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Case 1

Case 1. 2-month-old previously healthy female presents to the ED with a 3-day history of poor feeding, lethargy, and a weak cry. She has not stooled for 3 days, but normal pattern was every other day. Mother describes her feeding, as licking instead of sucking with poor head control.

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Case 1

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  1. Case 1 • 2-month-old previously healthy female presents to the ED with a 3-day history of poor feeding, lethargy, and a weak cry. She has not stooled for 3 days, but normal pattern was every other day. Mother describes her feeding, as licking instead of sucking with poor head control. • The day of admission, she developed a fever to 39°C and became more lethargic. • She was exclusively breast-fed. The family are avid hikers, and the mother is an active gardener. • On examination, the infant is ill-appearing but not distressed. Her vital signs are normal. She has a flat affect, bilateral ptosis, a weak suck, and a weak gag reflex. Her upper extremities are flaccid, and her lower extremities nearly so. She has absent DTR. • Blood glucose is 50 mg/dL. Complete blood count, C-reactive protein, ABG, and head CT are all normal.

  2. Differential Diagnosis • Sepsis: • Bacterial; • Streptococcus pnuemoniae, Neisseria meningitidis, Haemophilus influenzae type b, Staphylococcus aureus, Salmonella sp. • Nonbacterial: rare • Respiratory syncitial virus, enteroviruses, influenza virus, adenovirus, herpes simplex virus • Other • Metabolic • Neurologic: includes infant botulism

  3. Clinical Course • The baby was treated for hypoglycemia, dehydration, and possible sepsis and then transferred to a tertiary care center where the diagnosis of infant botulism was confirmed by stool study. She received BabyBIG and made a full recovery over several months. She never required endotracheal intubation.

  4. Infant Botulism • Most common presentation of botulism in the US • Young infants have risk factors for overgrowth • Altered flora, pH and motility • Caused by Clostridium botulinum • Found in soil and agricultural products • 3 forms: infantile, foodborne, and wound • Spores in honey have been mplicated, but not spores in light or dark corn syrup • Diagnosis • Culture • Toxin in stool • Electromyography demonstrates a characteristic pattern

  5. Differential Diagnosis of hypotonia • Hypothyroidism: more indolent, no cranial nerve involvement • Myasthenia gravis: earlier in neonatal period: symptoms wax and waned, weakness not characteristic • Guillan-Barre: rare < 2: presents as ascending paralysis • Polio: usually asymmetric

  6. Question 1 • A 3 wk old infant is admitted w/ fever, irritability and poor feeding. On PE she has temp 38.6oC, weak suck, and poor tone. Her CSF is cloudy w/ a WBC of 250/mm3 • What is the most likely etiology of this child’s illness? • 1. group B beta-hemolytic Streptococcus • 2. Haemophilus influenzae type b • 3. Neisseria meningitidis • 4. Staphylococcus aureus • 5. Streptococcus pneumoniae

  7. Neonatal Sepsis • Pathogens: • group B beta-hemolytic Streptococcus • Escherichiacoli • enterococcus • Listeria monocytogenes • other gram negative enterics • Incidence greatly decreases after 4 weeks • 1 mo – 2yrs Streptococcus pneumoniae and Neisseria meningitiids account for about 75% of cases of meningitis

  8. Neonatal Sepsis • Listeria: • In neonates causes sepsis, early (≤ 7 days) and late (> 7 days- 3-5 months) onset • Pneumonia and sepsis predominate early, may have erythematous, nodular rash • Late on set meningitis predominates • Listeriosis in pregnant woman, the elderly and immunocompromised is a foodborne illness • Can present with flu-like symptoms or meningitis and parenchymal brain illness, rhomboencephalitis (brain stem encephalitis), brain abscess and endocariditis • Treatment is with ampicillin with or without gentamicin for synergy

  9. Case 2 • 5mo male with 2 day h/o tactile temps, irritability/decreased po intake. Temp 40oC in office: PE- nl. Pt UTD on immunizations, no ill contacts • Any further w/u work up needed • Differential Diagnosis

  10. Considerations • Likelihood of this child having a serious bacterial illness (SBI) • Pneumococcal bacteremia/ sepsis • Most commonly 6-24 mo • continues to occur despite PCV7 but numerous reports with decreased incidence • Before Prevnar- 7 serotypes caused 80% of IPD now they cause only 7% • Reported IPD is 50% bacteremia, 30% pneumonia

