorineural hearing loss �.��g.������.�.���.I.�� .............................................................
• Low socioeconomic group, young maternal age, and exposure v treatment of those with symptomatic congenital CMV and
to young children CNS disease reduced progression of hearing loss
132 • Blueprints Pedia tric Infectious Diseases Ch.17: CongenitallPerinatal lnfections • 133
• Hearing tests recommended every 3 months for the first year Neonatal infection occurs after vaginal delivery in 35% to
of life and then varies based on the presence or absence of 50% exposed to primary maternal infection vs. 3% to 5%
findings exposed to recurrent maternal infection
- Primary infection has higher viral load, longer viral shedding
• Complications period, and decreased amount of protective antibodies to be
• 15% to 30% of newborns with symptomatic infection die in A passed to the neonate
the newborn period • Postpartum transmission: Postnatally via contact with active
• 50% to 90% of surviving neonates with symptomatic infection lesions (rare)
have CNS impairment, including mental retardation, cerebral
palsy, and visual abnormalities • History
• Progressive hearing loss in 50% of patients with symptomatic • Known maternal infection or vesicular lesions at delivery
infection and 5% of patients with asymptomatic infection OJ • 60% to 80% of infected infants born to asymptomatic mothers
X
V
A • Physical Examination
Neonatal Herpes Simplex Virus Infection
-------------- - • Onset varies from birth to 3 weeks of life (typically at I I to 17
- ------- - ------- --.-- - -------------- ------ - ---------
- - ----------------------
• Management
• Acyclovir:
- Skin/eye/mucous membrane disease: 60 mg/kg/d IV divided
into three doses for 14 days
- CNS/disseminated disease: 60 mglkg/d IV divided into
three doses for 21 days A
Elizabeth R. Alpern, MD, MSCE and Samir S. Shah, MD
Consider suppressive acyclovir for those with recurrent skin
lesions
• Symptomatic neonate: Cultures and CSF PCR immediately, IV
acyclovir f�.��.i.��.�.���.��� ...................................................................
• Vaginal birth (primary infection): Cultures and CSF PCR at 24 • Fever (38.0°C or higher) in a well-appearing infant (0 to 60
to 48 hours, acyclovir OJ
:c days of age) without identifiable source of infection. Infant is
• Vaginal birth (recurrent infection): Surface cultures at 24 to 48 v
A at risk for occult serious bacterial infections (SB!)
hours, IV acyclovir for positive cultures or onset of symptoms
(if positive, Tequires lumbar puncture) • Epidemiology
• Cesarean section, primary OT recurrent infection with rupture
• Epidemiology, evaluation, and treatment are differentiated by
of membranes less than 4 hours: Surface cultures at 24 to 48
age (0 to 28 days and 29 to 60 days of life) due to stratified risk
hours, obseTve, treat if positive cultures or onset of symptoms
of SBI and sensitivity of screening procedure
• History of genital HSV without lesions at birth: Observe
• 10% to 15% of neonates with fever have SBI
• Complications
• Risk Factors
• Skin/eye/mucous membranes disease: Low risk of morbidity
• Untreated pre- or perinatal maternal infection (e.g., Neisseria
and mortality
gonorrhoeae)
• CNS disease: 5% mortality but 60% of survivors have severe
• Exposure to pathogens from birth canal or postnatal exposure
neurologic sequelae
to ill contacts
• Disseminated disease: 30% mortality but fewer than 20% of
• Relative immune compromised state of young infants
survivors have neurologic sequelae
• Etiology
• Most common pathogens: Escherichia coli, Klebsiella species,
Streptococcus pn eumoniae, group B Streptococcus, Staphylococcus
aureus, Enterococcus spp. , Listeria monocytogenes
• History/Physical Examination
• Vague or nonspecific signs and symptoms of illness (may pres
ent with just an isolated fever)
• Fever, irritability, lethargy, poor feeding, emesis, diarrhea, jaun
dice, rash
• Search for findings that suggest a likely cause (see "Differential
Diagnosis")
• Lack of ill appearance does not rule out SBI in neonates
• Additional Studies
• Negative screen (Philadelphia protocol) indicates low risk for
SBI (Baker et al):
135
136 • Blueprints Pediatric Infectious Diseases Ch.18:Fever • 137
• Additional Studies
• WBC count: 95% more than 10,000/mm3; 50% more than
15,OOO/mm3
• Hemoglobin: 75% less than two standard deviations below the
mean
• Platelets: Increase during second week; usually increase to
more than 750,OOO/mm3
• ESR: Elevated in more than 90%
• Urinalysis: Sterile pyuria due to urethritis may be missed by
bladder catheterization; therefore, fresh void specimen pre
ferred.
• Echocardiogram: Detects coronary aneurysms; usually present
at I O to 2 1 days
• Differential Diagnosis
• Infectious: Measles; scarlet fever; Epstein-Barr virus; aden
ovirus; enterovirus; parvovirus B 1 9 ; S. aureus toxin-mediated
disease; Rocky Mountain spotted fever
• AllergiclrheumatologiC: Drug reaction; Stevens-Johnson syn
drome; systemic JRA; polyarteritis nodosum; Reiter syndrome
• Management
• Intravenous immune globulin (IVIG): 2 g/kg over 1 2 hours.
Repeat if still febrile 24 hours after completion of first dose
(10% of patients)
Ch.19:Fever and Rash · 147
infection; risk highest if under 2 years old or ill appearing _ Additional Studies
146
148 • Blueprints Pediatric Infectious Diseases Ch.19:Fever and Rash • 149
• Pathogenesis • Complications
• Rickettsiae are obligate intracellular pathogens. Humans are • Venous thrombosis; pneumonitis; pericarditis; myocarditis;
incidental host pleural effusions
• Systemic capillary and small vessel endothelial damage results
in vasculitis and shock �y��-�����-------------------------------------------------- --------------------
• History/Physical Examination • Epidemiology
• Suspect rickettsial infections in those with flulike illness in • The most common vector-borne disease in the United States
spring or summer • Most cases occur in the Northeast (Maine to Maryland), the
• High fever, severe frontal headache, malaise, myalgias, and upper Midwest (Wisconsin and Minnesota), and the West
vomiting (California and Oregon).
• Rash appears 2 to 3 days (range I to 1 4 days) after the onset of • Most cases in June, July, and August. Peak incidence is at age 5
illness; more likely with RMSF than with ehrIichia to 14 years
• Rash starts on the wrists and ankles and then the palms and
soles, face, and trunk. It progresses from macular to papular to • Risk Factors
petechial to purpuric • Borrelia burgdorferi lives in tick midgut so infection requires
• Hepatomegaly, meningismus, decreased breath sounds with rales more than 24 to 36 hours of attachment
• A necrotic eschar ("tache noir" or "black spot"; 30% to 90% of • Environment risk: Region, climate, landscape, and close associ
patients) originates at the site of the bite. Look for this in the ation with wildlife
scalp with associated regional lymphadenopathy • Behavioral risk: Woodcutting, outdoor activities (more than 30
hours per week)
• Additional Studies
..
x
• Leukopenia, thrombocytopenia, elevated serum hepatic o • Etiology
�
transaminases, hyponatremia .. • Lyme disease caused by the spirochete B. burgdorferi and trans
"
• Fourfold rise in specific acute and convalescent antibodies by mitted by Ixodes ticks
indirect fluorescent antibody assay (sensitivity greater than
90%). Antibodies detectable 7 to 14 days after onset • Pathogenesis
• Ehrlichiosis: Light microscopy of blood smear reveals morulae • Stage I : Localized erythema migrans (EM) rash. After the bite,
in neutrophil cytoplasm (50% of cases) the B. burgdorferi organisms spread superficially through the
• RMSF: If rash present, immunofluorescence or immunoperox skin and tissue
idase staining of skin biopsy reveals R. rickettsii in vascular • Stage 2: Early dissemination follows stage 1 within days or
endothelium (sensitivity 70% to 90%) weeks; may result in multiple skin lesions (disseminated EM)
• Polymerase chain reaction (PCR) assay available in some or affect the joints, nervous system, or heart
research settings • Stage 3: Late dissemination (affects joints) follows stage I
"
x within weeks or months.
• Differential Diagnosis '"
'"
u
• Measles; meningococcemia; secondary syphilis; viral infections v • History
(especially enteroviruses); infectious mononucleosis • History of rash with a slowly expanding skin lesion (EM)
1 50 • Blueprints Pediatric Infectious Diseases Ch.19:Fever and Rash · 1 5 1
• The skin lesion may be accompanied by a history of flulike - Treat for 1 4 to 2 1 days. Alternate for allergy use cefuroxime
symptoms (malaise, fatigue, headache, arthralgias, myalgias, or macrolide
fever, regional lymphadenopathy) • Stages 2 and 3
- Disseminated EM or isolated Bell palsy: Same as for stage I
.. Physical Examination
- Arthritis: Same as for stage I but treat for 28 days. Some
Stage 1 1\ require ceftriaxone
• Rash of EM (more than 5 cm in diameter) - Meningitis, other neurologic involvement, or carditis:
• Usually macular, but may be slightly raised with occasional Ceftriaxone for 21 to 28 days
central ulceration • First recurrence of arthritis may result from incomplete initial
treatment and warrants second course of antibiotics. Subse
Stage 2
quent recurrences treated with NSAIDs. Recurrences diminish
• Neurologic: Lymphocytic meningitis; subtle encephalitis; cra
in frequency over I year
nial neuropathies (unilateral or bilateral, especially 7th); optic
nerve involvement leading to blindness (more common in chil
II!! Complications
dren); motor or sensory radiculoneuritis; cerebellar ataxia
• Cardiac: Commonly atrioventricular block; occasionally acute • Untreated localized disease may progress to early or late
myopericarditis; rarely cardiomegaly or pancarditis dissemination
- Occurs in 5% of untreated patients
• Joint involvement: Arthritis (knee most commonly)
Stage 3
• Prolonged neurologic abnormalities including motor or sensory • Major childhood exanthems cause systemic illness and a char
radicuioneuritis, cerebellar ataxia, subacute encephalopathy, acteristic rash
memory impairment, sleep disturbances • Exanthems: Blanching macular or papular lesions (less than 1
in diameter)
em
.. Additional Studies
• Morbilliform: Lesions that coalesce (e.g., measles)
• Base decision for serologic testing on finding the above signs • Scarlatiniform: Lesions with a sandpaper feel on palpation
and symptoms (e.g., scarlet fever)
• If EM is found, no laboratory testing needed
• Antibody testing: Initial testing by ELISA to B. burgdorferi. If II!! Etiology
IgM or IgG positive, confirm by Western blotting. ELISA alone
• Enteroviruses are most common cause (Table 1 9-2)
has high false-positive rate
• Bacterial causes include group A Streptococcus, Staphylococcus
• PCR of joint fluid (usually not needed) for diagnosis of Lyme
aureus, and Arcanobacterium haemolyticum
arthritis
• CSF antibodies may be diagnostic of Lyme meningitis. CSF PCR
II!! Pathogenesis
test has poor sensitivity
• Most commonly either 1) infection of the dermal blood vessel
.. Differential Diagnosis endothelium (e.g., measles) or 2) host immunologic reaction
• EM-like rash: Tinea corporis, insect bite, eczema, cellulitis, ery against the pathogen (e.g., parvovirus B I 9)
thema multiforme • Circulating toxins cause the scarlatiniform exanthem in S. pyo
• Rash and arthritis: Serum sickness, juvenile rheumatoid arthri genes and S. aureus
tis, acute rheumatic fever, systemic lupus erythematosus
• Meningitis/neurologic abnormalities: See Chapter 7 II!! History/Physical Examination (Table 19-2)
Additional Studies
immunocompromised
Ch. 20: Infections in Children with Cancer • 155
• Pathogenesis
• Disruption of skin/mucous membranes 2° to therapy, surgery;
indwelling catheters
• Depletion of host defense cells (neutrophils, lymphocytes,
others)
A
Anne F. Reilly, MD, MPH
• History/Physical Examination
• Recent chemotherapy (to judge expected period of neutropenia)
• Any complaint could be important: Cough, headache, diar
rhea, dysuria, rash
• Fever in a child with cancer may be the first sign of serious • Infection may not be obvious when the ANC is low; neu
"
x trophils are critical to the inflammatory response. Tenderness
invasive infection V
• Fever: Temperature greater than 38.3°C even once, or 38.0°C A
may be the only localizing sign of infection
or higher for more than I hour • Careful examination of entire body; examine skin for rashes.
"
....
• Neutropenia: Absolute neutrophil count (ANC) less than '" ulcers, vesicles, erythema
II)
SOO/mm3, or less than 1000 mm3 and falling ...
.2 • Additional Studies
.,
• Epidemiology g • CBC, chemistries, urinalysis (may not see pyuria in a neu
v tropenic patient)
• A definite source of infection is found in 20% to 40% of febrile
• Blood cultures, including samples from each lumen of a central
neutropenic patients
venous catheter
• Other cultures as indicated: Urine, stool, CSF, oral Qr skin lesions
• Risk Factors • CXR: Consider in all patients. particularly with respiratory
• Low risk of serious infection: J) ANC 100 cells/mm3 or more; symptoms
2) neutropenia expected to last less than 10 days; 3) normal
CXR; 4) no other significant comorbidities • Differential Diagnosis
• High risk of serious infection: All patients not at low risk • Common sites of infection in febrile neutropenic patients
include bloodstream; skin/soft tissue; mouth/oropharynx; gas
• Etiology .. trointestinal (GI) tract; lungs; sinuses
x
o
• Infectious: .g; • Management
..
