Peds Case 11- 5Y/o With Fever And Adenopathy

Front 1

tx of suspected pharyngitis w neg rapid strep and cultures pending

Back 1

Group A strep infections should be treated with a susceptible antibiotic within the first nine days of symptoms to prevent the complication of rheumatic fever, so in this case there would have been time to wait. Although penicillin is the drug of choice for GAS pharyngitis, the suspension form does not have a pleasant taste. For that reason, many pediatricians opt for oral amoxicillin, which is more palatable. In a child who refuses oral medications or in a non-compliant family, a single intramuscular injection of penicillin may be the best option.

Front 2

not Legg-Calve-Perthes Disease

not Sinusitis

Back 2

cause a limp, but would not be associated with fever, rash, or conjunctivitis

unlikely to cause the rash, and although a child with sinusitis may be more fussy than usual, one would not anticipate this much irritability in a five year old.

Front 3

Meningococcemia

Back 3

unlikely with the duration of this illness – it tends to progress much more quickly.

Neisseria meningitidis, the onset is abrupt and accompanied by fever, chills, malaise and prostration.

The initial rash may be urticarial, maculopapular or petechial (marked by small, purplish hemorrhagic spots). In fulminant cases, it can become purpuric, marked by large hemorrhages into the skin

Front 4

Kawasaki disease

Back 4

always be high on the list of possible diagnoses in any young child with a fever lasting more than five days.

non-purulent conjunctivitis (which may have cleared prior to presentation),
rash
changes in the extremities characterized by swelling and erythema. The swelling in the feet can lead to painful walking.

Front 5

Stevens-Johnson syndrome,

Back 5

a mucocutaneous disorder, presents primarily with a rash= erythema multiforme.

fever, though usually not as long as seven days;
mucosal changes, primarily stomatitis;
conjunctivitis.

no LAD
blistering rash, frequently with purpuric macules on the face and trunk. Mucosal changes are usually severe. Cervical adenopathy is not usually seen with Stevens-Johnson syndrome, unless there is secondary infection.

Front 6

Juvenile idiopathic arthritis (JIA)

Back 6

group of common rheumatic diseases subdivided into oligoarthritis or pauciarticular disease, polyarthritis, or systemic-onset disease.

Systemic-onset disease- prolonged fever, rash, arthritis, and visceral involvement such as hepatosplenomegaly, lymphadenitis, and serositis

more diffuse adenopathy

Front 7

Viral syndrome

Back 7

viruses most likely to cause fever, a non-descript rash, and presenting in late summer/early fall would be the enteroviruses (oral mucosal changes)

bilat cervical adenopathy

The fever associated with these viral infections in a normal host usually last no longer than three to five days

Front 8

Scarlet fever,

Back 8

secondary to Group A streptococcus,
rash that is diffuse, erythematous, and finely papular, w "sandpaper" texture.
begins around the neck, axillae, and groin and then spreads over the trunk and extremities.
A positive family history for a recent streptococcal infection keeps this on the differential diagnosis.

very fine papules, often described as "sandpaper." It is erythematous, but blanches.

starts in the groin, axillae and neck, but rapidly spreads. The fever can be high, and the disease is usually self-limited, lasting less than 10 days. The etiologic agent is Group A streptococcus. It is important to treat this to prevent nonsuppurative complications of strep, including rheumatic fever.

Front 9

Rocky Mountain Spotted Fever,

Back 9

caused by Rickettsia rickettsii, occurs following a bite from an infected tick.

triad of fever,
headache, and
rash
is seen in a minority of patients at presentation. In younger children, headache may be manifested by irritability. The rash classically

starts on the wrists and ankles and progresses centrally and is frequently petechial not macupapular

retinal changes more common than conjunctivits

Front 10

Bone or Joint infection

Back 10

is always of concern in a young child who suddenly stops walking. However, the fever associated with osteomyelitis or septic arthritis is usually not as high as in this case

Front 11

normal heart rate for a 5-year-old is

Back 11

80 to 100 beats per minute

Front 12

red and flat in some areas, and small papules in other areas

Back 12

erythematous maculopapular rash.

