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Pediatric Case Management

Pediatric Case Management. By Dr. Rachel Gast MD & Dr. Apryle Funderburk MD March 2 nd 2010. January Cases. BR 3 mo FT baby found face down, not breathing in crib, after 1.5 weeks of nasal congestion, presented to ER, RSV +,CXR wnl died

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Pediatric Case Management

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  1. Pediatric Case Management By Dr. Rachel Gast MD & Dr. Apryle Funderburk MD March 2nd 2010

  2. January Cases • BR 3 mo FT baby found face down, not breathing in crib, after 1.5 weeks of nasal congestion, presented to ER, RSV +,CXR wnl died • TD Teenager with Wrist laceration, tendon exposure-transferred to Union Memorial for Hand surgery • KT 4yo presented to ER with facial, LE swelling & abd distension x 1 week, Hpt, Blood and pr in urine –transferred to JHU for acute Hpt in face of AGN.

  3. HPI • 15 year old male • Headache x 2 days • Pain in middle of back on morning of admission radiating to chest • Progressive weakness in L.E. bilaterally • Patient First → St. Joseph’s E.D.

  4. Past History PMH ADHD, exercised-induced asthma, depression, migraines Meds Atomoxetine, Trazadone Allergy Shellfish, wheat, soybeans, peanuts Vacc UTD, received H1N1 (I.M.) one month prior Fam Hx Mother-COPD, arthritis, Father - Hepatitis B & cysts in brain, “misalignment” in spine, healthy siblings Social: Attends 10th grade, lives with mom & step-dad and cats, mom smokes

  5. Physical Exam – St. Joseph E.D. • Pulse = 58, B.P. = 160/100 • General: unable to walk, nausea with emesis x 1 • Moving legs per ED physician; absent reflex in right LEand diminished in RE • Weak grasp • ↑ tone in upper extremities with intact reflexes • WBC = 8.6 • Hgb = 14.8/Hematocrit = 43.8 • Platelets = 275 • Electrolytes and coags normal • Toxicology screen = normal • CXR/Head CT/ECG = normal

  6. Solu-medrol 125 mg, IV Labetolol Zofran Transferred to Sinai PICU

  7. Case #2 • 7 yr. old male with juvenile-onset D.M. type 2, in usual state of health • Flu-like symptoms week prior to presentation • “Bronchitis” – prednisone, clarithromycin, albuterol • Day prior to presentation – at school – left leg weakness, limping, gradual loss of motor function • No tingling, numbness nor loss of sensation • No incontinence • ED – progression of weakness, loss of function, areflexia; symptoms starting in opposite leg • Admitted to PICU for further work-up

  8. P.E./Labs • P.E. – Flaccid left LE, strength 0/5, intact sensation and vibratory sense, ↓ tone in right LE, motor 0-1/5, able to dorsi-/plantar flex right foot, absent DTRs, negative Babinski • Labs – • CBC WBC 13.7 ( N 51 L 36, M 9.2, E 2.2, B 0.2) • CSF WBC 168 (N 38, L50,M12 RBC = 59, Glu 95, Pr59 • CSF (-)GS/Cx • Stool Cx (+) for heavy Candida albicans • EBV IgM 2.3 , VCA Ab IgG positive, EBNA Ab IgG positive • Anticardiolipin Ab IgM positive

  9. Objectives To discuss updates on current influenza activity To discuss neuronal injury from influenza / influenza vaccine To discuss adverse events from H1N1 2009 influenza strain vs. those from H1N1 vaccine To discuss current CDC statement concerning H1N1 vaccine

  10. www.cdc.gov

  11. Pediatric Deaths from Influenza 2009-10 www.cdc.gov

  12. Influenza Vaccine • Seasonal Flu – trivalent inactivated, live attenuated – 3 virus strains • A • H1N1 • H3N2 • B • For the 2009--10 influenza season, the influenza B vaccine virus strain was changed to B/Brisbane/60/2008, a representative of the B/Victoria lineage, compared with the 2008--09 season. The influenza A, H1N1 and H3N2 vaccine virus strains were not changed • “Swine” Flu – • A/California/07/2009

  13. Mechanism of neuronal Injury • Vaccinations may induce autoimmune process • Influenza vaccines made in chicken eggs which are endemically infected with Campylobactor • Antibodies cross-react against peripheral-nerve antigen • However, the immunologic process that leads to GBS or other neuronal injury is largely unknown

  14. Vaccine Adverse Event Reporting System • National reporting system jointly administered by CDC Immunization Safety Office and FDA • reports submitted voluntarily by people who believe an adverse event occurred after vaccination • May be submitted healthcare providers, patients, or family members • VAERS staff follow-up on all serious and other selected adverse event reports • Data does not infer causality

