Infectious Disease Board Review

Stephen Barone MD Pediatric Program Director Schneider Children's Hospital Associate Professor New York University School of Medicine Michael Lamacchia, MD Chairman St. Joseph’s Children’s Hospital Associate Professor Mount Sinai School of Medicine Infectious Disease Board Review

A healthy 3 year old presents with a fever to 39.8 and stridor. The child reportedly has had a 3 -day history of a “bark-like” cough, low grade fever and URI symptoms. She became acutely worse today and appears “toxic” The most likely diagnosis is? Viral laryngotracheitis Epiglottis Retropharyngeal abscess Foreign body Bacterial tracheitis Question 1

Viral laryngotracheitis Epiglottis Retropharyngeal abscess Foreign body Bacterial tracheitis Question 1 A healthy 3 year old presents with a fever to 39.8 and stridor. The child reportedly has had a 3 -day history of a “bark-like” cough, low grade fever and URI symptoms. She became acutely worse today and appears “toxic” The most likely diagnosis is?

Key Points # 1 • Bacterial tracheitis • Fever, toxic, stridor, secretions, S aureus • Epiglottis • Older, unimmunized, drooling , toxic, no cough, H. Influenza • Viral laryngotrachitis • Cough, stridor, non-toxic, parainfluenza • Retropharyngeal abscess • Young, drooling, stiff neck • Foreign body • Acute onset, afebrile, historical clues

A 2 month old infant presents with a 2 -week history of a cough, perioral cyanosis and posttussive vomiting. The treatment of choice is? High dose Amoxicillin Azithromycin Clindamycin Steroids Trimethroprim - sulfamethoxazole Question 2

Key Point #2 • Pertussis • Infants or Adolescents • Macrolide - limit spread • Differential Diagnosis • Chlamydia trachomatis • Staccato cough, tachypnea afebrile, • PCP • Hypoxic, toxic , immunodeficiency

A 5 year-old presents with migratory arthritis and shortness of breath. On exam you notice a holosystoic murmur The most likely diagnosis is? Fifth disease Juvenile rheumatoid arthritis Rheumatic fever Systemic Lupus Lyme Disease Question 3

Fifth disease Juvenile rheumatoid arthritis Rheumatic fever Systemic Lupus Lyme Disease Question 3 A 5 year-old presents with migratory arthritis and shortness of breath. On exam you notice a holosystoic murmur The most likely diagnosis is?

Key Points #3 • Group A Streptococcus infections • Exudative pharyngitis, fever, anterior nodes • Treatment – Penicillin • Rheumatic fever • Arthritis, chorea, carditis, nodules, erythema marginatum • Prophylaxis • Scarlet fever – no prophylaxis • PSGN • Skin infections, not preventable with antibiotics

A 12 year boy with a three week history of nasal congestion, cough and nasal discharge presents with a headache, vomiting and 6th nerve palsy The next step in his evaluation should be? Lumbar puncture CT scan head and sinuses Lyme serology Maxillary sinus aspiration Slit lamp examination of the eyes? Question 4

Key Points #4 • Symptoms – 2 weeks • Congestion, • Nasal discharge • Facial pain • Complications of sinusitis • Cerebral venous thrombosis • Orbital cellulitis • Brain abscess – Pott’s puffy tumor • S. pneumoniae, M. catarrhalis, H. influenzae • Chronic – S. aureus, anaerobes

A 5 year old with chronic ear infections who had a chronic inflammation of the middle ear, perforation and otorrhea has what condition? Cholestatoma Chronic suppurative otitis media Serous otitis media Otitis externa Labyrinthitis Question 5

Key Points #5 • Acute Otitis Media • S. pneumoniae, H. influenzae, M. catarrhalis • Chronic Suppurative Otitis Media • Above plus S. aureus, P.aeruginosa • Cholesteatoma • Cystic structure – chronic OM • Otitis Externa • Intact TM - P.aeruginosa and S. aureus

A 3 year old presents with a 1 month history of unilateral cervical adenitis. The child has been well appearing, afebrile and has had not traveled. A PPD measures 6 mm The next step in the management is? Isoniazid and Rifampin for 6 months A repeat PPD in 3 months A CT of the neck Excisional biopsy Azithromycin for 4 weeks Question 6

Key Points #6 • Unilateral adenitis • Acute • S. aureus, Group A Streptococcus • Antibiotics • Sub acute • Atypical Mycobacterium • History, PPD, excisional biopsy • Cat Scratch • History, serology, no treatment • Kawasaki Disease • IVIG • Chronic • Malignancy

A 15 year old boy develops a fever to 101oF, headache and bilateral swelling of his parotid glands. The most likely complication of this illness is? Acute airway obstruction Sensorineural hearing loss Orchitis Myocarditis Arthritis Question 7

A 15 year old boy develops a fever to 101oF, headache and bilateral swelling of his parotid glands The most likely complication of this illness is? Acute airway obstruction Sensorineural hearing loss Orchitis Myocarditis Arthritis Question 7

Key Points #7 • Parotitis • Bacterial – ill appearing • Viral • Mumps • Viral syndrome with swelling of parotid glands • Complication • Orchitis • CSF pleocytosis – most asymptomatic • Rare – myocarditis, arthritis etc. • Vaccine • Live vaccine

A 15 year old complains of a sore throat, fever and a muffled voice. She stepped on a sharp piece of metal 4 days ago. On examination The adolescent also has trismus. The most likely diagnosis is? Tetanus Retropharyngeal abscess Infectious mononucleosis Peritonsillar abscess Herpangia Question 8