- Bacteria: OJ
- Gram positive (most common): Coagulase-negative sta- • Antibiotics: Prompt empiric broad-spectrum antimicrobial
phylococci, Staphylococcus aureus, viridans streptococci, therapy
enterococci, Clostridium difficile Potential Regimens
Gram negative: Escherichia coli, Klebsiella, Enterobacter, Potential regimens may vary depending on institution:
Pseudomonas spp., anaerobes • Monotherapy: Ceftazidime or cefepime or carbapenems
- Fungi: Candida spp., Aspergillus spp., Pneumoc.ystis carinii, (imipenem/cilastatin, meropenem)
cryptococci • Duotherapy: Aminoglycoside (gentamicin, tobramycin. or arni
Viruses: Herpes simplex virus (HSV), varicella-zoster virus kacin) plus ticarcillin-clavulanic acid or piperacillin-tazobactam
(VZV), cytomegalovirus (CMV), Epstein-Barr virus (EBV), or cefepime or ceftazidime or carbapenem
respiratory syncytial virus (RSV), adenovirus, influenza virus, • Add vancomycin when resistant organisms are common, par
parainfluenza virus ticularly viridans group streptococci. Vancomycin can be dis
• Noninfectious: Medications; underlying malignancy; blood continued after 24 to 48 hours if no such organism is found on
products culture
154
156 • Blueprints Pediatric Infectious Diseases Ch. 20: I nfec tions in Children with Cancer • 157
• Up to 10% of fever/neutropenia episodes may be caused by • CXR; CT scans for further evaluation, or if CXR negative with
pneumonia an abnormal lung examination
• If patient is progressing or very ill, consider bronchoalveolar
• Risk Factors lavage (BAL) or lung biopsy (open biopsy or transthoracic
• Those with leukemia, lymphoma, and stem cell transplant are at needle biopsy) for pathology and cultures
particularly high risk for pulmonary bacterial and fungal disease
• Graft versus host disease, steroid therapy, radiation therapy to • Differential Diagnosis
lungs increase risk • Drug-induced or chemical pneumonitis; hemorrhage; atelecta
sis; pulmonary edema; tumor; lymphoma; leukemic infiltrates;
• Etiology radiation pneumonitis
• Localized in filtr at es:
- Bacteria: Respiratory pathogens, Mycobacteria, Legionella, • Management
Nocardia
• Local infiltrate:
Fungus: Aspergillus, Fusarium spp., PseudaUescheria boydii, Initial therapy with broad-spectrum antibiotics (see
Rhizopus, Mucor, Candida
"Management" under "Fever and Neutropenia"). Consider
- Viral: HSV. VZV-Iess likely adding macrolide if Mycoplasma or Legionella suspected
Mycoplasma pneumoniae
If no improvement in 3 or 4 days, obtain tissue diagnosis if
• Diffuse infiltrates:
possible with BAL, or biopsy; treat according to findings
- Bacteria: Usual respiratory pathogens, gram positi�e and If tissue diagnosis not possible, begin antifungal therapy with
negative amphotericin B, liposomal amphotericin product, or vori
- Fungus: Most common is P. carinii conazole
- Viral: Cytomegalovirus (CMV), RSV, adenovirus, HSV, Surgical excision indicated for locally destructive Mucor or
VZV, influenza virus, parainfluenza virus, human herpes Aspergillus
virus 6 (HHV-6) • Diffuse infiltrate:
Mycoplasma pneumoniae
Begin broad-spectrum antibiotiCS, plus trimethoprim
sulfamethoxazole (for P. carinii) and macrolide (for atypical
• Pathogenesis
bacterial pneumonia)
• Colonization of the upper respiratory tract provides a close Reassess after 3 or 4 days:
reservoir of pathogens - Improved: Continue antibiotics for 2 weeks
• Immunosuppression, poor mucociliary function lead to de - Not improved: Obtain tissue (BAL or biopsy) and treat
creased pathogen clearance accordingly
• Additional Studies
• Epidemiology
• Blood work: Blood counts, blood cultures, arterial blood gas in
very sick patients • Pathogens are acquired from endogenous flora, other persons,
• Sputum collection, nasopharyngeal (NP) aspirates for viral or contaminated food or water
antigen testing and culture, consider Mycoplasma polymerase • GI infections make up 5% to 7% of infections in those with
chain reaction of NP aspirate fever/neutropenia
160 • Blueprirn;s Pediatric Infectious Diseases Ch. 20: Infections in Children with Cancer • 161
• Additional Studies
TABLE 20-2 Common Organisms Causing GITract Infection
• Blood culture, CBCs, liver function tests
Symptom Potential Organisms • Cultures of stool; antigen testing for viral pathogens, C. di/ficile
toxin testing
Aetomonas spp., Compylobactet; C difficilt, £ wIi, Listeria,
• Abdominal imaging: Radiographs (look for obstruction, free
ShigelkI, SoImoneIIa, v. choIetrJe, Y. enteroaJlitiaJ. rotavirus. A
adenovirus, astroViruses, (rypfosporidium, (ydosporo, air), cr scans (detect abscesses, areas of bowel well thickening)
Entamoebo,G.1ambIia • If diagnosis unclear, consider diagnostic endoscopy, colonoscopy,
Esophagitis (IX/dido spp., HSv;CMY, other viruses. and many bacteria or liver biopsy
1YPhJitis Anaerobes, �ric gram-negative bacteria, (. diffidIe
• Differential Diagnosis
Peritonitis Anaerobes, enteric gram-negative bacteria, OosIridium spp.
Hepatitis Hepatitis viruses A, B, C, D, E, G; HS'l CMV. Eov, VVI "
• Diarrhea caused by medications, radiation colitis, diet
:r:
• Esophagitis secondary to chemotherapy, acid reflux
Hepatic abscess Enteric gram-negative baaeria,S.OUI!IJS, CDnddo spp.,Mucor v
A
Perianal (e/luitis Enteric gram-nEgative bacteria, anaerobes,S/rqJtorocCIJS spp. • Management
• Supportive care with flUids, intravenous nutrition if necessary
• Antimicrobials:
• Risk Factors Bacterial infections: appropriate antibiotics
• Disruption of gut mucosa (e.g., chemotherapy-induced C. di/ficile diarrhea/colitis: Oral metronidazole (first line).
mucositis) Alternative: IV metronidazole or oral vancomycin
• Alteration of normal gut microbial milieu: Antibiotics, surgery, - Herpetic stomatitis or esophagitis: Acyclovir intravenously
mucositis - Candidal infections: Fluconazole or amphotericin B product
• Gut manipulation (e.g., rectal manipulation associated with • Typhlitis (inflammation of the cecum): Conservative manage
perirectal abscess) ment with antimicrobials; surgery only for acute abdomen!
signs or perforation
• Etiology (Table 20-2)/Pathogenesis
• Complications
• Changes in intestinal bacterial flora due to antibiotics, chemo
therapy and other infections allow colonization by pathogenic • Chronic diarrhea; chronic hepatitis; esophagitis may lead to
organisms strictures
..
• Disruptions in intestinal mucosa allow entry of potentially :r:
o
pathogenic organisms .€::
• Immunosuppression allows pathogenic organisms to dissemi ..
OJ
nate
• History
• Abdominal pain, distension, diarrhea, constipation, blood in
stool, fever
• Pain on swallowing, chest pain, reflux accompany esophagitis
• Jaundice, right upper quadrant pain suggest hepatic pathology
• Perianal pain, pain with defecating suggest perirectal lesion
• Physical Examination
• Mouth: Erythema, ulcers, mucositis, thrush
• Abdomen: Distention, tenderness, masses, rebound, guarding,
change in bowel sounds, perianal tenderness or fluctuant area
• Jaundice, hepatomegaly
Ch.21:Human Immunodeficiency Virus Infection • 163
• The CD4 cell is the key target cell. Though all arms of the
immune system are affected, the degree of immune dysfunc
tion can be staged by measurement of the T -cell subset of CD4
percentage and number
A • History
Richard M. Rutstein, MD
• Inquire about risk factors in the parents (substance abuse,
transfusions, STDs)
• Inquire about risk factors in the patient (sexual activity/abuse,
HIV
substance abuse)
• Epidemic continues despite recent decreases in mother-child • Inquire about HIV testing in the parents
"
transmission (MCT ) and mortality/morbidity in areas with :r: • Frequent invasive infections: pneumonia, arthritis, bacteremia
v
access to antiretroviral therapy (ART) A
• Chronic or recurrent thrush
• Worldwide, approximately 1500 children infected daily. Most • Unexplained hepatitis, chronic diarrhea, poor growth
(more than 90%) have limited ART access
• Physical Examination
• Epidemiology
• Poor growth statistics
• HIV transmitted via exposure to infected fluids: Blood (sharing • Generalized adenopathy, usually less than Z cm
contaminated needles, transfusion of tainted blood, rarely • Mild to moderate hepatosplenomegaly
occupational exposure); body fluids (through anal or vaginal • Chronic lung disease or hypoxemia at rest
intercourse, breast-feeding) • Acquired gross motor abnormalities or loss of developmental
• More than 95% of new pediatric cases occur secondary to milestones
Mer
• Mer may occur in utero, intrapartum, or postpartum (via • Diagnostic Evaluation
breast-feeding)
Who Should Be Tested?
• In the absence of breast-feeding, 80% of Mer occurs intra
• All pregnant women
partum
• All sexually active adolescents should have routine HlV coun
• Rick Factors seling and testing
..
:r:
o
• All children with parental history of: SexualJy transmitted dis
• For Mer: High maternal viral load, low CD4 count, preterm
.g: ease (STD); substance abuse, including non-IV cocaine use;
delivery, chorioamnionitis, breast-feeding, prolonged rupture ..
OJ bisexuality
of membranes, vaginal delivery
• All infants or children with: Failure to thrive; generalized
• For non-MCT: Unprotected intercourse (receptive anal inter
adenopathy; recurrent invasive bacterial disease; chronic paroti
course greater risk than receptive vaginal intercourse), expo
tis; chronic diarrhea; unexplained hepatitis
sure to infected blood
• Children with atypical idiopathic thrombocytopenic purpura
. Etiology • Loss of developmental milestones, if no other cause easily noted
• Chronic or recurrent thrush, especially after the age of Z years
• HIV- l (99% of cases) and HrV-Z, related retrovirus
What Test to Use?
• Pathogenesis
ANTlIIODY TESTING
• Prolonged period of clinical latency following infection (up to
10 years in adults) • HIV enzyme-linked immunosorbent assay (ELISA)
• Active viral replication slowly overwhelms the immune system - Sensitive and specific, though rarely false positives do occur
causing severe immunodeficiency. Frequent bacterial and - First screening test to confirm exposure in patient younger
opportunistic infections (01) result than Z years
162
164 • Blueprit1w Pediatric Infectious Diseases Ch.21:Human Immunodeficiency Virus Infection • 165
- IgG-based antibody, so all infants born to HIV-positive • Quantitative viral PCR (viral load, VL)
mothers will be ELISA positive at birth, by virtue of - Measures viral RNA per milliliter. Range of tests from fewer
transplacental transfer of anti-HIV antibodies. Maternal than 40 copies per milliliter to more than 10 million per
antibodies detectable until IS to 18 months of age milliliter
• HIV Western blot - In the first year of life, VLs are in 100,000 to 300,000 range
- Used as confirmatory test if ELISA positive. IgG based, more 1\ prior to treatment. In older children, 50,000 to 100,000
specific than ELISA range (as in most adults at time of diagnosis)
- For patients older than 2 years, two positive ELISA and - In general, the higher the VL, the greater the risk of progres
Western blot (WB) tests confirm HIV infection sion to AIDS/death. Measure every 1 to 3 months initially
but once stable on treatment, follow every 3 months
VIRAL SPECIFIC TESTS
• HIV PCR DNA assay
• Differential Diagnosis
- High sensitivity (greater than 98%) and specificity when
performed after I month of age • Adenopathylhepatosplenomegaly: Primary CMY, EBY, toxo
- Because of 2% false-positive and false-negative rate, one pos plasmosis, lymphoma
itive does not prove HIV infection, and one negative does • Frequent infections: Primary immune deficiency (see Chapter
not rule out infection 22)
• HIV blood culture
- Also more than 98% sensitive and specific after 1 month of • Management
age but technically demanding, less available • HIV-exposed infants
• HIV PCR RNA quantitative assay (viral load, VL) - ZDV for first 6 weeks of life, then start TMP-SMX bid, 3
- May be as sensitive as DNA assay, but more false positives at days/week
low values - Test by PCR DNA assay at least at birth, 1 month, and 4 to
- If used for diagnosis, should be confirmed by DNA assay or 6 months
blood coculture Continue T MP/SMX until 4-month PCR DNA assay is
negative
Evaluation of Exposed Infants - Routine immunization schedule
• Perform, at a minimum, HIV PCR DNA assay or blood cocul • HIV-infected infants/children
ture at 1 month and 4 to 6 months of age. A positive test - Measure CD4 and viral load at least every 3 months
should be repeated immediately. Two positive viral specific test - TMP/SMX in first year of life, and then based on CD4
results confirms HIV infection counts
• If negative at I month and 4 to 6 months, patient is considered Initiate combination antiretroviral therapy for 1) all identi
uninfected. Most consultants would still follow the infant until fied infected infants younger than 12 months; 2) CD4 count
seroreversion (negative HIV antibody test), at 15 to 18 months moderately suppressed for age; 3) HIV-related symptoms
of age
• For children and adolescents, two positive ELISA and WE tests Antiretroviral Agents
confirms HIV infection • Presently, there are five classes of antiretroviral agents, with a
total of 19 FDA-approved antiretroviral drugs (Box 21-1)
• W hen initiating therapy, use combinations of three or four
• Additional Studies
agents, from at least two classes
• T-cell subsets • Some drugs are coformulated to improve adherence (e.g.,
- Measurement of CD4+ % and absolute cell number allows Combivir ZDV + 3TC). Choices for children unable to swal
=
for staging of immunodeficiency. Use age-adjusted norms, as low capsules/tablets are limited; many agents do not come in
counts are high in infancy (normal 2500 to 3000/mm3 in liquid form, some that do are unpalatable, or have high alcohol
first year of life) and slowly fall to adult values (700 to content
1000/mm3) by age 7. In infected children, should be meas • Only 40% of children achieve viral loads of less than 40 copies
ured every 1 to 3 months per milliliter for more than 12 months
166 • Blueprints Pediatric Infectious Diseases Ch.21:Human Immunodeficiency Virus Infection • 167
TABLE 22-1 Chief Complaints a nd Suspected • Tests for cellular immunodeficiency: Lymphocyte count; T
Immune D eficiencies lymphocyte enumeration (flow cytometry); delayed-type hyper
sensitivity skin tests (limited value in infants younger than I year);
Consider These Primary thymic shadow on CXR; HN antibody; mitogen/antigen lym
ChiefComplai'lt Immune Deficienc:ies phocyte stimulation
Chronic diarrhea IgA defICiency, 5[ID, XlA 1\ • Tests for phagocyte defect: Neutrophil count; NBT test or
Recurrentotitis media/sinusitis IgA deficiency, XLA,eVID dichlorofluorescin if available; neutrophil chemotaxis assay
• Tests for complement deficiency: CHso' AHso; C3, C4, and
Recurrentpneumonia IgA deficiency, X LA, (vID,h y per -l g E, (GO,SClO
other complement components when indicated
Recurrent meningitis Complement deficiency
Recurrent skin/soft-tissue infections (GD III Differential Diagnosis
Fungal infections T-celVcombined defICiency, (GO
• Consider diseases that may mimic or be associated with immun
odeficiency: Asthma, allergies, cystic fibrosis, inflammatory
- Candida spp.: Cellular or combined deficiency, or phagocyte bowel disease, leukemia/lymphoma. protein-losing enteropa
defect thy, metabolic disorders
- Mycobacterium avium: Cellular or combined deficiency, • Consider causes of secondary immunodeficiency: HIV/AIDS,
phagocyte defect, HIV malnutrition, chemotherapy, and steroid use
- Pneumocystis carinii: Combined deficiency, phagocyte defect,
HN
- Enteroviruses (recurrent or severe): Humoral or combined
deficiency • Most common group of primary immune deficiencies
• Symptoms appear at 3 to 6 months of life as maternal antibod
III Physical Examination ies wane below protective levels
• Search for previously unrecognized but significant physiologic Transient Hypogammaglobinemia of Infancy
or anatomic abnormalities. Examples: • Abnormal delay in onset of antibody production
- Dysmorphic facial features (DiGeorge syndrome, hyper-IgE • Normal physiologic nadir is lower and more prolonged
syndrome) • Affected patient may suffer recurrent upper respiratory tract
Gingivitis, ulcerations, periodontal disease (neutropenia) infections
- Paucity of tonsillar tissue (X-linked agammaglobulinemia) • Diagnosis: Serum IgG and IgA low with normal IgM
Petechiae (Wiskott-Aldrich) or seborrhea-like dermatitis • Antibody response to protein antigens normal and circulating
(chronic granulomatous disease, Langerhans histiocytosis) B cells normal
• Spontaneous resolution, usually by 2 to 3 years of age
III Diagnostic Evaluation
X-linked Agammaglobulinemia (Bruton Agammaglobulinemia)
• Basic screening for immunodeficiency: • Arrest of B-cell development at the pre-B-cell stage
- CBC with differential, noting absolute lymphocyte and neu • Mutation in Bruton's tyrosine kinase gene located on Xp22
trophil counts and peripheral blood smear • Occurs in I in 50,000 to 1 in 100,000
- Quantitative immunoglobulins including IgG, IgA, IgM, and • Most common infections: Sinopulmonary infections (60% of
IgE affected children); gastroenteritis (35%); pyoderma (25%);
Titers to previous vaccines including tetanus, Haemophilus arthritis (20%); meningitis (16%); sepsis (10%)
inJluenzae type B, diphtheria, and pneumococcus • Occasionally present with enteroviral encephalitis, viral hepa
- Consider CHso' nitroblue tetrazolium (NBT; see below), and titis, or disseminated polio (live virus vaccine strain)
HIV antibody • Small to no lymphoid tissue (absent tonsils), arthritis,
• Tests for humoral immunodeficiency: Quantitative immuno dermatomyositis-like syndrome
globulins (lgG, IgA, IgM, IgE); antibody titers to vaccines; IgG • Total absence or marked deficiency of all types antibody,
subclasses (controversial) including protective antibody
174 • Blueprints Pediatric Infectious Diseases Ch.22: Inherited Immune Deficiencies • 175
• Diagnosis: Absent or low (less than 2%) circulating B cells or • Absolute lymphocyte count (ALC) is a big clue to the diagno
lymphocytes with surface immunoglobulin sis. (ALC in newborns should be greater than 2000 to 11,000,
• Treat with monthly intravenous immune globulin (IVIG) to and in 6- to 7-month olds greater than 4000.)