  15. Addressing parents’ concerns: do vaccines contain harmful preservatives, adjuvants, additives or residuals?Offit, Paul A., Jew, Rita K. Pediatrics, 2003 Preservatives Adjuvants Additives Residuals Antibiotics Cellular residuals

  16. www.cdc.gov

  17. Pediatric hospitalizations associated with 2009 pandemic influenza a (H1N1) in Argentina. Libster, R., et al. N. Engl J Med2010

  18. Vaccine 27 (2009) 2114-2120 1990-2005 Adults > 18 years of age 747.1 million doses of TIV Event reporting rate to VAERS of 24.4 per million TIV 18,245 (14%) were classified as serious events

  19. VAERS

  20. Vellozzi, C., et al. Safety of trivalent inactivated influenza vaccines in adults: Vaccine 27 (2009) 2114-2120

  21. Lancet 2010; 375: 49-55 • Pandemic vaccine – Fluval P – monovalent vaccine with 6 υg haemagglutinin per 0.5 ml content and aluminum phosphate gel adjuvent (n = 178) • Seasonal vaccine – Fluval AB - trivalent inactivated whole-virion • (n = 177)

  22. Vajo, Z., et al. Safety and immunogenicity of a 2009 pandemic influenza A, H1N1 vaccine , Lancet 2010; 375: 49-55

  23. VAERS

  24. GBS and H1N1 vaccination • October 1997 – the Advisory Committee on Immunization Practices of the U.S. Public Health Service recommendations noted: • “ Among persons who received the swine influenza vaccine in 1976, the rate of Gullain-Barre syndrome that exceeded the background rate was slightly less than 10 cases per million vaccinated. Even if Guillain-Barre syndrome were a true side effect in subsequent years, the estimated risk for Guillain-Barre syndrome of 1-2 cases per million persons vaccinated is substantially less than that for severe influenza…”

  25. CDC Statement As of November 24, VAERS had received 10 reports of Guillain-Barré syndrome, and two additional reports of possible Guillain-Barré syndrome were identified by medical officers reviewing other reports to VAERS describing neurologic events After chart review, four of these 12 reports met Brighton Collaboration criteria for Guillain-Barré syndrome, four did not meet the criteria, and four are under review

  26. References Libster, R., et al. Pediatric hospitalizations associated with 2009 pandemic influenza a (h1n1) in argentina. N Engl J Med 2010; 362: 45-55 Vellozzi, C., et al. Safety of trivalent inactivated influenza vaccines in adults: background for pandemic influenza vaccine safety monitoring. Vaccine 27 (2009) 2114-2120 Kerr, Douglas A., Ayetey, Harold. Immunopathogenesis of acute transverse myelitis. Current Opinion in Neurology 2002, 15: 330-347 Mossad, Sherif B. The resurgence of swine-origin influenza a (h1n1). Cleveland Clinic Journal of Medicine Volume 76 Number 6 June 2009 Haber, P., et al. Guillain-barre syndrome following influenza vaccination. JAMA, November 24, 2004—Vol 292, No. 20 Scheibner, Viera. Adverse effects of adjuvents in vaccines. Nexus Dec 2000 (Vol 8, No1) & Feb 2001 (Vol 8, Number 2) Vajo, Z., et al. Safety and immunogenicity of a 2009 pandemic influenza a h1n1 vaccine when administered alone or simultaneously with the seasonal influenza vaccine for the 2009-10 influenza season: a multicentre, randomised controlled trial. Lancet 2010; 375: 49-55. MMWR. “Update on Influenza A (H1N1) 2009 Monovalent Vaccines.” October 9th, 2009. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5839a3.htm

  27. HPI • C.A • Day 1 • Severe HA, b/L hip pain, low grade fever, generalized malaise/ mylagias, H/o visit to Nigeria 3 weeks prior. • Day 2 -Taken to PMD • Congestion /T-103 with HA dx as acute sinusitis • Sent home on Bactrim • Day 3 - Taken to first OHS • Symptoms worsen with persistent fevers • Chest-xray –negative/Rapid strep positive • Sent home with Pen VK (no h/o sore throat)

  28. HPI • Day 3 • Symptoms persisted plus onset of abdominal pain/vomiting • Taken to 2nd OHS ER • CT-negative for acute abdominal process/patchy infiltrate of LLL- on chest x-ray • Thrombocytopenia/elevated LFT’s/hyponatremia/ febrile • Patient admitted for w/u of poor clinical status and abnormal labs

  29. HPI • Day 4-5 • HD 2-3 • Worsening thrombocytopenia, onset of anemia and hyponatremia with elevated creatinine • Persistent fevers • CMV neg, EBV positive, Hepatitis panel neg, Mono spot neg, Urine cx / Blood cx neg • HD 2-Malaria Smear obtained • HD 3- Worsening labs/ Smear positive for P.falciparum • Obtained first dose of atovaquine-proguanil • Hypotensive to 80/50’s with heart rate 100’s/dizzy/ decreased UOP transferred to Sinai PICU

