Pediatric Photo Diagnostic Challenges

1. Pediatric Photo Diagnostic Challenges Laura Drach DO, MSN, FAAP All Children’s Hospital -Johns Hopkins Medicine

2. I have no financial disclosures.

3. A 5 month male old presents with macrocephaly, intermittent fever and extreme irritability. Hits his head with hand at times. Presents to ER after having a 30 second seizure. You obtain an MRI and see the following.

5. What’s your diagnosis? • Glioblastoma • Subdural abscess • Epidural hematoma

6. Glioblastoma • Subdural abscess • Epidural hematoma

7. Right frontal subdural abscess. • Right parasagittal subdural abscess. • Left temperoparietal subdural abscess.

8. Subdural Abscess • Occurs in 13 percent of patients with neonatal meningitis. • Occurs in 11 to 19 percent of patients with gram-negative neonatal bacterial meningitis. • The risk of brain abscess is increased in neonates with meningitis caused by Citrobacter koseri , Serratia marcescens, Proteus mirabilis, and Enterobacter sakazakii.

9. Subdural Abscess • Usually needs a combination of antibiotics and surgical intervention. • Physical exam findings might include vomiting, bulging fontanelle, increased head circumference, separation of the cranial sutures, hemiparesis, focal seizures, and increased peripheral white blood cell (WBC) count.

10. CSF will show pleocytosis with elevated WBC, depressed glucose and elevated protein. • Initial treatment of brain abscess includes Vancomycin, Ceftriaxone or Cefotaxime and Flagyl.

11. 8 y/o female spent 10 days in Tennessee mountains in June. She presents with fever, myalgia and photophobia. Rash started on the wrist/hands and feet.

12. What’s your diagnosis? • Rickettsia rickettsii • Borrelia burgdorferi • Parvovirus B19

13. Rickettsia rickettsii • Borrelia burgdorferi • Parvovirus B19

14. 2010 incidence of RickettsiaRickettsii by CDC

15. Rocky Mountain Spotted FeverRickettsia rickettsii • 2-14 days after bite-fever, erythematous macular rash, myalgia, nausea, vomiting, photophobia, conjunctivitis, headache • May progress to severe disease with multiorgan involvement • Diagnosis with acute and convalescent serology • Treatment with doxycyline for seven days

16. Dog Tick

17. One week of fever • 18 month female is admitted with five days of fever (Tm 104) and irritability. She was treated as an outpatient with Amoxil for neck lymphadenitis without improvement. She is admitted to the hospital and found to have other findings on physical exam.

18. Exam findings

19. What’s your diagnosis? • Staphylococcal lymphadenitis • Kawasaki Disease • Disseminated S. pyogenes infection • Hypersensitivity reaction to antibiotics

20. Staphylococcal lymphadenitis • Kawasaki Disease • Disseminated S. pyogenes infection • Hypersensitivity reaction to antibiotics

21. Kawasaki Disease • Systemic vasculitis of small arteries • Fever for at least 5 days with at least four other physical exam findings; -conjunctivitis -rash -oral mucosal changes, strawberry tongue -edema of the hands and feet -lymphadenopathy

22. Kawasaki Disease • Atypical (incomplete) diagnosis made if not all 4 criteria met, with (+) ancillary data - CRP > 3.0, ESR >40 - Hypoalbuminemia - Sterile pyuria - Elevated ALT, AST - Anemia, hyponatremia

23. Kawasaki Disease Pearls • Positive throat culture or adenovirus does not rule out KD. • Treat with 2 gm/kg IVIG no more than 2 times. • High dose steroids for IVIG failures • Normal echocardiogram at 6 weeks predicts normal echocardiogram at 6 months • Bilateral conjunctival injection occurs simultaneously • Infants are more likely to develop aneurysms • Defer MMR for 11 months after IVIG. • High dose to low dose aspirin when symptoms resolve • Influenza immunization during the “flu” season since the patient will be on aspirin

24. A 8 year old has relapsed ALL. She is s/p stem cell transplant & chemotherapy. Oncologist states outcome is grave but she is eligible for a phase 1 study. Family asks you what you would do. They want to keep their child comfortable but also provide every chance at cure possible.

25. What should you advise? -Go home with hospice -Seek treatment with phase 1 trial -Advise the family to seek concurrent care.

26. What should you advise? -Go home with hospice -Seek treatment with phase 1 trial -Advise the family to seek concurrent care.