maintain normal serum IgG concentrations • Several genotypes/phenotypes. T cells may be low or absent. B
cells may be normal, low, or absent
Common Variable Immune Deficiency (CVID)
1\
• Heterogeneous group of disorders with B-cell and T-cell dys DiGeorge Syndrome (22q11.2 Deletion Syndrome,
function Velocardiofacial Syndrome)
• "Variable" reflects the wide age range at diagnosis and the • Wide variation in clinical disease; occurs in 1 in 2000 to I in
degree of hypogammaglobinemia 5000 live births
• Recurrent otitis media, sinusitis, pneumonia, and bronchiectasis • Associated with defect in embryologic development of third
• 50% with GI involvement chronic diarrhea, atrophic gastritis, and fourth pharyngeal pouches
pernicious anemia, nodular lymphoid hyperplasia �
V • Thymus absent or hypoplastic (SCID-like or mild lymphopenia)
• Lymphoid hypertrophy including spleen and liver with sec 1\
• Cardiac defects (conotruncal defects, atrial septal defect, ven
ondary thrombocytopenia Q) tricular septal defect, interrupted aortic arch, right-Sided aortic
....
• 25% with autoimmune disorders rheumatoid arthritis, hemolytic "
., arch)
anemia, immune thrombocytopenia purpura, Guillain-Barre ...
• Possible associated defects: Esophageal atresia, bifid uvula,
o
...
syndrome, autoimmune thyroid disease hypertelorism, low-set ears, palatal insufficiency
.,
• Diagnosis: Low immunoglobulin (Ig) levels, absent specific o
" • Hypoparathyroidism, hypocalcemia
antibodies, variable T-cell function v
• Diagnosis: Fluorescent in situ hybridization (FISH) to detect
• Treat with monthly IVIG. Prophylactic antibiotics benefit 22q11.2 deletion
some patients with recurrent respiratory infections • Multidisciplinary approach to care: Speech pathology, genetics,
IgA Deficiency cardiology, immunology, development
• Most common antibody deficiency with prevalence ranging • No specific treatment unless profound defect necessitates thymic
from I in 400 (whites) to 1 in 5000 (Asians) explants
• In many with isolated IgA deficiency disease is asymptomatic;
others develop recurrent sinopulmonary infections Wiskott-Aldrich Syndrome
• Associated with atopy and autoimmune disorders • Triad of immunodeficiency, eczema, and thrombocytopenia
• Diagnosis: Serum IgA concentration less than 7 mg/dL (platelets also small and defective)
• Risk for developing anti-IgA antibodies from blood products • X-linked recessive inheritance; defect in WASP gene (product
and subsequent anaphylaxis important for actin polymerization)
• Increased susceptibility to infection (5. pneumoniae, P. carinii,
herpes virus)
• Poor antibody responses to polysaccharides
Severe Combined Immunodeficiency (Sc/D) • Usual presentation in infancy with prolonged bleeding (cir
• Category of diseases resulting in abnormal lymphocyte number cumcision, diarrhea, or bruising)
and function • Diagnosis: Specialized genetic testing to confirm diagnosis
• May be X-linked or autosomal recessive. Occurs in approxi • Human leukocyte antigen-identical sibling bone marrow
mately 1 in 100,000 live births transplants may be indicated
• Manifestations include failure to thrive, recurrent/chronic res
piratory infection, opportunistic or fungal infection
• Graft versus host disease rash from maternal T cells in some cases '"
�.��g.���.�-��-����-��-�--------------------------------------_._-----------------
'"
• Initial management: Strict isolation, IVIG, no live vaccines, "
'"
only irradiated CMV-negative blood products if necessary, <l Neutrophil Disorders (Table 22-2)
V
trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis, • Diminished neutrophil number or function (chemotaxis,
search for bone marrow or stem cell donor phagocytosis, oxidative burst)
176 • Blueprints Pediatric Infectious Diseases Ch.22: Inherited Immune Deficiencies • 177
• Manifest as recurrent or severe infections with common bacte - Neutrophil chemotaxis assay and neutrophil expression of
ria and opportunistic pathogens (see "History" in section "Eva CDllb/18 evaluates disorders associated with decreased
luation of Suspected Primary Immune Deficiency") neutrophil chemotaxis and leukocyte adhesion defect
• Production disorders - Bactericidal killing assay evaluates neutrophil killing of S.
- CBC with manual differential to evaluate for decreased pro aureus compared to normal control. Detect any deficiency in
duction (cyclic neutropenia, Kostmann syndrome, and " neutrophil abilicy to recognize, phagocytose, and kill pathogens
Shwachman syndrome) and abnormal morphology (Chediak Macrophage Disorders
Higashi, specific granule deficiency) • Characterized by defects in intracellular killing. First mfection
- Antineutrophil antibodies used to evaluate autoantibody usually before age 3 years
neutropenia • Autosomal recessive inheritance; most common defect is in
• Functional disorders interferon-y (IFN-y)receptor 1 chain
- NBT and dihydroxyrhodamine 123 (DHR) . Both tests eval � • Increased susceptibility to intracellular infections, especially
uate neutrophil oxidative burst. DHR with flow cytometry v
mycobacteria (Mycobacterium avium most common infection;
"
is more quantitative and requires less blood for evaluation others include M. bovis, M. !ortuitum, and M. tuberculosis) and
Q)
.-1
" Salrrwnella species.
'"
'" • 20% of patients with early death from infection
o
.... • Diagnosis usually requires testing to evaluate lFN-y receptor
.,
i TABLE 22-2 Manifestation and Inheritance of Specific o expression and function
"
Neutrophil Disorders v • Immunomodulator therapy: IFN-y has shown benefit except in
complete IFN-y receptor defects
Clinic...1 Disease Manifestations
Production Disorders
CYc\k lleIJtropenia Recurrent fever, mlJcosal ulc;ers,{utaneous
infections, lymphadenopathy, approximately
l1-day cyc\e
Kostmann syndrome Low neutrophil counts
Sdlwarnman-{)iamond syndrome Metaphyseal dysostosis multiplex,pancreatic "
insuffldency,neutropenia �
Function DiSorders ,:
x
0
Chronic granulomatous disease Recurrent infections-catalase-positive
,g;
bacteria, filamentous fungi, inflammatory E<
OJ
complkatioos, inflammatory bowel disease
�
leukocyte adhesion deficiency type 1 Soft-tissue infection, tooth loss, omphalitis,
delayed sepal'iltion of umbilkal (ord,
�
�
perirectal infections
"
leukocyte adhesion deficiency type 2
:;:
Infections similar to type 1; i1 addition,short 0
stature, mental retardation it
..
x
Chediak-Higashi syndrome Recurrent infections cellulitis, abscess, otitis, 0
'"
I
periodontal disease with bone loss,
Q{ulocutaneous albinism, peripheral
�"
neuropathy, Iymphoproliferative disorder �
�
'"
Myeloperoxidase deficiency Most asymptomatic,rarely associated with
x
severe candidiasis "
'"
0
Spedfic granule deficiency Indolent skin and respiratory infections, otitis,
v
and mastoiditis
Ch. 23: Infections in Other Immunocompromised Hosts • 179
1\
Bacteremia S. pneumoniae H. influenzae
Marian G. Michaels, MD, MPH and Shruti M. Phadke, MD Salmonella species Candida spedes"
:s: CoagUlase-negative GNR
'"
'"
"! staphylococci" a-Hemolytic streptococci
0
S.aureus Neisseria meningitidis
g.
'" Osteomyelitis Salmonella species N/A
"
• Sickle cell disease (Hb SS): An autosomal recessive disorder "! S.aureus
" EntericGNR
Valine is substituted for glutamine at the sixth position of J:
v
the f3-globin gene Pneumonia S.pneumoniae N/A
1\
M.pneumoniae
Abnormal red blood cell structure and life span OJ
..., C. pneumoniae
• Increased risk for severe infections largely due to functional '"
III
asplenia Other Aplastic crisis: parvovirus 819 Urinary tract infections:
14
iii Epidemiology
• Defective alternate complement pathway: Decreased heat
• Highest risk for infection occurs during infancy through first 5 labile opsonic activity
years of life • Local infarction and tissue necrosis
• Decreased risk during neonatal period due to persistent fetal • Possible decrease in chemotaxis of neutrophils
hemoglobin
• Risk of invasive Streptococcus pneumoniae 100 to 500 times
greater than normal child Etiology/Pathogenesis (Table 23-1)
Same serotypes of S. pneumoniae as those infecting healthy • Bacteremia with encapsulated organisms cannot be cleared
children efficiently
- Increased risk of resistant S. pneumoniae because of frequent • Bone crisis leads to devitalized areas and increased risk of
antibiotic use osteomyelitis
Anticipate decreased frequency of S. pneumoniae with use of • Intravascular sickling of vessels of the bowel may lead to
conjugate vaccine microischemia and damage the mucosal integrity leading to
• Conjugate vaccine against Haemophilus inf/uenzae type b led to bacteremia from enteric organisms
decreased disease
• Gram-negative rods (GNR) predominate in older children (e.g.,
Salmonella) III Physical Examination
• Severe pneumonia or acute chest syndrome can occur with infec • Often deteriorate quickly
tion with Mycoplasma pneumoniae and Chlamydia pneumaniae • Fever usually present
• Look for signs of specific infections. Most commonly: Sepsis,
III Risk Factors
meningitis, pneumonia, osteomyelitis, urinary tract infection,
• Splenic dysfunction: Lack of clearance of bacteria and decreased and parvovirus B19 infection (see relevant chapters for specific
antibody synthesis examination findings)
178
Ch. 23: Infections in Other Immunocompromised Hosts • 181
180 • Blueprints Pediatric Infectious Diseases
• Additional Studies • Some similarities exist regardless of the type of organ trans
planted
• CBC with differential and platelet count (severe anemia with
- Stereotypical timing of infections (see "Epidemiology")
low reticulocyte count in parvovirus B19; leukocytosis with
Opportunistic infections
other infections)
• Blood culture • Epidemiology/Risk Factors (Box 23-1)
1\
• Urinalysis and urine culture
Immunosuppression to prevent rejection
• Depending on physical examination and lab values, additional
• Surgical manipulation
studies include:
- Chest radiograph: I) Respiratory symptoms present; 2) pos • Underlying disease
itive culture for S. pneumoniae - Cystic fibrosis patients infect new lungs with organisms
- Radiographic studies to evaluate possible osteomyelitis: 1) from trachea/sinuses
OJ
Symptoms referable to joint or bone; 2) positive blood cul X - Short-bowel syndrome, 'antibiotic-resistant organisms sec
ture for Salmonella spp. or S. aureus
V ondary to previous antibiotics
1\
- Lumbar puncture if CNS signs or symptoms • Absence of primary immunity to many infectious agents prior
OJ
... to the time of transplantation (often age dependent)
'"
"' • Donor-associated infections
• Differential Diagnosis ...
.B - Cytomegalovirus (CMV) (donor positive/recipient negative)
• Vaso-occlusive ischemia: Acute chest syndrome versus pneu +>
o
monia; bone pain crisis versus osteomyelitis; stroke versus CNS c:
v BOX 23-1 Typi ca l Period ofTime for Specific Infections
infection; viral illness
Noted After Transplantation
" - Nocardia
:;;
u - Toxoplasma gondii
g-
III
• Infections are a major cause of morbidity and mortality after X
o
'"
Late (>12 months)
transplantation I Community acquired
• The transplanted organ is often a major focus for the site of is'" Bacterial (chronic rejection)
infection �
"1: Aspergillus or other fungi
- Urinary tract infections or pyelonephritis after renal trans '" Epstein-Barr virus (PTLD)'
plantation '"
'"
'"
Cholangitis and hepatitis after liver transplantation u • EBVIPTLD ongOing risk in late period althoogh less than in middle period.
v
- Pneumonia after lung transplantation
182 • Blueprints Pediatric Infectious Diseases Ch. 23: Infections in Other Immunocompromised Hosts • 183
..
- Significant contributor to progressive small airways obstruc
III History
x
o tion and fibrosis and destruction of lung parenchyma
i
• Time after transplantation • Previous infections
• Epidemiology
• Serologic status of recipient • Type of transplant
and donor • Presence of catheters • Incidence: Northern European descent: 1 in 3200; African
• Type of immunosuppression • Immunosuppression levels descent: I in 17,000; Asian descent: 1 in 90,000
• Type of antimicrobial • Exposures • Genetics:
prophylaxis - Gene (on long arm of chromosome 7) codes for a protein
that functions in chloride conductance (Cystic Fibrosis
III Additional Studies Transmembrane Conductance Regulator, or CFTR)
• Additional Studies
• Sputum culture for bacterial pathogens with antibiotic suscep
tibilities
• Pulmonary function tests for changes in spirometric parameters
• Chest radiographs for evidence of bronchiectaSis, peribronchial
thickening and cuffing, hyperinflation, and infiltrates
Ch. 24: Biowarfare Agents • 187
Gastrointestinal
• Initially fever, nausea, anorexia then abdominal pain, hema
Oropharyngeal
• Neck swelling from lymphadenopathy can compromise airway
A
Andrew L. Garrett, MD and Fred M. Henretig, MD • T hroat pain, dysphagia, and ulcers at base of tongue
186
188 • Blueprints Pediatric Infectious Diseases Ch.24: Biowarfare Agents • 189
.. Additional Studies
.. Additional Studies ..
x
o • Elevated creatine phosphokinase (rhabdomyolysis) with typ
• CXR: Bilateral infiltrates in pneumonic plague
� hoidal form
• LeukocytOSiS with more than 80% neutrophils. DIC may occur ..
