PAINE #PANCE Pearl – Pediatric Edition



Question

 

What are the six (6) classic infectious exanthems of childhood and what organism causes each?

 



Answer

 

The chart below lists the classic exanthems of childhood, the organism that causes, and the “number” disease that were given to them in 1905.

 

It should be noted that Duke’s Disease (fourth disease) is not widely accepted as a true infectious exathem.


References

  1. Bialecki C, Feder HM, Grant-Kels JM. The six classic childhood exanthems: a review and update.. Journal of the American Academy of Dermatology. 1989; 21(5 Pt 1):891-903. [pubmed]
  2. Drago F, Ciccarese G, Gasparini G. Contemporary infectious exanthems: an update.. Future Microbiology. 2017; 12:171-193. [pubmed]

Infectious Disease Answer

 

Diagnosis: Acute rheumatic fever

Criteria: Jones criteria

 

Acute rheumatic fever (ARF) is a sequella of symptoms that typically occur 2-4 weeks after an untreated bout of group A Streptoccocal (GAS) pharyngitis.  Symptoms include arthritis, carditis, erythema marginatum, CNS symptoms, and subcutaneous nodules.

 

Jones criteria is constellation of symptoms of ARF and are subdivided into major and minor manifestations.

 

Major

Carditis

Arthritis

CNS involvement

Subcutaneous nodules

Erythema marginatum

Minor

Arthralgia

Fever

Elevated acute phase reactants

Prolonged PR interval

 

The diagnosis of ARF is made using the Jones criteria and is positive if the patient has evidence of a preceding GAS infection and:

  • Two major manifestations

or

  • One major and two minor manifestations

Infectious Disease Question

 

You are participating in a medical mission in South America and are seeing a 11yo boy who is brought in by his mother.  He has been complaining of joint pain and fever for the past 2 weeks.  She tells you that it seems to “move” from joint to joint over this time and nothing seems to help.  She does report that he has seemed to be sick for 4-6 weeks with various “cold” symptoms, but they didn’t seem too severe.  On examination, he has temperature of 101.2oF and the below rash.

erythema-marginatum-pictures-2

 

What should be your concern and what criteria can help make the diagnosis?

Update to Pneumonia Podcast

 

It figures.

 

As with any educational or academic en devour, as soon as you finish a paper/poster/presentation, a new publication comes out that would have been awesome to include.  I finished and published the Pneumonia podcast on July 12th and on July 14th, the IDSA/ATS released their updated guidelines on managing healthcare-associated (HAP) and ventilator-associated (VAP) pneumonia.  Luckily, they didn’t change anything earth-shattering, just tightened them up a bit.  Antibiotic regimens are below and they recommend 7-days total of therapy.

Screen Shot 2016-07-15 at 7.21.23 AM

2016 IDSA/ATS Guidelines

Screen Shot 2016-07-15 at 7.20.55 AM

2016 IDSA/ATS Guidelines


References

#16 – Pneumonia



 

Classifications of Pneumonia

  • Community-Acquired (CAP)
  • Healthcare-Associated (HAP)
    • Any IV therapy, wound care, or chemotherapy within 20 days
    • Resident of nursing home or other long term care facility
    • Hospitalization for ≥ 2 days within 90 days
    • Visit to outpatient clinic or hemodialysis within 30 days
  • Ventilator-Associated (VAP)
    • Currently or previously intubated during current hospitalization

Epidemiology

  • 6 cases per 1000 persons per year (~ 5 million cases per year)
  • Top 10 in mortality in US (~60,000 deaths/year)
  • 12% 30-day mortality in patients requiring admission
  • 28% all-cause mortality within one year

 

Pathogenesis

4 phases of development

  • Edema
    • Proteinaceous exudate in the alveoli
    • Bacteria accumulation
  • Red hepatization
    • Erythrocyte extravasation
  • Grey hepatization
    • Neutrophil extravasation with bacterial clearance
  • Resolution
    • Macrophage proliferation with inflammatory response

 

Picture1

Murthy SV. Pathology of Pneumonia. SlideShare.

Risk Factors

  • Age
  • Winter months
  • Increased risk of aspiration (AMS, CVA, intoxication, seizures)
  • Smoking
  • Underlying pulmonary disease (Asthma, COPD, cancer)
  • Immunosupression
  • Viral URI
  • Decreased host defenses (impaired ciliary clearance)
  • Acid-reducing medications
  • Malnutrition
  • Inhalation exposures
2

Up To Date. 2016.