Front 13

Macule -
Papule -
Vesicle -
Pustule -
Plaque -
Desquamate -

Back 13

Macule - flat, discolored spot
Papule - small, well-defined solid bump
Vesicle - small, well-defined bump containing fluid
Pustule - small, well-defined bump containing purulent material
Plaque - patch or small differentiated area on a body surface
Desquamate - shedding of outer layer of any surface

Front 14

enterovirus rash

Back 14

erythematous and maculopapular and may involve the palms and soles.

Infrequently, it can be a petechial rash.

Enteroviruses are usually seen in late summer and early fall.

While the fever associated with enteroviruses may be high, it usually lasts only a few days.

Front 15

In hand-foot-and-mouth disease (caused by Coxsackievirus), it presents as a (rash)

Back 15

vesicular rash on the hands and feet and with ulcers in the mouth.

Front 16

Erythema infectiosum - Also called fifth disease, this is caused by

Back 16

parvovirus B19.
low-grade fever (37.8 - 38.3 C;100-101 F) with a rash appearing 7 to 10 days later.

starts as facial erythema -- the "slapped cheek" appearance. This can spread to the trunk and have an erythematous macular appearance. Central clearing of the rash appears, giving a lacy appearance.
The rash often lasts longest on the extremities, where it has a lacy, reticular appearance.

Front 17

Measles

Back 17

After a prodrome of fever (over 101 F), cough, coryza, and conjunctivitis, this maculopapular rash starts on the neck, behind the ears, and along the hairline.
It spreads downward, and reaches the feet in 2-3 days.

The initial rash appears on the inner aspects of the cheeks as red lesions with bluish white spots in the center or Koplik spots. These have frequently disappeared by the time the patient presents to medical attention.

Immunization is very effective in preventing this infection.

Front 18

Roseola

Back 18

macular or maculopapular rash

starts on the trunk and spreads to the arms and neck.
usually less involvement of the face and legs.

preceded by 3-4 days of high fevers, which end as the rash appears.

children less than 2 years old.

Front 19

Varicella

Back 19

starts on the trunk and spreads to the extremities and head.
Each lesion progresses from an erythematous macule to papule to vesicle to pustule, and then crusts over.
Lesions at various stages of development are seen in the same area of the body. There is usually a mild fever. The disease is self-limited, lasting about 1 week.

Front 20

Assc w strawberry tongue

Back 20

GAS pharyngitis and Kawasaki disease

erythematous tongue with prominent papillae

can be seen in infectious mono but usually b/c coinfection w strep pharyngitis

Front 21

enlarged unilateral cervical LN ddx

Back 21

bacterial Cervical adenitis,
cat scratch disease,
reactive node from a pharyngeal infection,
Kawasaki disease,
mycobacterial infection

Cervical adenopathy is common in children. What makes it more significant in this case is that it is unilateral. The more likely causes of unilateral cervical lymphadenopathy include cervical adenitis, cat scratch disease, reactive node from a pharyngeal infection, and Kawasaki disease. Mycobacterial infection (both tuberculosis and atypical mycobacteria) can present with unilateral cervical lymphadenopathy, but the course is more indolent than Jason's.

Front 22

ddx of swollen extremities

Back 22

The lack of any associated pain argues against arthritis or arthralgia. If there were pain, it would be important to determine if the swelling involved the joints, as would be seen in arthritis. Cellulitis also needs to be considered in the differential of an erythematous, swollen extremity, but is unlikely to be the cause if multiple extremities are involved.

