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Rhinosinusitis Bronchitis Tuberculosis Atypical Respiratory Infections ( Chlamydia/ Mycoplasma pneumonia). RESPIRATORY DISEASES. Pua Santos. Rhinitis. Inflammation of the nasal mucosa Common etiologic agent: RHINOVIRUS
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RhinosinusitisBronchitisTuberculosisAtypical Respiratory Infections (Chlamydia/ Mycoplasma pneumonia) RESPIRATORY DISEASES Pua Santos
Rhinitis • Inflammation of the nasal mucosa • Common etiologic agent: RHINOVIRUS • Mannose-binding lectin deficiency – associated with increased incidence of colds in children • Acute inflammatory response appears to be responsible for the symptoms • Most common complication: Otitis Media
Rhinosinusitis • Inflammation of the nares and paranasal sinuses • Bacterial Pathogens: • Streptococcus pneumoniae – 30% • Nontypable H. influenzae – 20% • Moraxella catarrhalis – 20%
Pathogenesis: Bacterial Sinusitis Bacteria from the nasopharynx that enter the sinuses are normally cleared During viral rhinosinusitis, inflammation and edema – block sinus drainage, impair mucociliary clearance of bacteria
Acute Bacterial Sinusitis Persistent of URTI (nasal discharge and cough) > 10-14 days without improvement Severe respiratory symptoms, including fever Purulent nasal discharge for 3-4 consecutive days
Complications Orbital, periorbital cellulitis – due to close proximity to the parasinuses Intracranial complications – meningitis, cavernous sinus thrombosis, subdural empyema, brain abscess
Treatment • Amoxicillin 45 mkd for uncomplicated acute bacterial sinusitis • Appropriate duration has yet to be determined – usually treat up to 7 days after resolution of symptoms • Co-amoxiclav for children with risk for resistant bactria • Age < 2 yo • Daycare attendance • Antiobiotic treatment in preceding 1-3 months
Bronchitis Nonspecific bronchial inflammation and is associated with a number of childhood conditions
Acute Bronchitis • Commonly preceded by viral upper respiratory tract infection • Invasion of tracheobronchialepithelium ----- activation of inflammatory cells and release of cytokines • Tracheobronchial epithelium significantly damaged or hypersensitized ----- protracted cough lasting 1-3 wk.
Signs/Symptoms Usually lasts about 2 weeks and seldom 3 weeks Low grade fever, malaise Nonspecific upper respiratory infectious symptoms Dry hacking cough which later becomes purulent Chest pain exacerbated by coughing PE: Coarse and fine crackles and scattered high-pitched wheezing on auscultation Chest radiographs are normal or may have increased bronchial markings
Treatment • No specific treatment • Self-limited • Antibiotics do not hasten improvement
Chronic Bronchitis • Recognized in adults, controversial as a disease entity in children • ≥3 mo of productive cough each year for ≥2 yr. • Children with chronic inflammatory diseases or those with toxic exposures can develop damaged pulmonary epithelium
Tuberculosis • M. tuberculosis is the most important cause of tuberculosis disease in humans. • Non-spore-forming, nonmotile, pleomorphic, weakly gram-positive rods 2-4nm long • Obligate anaerobes • Hallmark of all mycobacteria is acid fastness
Transmission • Person to person, usually by airborne mucus droplet nuclei • Young children with tuberculosis rarely infect other children or adult • Tubercle bacilli are sparse in the endobronchial secretions of children with pulmonary tuberculosis, and cough is often absent or lacks the tussive force
Pathogenesis Inhalation of infected droplets Development of primary parenchymal lesion (GHON complex) with spread to the regional lymph nodes Immune response (delayed hypersensitivity and cellular immunity) develops in 4-6 weeks TB infection
Recommended approach to Diagnose TB in children WHO 2006 • Careful History • Contact • Signs and symptoms consistent with TB • Clinical Examination • Tuberculin skin testing • Bacteriologic confirmation, if possible • Further investigation relevant to suspicion of TB
Clinical Manifestation most suggestive of childhood tuberculosis Cough or wheezing > 2 weeks Taken together is most suggestive of childhood TB disease Unexplained or prolonged fever Hx of recent weight loss or failure to gain weight 2008 PPS Evidence based CPG for Childhood TB
TB symptomatic – a child with any of the 3 or more of the ff. signs/symptoms 2008 DOH-NTP Training Modules for TB in children • Cough/ wheezing of 2 weeks or more • Unexplained fever of 2 weeks or more • Either loss of appetite, weight loss, failure to gain weight or weight faltering • Failure to respond to 2 weeks of appropriate antibiotic tx for LRTI • Failure to regain previous state of health after 2 weeks of viral infection • Fatigue, reduce playfulness or lethargy
Tuberculin skin test (TST) Used to screen children exposed to TB Most widely used method to demonstrate TB infection Based on a delayed hypersensitivity to certain antigens of the TB organism