 

Pathogens

  • Viral (most common)
    • Rhinovirus (most common)
    • Influenza
    • Adenovirus
    • Respiratory Syncytial Virus (RSV)
  • Bacterial
    • S. pneumoniae (most common CAP)
    • H. influenza
    • M. pneumoniae (most common atypical)
    • K. pneumoniae (tends to be more severe)
    • Legionella
    • ESKAPE bugs (>80% of VAP)
      • Enterococcus
      • Staphylococcus
      • Klebsiella
      • Acinetobacter
      • Pseudomonas
      • Enterobacter
  • Fungal (immunocompromised)
    • Histoplasmosis
    • Cryptococcus
    • Coccidioides
    • Blastomycosis
    • Aspergillus

Signs and Symptoms

  • Productive cough
  • Fever
  • Chills and/or rigors
  • Dyspnea
  • Pleuritic chest pain
  • Nausea/vomiting
  • Altered mental status

 

Physical Exam Findings

  • Vital signs
    • Febrile (elderly may not mount a response)
    • Tachycardic
    • Tachypnic
  • Pulmonary
    • Rales and/or rhonchi
    • Signs of consolidation
      • Decreased breath sounds
      • Dullness to percussion
      • Increased tactile fremitus
      • Egophany
      • Whispered pectoriliquoy

 

Radiographic Evaluation

  • Bacterial
    • Unilateral, lobar, air bronchograms

3

  • Viral
    • Diffuse or perihilar, bilateral

4

Laboratory Evaluation

  • CBC with differential
  • Blood cultures
  • Sputum culture and gram stain
    • Good sample = PMNs with < 10 squamous cells per LPF
  • Urine antigen (pneumococcal and Legionella)
  • Multiplex PCR
5

Up To Date. 2016.

Should They Stay or Should They Go Now????

  • Pneumonia Severity Index (PSI)
    • Step 1
      • If none of the following, then Class I and outpatient treatment
        • Age > 50 years
        • Neoplastic disease
        • Heart failure
        • Cerebrovascular disease
        • Renal disease
        • Liver disease
        • Altered mental status
        • HR ≥ 125/min
        • RR ≥ 30/min
        • SBP ≤ 90 mmHg
        • Temperature ≤ 35oC or ≥ 40oC
    • Step II
Screen Shot 2016-07-12 at 7.45.22 AM

Step II of PSI/PORT Score for Risk Stratification

  • CURB-65 Score
    • 5 variables
      • Confusion
      • Urea (BUN ≥ 20 mg/dL)
      • Respiratory rate ≥ 30/min
      • Blood pressure (SBP < 90 mmHg or DBP < 60 mmHg)
      • Age ≥ 65 years
    • Interpretation
      • Score 0-1 = Outpatient management
      • Score 2-3 = Inpatient management
      • Score 4-5 = ICU management
  • SMART-COP Score
    • Used to predict need for respiratory or vasopressor support

6

 

Treatment

  • Care should be taken to think about patients with risk factors for drug-resistant S. pneumoniae:
    • Age > 65 years
    • Beta-lactam, macrolide, or fluouroquinolone in the past 3-6 months
    • Alcoholism
    • Medical comorbidities
    • Immunosuppression
    • Exposure to child in daycare
  • Community-Acquired
7

Treatment for Community-Acquired Pneumonia. IDSA/ATS 2007 Guidelines.

  • Healthcare-Associated
8

Treatment of Healthcare-Associated Pneumonia. IDSA/ATS 2007 Guidelines.


Cottage Physician

CottageMD

Cottage Physician. 1893.


References

  1. Mandell LA, Wunderink RG. Pneumonia. In: Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J. eds. Harrison’s Principles of Internal Medicine, 19e. New York, NY: McGraw-Hill; 2015. http://accessmedicine.mhmedical.com/content.aspx?bookid=1130&Sectionid=79733578. Accessed July 11, 2016.
  2. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. American journal of respiratory and critical care medicine. 171(4):388-416. 2005. [pubmed]
  3. File TM, Marrie TJ. Burden of community-acquired pneumonia in North American adults. Postgraduate medicine. 122(2):130-41. 2010. [pubmed]
  4. Murthy SV. Pathology of Pneumonia.    http://www.slideshare.net/vmshashi/pathology-of-pneumonia.  Accessed on July 11,  2016.
  5. Almirall J, Bolíbar I, Balanzó X, González CA. Risk factors for community-acquired pneumonia in adults: a population-based case-control study. The European respiratory journal. 13(2):349-55. 1999. [pubmed]
  6. Mandell LA, Wunderink RG, Anzueto A. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 44 Suppl 2:S27-72. 2007. [pubmed]
  7. Musher DM, Thorner AR. Community-acquired pneumonia. The New England journal of medicine. 371(17):1619-28. 2014. [pubmed]
  8. Jain S, Self WH, Wunderink RG. Community-Acquired Pneumonia Requiring Hospitalization among U.S. Adults. The New England journal of medicine. 373(5):415-27. 2015. [pubmed]
  9. Metlay JP, Kapoor WN, Fine MJ. Does this patient have community-acquired pneumonia? Diagnosing pneumonia by history and physical examination. JAMA. 278(17):1440-5. 1997. [pubmed]
  10. Fine MJ, Auble TE, Yealy DM. A prediction rule to identify low-risk patients with community-acquired pneumonia. The New England journal of medicine. 336(4):243-50. 1997. [pubmed]
  11. Lim WS, van der Eerden MM, Laing R. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 58(5):377-82. 2003. [pubmed]
  12. Charles PG, Wolfe R, Whitby M. SMART-COP: a tool for predicting the need for intensive respiratory or vasopressor support in community-acquired pneumonia. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 47(3):375-84. 2008. [pubmed]
  13. Pugh R, Grant C, Cooke RP, Dempsey G. Short-course versus prolonged-course antibiotic therapy for hospital-acquired pneumonia in critically ill adults. The Cochrane database of systematic reviews. 2015. [pubmed]