OJ • CXR: Typical or interstitial pneumonia possibly with pleural
• Identification of a coccobacillus in lymph node aspirate,
effusion
sputum, blood, or CSF
• Polymerase chain reaction (PCR) useful from swabs of ulcers
• Organism grows slowly in routine culture medium, so enzyme
• Bacteria may be cultured from blood, lesion swabs, and
linked immunosorbent assay Fl Y. pestis antigen detection con '"
:. sputum, but require specific media and precautions given risk
firms the diagnosis o
�
"'
of spread of tularemia
.. Differential Diagnosis
x
o • Antibodies present 1 1 to 2 1 days after onset of symptoms.
'"
I
• Community-acquired pneumonia, hantavirus pulmonary syn &l'"
.. Differential Diagnosis
drome, rickettSiosis, meningococcemia, pneumonic plague, �
�
ricin or staphylococcal enterotoxin B • Severe pulmonary infections: Mycoplasma, plague
"
x • Typhoidal illnesses: Malaria, salmonella, rickettSia
'"
.. Management '"
o
• Prophylaxis with doxycycline for 2 weeks if exposed but infec • In the event of a documented case, vaccination of the public
tion is asymptomatic via scarification may contain an outbreak. It may be useful up
• Vaccination via a live attenuated product is available for labo to several days after exposure
ratory workers • Pre-event vaccination of certain groups (military, physicians,
etc.) is controversial. Live vaccinia virus currently used, but tissue
" cell culture vaccines are in development. Potential vaccine
�-I!! �����---------------------------------------------- _________________________________ related complications include cardiac disease and death
• Vaccinia immune globulin may treat severe side effects of vac
• Caused by the Orthopoxvirus variola; two forms: major and
cination
minor
• Antivirals (e.g., cidofovir) are being investigated for use in
• Endemic disease eliminated in 1 980 by World Health Organi
smallpox
zation, but integrity of the few remaining stockpiles of the virus
is unknown
y���ttl �I!!� ����9�� ����� �
_ _ _ _ __________________________________________________
• Pathogenesis
• Viral hemorrhagic fever (VHF): Potential bioweapon due to
• Infection by inhalation of aerosolized virus or indirect contact
aerosol infectivity
(contaminated fomites)
• Four families of virus and some of their respective illnesses:
- Arenavirus: Machupo, Lassa, Argentine hemorrhagic fever
• History/Physical Examination
Bunyavirus: Hantavirus, Congo-Crimean fever, Rift Valley
• Incubation period: 7 to 19 days fever
• Febrile prodrome: 1 to 4 days before rash; fever, headache, my Filovirus: Ebola, Marburg
algias, backache, vomiting, or abdominal pain - Flavivirus: Yellow fever, dengue
• Evolution of lesions from macules to papules to pustules (each • Oubreak of Ebola v Reston among primates imported to the
stage lasts 1 to 2 days) United States in 1989 inspired the book The Hot Zone. This
• Classic lesions: Deep-seated, firm, round, well-circumscribed strain was not pathogenic in humans
vesicles or pustules that may become umbilicated or confluent
• Centrifugal distribution: Lesions concentrate on face and distal • Epidemiology/Pathogenesis
extremities_ On any one part of body, all lesions are in the same • Arenavirus (carried by rodents): Inhaled dust contaminated by
stage of development rodent waste. Endemic in areas of Central America and West
• Patients infectious from rash onset until scab separation (7 to Africa
10 days after rash onset) • Bunyavirus (carried by ticks, rodents, mosquitoes): Inhaled
• Milder illness in variola minor infections and in previously dust contaminated by rodent waste or by infected arthropod or
immunized individuals insect bite. Endemic in Africa, Europe, Asia. Hantavirus, car
ried by rodents, is seen in the southwestern United States
• Additional Studies
• Filovirus (carrier unknown): Infectious body fluids and in
• DiagnosiS by electron microscopy of vesicular scrapings_ Con some cases by respiratory route. Endemic in areas of Africa, but
sider silver staining or PCR of specimens_ Specimens should be periodically emerges into humans and primates
handled at one of a small number of federal laboratories • Fiavivirus (carried by mosquitoes and ticks): Infectious by bite
of infected carrier
• Differential Diagnosis
• Common pathophysiology: Degradation of the vascular system
• Varicella, monkeypox, cowpox, erythema multiforme, contact and coagulopathy
dermatitis
• History/Physical Examination
• Management
• Fever, myalgias, weakness
• Initial outbreak response focuses on containment of symptomatic • Microvascular degradation, coagulopathy, and complement
patients system activation
192 • Blueprints Pediatric Infectious Diseases Ch.24: Biowarfare Agents • 193
• Conjunctival injection, hypotension, flushing, petechial lesions, • Initial manifestations: Autonomic effects (mydriasis, ileus, con
edema stipation, dry mouth) and cranial nerve palsies (diplopia,
• Some progress to shock, mucous membrane hemorrhage, DIC, ptosis)
multiorgan failure • Later manifestations: Symmetric descending flaccid muscu
loskeletal paralysis and respiratory failure
• Additional Studies "
• Additional Studies
• Clusters of unusual diseases will likely be the first signs. Not all
cases of VHF will be a bioweapon attack, as these diseases are • Clinical diagnosis but may have tranSiently positive edropho
endemic in some locations. nium (Tensilon) test
• Thrombocytopenia, leukopenia, elevated hepatic enzymes, pro • Toxin neutralization assay in mice identifies botulinum toxin
teinuria, and hematuria in serum and stool
• Enzyme-linked immunoassays may provide rapid diagnosis of Q)
:c
the viremia in some cases. Viral culture may also diagnose a sus v • Differential Diagnosis
"
pected VHF virus • Guillain-Barre syndrome, tick paralysis, myasthenia gravis,
nerve agent, cholinergic intoxication, and food-borne botulism
• Differential Diagnosis
Botulinum
• Pathogenesis
• History/Physical Examination
.g;
• Erythrornytll estolate (14 daysl.Azitlllllll�cilr (5-7 days)
Globulin Products ..
may be as effective
OJ
HepatitIs 8 infection • None if exposed peISOIl has positive HBsAb
1herapeutic Indication!s) • HBIG once and begin H8V series if exposed per50Il never
vaccin;ml;tlBIG twice if exposed person vaccinated but
Intravenous inmune Replacement fer IgG deficiency; Kawasaki d�ase; has negat� titer
globuli n (lVIG) hepatitis A eJCpOSIJre; immlllle-rnedi;mi • Evakiation:HBsAg,HBsAb,and liver enzymes at baselile,
thrombocytoper1ia;GuiHain-l!arre syndrome 3,and6months
Cytomegalovirus immutie (MV IG may be synergistic in managing (MV Hepatitis ( infection • tfo prophylaxis avaiIilbIe.Evaluation: HCV Ab, 1iver
g/obuill «(MV IGJ pneumonia in bone marrow transplant patients enzymes at baseline.3,and 6 months
when given with ganddovlr
Influenza • Amantadine, rimantadine,or oseItamivir for 5 days
Botulinum immune !llobUlln Infantile botuism;use equine-derived antitoxin in • Also give influenza vaccine If unvaccinated
{H8IG;human IlotuIirum hypersensitivity-tested adults if HBIG not avaDabie
Varic:ellif • Varitdla vaccine lip to 5 days after exposure
antitollin)
• VZIG may be given (see Table 25-1)
Tetanus invnune globulin (JIG) Treatrnent for tetanus:admlrislerboth intramuscularly
and IocaIy arotIld woundUsein conjunction with • See <haplEr:t1 for cflSlUSSion ofllV posIeqJoSIn prnp/lyIaxk
antiJiotic (metronidazole or petidllin G) to redure the ·sU5U!pltie, exposed I6lI1h careworlifrs should be ftJIoughed from days 8toll following exp0-
number of vegetative forms ofClostridium Man; sure.VZ1G �fents shOllld be utoughell ll1lil day 28.
198 • Blueprints Pediatric Infectious Diseases Ch, 25: Prevention of Infection • 199
" rt1IIlImised IlOCOI11 hosts v.itb herpes mster infedlon.and inmJlIOCIlq)etent hosts v.ith
TABLE 25-4 Disease Transmission and P recautions dmeninaled dis&Ise mar 5IlI!d VII'IreIIa \'ius from the rtSpiraIIIry Ir.lCtand require<ontactpius
ai1xJme isolation fur the dInIion ofilness.
ModI of b��_,van<IlIIl)'dn-r ��e
Trallsmission �s.DIIl'ILS.ecIEIldespec1rU
d- m� �bactrria.
Applicable to aI body fluids, • Hand hygiene (haI;Id wasting
SeoetiGrll. aRd emetions . Grused�
swea;CoIIsilIer til! �as ' 1JI'IIIIKt) beiwftn P.*m ., and the Joint Commission on Accreditation of Healthcare
pdJIy infec:tioUS b bhied iind �erreniiWal of� Organizations (JCAHO).
bome�sud1 as HlV �� , ' • Traditionally infection control programs focused on nosoco
• GIcM!S to be worn wilen toui:It" ;
mial infections, However, basic principles now applied to set
ing blood, bhdy tii;oicOO-> :
taRHnated'1teins tings outside of the hospital , including outpatient clinics,
• M.lsfls alidtor� jmec1Ion If : long-term care facilities, and home health
generiIiGn of 5jlIiIJ (I spIaslI�� General Principles of Isolation
&ids Pc5slbE Goal is to limit transmission from infected host to other persons
'. � (nonsterIet � •
A
Career Opportunities in Pediatric
Ped iatrics a n d Ped iatric Infectious Diseases
I nfect i o u s D i sea ses According to the Pediatric Infectious Diseases SOCiety, two thirds
of all board-certified pediatric ID physicians practice in a medical
1\ school or university setting. They may see ID patients in the inpa
tient or outpatient setting, teach reSidents and medical students,
conduct research, or perform a combination of these activities.
Other pediatric ID physicians work at public health agencies
There are currently 2 1 3 accredited categorical pediatric residen including the Centers for Disease Control and Prevention and the
cy training programs in the United States and 1 6 accredited pro National Institutes of Health. In this capacity, the investigate dis
grams in Canada. Each year 2500 to 3000 residents begin pedi ease outbreaks, educate the public, and proVide leadership in the
atnc training. At the completion of a 3-year residency, candidates field of infectious diseases epidemiology. ID specialists are also in
may take the General Pediatrics Certifying Examination to great demand by pharmaceutical companies. Their expertise per
become a board-certified pediatrician. mits involvement in many aspects of the development of vaccines
and antimicrobial, antiviral, and antifungal agents. Approximately
5% of pediatric ID specialists are engaged in private sector patient
care. Some specialists practice exclusively in the office setting
Each year 25% to 30% of graduating pediatric residents begin whereas others combine outpatient and inpatient care.
subspecialty fellowship training. Possible pediatric fellowship Additional information can be obtained from the American
choices include the following: Board of Pediatrics (www.abp.org) and the Pediatric Infectious
Diseases SOCiety (www.pids.org) .
• Adolescent medicine • Hematology-oncology
• Behavioral/developmental • Infectious diseases
pediatrics • Neonatal-perinatal medicine
• Cardiology • Nephrology
• Critical care • Pharmacology-toxicology
• Emergency medicine • Pulmonology
• Endocrinology • Rheumatology
• Gastroenterology • Sports medicine
A. Gentamicin
B. Ciprofloxacin
C. Cephalexin (first-generation cephalosporin)
D. lmipenem
E. Amoxicillin
A
5. A 9-year-old girl was diagnosed with pneumonia and treated with
amoxicillin. She remains febrile after 48 hours of therapy. In addi
tion, she complains of pleuritic chest pain. What should be the next
QUESTIONS
step in the evaluation?
1. A 3-year-old girl presents with unilateral eyelid edema and ery A. Nasopharyngeal bacterial culture
thema with mild propto sis. Extraocular movements are restrict B. Transthoracic needle biopsy
ed. Orbital CT scan confirms the diagnosis of orbital cellulitis. C. Mycoplasma polymerase chain reaction of the nasopharyngeal
What i s the most appropriate antibiotic for empiric therapy in this aspirate
patient? D. Chest radiograph
E. Radionuclide milk scan
Q)
A. Tetracycline ..,
B. Ceftazidime
'"
III 6. Which of the following is associated with toxic shock syndrome due
C. Ampicillin-sulbactam 14 to Streptococcus pyogenes?
o
....
D. Trimethoprim-sulfamethoxazole ...,
A. Epstein-Barr virus infection
o
E. Metronidazole <: B. Tampon use
2. An 1 8-month-old boy awakens with a hoarse voice and a seal-like
v C. Varicella infection
"barking" cough. He is relatively well appearing. The oxygen satura D. Prolonged hospitalization
tion is 1 000/0 in room air. On examination, he has suprasternal retrac E. Stepping on a nail through a rubber-soled sneaker
tions and mild in spiratory stridor. What is the most appropriate 7. A 1 2-year-old boy presents to the emergency department with an
management? infected hand wound. Eikenella corrodens is isolated from wound
A. Oral dexamethasone (0.6 mg/kg) culture. What is the most likely mechanism of injury?
A. Nontuberculous mycobacteria 2 several days after fever on set. Uveitis is detected on ophthalmolog-
'" ic examination. What is the most appropriate management?
B. Bartonella henselae :;:
u
C. Staphylococcus aureus 0. A. Treat with gamma globulin regardless of echocardiogram results
Q)
D. Group B Streptococcus " B. Treat with high-dose acetaminophen
J:
0
E. Anaerobes '" C. Treat with amoxicillin
I
!< D. Defer specific treatment until the fever has been present for at
4. A previously healthy 2-year-old boy presents with a 2-day history of '"
'"
'" least 10 days
worsening fever and cough. On examination, there is tachypnea but Q)
R:
E. Treat with gamma globulin only if echocardiogram is abnormal
no grunting or nasal flaring. No rales are appreciated. Chest radi "
ograph reveals a right lower lobe opacity but no pleural effu sion. '" 9. A 9-day-old infant presents with a temperature of 38.8°C. On exam-
'"
'" ination, he is well appearing. There are no findings of focal bacterial
What antibiotic would be most appropriate in the outpatient treat u
ment of this child with pneumonia? v infection. What is the most appropriate treatment of this child?
202
204 • Blueprints Pediatric Infectious Diseases Appendix B • 205
A. Discharge home to follow-up with the pediatrician the next 1 5. A 7-year-old girl presents in January with a I -day history of fever,
morning headache, photophobia, and vomiting. On examination, she is ill
B. Blood culture, CBC, and empiric antibiotics only if the white blood appearing. Passive flexion of the neck results in spontaneous flexion
cell count exceeds 1 5,OOO/mm3 of the hips (Brudzinski sign). You suspect bacterial meningitis. Her
C. CBC, blood culture, and intramuscular ceftriaxone serum glucose is 70 mg/dL. Which of the following cerebrospinal
D. CBC, blood, urine, and CSF cultures, and empiric antibiotics fluid results is most consi stent with bacterial meningitis?
"
E. Consult infectious diseases for evaluation of fever of unknown origin
WBC Neutrophils Protein Glucose
1 0. An l 1 -year-old boy residing in Connecticut develops a lO-cm ery
(per mm3) (%) (mg/dL) (mg/dL)
thematous macular rash with central clearing on his leg. The rash
A. 2000 85 90 30
has expanded since 4 days ago when it was only 5 cm in diameter.