Front 23

most common cause of viral conjunctivitis

Back 23

adenovirus
it is purulent

Front 24

eval for incomplete kawasaki's

Back 24

(2) Infants ≤ 6 months old on day ≥ 7 of fever without other explanation should undergo laboratory testing and, if evidence of systemic inflammation is found, an echocardiogram, even if the infants have no clinical criteria.
(3) Patient characteristics suggesting Kawasaki disease are listed in Table 1. Characteristics suggesting disease other than Kawasaki disease include exudative conjunctivitis, exudative pharyngitis, discrete intraoral lesions, bullous or vesicular rash, or generalized adenopathy. Consider alternative diagnoses (see Table 2).
(4) Supplemental laboratory criteria include albumin ≤ 3.0 g/dL, anemia for age, elevation of alanine aminotransferase, platelets after 7 days ≥ 450 000/mm3, white blood cell count ≥ 15 000/mm3, and urine ≥10 white blood cells/high-power field.
(5) Can treat before performing echocardiogram.
(6) Echocardiogram is considered positive for purposes of this algorithm if any of 3 conditions are met: z score of LAD or RCA ≥2.5, coronary arteries meet Japanese Ministry of Health criteria for aneurysms, or ≥ 3 other suggestive features exist, including perivascular brightness, lack of tapering, decreased LV function, mitral regurgitation, pericardial effusion, or z scores in LAD or RCA of 2–2.5.
(7) If the echocardiogram is positive, treatment should be given to children within 10 days of fever onset and those beyond day 10 with clinical and laboratory signs (CRP, ESR) of ongoing inflammation.
(8) Typical peeling begins under nail bed of fingers and then toes.

Front 25

CBC w diff

Back 25

CBC with differential will help evaluate for possible infection or inflammatory response. It is also useful to evaluate for possible anemia, thrombocytopenia or thrombocytosis, any of which could be present in this patient.

WBC: The white blood count is usually elevated, with a predominance of neutrophils.
Hbg/Hct: A normochromic, normocytic anemia is common.
MCV: The MCV is usually normal. Jason's MCV is normal.
Platelets: The markedly elevated platelet count associated with Kawasaki disease is usually not seen until the second week of the illness. Therefore, Jason's platelet count may not be elevated at this point. Jason's platelet count is normal.

Front 26

tests

Back 26

CBC w diff
Blood culture:
The clinical course is long for bacteremic illnesses, though the height of the fever and the clinical appearance of the patient can justify the culture.

A blood culture is obtained and is subsequently reported as negative.


Liver enzymes:
Liver enzymes can be elevated for a number of reasons, including both Kawasaki disease and Stevens-Johnson syndrome.

serum albumin level is frequently low in Kawasaki disease.

negative ESR would argue strongly against Kawasaki disease. The persistence of an elevated ESR after the fever has subsided can help to distinguish KD from other infectious rash/fever illnesses.

urinalysis
sterile pyuria is associated with Kawasaki disease, secondary to a sterile urethritis. A clean-catch urine is likely to show white cells, whereas a catheterized urine may not because the white cells come from the urethra.

Front 27

Bacterial cervical adenitis:

Back 27

1-5yrs with a history of a recent upper respiratory tract infection.
Staphylococcus aureus and Streptococcus pyogenes are the organisms most commonly identified.

high fevers and a toxic appearance. Overlying cellulitis and development of fluctuance are common.

Front 28

Cat scratch disease:

Back 28

Bartonella henselae
can be asymptomatic or symptomatic
introduced by a scratch from a kitten, with subsequent infection of the node or nodes draining that site.
The site that is involved most commonly is the axilla, followed by cervical, submandibular, and inguinal areas.
This is usually a self-limited disease, with regression of the lymph node in four to six weeks.

Front 29

Mycobacterial infection:

Back 29

diffuse lymphadenopathy or isolated lymphadenitis.

Lymphadenitis is the most common manifestation of nontuberculous mycobacteria in children, peak @ 2-4yrs.

Tuberculosis is the most common cause of mycobacterial lymphadenitis in children over twelve years of age.

appear well with minimal if any constitutional signs and symptoms. The overlying skin may be erythematous initially, but left untreated often becomes violaceous as the nodes enlarge. Nodes may rupture through the skin, resulting in a long lasting draining sinus tract.