  30. Physical Examination, Day 5 • Day 5, Transfer to Sinai PICU • VS: Wt-74.6kg, B.P-100/50, H.R-90’s,R.R-18 100% on 1LNC • General: Tired appearing but interactive • Skin: No lesion or rashes • HEENT: No oropharyngeal erythema, PERRL, anicteric, no nystagmus • Neck: Normal ROM with some tenderness • CV: RRR,S1S2 normal. No murmurs, rubs, gallops. cap refill < 2sec • Lungs: Occasional course BS with adequate/equal air entry • Abdomen: Tender diffusely, RUQ most tender, No guarding or rebound, No HSM with normal BS • Neuro: CN II-XII intact with motor/sensation intact throughout. Alert/oriented X3 • MS: Pain on passive extension/flexion of hip. Negative hip roll. No effusions or tenderness of joints. 3/5 strength of b/l lower extremities ,5/5 strength of upper extremities

  31. Labs Remarkable for • Creatinine of 1.13 • T/D.bilirubin of 7.4/5.8, AST of 164, ALT of 140 and CBC with Hgb / Hct of 9.8/29.6 and Platelets of 28 • Slightly abnormal coagulapathy with INR of 1.2, D-dimer of 35.2, PT of 12.3,PTT of 38.7 • Low haptoglobulin • Negative urine dip and normal VBG • Normal: Hgb electrophoresis, G-6PD study

  32. PICU Course • Day 5-8 • Continue on atovaquine-proguanil with improvement in fever curve after 24 hours • Anemia persisted but all other labs improved • Blood smears collected every 12 hours,parasite density fell from 13% to 4% in 24 hours and less than 1% prior to floor transfer • Day 8-12 • On the floor improving symptoms except on Day of illness 11 • Double vision and headache reoccurred with dizziness • CT of head negative • Transfused with PRBCS for Hgb of 5.8 with resolution of symptoms • D/C home after 3 negative smears, Course of 3 days of oral anti-malarial and improved fever

  33. Labs Remarkable for • Creatinine of 1.13 • T/D.bilirubin of 7.4/5.8, AST of 164, ALT of 140 and CBC with Hgb / Hct of 9.8/29.6 and Platelets of 28 • Slightly abnormal coagulapathy with INR of 1.2, D-dimer of 35.2, PT of 12.3,PTT of 38.7 • Low haptoglobulin • Negative urine dip and normal VBG • Normal: Hgb electrophoresis, G-6PD study

  34. Blood Smear : Pre-treatment

  35. Pre-treatment

  36. Pre-treatment

  37. Post treatment

  38. Post Treatment

  39. Objectives Discuss Malaria and its Presentation Review Differential Diagnosis of Febrile Traveler Study CDC Guidelines for chemoprophylaxis of malaria Present CDC Treatment Guidelines Investigate recent studies on Treatment of Severe Anemia caused by malaria

  40. Definition • Parasitic infection with Plasmodium protozoa • Transmitted by vector female Anopheles mosquito • 4 species to cause infection in humans • P. falciparum • P.vivax • P.ovale • P.malariae • Plasmodium knowlesis recently identified to cause human infection

  41. Epidemiology • 350-500 million cases worldwide • Predominates in tropical areas • Over 1 million people die • Most young children in Sub-Saharan Africa • Account 20% of childhood deaths in Africa • Every 30 seconds a child dies from malaria • 1200 malaria cases reported annually

  42. Epidemiology

  43. http://wonder.cdc.gov/wonder

  44. Sources of Infection in U.S • Imported • Majority of cases • Airport Malaria • Mosquitoes fly from endemic to non-endemic area and infect local residents • Locally transmitted • h/o of outbreaks in Southeast • Congenital • Blood Transfusions • One case every 2 years • 1 case per 4 million units of blood

  45. Sources of Infection in U.S • 1997 to 2006-10, 745 cases of malaria reported in the U.S • 59.3% -sub-Saharan Africa • 13.9% -Asia • 13.3%-Caribbean and Central/South America • 0.03% -Oceania • 54 fatal cases reported in the U.S • 85.2% caused by P.falciparum • 71.1% from sub-Saharan Africa

  46. Life Cycle

  47. Clinical Presentation • Symptoms present as early as 7-14 days or as late as several months or longer after exposure • Uncomplicated • Fever, Anemia, influenza-like symptoms, jaundice, transient HA, myalgias • Severe • >5% parasite load • Mental confusion, seizures, kidney failure, acute respiratory distress syndrome, coma, death

  48. Differential To Consider Typhoid Fever Dengue Filarians Leishmanians Onchoncerciasis African trypanosomiasis

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