B. 200 50 200 20
What is the most appropriate management?
C. 200 75 20 55
A. Test for Lyme IgM and IgG antibodies
� D. 1 00 8 20 55
B. Test for Rocky Mountain spotted fever antibodies v E. 200 30 90 55
C. Prescribe oral doxycycline "
D. Send a blood culture and admini ster intramuscular ceftriaxone III 1 6. Which TORCH infection is most commonly associated with periven
...
E. Obtain an electrocardiogram " tricular intracranial calcifications?
OJ)
...
1 1. What is the most appropriate test to perform on the blood of a o A. Rubella
....
neonate born to an HIV-positive mother? ., B. Cytomegalovirus
o
A. HIV antibody by ELISA " C. Syphilis
v
B. HIV DNA PCR D. Toxoplasma
D. HIV antibody by Western blot 1 7. A hospitalized patient with which one of the following diseases
E. Total WBC count would require droplet precautions?
1 2. A 2-month-old boy presents to your office for a well-child visit. On A. Clostridium difficile colitis
examination you detect a harsh holosystolic murmur suggestive of a B. Influenza
ventricular septal defect. Chest radiograph reveals a right-sided aortic C. Rotavirus g astroenteritis
arch and absence of the thymus. What is the most likely diagnosis? D. Respiratory syncytial virus bronchiolitis
B. Direct inoculation from penetrating trauma 19. A 1 2-month-old girl presents for evaluation of fever and abdominal
C. Hematogenous seeding after bacteremia pain. Urinalysis reveals 2+ leukocyte esterase by dipstick. What
D. Spread from adjacent septic arthritis pathogen will most likely be isolated from urine culture?
E. Spread from adjacent cellulitis A. Escherichia coli
1 4. Which of the following is considered a HACEK organism? B. Staphylococcus aureus
A. Campylobaeterjejuni 25. A 1 0-year-old boy pre sents to the emergency department several
B. Escherichia coli 01 57:H7 hours after eating leftover fried rice at home. He complains of nau
C. Yersinia enterocolitica sea and diarrhea.You suspect food poisoning.What is the most like
D. Clostridium difficile ly organism?
E. ShigeJla species A. Bacillus cereus
2 1 . A 40-year-old girl with acute lymphocytic leukemia has been neu A B. KingeJla kingae
tropenic for 21 days during induction chemotherapy. She now com C. Cryptosporidium ovale
plains of headache and facial pain.On examination, there is left peri D. Enterobius vermicularis
orbital swelling. A small area of blackened eschar is noted within the E. Clostridium difficile
nose. Sinusitis due to Aspergillus species is suspected. What is the
most appropriate therapy while awaiting surgical debridement?
A. Fluconazole
B. Voriconazole
C. Nystatin
D. Clotrimazole troches Q)
..,
'"
E. Acyclovir III
14
22. A 6-month-old girl presents with severe hypoxia and tachypnea. On o
....
examination there are marked intercostal retractions but few rales. ...,
o
In talking with the mother you discover that the father is HIV posi <:
v
tive.The mother has never been tested.This information, combined
with the clinical presentation, makes you suspect Pneumocystis
carinii pneumonia. You order a broncho scopy. Which of the follow
ing tests would be most useful in making the diagnosis?
A. Streptococcus pneumoniae
B. Citrobacter diversus
C. Group B Streptococcus
D. Streptococcus milleri group
E. Staphylococcus epidermidis
24. A 2-year-old child i s evaluated in the infectious diseases clinic for
recurring "boils."What is the medical term for "boil"?
A. Bordet-Gengou
B. Shell vial
C. Furuncle
D. Tache noir
E. Bubo
208 • Blueprint$ Pediatric I nfectious Diseases Appe nd ix B • 209
v
rather than subacutely. On eXamin ati on it is usually extremely ten
1 . C. The most likely causes of orbital cellulitis in dude gram
der with overlying cellulitis.Group 8 Streptococcus is associated with
adenitis in neonates. Anaerobic cervical adenitis is usually associat
positive organisms such as Staphylococcus oureus, Streptococcus
ed with dental infection.
pnellmonloe, and Streptococcus pyogenes, and anaerobes. The
ampicillin component of ampidllln-sulbactam provides excellent 4. E. The most likely bacterial cause of lobar pneumonia in a toddler is
coverage against S. pneumoniae and S.pyogenes. The sUlbactam Stteptococ:cus pneumoniae. Whtle the prevalence of drug·resistant
cornponent, a J3-lactamase inhibitor, ailows the antibiotic to be S. pneumoniae is increasing. failures due to penicillin or arnoxi
effective against bacteria that have p-lactamase production as Ciliin as a consequence of resistant 5.pneurflonioe pneumonia are
a mechanism of resistance (e.g.. S. Qureus and anaerobes). uncommon. Gentamicin provides excellent coverage against gtam
Tetracycline use would be inappropriate in a toddler when ather negative{)rganisms but provides no coverage against S.pneumoni
options exist. Potential side effectS of prolonged tetracycline use In ae, the most likely bacterial cause of pneumonia in this child. In
a toddle.r include permanent tooth discoloration. �mamel defects. addition, In the outpatient setting, an o ra l rather than intravenous
and retardation of bone growth. Ceftazid ime does not provide ade-' antibioti<: would be preferred. Oral gentamiCin is poorly absorbed
quate coverage against S. aureus or anaerobes. Trimethoprim and should not be used to manage systemic infection. Ciprofloxacin
sulfamethoxazole (Bactrim) is not active against anaerobes and has would be inappropriate in a patient this young when otherconven
poor activity against S.pneumoniae a nd S. pyogenes. Metronidazole ien t options are available. First-gE!neration cephalosporins hiM�
provides excellent anaerobic coverage but has no activity against only fair activity against S. pneumoniae, the most likely bacterial
gram-positive aerobes such as S. oureus, S. pneumonioe, and S. cause of pne u monia in young ch ildren. lmipenem is effective in
pyogenes management of S. pneumoniae but is nor currently available in an
oral formulation. Furthermore, the broad-spectrum coverage prO"
2. A. ln a welktppearing child with croup and increased respiratory
vided by imipenem is not required i n an otherwise healthy, relative
effort, oral corticosteroids are appropriate to decrease laryngeal
edema. The duration of action of dexamethasone Is usuaRy more ly well-ap peatin g patient with uncomplicated community-acquired
pneumonia.
than 36 hOUfS.While a chest radiograph reveals the"steeple sign» I
In 50% of children with croup, routine radiographY is unneces· S. O. In a child with fever and pleuritic chest pain, the most likely
'"
sary since the diagnosis can easily be made by careful dinical ' :t diagnOSis Is pleural effusion complicating pneumonia. A chest
'"
evaluation. Racemic epinephrine is required only for severe or '"
"
radiograph would provide the diagnosis. A blood culture should
acutely worsening respi ratory distress. Children receiving racemiC v also be obtained because 1 0% to 25% of children with pleural
epinephrine require several hours of obser"ltion since symptoms , effusion have associated .bacteremia. Nasopharyngeal bacterial
21 0 • Blueprin1;s Pediatric Infectious Diseases Appendix B • 211
cultures correlate pOOrly with results of lung biopsy and, therefore, Kawasaki syndrome, it is not associated with scarlet fever.
are not used in the evaluation of children with pneumonia. Management of Kawasaki should occur prior to the 1 0th day of
Transthoracic;: needle biopsy should be considered in children with fever to reduc;:e the risk of coronary aneurysms. A nQrmal echocar
pneumonia who are immunodefident or dinically worsening with diogram does not exclude the diagnosis of Kawasaki syndrome
out apparent cause. This would not be part of the initial evaluati on. because not all patients with known Kawasaki develop coronary
Mycoplasma PCR is useful in diagnosing pneumonia due to A
aneurysms. Furthermore, the initiai echocardiogram is often norma.1
Mycoplasma pneumoniae. While the diagnosis of Mycoplasma infec sinc;:e aneurysms, when they OCCUl; do not usually develop until 1 0
tion would explain the poor response to amoxidllin, this is not the :;: to 2 1 days after symptom onset.
'"
'"
first study to consider in a child with fever and pleuritic chest pain. "!
0 9. D. Up to 1 5% of neonates (younger than 30 days) with fever in
A radionudide milk scan is useful in diag nosing aSpiration in a g. excess of 38.0oe have a serious bacterial infection. including
patient with a history suggestive of aspiration pneumonia or recur '"
" meningitis, pyelonephritis, and bacteremia. Approximately 6SOAl
"!
rent wheeZing. Gastroesophageal reflux would not explain the reta of neonates with a serious bacterial infection have a normal
Q)
tively acute development of fever and pleuritic chest pain in this J:
examination at presentation. This finding has given rise to the
v
child. A saying. "Never trust a baby." Therefore, all febrile neonates
6. C. Varicella is associated with InVasive infections due to Q)
deserve aggressive evaluation for bacterial infection.This evalua
..,
Streptococcus pyogenes (group A Streptococcus). Varicella vaccine '"
III
tion includes cultures of blood, urine, and eSF. Empiric antibiotics
use has decreased the incidence of severe varicella infections. by 14 (usually ampicillin plus gentamiCIn or ampicillir. plus cefotaxime}
0
95%. Epstein-Barr virus causes an exudative pharyngitis that can be .... are administered undl cultures are negative for at least 48 hours.
..., For a positive culture. treatment is modified as appropriate.
mistaken fot ·Strep throat." Tampon use is associated with 0
<:
Staphylococcus aureus toxic shock syndrome. Prolonged hospitaliza v
Febrile infants (ages 2 tc 24 months, or 3 to 36 months) at risk for
tion is associated with many different types of nosocomial infec occult bacteremia may be treated with dose follow-up alone if the
tions, usually due to coagulase-negative staphylococci or aerobic examination is normal. An altemative acceptable strategy in infants
gram-negative rods. Stepping on a nail through a rubber-soled (not neonates) is to :selectively administer empiric antibiotics to
,
sneaker is associated with Pseudomonas aeruginosa osteomyelitis of' those at highest risk of occuit bacteremia and its complications
the foot (such as those with peripheral WI,K counts in excess of
15,ooo/mm�). The above patient is too young for either of these
7. B. Eikenella corrodens is part of the oral flora of humans. This
strategies. All febrile neonates require aggressive evaluation, in
organism may complicate human bite wounds. A hand injury sus
Cluding lumbar puncture. to detect serious bacterial infection. Fever
tained while punching someone in the mouth is equivalent to a A
of unknown origin is used to describe a child with more than 2 weeks
human bite. The cutaneous form of anthrax can be contra cted wf1i1e :>.
0.
of fever and an undear SOurce after careful history, examination,and
working with infected livestock. Inhalational anthrax was known as
,: initial evaluation.This neonate does not meet the criteria for fever of
wool sorter'S disease because it often occurred among workers han J:
0
0. unknown origin.
dling infected hides and wool. Dog bite infections can be caused by .f>
child has early localized Lyme disease and electrocardiogram will 14. E. The HACEK organisms are oral gram-negative bacilli that cause
likel y be normal (and unnecessary). up to 10% of cases of native valve endocarditis. The acronym
1 1. 8.The HIV DNA peR is highly sensitive and specifi(.A positive test HACEK represents the following organisms: Haemophilus species
shQuld still be repeated to confirm the diagnosis. Infants born to (H. parainfluenzae. H. aphrophilus, and H. paraphrophilus).
HIV-positive mothers should receive zidovudine for the first 6 Actinobacillus actinomycetemcomitans, Cardiobacterium hom/nis,
weeks of life to decrease the risk of perinatal transmission.� I Eikenella corroclens. and Kingella species. These organisms have
A
cysti$ carini; prophylaxis with trimethoprim-sulfamethoxazole specific nutritional requirements and. as a result. grow slowly in
should be started at approximately 6 weeks of life and can be dis :;: routine culture medium.Therefore. when endocarditis is suspect
'"
'" ed. blood cultures should be retained for at least 2 weeks to allow
continued at4 months if the HIV DNA PCR result remains nega "I
0
tive. The HlV ELISA is an IgG-based test. Infants born to H1V-positive g. for growth of a HACEK organism.These organisms are best treat
mothers have detectable HIV antibodies from intrapartum trans '" ed with a third-generation cephalosporin. H. influenzae type b
"
missiOn.This ref lects the HIV status of the mother not the infant. The
"I
(HlS) was formerly a (ommon cause of childhood meningitis. With
Q)
passively acquired antibodies may per$ls t u ntil 15 to 18 months of J: the introduction of r out ine HIB, this organism rarely (auses invasi ve
age in uninfected infants. The CD4+ count is normal in most HlV�
v
infection in immun ized p opulat ions . A. hae molyticum causes
A
infect ed neonates.This test would not detect the majority of infect pharyngitis associated with a scarlatiniform rash on the extensor
Q)
ed neonates. The HIV Western blot test is used to confirm a positive .., surfaces of the arms and legs. Cytomegaloviru s is a ssoci ated with
'"
ELISA. Si nce this is also an lgG antibody�based test, this i nfan t will
III
(ongenital infections and infectiou5 mononucleosis; in addition, in
14
have detectable antibodies from passive maternal transfer during 0
.... immunocompromised patients, p neu monia. E. co/� a gram-negative
the third trimester. Antibodies detected in an infant this YO\lng ..., rod. causes many different types of infections including urinary tract
0
reflect the HIV status of the mother, not the infant. The tot al WBC <: infections, neonatal meni ng itis , and catheter--related bloodstream
v
count is usually normai in H IV-infected neonates. This wo uld not infections. It does not have fastidious g rowth requireme nts.
help disti ng uish infected from uninfected neonates. 15. A. The CSFfindings in bacterial meningitis vary depending on the
12 E. DiGeorge syndrome Is due to defective embryologic develop infecting 'Organism as well as the timing of the lumbar puncture
ment of the third and fourth pharyngeal pouches. Affected chil in relation to onset of symptoms. Bacterial meningitis is usually
dren have variable deletions of chromosome 22q1t. The thymus associated with dramatic neutrophilic (SF pleocytosis. The pro
is usually hypoplastic or absent. Associated cardiac defects In teln content is high due to leptomeningeal inflammation while
clude conotruncal defects, atrial and ventricular septal defects. the glucose content is low (less than two thirds the serum level).
and aortic arch abnormalities. Other associated defects include Tuberculous meningitis presents with a mild pleocytosis but a dra
A
palatal insufficiency. esophageal atresia, and bifid uvula. Wiskott" maticaUyelevated protein and low glucose. Chi ldren may have asso·
:>.
Aldrich syndrome is associated with the triad of immu nodeficiency,
0. ciated miliary disease. Viral meningitis (often enteroviruses in th e
eczema, and thrombocytopeni a. Transient hypogammagiobuline ,: summer) may have a neutrophil predominance early in th e l1Iness.
J:
thrive, hydrocephalus, mucocutaneous bullous lesions, bloody rhini- reactive arthritis. Clostridium difficile infections may cause a reactive
tis ("snuffles"), hepatosplenomegaly, osteochondritis, and jaundice. arthritis.