Key Points #8 • Peritonsillar abscesses • Adolescent, sore throat, hot potato voice, trismus • Dx – exam • Organisms –S. aureus. Group A Streptococcus, Anaerobes • Retropharyngeal abscess • Toddler, stridor, stiff neck, dysphagia, torticollis • Dx – CT scan • Infectious Mononucleosis • Adolescent, sore throat, lymphadepathy, fatigue, fever • Tetanus • Trismus and muscle spasm • C. tetani • Treatment • Tdap, TIG • Penicillin • Herpangina • Peritonsillar ulcers/vesicles • Enteroviral infection

A 9 month old presents with vesicular lesions on his lips and bleeding gums. He is drooling and unable to eat. On his trunk is a “target lesion rash” In addition to hydration, Which therapeutic regime will be most effective? IV acyclovir IV nafcillin Topical nystatin Topical mupirocin IV steroids Question 9

Key Points #9 • Herpes gingivostomatitis • Young child, anterior vesicles, swollen gums • Treatment – supportive, Acyclovir • Complication – erythema multiforme • Dx – Culture, DFA • Herpangina • Posterior vesicles • Candida • Cottage cheese plaques on buccal mucosa • Impetigo • Honey crust lesions on the skin • Group A Streptococcus, S. aureus

A 3 year old presents with a three day history of fever and cough. Today he developed respiratory distress. In addition to supportive care what is the most appropriate treatment plan? CT Scan of chest Ceftriaxone PPD Bronchoscopy Amphotericin Question 10

Key Points #10 • Pneumococcal pneumonia • Most common bacterial pneumonia • Acute, fever, tachypnea, cough, focal infiltrate • Round pneumonia • Treatment • Inpatient – Ceftriaxone • Outpatient – High dose Amoxicillin • Resistance – Lack of PCP’s

A 5 year old presents with a month history of cough, fever and weigh loss. His CXR shows a focal infiltrate with hilar lymphadenopathy. A PPD is 7 mm. The most appropriate treatment plan is? Repeat PPD in 3 months Bronchoscopy Gastric lavage Isoniazid for nine months Isoniazid, Rifampin and Ethambutal for 6 months Question 11

Key Points # 11 • Mycobacterium tuberculosis • History • Immigrant, insidious, weight loss, hilar nodes • PPD • 5 mm – high risk – symptoms, HIV • 10 mm – medium – age less than 6, immigrant, travel • 15 mm – low • Diagnosis – gastric lavage • Treatment • Four drugs then based on sensitivities • Side-effects • Prophylaxis • INH – 9 months

A ten year old boy presents with a four day history of cough, fever and myalgia. A rapid influenza test was positive two days ago in his physician’s office. Today he became acutely worse and is in respiratory distress. The most appropriate therapy is? Oseltamivir Ribavirin Clindamycin Aztreonam Azithromycin Question 12

Key Points #12 • Influenza • Fever, cough, myalgia • Oseltamivir – within 48 hours • Influenza vaccine – 2A, 1B • Antigenic shift vs. antigenic drift • Complications • S. aureus pneumonia • MRSA • Clindamycin, Vancomycin

A febrile irritable 20 month old male presents with a two day history of a “crusty” excoriation under his nose This was followed by a diffuse erythematous painful rash. The most likely diagnosis is? Kawasaki disease Staphylococcal scalded skin syndrome Toxic shock syndrome Roseola Enteroviral infection Question 13

Key Points #13 • Staphylococcal Scalded Skin Syndrome • Symptoms • Non-toxic, impetigo, painful, sunburn rash, skin peels readily. • Toxic Shock Syndrome • Hypotension • Fever • Rash • Desquamation • Plus three or more organ systems involved

Which of these infectious diseases often is accompanied by hyponatremia? Roseola Measles Rocky Mountain Spotted Fever Lyme disease Leptospirosis Question #14

Key Points # 14 • Rocky Mountain Spotted Fever • Epidemiology, distal petiechiae, headache, increased LFT’s, hyponatremia • Treatment – doxycycline • Lyme Disease • Northeast, Wisconsin, Northern CA • Rash, arthritis (mono), meningitis • Treatment • Amoxicillin, Doxycycline • Ceftriaxone

A year old child presents with a four day history of irritability and recurrent fevers. Today he is afebrile and had a diffuse erythematous rash on his trunk. You diagnosis the child with roseola. Which of the following is a common complication of this disease? Arthritis Febrile seizures Aseptic meningitis Thrombocytopenia Hepatitis Question #15

Key Points # 15 • Roseola • Fever followed by rash • HHV6 infection • Complications • Febrile seizures • Complications • Parvovirus – arthritis • EBV – hepatitis • Aseptic meningitis – Kawasaki • Thrombocytopenia - RMSF

A child presents with abdominal pain, arthritis and this rash. What is the most appropriate treatment? Ceftriaxone IVIG Doxycycline Clindamycin Supportive care Question 16

Key Point #16 • Henoch – Schonlein Purpura • Palpable purpura, lower extremities, bloody stools (colitis, intussusception) ,arthritis, hematuria • Treatment • Supportive • Steroids? • Differential Diagnosis • Meningococcal – Ceftriaxone • RMSF – Doxycycline • Kawasaki - IVIG

Which vaccine(s) is (are) not routinely recommended for catch up vaccination for children greater than 5 years of age? Varicella Hib Pneumococcal Hib &Pneumococcal DTaP Question #17

Infectious Disease Board Review