Treatment is surgical excision, as incision and drainage can also resulting in a sinus tract.
Young children with nontuberculous lymphadenitis will often react to a PPD, but the reaction is usually less than 10 mm.

Front 30

tuberculin skin test

Back 30

most widely used method for identifying infection with Mycobacteria tuberculosis in people who do not have active disease.
PPD, purified protein derivative, is isolated from a culture filtrate of tubercle bacilli by protein precipitation. A standardized 5-tuberculin unit dose, in a volume of 0.1 ml., is injected intradermally into the forearm.
Done properly, this should cause a wheal of 6 to 10 mm. in diameter. The test is based on a delayed hypersensitivity reaction, which peaks at 48 to 72 hours, when the test should be read. Reading the test involves measuring the diameter of any induration, not erythema. Interpretation of the test is based on risk factors for the individual being tested, including HIV positivity, exposure to high-risk congregate settings (such as prisons, nursing homes, homeless shelters), and children under 4 years of age or infants, children, adolescents exposed to adults in high-risk categories. A positive test in a person with no risk factors is induration greater than or equal to fifteen millimeters.

Front 31

five criteria for kawasakis

Back 31

fever >5days

Changes in oral mucosa
Extremity changes (redness/swelling)
Unilateral cervical lymphadenopathy
Rash
Conjunctivitis

one least likely to be present is the cervical adenopathy. Though irritability is very common, it is not part of the diagnostic criteria. The final criterion is that there is no other apparent cause for the presentation. A child presenting with an obvious site of infection, even if meeting all criteria for Kawasaki, cannot be given the diagnosis

Front 32

complication of Kawasaki's that requires hospital eval

Back 32

coronary aneurysms.
All patients should receive an echocardiogram during the acute phase, both to look for the presence of aneurysms and to provide a baseline for future comparisons.
Aneurysms may be present by the end of the first week, but usually present later
almost always within four weeks of the onset of the disease.

percentage of patients with each complication is:
- CNS manifestations: 90% (including irritability, lethargy, aseptic meningitis)
- Coronary artery aneurysm: 20-25% (in untreated patients).
- Liver dysfunction: 40%
- Arthritis: 30%
- Hydrops of the gallbladder: 10%

Front 33

tx kawasaki's

Back 33

High-dose aspirin and high-dose intravenous immune globulin (IVIG)

The use of IVIG in Kawasaki disease has decreased the incidence of coronary artery aneurysms from 20-25% down to 2-4%
single dose of IVIG has been shown to be more effective in reducing the risk of coronary artery aneurysms than multiple lower doses
Aspirin is used as an anti-inflammatory drug that also shortens the febrile course of the illness. (It has no effect on the development of aneurysm.)
Other antipyretics are usually not effective for fever control. Furthermore, use of ibuprofen has been shown to antagonize the irreversible platelet inhibition induced by aspirin and therefore should be avoided in children with coronary aneurysms taking aspirin for its antiplatelet effects.
Antibiotics have not been shown to have any effect on the clinical course. The role of steroids is unclear. For years, steroids were felt to have no role, or even to be detrimental. Newer studies suggest that they may have a role in the acute management, and additional information is needed.

(peeling of the skin, especially the fingers, toes, and perineal area, is common)

Front 34

Reye syndrome

Back 34

long-term aspirin therapy get this after influenza virus infection.
Although ACIP (Advisory Committee on Immunization Practices) recommends an annual influenza vaccine for all children 6 months to 18 years of age, physicians should be particularly vigilant about recommending a flu shot for children who are taking aspirin

Front 35

aspirin in Kawasaki's patients

Back 35

High dose aspirin, as an anti-inflammatory drug, is continued until the patient is afebrile.

If there are coronary artery abnormalities, low dose aspirin is continued indefinitely as an anti-platelet agent.