  11. Febrile child- Child-Pre Prevnar/HiB Era Baraff, et. al. Pediatr:1993;92:1-12 • Febrile infants that are toxic appearing • 1-3 months-17% probability of SBI • 11% bacteremia with 4% meningitis • >3 months-10% probability of SBI • Nontoxic infants still have 8.6% probability of SBI • 2% bacteremia and 1% meningitis • Low risk infants have 0.7-1.4% probability of SBI-when these guidelines are applied to practice. Higher rates reflect SBI 2o Salmonella species and has been decreased with stool evaluation in patients with diarrhea • Negative predictive value 99.1%

  12. Febrile Child-Post Prevnar/HiB Era • 1.3-1.8 % rate of occult bacteremia from multiple studies • Peds: 2004 • 75% decrease in invasive pneumococcal disease ≤ 2 yrs • Up to 66% increase in rates related to NV serotypes and increased Penicillin resistance • JAMA: 2004 • 1.8% bacteremia • 0.5% meningitis • 5.4% UTI • Predictors of SBI: • age <30 days • higher temperatures • ill appearance • abnormal cry • abnormal WBC count

  13. Febrile Child-Post Prevnar/HiB Era • PIDJ: 2005 • Decreased rate of invasive pneumococcal disease • 69% decrease in incidence • 7.8 fold higher in infants < 12 mo, 2 fold higher in AA and Hispanics • 31% with co-morbid conditions • 29% vaccine serotypes, 23-vaccine related • 23% had 3 doses of vaccines

  14. S. Pneumoniae Pre vs.Post Prevnar Change in incidence from 1998-2003 80.0 cases per 100,000 population to 4.6, a decline of 94% MMWR:September 16, 2005 / 54(36);893-897

  15. S. Pneumoniae Pre vs.Post Prevnar • Overall IPD dropped from 98.7 cases per 100,000 during 1998--1999 to 23.4 cases in 2005-77% decline • Plateau 2002--2005 • 62,000 cases of IPD prevented among children <5 years • 53% prevented directly by vaccine use • Greatest decline in children < 12 mo

  16. S. Pneumoniae Pre vs.Post Prevnar • Non-PCV7 strains are on the rise • Accounting for 1200 ICP cases • Predominant replacement strain 19A

  17. Sur, D, et al. Evaluating Fever of Unidentifiable Source in Young Children, Am Fam Physician. 2007 Jun 15;75(12):1805-11

  18. Case 3 • 9 yr old previously healthy female presents with a one day history of fever and progressive lethargy. She has had a mild URI for the preceding 3 days. Findings on PE include Temp 39.5oC, a stiff neck, and a petechial rash. Your order a blood culture and perform a lumbar puncture. • The best initial treatment is • 1. Ampicillin and gentamicin • 2. Cefotaxime and gentamicin • 3. Ceftazidime plus vancomycin • 4. Ceftriaxone plus vancomycin • 5. Vancomycin alone

  19. Meningitis in Childhood • Most common etiology is viral • Of bacterial causes Streptococcus pneumoniae and Neisseria meningitidis are now the most common (post Hib and Prevnar)

  20. Case 4 • 2.5yo presents w 4 day history of watery stools, w/o blood or mucous associated with severe abdominal cramping. He has no fever/N/V/ and rest of ROS neg. He has had intermittent episodes of diarrhea for several weeks, and he c/o 1-2 times/week of cramping pain. His mother feels his stomach appears bigger/bloated. PE: nl except for distended abdomen • Exposure h/o: attends daycare, several children have had diarrhea, none currently, • daycare went on a trip to a public park, kids did drink from a water fountain about 6 days prior

  21. Considerations • Significant exposures include • Daycare attendance • Rotavirus, salmonella, shigella, giardia, other viral AGE • Water from public fountain • Escherichia coli, cryptosporidium, trichlorethylene, perchlorethylene • Contaminated water or food/vegetables • Escherichia coli

  22. Epidemiology: what fits • This episode could be AGE, but must R/O other • Giradia common in daycare centers, symptoms can be variable and intermittent, bloating and cramping common • E. coli some strains more common in this age group, easily spread person-person or contaminated water • Usually very watery or bloody stools, cramping common, usually not intermittent • Dysentery strains less likely given clinical presentation (also shigella, but salmonella could cause this). • Cryptosporidium can cause symptoms in immunocompetent, but usually self limiting

  23. The Work up • Stool culture: • neg for bacterial pathogens including E. coli O157:H7 • Rotavirus neg • Giardia EIA positive • The antigen test must be ordered separately from O + P and is positive in 80-90% from one stool specimen • Pt. treated with 7 days of metronidazole

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