27. Concurrent Care Act -Allows qualified hospice providers to provide interdisciplinary palliative care to the entire family unit, including parents and siblings, and be reimbursed for this care. -PIC: individual, family, and group counseling, nursing and personal attendant care, physician pain and symptom management consultation, volunteer support, and respite. -Medicaid enrollment -Physician attestation that the child is not expected to live to age 21

28. 8 year old patient with cerebral palsy, global developmental delay and g-tube dependence. Mom states he cries at times during the day, possibly related to his feeds he receives through the g-tube. She thinks he is in pain but all current testing has been negative. The GI doctor has done a full work up, and you have found no etiology to this point. What is your next step?

29. What should you advise? • Trial of lortab • Trial of gabapentin • Follow up with neurologist

30. Trial of lortab • Trial of gabapentin • Follow up with neurologist

31. Visceral Hyperalgesia -Altered response to visceral stimulation, causing decreased activation threshold for pain in response to a stimulus. -Retching, pain related to feeding intolerance, flatus and bowel movements, & prolonged crying. Medications that maybe used; -gabapentin -cyprohepatadine -tricyclic antidepressants

32. Gabapentin • Used for neuropathic pain and seizures • Exact mechanism is unknown • Few drug interactions • Side effects include sedation, confusion, ataxia and dizziness. • Titrate slowly until desired effect

33. A 6 year old male presents to your office with history of fever and difficulty walking. He has no pets at home, but there are some neighborhood cats and dogs.

35. What’s your diagnosis? Staphylococcus aureus Bartonellaquintana Bartonella henselae Bartonellabacilliformis

36. Staphylococcus aureus Bartonellaquintana Bartonella henselae Bartonellabacilliformis

37. Bartonella henselaeCat-Scratch Disease • Begins as papule at site of tick, scratch, or bite • 85% of patients solitary lymph node • Dissemination may occur and present as FUO in children • Other organ systems involved: liver, spleen, CNS, ocular, and bone • In-vitro susceptibility to multiple classes of antibiotics

38. Bartonella henselae;Cat-Scratch Disease < <

39. Bartonella henselaeCat-Scratch Disease

40. 8-month old male with a history of severe atopic dermatitis presents with a pruritic and painful rash involving the face. dermatlas.med.jhmi.edu

41. What’s your diagnosis? -PapularAcrodermatitis of Childhood -Eczema herpeticum -Impetigo -Scabies

42. Papular Acrodermatitis of Childhood Eczema herpeticum Impetigo Scabies

43. Eczema Herpeticum • Complication of eczema with herpes simplex virus infection • HSV-1 or HSV-2 • Vesicles begin to cluster and eventually become hemorrhagic • Surface viral culture and HSV DNA PCR • Treatment with acyclovir • Monitor for bacterial superinfection pediatricsconsultant360.com

44. 7 y/o girl with cellulitis is admitted to the hospital after she fails to improve on seven days of PO TMP-sulfamethoxazole. Her 10 y/o sister was recently diagnosed with Streptococcal pharyngitis. What would be your empiric antibiotic treatment?

45. Which is the correct drug? Penicillin IV TMP-sulfamethoxazole IV Ciprofloxacin IV Metronidazole IV

46. Penicillin IV TMP-sulfamethoxazole IV Ciprofloxacin IV Metronidazole IV

47. Streptococcus pyogenes • 4-5 million infections/year • > Winter and spring months • Streptococcal infection common in ages 5-12 years • Children 6-15 y/o have highest streptococcal titers • Manifestations of disease: toxin, suppurative and immune mediated

48. Streptococcus pyogenes • Suppurative sequelae (invasive disease) • Bacteremia, toxic shock, and deep tissue/bone/joint • Non- suppurative sequelae • glomerulonephritis • acute rheumatic fever • arthritis

49. Streptococcus pyogenes • If concerned about non-Suppurative sequale, obtain ASO and Anti- DNAse B together. • Glomerulonephritis occurs more often after impetigo than pharyngitis, • Pharyngitis, both ASO & Anti DNAse B are increased but with impetigo, ASO does not rise as high as anti DNAse B.

50. Streptococcus pyogenes Invasive Disease Treatment • Trimethoprim-sulfamethoxazole has poor activity against S. pyogenes • Treatment of choice penicillin,cephalosporins and clindamycin • Invasive infections consider combination therapy with penicillin and clindamycin