Infants with toxoplasmosis also have Intracranial calcifications. 21. B. Voriconazole, a triazole antifungal agent. is effective against
However, in these infants the calcifications tend to be generalizeD
many fungi. including Aspergillus species. The blackened eschar
rather than periventricular. Herpes simplex virus usually causes a in the nose is a clue to the diagnosis ofAspergillus in this immuno
perinatal rather than congenital infection. Vesicular skin lesions are � A compromised patient. Flu conazole has activity against several
characteristic. Despite p rompt initiation of acyclovir, m ortality � Candida species. However, it does not have activity against
remains high in those with systemic disseminati�on. Survivors of cen-·
Aspergillus species. Nystatin is useful for oral management of thrush
tral nervous system infection have significant neurologic sequelae.
and topical management of candidal dermatitis. It is not effective
17. B. Droplet precautions are required for infections spread by against Aspergillus species. Sinusitis due to Aspergillus is life threat
propulsion of larger droplets directly onto mucosal surfaces !e.g.. ening. Appropriate systemic therapy (not a troche) is warranted
conjunctivae, mouth) over a short distance. influenza is the only Furthermore, clotrimazole has no activity against Aspe rgillus.
one of the choices spread by this route. Other infections requiring Acyclovir is effective in the management of viral infections such as
droplet precautions in hospitalized patients indude pertussis, those due to herpes simplex and varicella viruses. It does not have
meningococcemia, rubella, and mycoplasma. The remainin!j Q)
ilntifungal activity.
.-i
choices all require contact precautions. '"
22. A. The Gomori silver stain is used to detect P. carinii. Other
III
20. E. Seizures may precede the bloody diarrhea in chifdren with tricular shunt infections in older children. Bacteria of the Strepto
Shigella Infection. making the diagnosiS. difficult at first. Campy/o' coccus millen group are associated with intracranial complications
nodosum, and GuiHain-Barre syndrome. Escherichia coli OlS7;H7 is 24. C. The wordMboil"is �e lay term for furuncle, a bacterial infection
associated with hemolytic uremic syndrome. Yersinia enterorolltic:a, of the hair follicle. Borc:let-Gengou is the culture medium for growing
is associated with erythema nodosum. glomerulonephritis, and� &>rdetella pertussis. The shell vial assay is performed by inoculating
216 • Blueprints Pediatric Infectious Diseases
�
� Erythromycin 30-50 mglkg/d as base or ethylsuccinate divided TID or OlD;
'" adults 250-500 BID-OlD as base or 400-800 mg BID-OlD as
x
" ethylsuccinate (max. 2 g/d)
"
0 Isoniazid Treatment: 10-20 mg/kg/d in 1-2 divided doses; adults 5
v
mg/kg/d once each day (max. 300 mg/d)
217
218 • Blueprints Pediatric Infectious Diseases
CHAPTER 6
219
220 • Blueprints Pediatric Infectious Diseases Appendix D • 221
American Academy of Pediatrics. Practice parameter: the diagnosis, Klein Jo. Management of the febrile child without a focus of
treatment, and evaluation of the initial urinary tract infection in infection in the era of universal pneumococcal immunization.
febrile infants and young children. Pediatrics 1999; 103:843-852. Pediatr Infect Dis J 2002;21:584-588.
Hoberman A, Wald ER, Hickey RW, et a1. Oral versus initial intra Mermel LA, Farr BM, Sherertz RJ, Raad II, O'Grady N, Harris JS.
venous therapy for urinary tract infections in young febrile chil Guidelines for the management of intravascular catheter-related
dren. Pediatrics 1999;104:79-86. 1\ infections. Clin Infect Dis 2001;32:1249-1272.
Lohr JA, O'Hara SM. Renal (intrarenal and perinephric) abscess.
In: Long SS, Pickering LK, Prober CG, eds. Principles and prac
tice of pediatric infectious diseases, 2nd edition. New York: CHAPTER 16
Churchill Livingstone: 2003:329-333.
Appelgren P, Bjomhagen V, Bragderyd K, Jonsson CE, Ransjo U
Seigel RM, Schubert CJ, Meyers PA, Shapiro RA. Prevalence of
sexually transmitted diseases in children and adolescents evalu A prospective study of infections in burn patients. Bums
ated for sexual abuse in Cincinnati: rationale for limited STD
2002;28:39-46.
Bell LM, Baker MD, Beatty D, Taylor L Infections in severely
testing in prepubertal girls. Pediatrics 19
, traumatized children. J Pediatr Surg. 1992;27:1394-1398.
Cummings P. Antibiotics to prevent infection in patients with
dog bite wounds: a meta-analysis of randomized trials. Ann
CHAPTER 13 Emerg Med 1994;23:535-540.
Hollander JE. Singer Al Laceration management Ann Emerg Med
Bhumbra N, McCullough S. Skin and subcutaneous infections.
1999;34:356-367.
Primary Care: Clin Office Pract 2003;30:1-24. Talan DA, Citron DM, Abrahamian FM, Moran GJ, Goldstein EI
Rhody C Bacterial infections of the skin. Primary Care: Clin Bacteriologic analysis of infected dog and cat bites. N Eng/ J
Office Pract 2000;27:459-473. Med 1999;340:85-92.
Stulberg DL, Penrod MA, Blatny RA. Caring for common skin
conditions: common bacterial skin infection. Am Fam Phys
2002;66:119-124. CHAPTER 17
Valeriano-Marcet J, Carter J, Vasey E Soft tissue disease. Rheum
Dis Clin North Am 2003;29: 77 -88. Arav-Boger R, Pass RE Diagnosis and management of cytomegalo
virus infection in the newborn. Pediatr Ann 2002;31:719-724.
Cooper LZ, Alford CA Jr. Rubella. In: Remington JS, Klein JO,
eds. Infectious diseases of the fetus and newborn infant, 5th ed.
"CHAPTER 14
Philadelphia: WB Saunders, 2001:347-388.
Fernandez M, Carrol CL, Baker CI Discitis and vertebral osteo Correa AG. Congenital syphilis: evaluation, diagnosis, and treat
myelitis in children: an 18- year review. Pediatrics 2000;105: ment. Semin Pediatr Infect Dis 1994;4:30-34.
1299-1304. Kimberlin DW, Lin C-Y, Jacobs RF, et a1. Natural history of
Glazer P, Hu SS. Pediatric spinal infections. Orthopedic Clin N neonatal herpes simplex virus infections in the acyclovir era.
CHAPTER 15
CHAPTER 18
Giroir BT Recominant human activated protein C for the treat
ment of severe sepsis: is there a role in pediatrics? Curr Opin Alpern ER, Alessandrini EA, Bell LM, Shaw KN, McGowan KL
Pediatr 2003;15:92-96. Occult bacteremia from a pediatric emergency department:
224 . Blueprints Pediatric Infectious Diseases Appendix D • 225
current prevalence, time to detection, and outcome. Pediatrics Neville K, Renbarger J, Dreyer Z. Pneumonia in the immuno
2000;106: 505-511. compromised pediatric cancer patient. Semin Respir Infect
Baker MD, Bell LM, Avner JR. Outpatient management without 2002;17:21-32
antibiotics of fever in selected infants. N Engl J Med Shenep JL, Flynn PM, Baker DK, et al. Oral cefixime is similar to
1993;329: 1437-144l. continued intravenous antibiotics in the empirical treatment of
Baker MD, Bell LM. Unpredictability of serious bacterial illness 1\ febrile neutropenic children with cancer. Clin Infect Dis
1 month of age. Arch Pediatr
in febrile infants from birth to 2001;32:36-43.
Adolesc Med 1999;153:508-511.
Gorelick MH, Shaw KN. Clinical decision rule to identifY young
febrile children at risk for UTI. Arch Pediatr Adolesc Med
2000;154:386-390. CHAPTER 21
Mason W H, Takashahi M. Kawasaki syndrome. Clin Infect Dis
American Academy of Pediatrics, Committee on Pediatric AIDS.
199928:169-187.
Evaluation and medical treatment of the HIV-exposed infant.
Ryan ET, Wilson ME, Kain KC Illness after international travel.
N Engl J Med 2002;347:505-516. OJ
Pediatrics 1997;99:909-917.
..,
'" Centers for Disease Control and Prevention. Public Health Service
Shah SS, Zaoutis TE. Fever following international travel: what's III
14 Task Force recommendations for the use of antiretroviral drugs
bugging this child? Pediatr Case Rev 2003;3:44-46. o
.... in pregnant women infected with HIV- l for maternal health and
...,
o
s::
for reducing perinatal HIV-l transmission in the United States.
CHAPTER 19 v MMWR Morb Mortal Wkly Rep 1998:47 (RR-02). (regular revi
sions available on line: http://aidsinfo.nih.gov/).
Jacobs RF, Schutze GE. Ehrlichiosis in children. J Pediatr Havens PL, and the Committee on Pediatric AIDS. Postexposure
1997;131:184-192. prophylaxis in children and adolescents for nonoccupational
Leach CT. Human herpesvirus 6 and 7 infections in children: exposure to Human Immunodeficiency Virus. Pediatrics 2003;
agents of roseola and other syndromes. Curr Opinion Pediatr 111:1475-1489.
2000;12:269-274. Working Group on Antiretroviral Therapy and Medical Manage
Mandl KD, Stack AM, Fleisher GR. Incidence of bacteremia in ment of HIV-Infected Children. Guidelines for the use of anti
infants and children with fever and petechiae. J Pediatr 1997; retroviral agents in pediatric HIV infection. Updated and avail
131:398-404. able on line: http://aidsinfo.nih.gov/ (revised June 25, 2003) .
Maslers EJ, Olson GS, Weiner SJ, Paddock CD. Rocky Mountain
spotted fever: a clinician's dilemma. Arch Intern Med
2003;163:769-774.
Nelson B, Jill S, Stone MS. Update on selected viral exanthems. CHAPTER 23
Curr Opin Pediatr 2000; 12:359-364.
Burnett MW, Bass Jw, Cook BA. Etiology of osteomyelitis com
Rosenstein NE, Perkins BA, Stephens DS, Popovic T, Huges JM.
plicating sickle cell disease. Pediatrics 1998;101:296-297.
Engl J Med 2001;344:1378-1388..
Meningococcal disease. N
Davis PB, Drumm M, Konstan MW. Cystic fibrosis. State of the
Steele A C Medical progress: Lyme disease. N Engl J Med
art. Am J Respir Crit Care Med 1996;154;1229-1256.
2001;345:115-125.
Fishman JA, Rubin RH. Infection in organ-transplant recipients.
Wells LC, Smith JC, Weston V, Collier J, Rutter N. The child with
N Engl1 Med 1998;338:1741-1751.
a non-blanching rash: how likely is meningococcal disease?
Green M, Michaels MG. Infections in solid organ transplant
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Ho M, Miller G, Atchison W, et al. Epstein-Barr virus infections
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cancer. Clin Infect Dis 2002;34:730-51. infection. J Infect Dis 1985;152:876-886.
226 • Blueprints Pediatric Infectious Diseases
Cyclospora cayetanensis, intestinal Dicloxacillin, 2 1 7 Electron microscopy, of viruses, in organ transplant recipient,
infection with, 82t DiGeorge syndrome, 1 75 14t, 1 6 1 82
Cytomegalovirus immune DNA sequencing, for Endophthalmitis, 33-35 Exanthems, major childhood,
globulin (CMV IG), 196/ mycobacteria, 3 fever and rash due to,
Enteritis, bacterial, fever due to,
Donor-associated infections, 1 5 1-153, 1 52t
142t
18 1-182 Exophiala werneckii, 6
DDS (dose dependent Enterococcus
susceptible) azoles, 23 Dose dependent susceptible antibiotics for, 21 t-22t Exudate, pleural effusion as, 67,
(DDS) azoles, 23 central venous catheter-related 68t
Deer fly fever, 1 89-190 A
Doxycycline, 2 1 7 ;;., infection due to, 1 1 6t
Dehydration, due to 0.
Droplet precautions, 198t, 1991 Enterovirus Famciclovir, spectrum of activity
gastroenteritis, 80 .:
x antiviral agents for, 28t of, 28t
Dengue fever, 142/ Drotrecogin alfa (Xigris), for 0
0.
sepsis, 1 1 3 .flo fever and rash due to, 153 Familial Mediterranean fever
Dermatophytes, 6 "
DTP (diphtheria-tetanus ., Enzyme-linked immunosorbent (FMF), 1 401, 1 4 1
Dexamethasone R: assay (ELISA), fo r HIV
pertussis) vaccine, adverse Fasciitis, necrotizing, 1 02-104
for bronchiolitis, 63
events with, 1 94-195 6 infection. 1 63-164
5-FC (5-fluorocytosine)
for croup, 53 2 Eosin-methylene blue (EMB) mechanism of action and
DHR (dihydroxyrhodamine 1 23) ., agar, I
EBV See Epstein-Barr virus (EBV) :;: resistance to, 24
test, for neutrophil disorders, u
0.
OJ Epidermophyton, 6 spectrum of activity for, 25t
1 76 Echinocandins, 24 III
x
0 Epidural abscess, 43-44 Fever, 135-145
Diagnostic microbiology, I-I I Echinococcosis. with hepatitis, 86 '"
I
!4 Epinephrine with cancer, 1 54-1 56
for bacteria, 1-5, 2/, 3t Echocardiography ID
'" nebulized, for croup, 53 deer fly, 1 89-190
for fungi, 5-8 of endocarditis, 74 0;
OJ
"< racemic, for bronchiolitis, 63 familial Mediterranean, 140t,
for parasites, 8-1 1 , 9t of myocarditis, 78
" Epstein-Barr virus (EBV)
141
Diagnostic virology, 12-17, 12t-15t Ehrlichiosis, 147, 148 " i n infant, 136-137
'" antiviral agents for, 28t
Diarrhea '"
Electrocardiogram (ECG) u in Kawasaki syndrome,
fever and rash due to, 1 52t,
with cancer, 1 60t of myocarditis, 78 v 143-145
1 53
due to gastroenteritis, 79 of pericarditis, 76
234 •
Index Index · 235
resistance to, 24
� Herpes zoster, with
meningitis due to, 4 1 1 HBIG (hepatitis B immune
spectrum of activity for, 251 '" conjunctivitis, 33
Genitourinary tract infections, :s:
0
globulin), 196/
F1ukes, 1 O 0- HHV-6 (human herpes virus 6)
90-97 OJ
.. HBIG (human botulinum
x antiviral agents for, 281
Fluorescent stain, 1 pelvic inflammatory disease 0 immune globulin), 1 96/
'" roseola infantum due to, 1 52,
FMF (familial Mediterranean and cervicitis, 94-96 I
Hb SS, 1 78
renal abscess, 93-94 �'" 1 52t
fever), 140/, 1 4 1 HBV. See Hepatitis B virus
in sexually abused child, � HHV-7 (human herpes virus 7),
Folliculitis, 1 0 1 - 1 02 <'t (HBY)
96-97 :s: roseola infantum due to, 1 52t
Food-borne illness, gastroenteritis HDCV (human diploid cell
urinary tract infection, 90-92, x
'" Histology, of viruses, l S I, 1 6
due to, 80
9 1 b, 921
'" vaccine), for rabies, 122
0 Histoplasma capsulatum, 6
Foscarnet, spectrum of activity y Helium-oxygen therapy, for
GenotypiC assays, for viruses, 1 51 antifungal agents for, 261
of, 28, croup, 53
antigen test for, 8
236 . Index Index • 237
HIV infection. See Human IG. See Immune globulin (IG) Immunoassay, for viruses, 14t IVIG. See Intravenous immune
immunodeficiency virus IgA deficiency, 1 74 Immunocompromised hosts, globulin (IVIG)
(HIV) infection infections in, 1 78-185
Immune deficiencies, inherited
Hookworm, intestinal infection (primary), l 70-1 7 7 with cystic fibrosis, 183-185 Joint aspiration, for septic
with, 82t cellular (T cell), l 7 1 t, 173, with sickle cell disease, arthritis, 106, 1 07
HSV. See Herpes simplex virus l 74-175 1 78-180, 1 79t
1\
Joint infections, 105-107, 1 06t
(HSV) combined (T cell and B cell), solid organ transplant
l l I t, 1 74-1 75
:s:
0;
recipients, 180-183, 1 8 1 b
Human botulinum antitoxin, '" Kawasaki syndrome, 143-145
1 96t common variable, 1 74 "I
0 Immunodeficiency. See Immune
14
roseola infantum due to, 1 52t history of, 1 70-1 72, 1 72t 0 Impetigo, 98-99 Klebsiella pneumoniae, antibiotics
....
Human immunodeficiency virus humoral (antibody, B cell), ..., Infection control, 198-199, 198t, for, 2 1 t-22t
0
I (HIV-l), resistance to I l I t, 1 72, 173-174 s:: 199t KOH (potassium hydroxide)
phagocyte disorders, 1 7 1 t, v
antiviral agents by, 27 Influenza stain, 7
Human immunodeficiency virus 1 75-177, 1 76t antiviral agents for, 28t Koplik spots, 1 52t
(HIV) infection, 162- 1 69 physical examination for, 1 72 resistance to, 27-29 Kostmann syndrome, 1 76t
additional studies for, 1 64-165 risk factors for, I 70 fever due to, 142t
complications of, 166-168 Immune globulin (IG), 195 postexposure prophylaxis for,
adverse events with, 1 95-197 197t Lacerations, infections due to,
diagnostic evaluation for,
botulinum, 196t 1 1 9 , 120
1 63-164 Intestinal parasites, 8 1-84, 82t
differential diagnosis of, 1 65 cytomegalovirus, 1 96t B-Lactamase, 1 9
Intracranial infection, 43-44
epidemiology of, 162 hepatitis B, 196t 1\ Lamivudine, spectrum o f activity
Intrarenal abscess, 93-94
etiology of, 162 indications for, 1 96t :>.
0. of, 28t
fever due to, 142t intravenous, 195 Intravenous immune globulin
,: Laryngotracheitis, 52-53
history of, 1 63 adverse events with, J: (IVIC}, 1 9 5
0
0. adverse events with, 1 95-197 Laryngotracheobronchitis, 52-53
management of, 1 65-166, 166b 195-197 -9<
for bronchiolitis, 63-ti4 0< for bronchiolitis, 63-ti4 Latex agglutination tests, 3
pathogenesis of, 162-163 '"
physical examination for, 1 63 indications for, 1 96t "1: indications for, 196t Leptospirosis, fever due to, 142t
postexposure prophylaxis for, for Kawasaki syndrome, � for Kawasaki syndrome, Leukocyte adhesion deficiency,
1 68- 1 69 , 1 69t 144-145 2 144-l45 1 76t
risk factors for, 1 62, 1 69t respiratory syncytial virus, '" respiratory syncytial virus,
:s:
Levamisole, for Ascaris
transmission of, 1 62, 169t 63-ti4, 196t u 63-ti4, 196t
0. lumbncoides, 82t
OJ
Humoral deficiency, l 7 1 t, 1 72, rabies, 1 22 III Isolation, 198t, 199
J: Levofloxacin, 2 1 8
tetanus, 196t 0
Isoniazid, 2 1 7
1 73-174 '"
for lacerations, 120 I Linezolid, spectrum o f activity of,
Q
Hutchinson teeth, in congenital '" Isospora belli, intestinal infection 22t
vaccinia, 1 9 1 '"
syphilis, 1 28 0;
OJ
with, 82t
varicella-zoster, 196t "1: LIP (lymphocytic interstitial
Hyper-IgD syndrome, 1 40t, 1 4 1 ;s; Itraconazole, spectrum of activity pneumonitis), 1 67
Immunization
Hyphae, 5 J: for, 25t, 26t
active, 1 94-195. See also '" Listeria monocytogenes, meningitis
'"
pseudo-, 7 u Ivermectin, for Strongyloides due to, 4 1 t
Vaccine(s)
v stercoralis, 82t
Hypogammaglobulinemia, passive, 1 95-197, 196t Lowenstein-Jensen media, 3
transient, of infancy, 1 73
238 . Index Index · 239
Lower respiratory tract me! genes, mutation in, 20 spectrum of antifungal activity Nebulized epinephrine, for
infections, 62-7 1 Meningitis, 38-4 1 , 39t-4 1 t against, 26t croup, 53
acute pneumonia, 64--67, 65t, cryptococcal, 40t Molecular amplification, of Necator americanus, intestinal
66t enteroviral, 38, 40t viruses, 1 4t, 1 6 infection with, 821
bronchiolitis, 62-64 parameningeal, 38, 401 "Monospot" test, for pharyngitis, Necrotizing fasciitis, 1 02- 104
pleural effusion, 67--69, 68b, 681 tuberculous, 39, 401 J\ 49 Needle aspiration, for septic
pulmonary lymphadenopathy,
Meningococcus infection, Moraxella, antibiotics for, 21 1-22t arthritis, 1 06, 107
69-7 1 , 70b
postexposure prophylaxis for,
"
�tt Morbilliform lesions, 1 5 1 Neisseria gonorrhoeae
Lyme arthritis, lOS, 1 06, 1 07 197t 0
0. MRSA (methicillin-resistant arthritis due to, lOS, 1 06, 107
Lyme disease, fever and rash due Metabolite tests c
'" Staphylococcus aureus) ophthalmia neonatorum due
to, 1 49-1 5 1 for fungi, 8
� antibiotics for, 2 1 /-221 to, 30, 3 1 , 3 1 /, 321
Lymphadenitis, cervical, 59--61 for parasites, II Q) pharyngitis due to, 49
:c osteomyelitis due to, 1 091
Lymphadenopathy, pulmonary, Methicillin-resistant v Neisseria meningitidis
MSSA (methicillin-sensitive
69-7 I , 70b Staphylococcus aureus (MRSA) J\
fever and petechiae due to,
Staphylococcus aureus),
Lymph node biopsy, for antibiotics for, 2 1 t-22t Qj 146
.... osteomyelitis due to, 1091
pulmonary lymphadenopathy, osteomyelitis due to, 1 091 '" meningitis due to, 4 1 1
III
Mucocutaneous lymph node
71 Methicillin-sensitive ... Nematodes, 9
0
.... syndrome, 143-145
Lymphocyte count, absolute, in Staphylococcus aureus (MSSA),
'-' Mucor, 6 Nephrectomy, for urinary tract
severe combined osteomyelitis due to, 1 09t 0
c: infection, 94
Mucorales, antifungal agents for,
immunodeficiency, 1 7 5 Metronidazole, 2 1 8 v
26t Neutropenia
Lymphocytic interstitial for Blastocystis hominis, 82 t
with cancer, 1 54-156
for Giardia lamblia, 82t Mulberry molars, in congenital
pneumonitis (LIP), 1 67 cyclic, 1 761
spectrum of activity of, 22t syphilis, 1 28
Lymphoma, HIV-related, 1 68 Neutrophil chemotaxis assay,
MIC (minimal inhibitory Multiwell plate, for viruses, 141
177
concentration), 4 Mycobacteria
MacConkey agar, I Neutrophil count, absolute, 1 54,
Microbiology, diagnostic, I-I I central venous catheter-related
Macrolide(s) 1 56
for bacteria, 1-5, 2t, 31 infection due to, 1 1 6t
resistance to, 20 for fungi, 5-8 J\ cervical lymphadenitis due to, Neutrophil disorders, 1 75-177,
spectrum of activity of, 2 1 t >, 60, 6 1 1 76t
for parasites, 8- 1 1 , 91 0.
Macrophage disorders, 1 7 7 identification methods for, 3 Neutrophil expression of
Microscopy .:
Malaria, fever due to, 142/ of bacteria, I, 21
:c
0 Mycobacterium avium, CD l lb/l8, 1 7 7
0.
Malassezia furfur, 6, 7 of fungi, 7 -eo disseminated, with HIV Niclosamide, for Taenia saginata,
E<
antifungal agents for, 261 of parasites, 1O-1 l (') infection, 1 68 82t
�
Mastoiditis, 56-57 Microsporidia, 9t Mycobacterium tuberculosis Nitazoxanide, 2 1 8
cervical lymphadenitis due to, for Crypwsporidium parvum,
MBC (minimal bactericidal Microsporum spp, 6
60, 6 1 821
concentration), 4 Minimal bactericidal '" pneumonia due to, 66
concentration (MBC), 4 " Nitroblue tetrazolium (NBD
Measles, 152, 1 521 0
0.
Q) Mycoplasma pneumoniae, test, for neutrophil disorders,
Measles-mumps-rubella (MMR) Minimal inhibitory concentration III
:c pneumonia due to, 65, 66 1 76
vaccine, adverse events with, (MIC), 4 0
"
I Mycoses. See Fungi Nontuberculous mycobacteria
1 95 MMR (measles-mumps-rubella) Q
co (NTM), cervical
'" Myeloperoxidase deficiency, 1 76t
Mebendazole, 2 1 8 vaccine, adverse events with,
� Myocarditis, 77-78
lymphadenitis due to, 60, 6 1
for Ankylostoma duodenale, 821 1 95 "t
" Nucleic acid hybridization assays,
for Ascaris lumbT'icoides, 82t Modified acid-fast bacillus stain, 7 Myringotomy, for mastoiditis, 5 7
:t
'" for viruses, 14t-15t
for Necator americanus, 82t "
Molds 0
for Trichinella spiralis, 82t Nucleic acid probes, for
defined, S v NBT (nitroblue tetrazolium) test,
mycobacteria, 3
Medications, oral, 2 1 7-2 1 8 identification methods for, 7 for neutrophil disorders, 1 76
240 • Index Index • 241
Nucleic acid synthesis, inhibitors Paracoccidioides brasiliensis, 6 Perinatal infections. See Pneumocystis carinii, 1 67
of. 19 CongenitalJperinatal infections with sickle cell disease, 1 791
Parainfluenza, antiviral agents for;
281 Perinephric abscess, 93-94 Pneumonic plague, 188
Occult bacteremia (OB), Parameningeal meningitis, 38, 40t Periodic fever, aphthous Pneumonic tularemia, 189
136-137 stomatitis, pharyngitis, and Pneumonitis, lymphocytic
Paramyxoviridae, 131
1\ cervical adenitis (PFAPA), interstitial, 167
O&P (ova and parasites) Parasites, 8-1 1
140, 1401, 1 4 1
examination, 10 classification of, 8-10, 9t :s: Polyenes, 23
Ophthalmia neonatorum, 30-32, intestinal, 8 1 -84, 821 �
C!
Periodic fever syndromes,
Polymerase chain reaction
laboratory methods to
') 139- 1 4 1 , 1401
3 l t, 321 0- (PCR), for HIV infection,
c
identify, 1 0-1 1 Periorbital cellulitis, 35-37 164, 1 65
Ophthalmologic infections, '"
30-37 Parasitic endophthalmitis, 34, 35 � Peritonitis, 87-88 Postexposure prophylaxis (PEP),
Q)
conjunctivitis in older child, :c with cancer, 1 60/ 1 97-198, 1 971
Paromomycin, 2 1 8
v
32-33 Peritonsillar abscess, 49-5 1 for f-ilV, 168-169, 1 691
Parvoviridae, 1 2/ 1\
endophthalmitis, 33-35 Pertussis Postinfectious encephalitis. 42
Parvovirus B 1 9, 1 52, 1 52t Qi
ophthalmia neonatorum, .... adverse events with vaccine
Passive immunization, 195-197, '" Potassium hydroxide (KOH)
30-32, 3 1 t, 321 " for, 1 94-195
... stain, 7
orbital and periorbital 196t 0
.... postexposure prophylaxiS for,
Poxviridae, 1 2/
cellulitis, 35-37 PCR (polymerase chain reaction),
.., 1 9 71
for HIV infection, 164, 165 0 PPO (purified protein derivative)
Opportunistic fungi, 6-7 c
Petechiae, fever and, 146-147, 1 47t
v test, for pulmonary
Oral medications, 2 1 7-2 1 8 P E (progressive encephalopathy),
PFAPA (periodic fever, aphthous lymphadenopathy, 7 1
with HIV infection, 167
Orbital cellulitis, 35-37 stomatitis, pharyngitis, and
Praziquantel, for Taenia saginaw,
Pediatric infectious diseases, cervical adenitis), 1 40, 1 401,
Organ transplant recipients, 821
career opportunities in, 201 141
infections in, 1 80-183, 1 8 1 b
Precautions, 1 98t, 1 99t
Pediatric residency training, 200 Phagocyte disorders, 1 7 1 /,
Orthomyxoviridae, 1 3t
Prednisone, for bronchiolitis, 63
Pediatric subspecialty training, 200 175-177, 1 761
Oseltamivir, spectrum of activity
Preseptal cellulitis, 35-37
of, 28t Pelvic inflammatory disease Pharyngitis, 48-49
(PIO), 94-96 Prevention, of infection,
OsteochondritiS, Pseudomonas, 1\ PhenotypiC assays, for viruses, 1 51
194-199
109, 1091 Pelvic osteomyelitis, 1 08 >, Picornaviridae, 1 31
0- by active immunization,
Osteomyelitis, 8b, 9t, 107-1 1 0 Penciclovir, spectrum of activity PIO (pelvic inflammatory
.: 194-195
of, 281 :c
with sickle cell disease, 1 791 0 disease), 94-96 by chemoprophylaxis,
0.
Penicillin, spectrum of activity of, ""
Otitis media (OM), 53-55 Piperacillin (PIPTAZ05), 197-1 98, 1971
..
2lt " spectrum of activity of, 221 by infection control, 198-199,
Ova and parasites (O&P)
I
examination, 1 0 Penicillin-binding proteins Pityriasis rosea, 1 521 1 98/, 1991
(PBPs), 1 9 by passive immunization,
Oxacillin, spectrum of activity of, Plague, 1 87-189
Penicillin resistance, 1 9-20 195-197, 1961
211 '" Pleconaril, spectrum of activity
Penicillin V potassium, 2 1 8 :s: Prevnar (pneumococcal vaccme),
Oxazolidinone, spectrum of 0
0-
of. 281
Q) 64
activity of, 221 Penicillium marneffei, 6 III Pleura) effusion, 67-69, 68b, 681
:c
0 Progressive encephalopathy (PE),
PEP (postexposure prophylaxis), " Pleural fluid assessment, 68, 681
I with HIV infection, ) 67
Palivizumab, for bronchiolitis, 64 197-198, 1 971 Q
co
'" Pneumococcal vaccine (prevnar),
for HIV, 168-169, 1691 Prophylaxis
Papovaviridae, 121 �
"t
64
chemo-, 1 97-198, 1971
Percutaneous aspiration, for
Papular acrodermatitis, 1 521 '" Pneumocystis carinii pneumonia, postexposure, 197-198,
urinary tract infection, 94 :c
Papular purpuric gloves and socks '" 1 67 1 971
Perianal cellulitis, with cancer, 1 60t "
syndrome, 1 521 0 Pneumonia for HIV; 1 68-1 69, 1 691
Pericardiocentesis, 76 v
ParacenteSiS, for peritonitiS, 87 acute, 64-67, 65/, 661 for sickle cell disease, 1 80
Pericarditis, 74-77, 75b with cancer, 1 5 8 for trauma, 120, 1 20/
242 • Index Index · 243
Protease inhibitors, for HIV Recombinant activated protein C Retropharyngeal mass, VS. gastroenteritis due to, 8 1 t
infection, 1 66b (rhAPC), for sepsis, 1 1 3 retropharyngeal abscess, 5 1 osteomyelitis due to, l 09t
Protein C, for sepsis, 1 1 3 Rectal swab, for sexual abuse, 97 Retroviridae, 1 3t Saprophytic protozoa, 9
Protein synthesis, inhibitors Renal abscess, 93-94 Reverse transcriptase inhibitors SBE (subacute bacterial
of, 1 9 Renal cortical scintigraphy, 92t (RTI), for HIV infection, 1 66b endocarditis), blood cultures
Protozoa, 8-9, 9t for urinary tract infection, 92 " Rhabdoviridae, 1 3t for, S
Pseudohyphae, 7 Reoviridae, 13t :;: Rhagades, in congenital syphilis, 128 SBI (serious bacterial infections),
Pseudomonas aerugirwsa, Reporting, of communicable �C! rhAPC (recombinant activated fever due to, 135-136
0
ophthalmia neonatorum due diseases, 199 0- protein q, for sepsis, 1 13 SBP (spontaneous bacterial
c
to, 30, 32 Residency training, in pediatrics, '" Rhizopus, 6 peritonitis), 87-88
Pseudomonas osteochondritis, 200 � Scarlatiniform lesions, lSI
Q)
Ribavirin
1 09, 109t Resistance x
aerosolized, for bronchiolitis, 63 Scarlet fever, 1 52t
v
Pulmonary infections. See antibiotic, I9-20 " spectrum of activity of, 28t Schistosomiasis
Respiratory tract infections to antifungal agents, 23-24 Rickettsia, fever due to, 1 42t fever due to, 142t
m
to antiviral agents, 27-29 ... hepatitis due to, 84
Pulmonary lymphadenopathy, .. with rash, 1 47-149
I/)
69-71 , 70b Respiratory syncytial virus (RSV) .. Rickettsia akari, 147 Schlicter test, 4
0
Purified protein derivative (PPD) antiviral agents for, 28t .... Schwachman-Diamond
Rickettsial pox, 147
bronchiolitis due to, 62-64 "
test, for pulmonary 0
c Rickettsia prowazekii, 147 syndrome, 1 76t
lymphadenopathy, 7 1 Respiratory syncytial virus v SCID (severe combined
Rickettsia typhi, 1 47
Pyelonephritis, 90-92, 91b, 92t intravenous immunoglobulin immunodeficiency), 1 74-1 75
(RSV IVIG, RespiGam), for Rifampin, 2 1 8
Pyrimethamine, for Isospora belli, Scrub typhus, 147
bronchiolitis, 63-64, 1 96t RIG (rabies immune globulin), 122
82t Sepsis, 1 1 1-1 1 3, 1 1 2b
Respiratory syncytial virus (RSV) Rimantadine, spectrum of
monoclonal antibody, 1 96t activity of, 28t Septic arthritis, 1 05-107, l 06t
Q fever, 1 42t, 147 Septicemic plague, 1 88
Respiratory tract infections "Ringworm," 6
Quinolones, spectrum of activity Septic shock, I I I
with cancer, 1 5 7-1 59 RNA quantitative assay, for HIV
of, 22t
lower, 62-71 " infection, 164 Serious bacterial infections (SBI),
Quinsy, 49-5 1 acute pneumonia, 64-67, :>. fever due to, 135-136
0- Rocky Mountain spotted fever
65t, 66t (RMSF), 1 47-148 Serologic tests, for hepatitis, 86t
,:
Rabbit fever, 189-190 bronchiolitis, 62-64 x
0 Roseola infantum, 152t Serology, of viruses, 1 St
pleural effusion, 67-69, 0-
...
Rabies, 1 2 l , 1 22 Roundworms, 9 Serum cidal test, 4
68b, 68t E<
Rabies immune globulin (RIG). .,
pulmonary intestinal infection with, 82t Severe combined
I't
1 22
Racemic epinephrine, for
lymphadenopathy, � RSV. See Respiratory syncytial immunodeficiency (SCID),
1 74-1 75
69-71 , 70b � virus (RSV)
bronchiolitis, 63 upper, 48-61 RTI (reverse transcriptase Sexually abused child, infectious
'"
Rash cervical lymphadenitis, :;: diseases in, 96-97
u
0-
inhibitors), for HIV infection,
with cancer, 1 5 6 59-61 Q)
III 1 66b Sexually transmitted diseases
croup, 52-53 x
fever and, 1 46-1 53 0
Rubella, 1 52, 1 52t (STDs), 96-97
'"
due to Lyme disease, mastoiditis, 56-57 I
Q
'" congenital, 1 29-130 Shah, Suresh and Meena, 5/1 9
149-1 5 1 otitis media, 53-55 ..
'" Shell vial, for viruses, 1 4t
due to major childhood peritonsillar and Q)
I't
exanthems, 1 5 1-153, retropharyngeal abscess, " Saber shins, in congenital syphilis, Shigella spp, gastroenteritis due
1 52t 49-52 '" 1 28 to, 8 l t
..
pharyngitis, 48-49 '" Sai, 5/2
due to rickettsial infections, u Shock
147-149 sinUSitis, 57-59 v
Salmonella spp septic, I I I
Retropharyngeal abscess, 49-52 antibiotics for, 21 t-22t toxic, 1 16-1 1 8
244 • Index Index · 245
Sickle cell disease, infections central venous catheter-related Subdural empyema, 43-44 Tetracyclines, 2 1 8
with, 1 78-1 80, 1 79t infection due to, 1 1 6t Subspecialty training, in spectrum of activity of, 22t
Sickle trait, 1 78 impetigo due to, 98 pediatrics, 200 Thiabendazole, for Strongyloides
osteomyelitis due to, l 09t stercoralis, 82t
Silver nitrate chemical Superficial fungi, 5-6
pneumonia due to, 65
conjunctivitis, 30, 3 l t, 32t Suprapubic aspirate, 92t Ticarcillinipotassium clavulanate
toxic shock syndrome due to'
Sinus aspiration, for sinusitis, 59 " (TICAR-CLAV), spectrum of
117 Surveillance, 199
activity of, 22t
Sinusitis, 57-59 Susceptibility testing
STDs (sexually transmitted
TIG (tetanus immune globulin),
SIRS (systemic inflammatory diseases), 96-97 antifungal, 8
1 96t
response syndrome), I I I antimicrobial, 4
SterOids for lacerations, 120
Skin and soft tissue infections' for bronchiolitis' 63 Swabs, for virus specimen
Tinea nigra, 6
98-104 for croup, 53 collection, 1 7
with cancer, 1 56-1 57, 1 57t Tinea versicolor, 6
Stool sample Syphilis, congenital, 1 27-129
cellulitis, 100-10I TMP-SMX. See Trirnethoprirn
for gastroenteritis, 80 Systemic inflammatory response
folliculitis, furuncles, and sulfamethoxazole (TMP
for intestinal parasites, 83 syndrome (SIRS), I I I
carbuncles, 101-102 SMX, Bactrirn)
Streptococcus Systemic mycoses, 6
impetigo, 98-99 Togaviridae, 13t
group A
necrotizing fasciitis, 1 02-104
antibiotics for, 21 t-22t "Tolerance," 4
Smallpox, 1 90-1 91 "Tache noir," in rickettsial
necrotizing fasciitis due to, TORCHES, 1 25
infections, 1 48
Soft tissue infections. See Skin 103 Torticollis, vs. peritonsillar or
and soft tissue infections Tachypnea, due to pneumonia,
pharyngitis due to, 48, 49 retropharyngeal abscess, 5 1
Solid organ transplant recipients, scarlet fever due to, 1 52t
64
Toxic shock syndrome (TSS),
infections in, 1 80-1 83, 1 8 1 b group B Taenia saginata, intestinal
I I 6-I I 8
antibiotics for, 21 t-22t infection with, 82t
SPACE, antibiotics for, 2 l t-22t
Toxoplasma gondii, 1 26
meningitis due to, 41 t Tapeworms, 9
Specific granule deficiency, 1 76t in organ transplant recipient,
osteomyelitis due to, l 09t TB (tuberculosis)
Specimen collecting and 1 82
Streptococcus pneumoniae (SPN) fever due to, 142t
handling, for viruses, 1 6-1 7 Toxoplasmosis, congenital,
antibiotics for, 2 1 t-22t postexposure prophylaxis for,
SPN. See Streptococcus 1 26-1 27
macrolide resistance by, 20 197t
pneumoniae (SPN) Transesophageal
penicillin resistance by, T cell and B cell deficiency, 1 7 l t,
Spontaneous bacterial peritonitis 1 9-20 echocardiography, for
1 74-1 75
(SBP), 87-88 pneumonia due to, 64 endocarditis, 74
T cell deficiency, 1 7 1 t, 1 73,
Sporothrix schenkii, 6 with sickle cell disease, 1 78 Transient
1 74-1 75
antifungal agents for, 26t Streptococcus pyogenes hypogarnmaglobulinemia of
T cell subsets, in HIV infection'
Sporotrichosis, 6 impetigo due to, 98 infancy, 1 73
164
Sporozoa, 9t toxic shock syndrome due to, Transplant recipients, infections
Technetium bone scan, of
117 in, 1 80-1 83, 1 8 1 b
Spotted fever, 147 osteomyelitis, 1 09
Streptogramin, spectrum of Transudate, pleural effusion as'
Stains Teeth, Hutchinson, in congenital
activity of, 22t 67, 68t
for bacteria, I, 2t syphilis, 1 28
for fungi, 7 Stridor, vs. peritonsillar or Transurethral catheterization, 92t
Tetanus, adverse events with
retropharyngeal abscess, TRAPS (tumor necrosis factor
Standard precautions, 198t, 1 99t vaccine for, 194-195
51 receptor-associated periodic
Staphylococci, coagulase Tetanus immune globulin (TIG),
Strongyloides stercoralis, intestinal syndrome), 1 4Ot, 141
negative, central venous 1 96t
infection with, 82t Trauma-related infections'
catheter-related infection due fur lacerations, 1 20
to, I I 6t Subacute bacterial endocarditis I I 9-1 20, I I 9t, 1 20t
Tetanus immunization, for
(SBE), blood cultures for, 5 Traveler, fever in returning,
Staphylococcus aureus lacerations, 1 20
antibiotics for, 2 1 t-22t Subcutaneous fungi, 6 1 4 1-143, 142t
246 • Index Index · 247
Trematodes, 1 0 Unilateral laterothoracic Ventricular shunt infections, VZV (varicella zoster virus)
Treponema pallidum, 1 2 7, 1 28 exanthem of childhood, 1 52t 46-47 antiviral agents for, 28t
Upper respiratory tract infections Vertebral osteomyelitis, with cancer, 1 5 7
intestinal
Trichinella spiralis,
infection with, 82t (URls), 48-61 1 09
cervical lymphadenitis, 59-61 Vesicoureteral reflux (VUR), and Water-borne illness,
Trichophyton spp, 6
croup, 52-53 A pyelonephritis, 90 gastroenteritis due to, 80
Trifluorothymidine, for mastoiditis, 56-57
ophthalmia neonatorum, 32t Vibrio cholerae, gastroenteritis Western blot, for HlV infection,
otitis media, 53-55 due to, 8 1 t 1 64
Trimethoprim-sulfamethoxazole peritonSillar and
(TMP-SMX, Bactrim), 2 1 8 Vidarabine, for ophthalmia Wiskott-Aldrich syndrome, 1 75
retropharyngeal abscess,
for Isospora belli, 82t neonatorum, 32t Worms, 9-10
49-52
for Pneumocystis carinii pharyngitis, 4�9 Viral conjunctivitis, 32-33 Wound infections
pneumonia, 167 Q)
sinusitis, 57-59 x Viral encephalitis, 42 due to bites, 1 2 1 -1 22
spectrum of activity of. 22t Urinary tract infection (UTI),
V
Viral hemorrhagic fever (VHF), due to bums, 1 22-1 24
A
Trophozoite, 8 90-92, 91b, 92t 142t, 191-192 due to trauma, 1 1 9-120, 1 1 9t,
Q) 1 20t
Trypanosomiasis, fever due to, Urine culture, 91 , 92t .-<
.. Viral load (VL), for HlV
142t I/)
infection, 1 65
..
TSS (toxic shock syndrome), .B Virology, diagnostic, 1 2-1 7, Xigris (drotrecogin alfa), for
Vaccine(s), 194-195
I l 6-1 1 8 '"' 1 2t-1 5 t sepsis, 1 13
botulinum, 1 93 o
C
Tsutsugamushi, 147 pneumococcal, 64 v Virus(es) X-linked agammaglobulinemia,
Tuberculin skin testing (PPD), for with sickle cell disease, 1 80 choosing tests for detection of. 1 73-1 74
pulmonary lymphadenopathy, smallpox, 191 1 5-1 6
71 Vaccine Adverse Event Reporting classification and properties of. Yale School of Medicine, 1 998
Tuberculosis (TE) System (VAERS), 1 94-195 1 2, 1 2t, 1 3t
Yeasts
fever due to, 142t DNA, 1 2t
Vaccinia immune globulin, 191 defined, S
postexposure prophylaxis for, laboratory methods to
Vaginal swab, for sexual abuse, 97 identification methods
1 97t identify, 1 2, 14t- 1 5t
for, 7-8
Valacyclovir, spectrum of activity RNA, 1 3t
Tuberculous meningitis, 39, 40t spectrum of antifungal activity
of. 28t specimen collecting and
Tuberculous pericarditis, 76 against, 25t
Vancomycin, spectrum of activity handling for, 1 6-1 7
Tularemia, 1 89-1 90 Yersinia enterocolitica,
of. 2 l t VL (viral load), for HIV
gastroenteritis due to, 8 1 t
Tumor necrosis factor receptor Varicella infection, 1 65
associated periodic syndrome Yersinia pestis, 187-189
with conjunctivitis, 33 Voiding cystourethrogram
(T�), 1 40� 141 postexposure prophylaxis for, (VCUG), 92t
22ql l .2 deletion syndrome, 1 75 197t Voriconazole, spectrum of Zanamivir, spectrum of activity
Tympanocentesis, for otitis Varicella vaccine, adverse events activity for, 25t, 26t of. 28t
media, 54 with, 195 VUR (vesicoureteral reflux), and Ziehl-Neelsen stain, I
Tympanostomy tubes, for otitis Varicella zoster immune globulin pyelonephritis, 90 Zygomycetes, 6
media, 55 (VZlG), I 96t VZIG (varicella-zoster immune antifungal agents for; 26t
Typhlitis, with cancer, 1 6Ot, 161 Varicella zoster virus (VZV) globulin), 1 96t
Typhoidal tularemia, 1 89 antiviral agents for; 28t
with cancer, 1 5 7
Typhoid fever, 142t
Variola, 190-191
Typhus, 147
VCUG (voiding
cystourethrogram), 92t
Ultrasound, for urinary tract
Velocardiofacial syndrome, 1 75
infection, 92
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