Tuberculin Skin Test PPS TB in infancy and childhood handbook 2010 • Mantoux test read at 48-72 hours regardless of BCG immunization • Positive if... • More than or equal to 5 mm induration in the presence of: Hx of close contact with a TB source, clinical findings suggestive of TB, CXR suggestive of TB, immunocompromised condition • More than or equal to 10 mm induration
Clinical Forms • Pulmonary or Endothoracic TB • Latent TB infection • Primary Pulmonary TB • Progressive primary TB • Reactivation TB • Endobronchial TB • Miliary TB • Extrapulmonary TB
Latent TB Infection • Latent tuberculosis infection (LTBI) occurs after the inhalation of infective droplet nuclei containing M. tuberculosis • A reactive tuberculin skin test (TST) and the absence of clinical and radiographic manifestations are the hallmark of this stage • Untreated infants with LTBI have up to a 40% likelihood of developing tuberculosis • Greatest risk for progression occurs in the 1st 2 yr after infection
Primary Pulmonary Tuberculosis • Primary complexincludes the parenchymal pulmonary focus and the regional lymph nodes. • About 70% of lung foci are subpleural, and localized pleurisy is common. • Nonproductive cough and mild dyspnea are the most common symptoms. • Systemic complaints occur less often. • Pulmonary signs are even less common
Progressive Primary Tuberculosis • A rare but serious complication of tuberculosis in a child occurs when the primary focus enlarges steadily and develops a large caseous center • Liquefaction can cause formation of a primary cavity associated with large numbers of tubercle bacilli • High fever, severe cough with sputum production, weight loss, and night sweats are common • Physical signs include diminished breath sounds, rales, and dullness or egophony over the cavity.
Reactivation Tuberculosis Rare in childhood, more common in adolescent More common in children who acquire initial infection after 7 years old Pulmonary tuberculosis in adults usually represents endogenous reactivation of a site of tuberculosis infection established previously in the body History of fever, cough, hemoptysis, weight loss
Endobronchial Tuberculosis Hyperemic and edematous lymph nodes impinge upon the wall of a bronchus – occlude the lumen usually the right middle lobe bronchus Right Middle Lobe Syndrome: adherence of LN through the airway wall – ulceration of mucosa – Granulation tissue – obstruct lumen of the bronchus
Miliary Tuberculosis • Occurs when massive numbers of tubercle bacilli are released into the bloodstream, causing disease in 2 or more organs • Bacilli spreads via lymphatics to capillaries of most organ system • Liver, Spleen, Marrow and Brain – most oxygenated organs
COMMONLY USED DRUGS FOR THE TREATMENT OF TUBERCULOSIS IN INFANTS, CHILDREN, AND ADOLESCENTS From American Academy of Pediatrics: Red book: 2009 report of the Committee on Infectious Diseases, ed 28, Elk Grove Village, IL, 2009, American Academy of Pediatrics, p 689.
Table 207-5 -- LESS COMMONLY USED DRUGS FOR TREATING DRUG-RESISTANT TUBERCULOSIS IN INFANTS, CHILDREN, AND ADOLESCENTS* In general, the treatment for most forms of extrapulmonary tuberculosis in children, including cervical lymphadenopathy, is the same as for pulmonary tuberculosis. Exceptions are bone and joint, disseminated, and CNS tuberculosis, for which there are inadequate data to recommend 6 mo therapy. These infections are treated for 9-12 mo.
MycoplasmaPneumoniae • Major cause of respiratory infections in school-aged children and young adults • Etiology: • Mycoplasmas are the smallest self-replicating biologic system, dependent on attachment to host cells, complete absence of a cell wall, double-stranded DNA • fastidious, and growth in commercially available culture systems is too slow to be of practical clinical use
Transmission • Occurs through the respiratory route by large droplet spread • Incubation period is 1–3 wk • High transmission rates have been documented within families
Pathogenesis • A possible mechanism of M. pneumoniae disease is the release of various proinflammatory and anti-inflammatory cytokines • Disease produced by M. pneumoniae is complex • Immunologic response of the host may be responsible for the manifestations of disease itself as well as for protection against infection
Clinical Manifestation Tracheobronchitis and bronchopneumonia are the most commonly recognized clinical syndromes associated with M. pneumoniae infection Characterized by gradual onset of headache, malaise, fever, and sore throat, followed by progression of lower respiratory symptoms, including hoarseness and cough Coughing usually worsens during the 1st wk of illness, with all symptoms usually resolving within 2 wk
Treatment Macrolides are effective in shortening the course of mycoplasmal illnesses, although they do not have bactericidal activity Recommended treatment: Clarithromycin (15 mg/kg/day divided bid PO for 10 days) or Azithromycin (10 mg/kg once PO on day 1 and 5 mg/kg once daily PO on days 2-5
Chlamydophilapneumoniae • Common cause of lower respiratory tract diseases, including pneumonia in children and bronchitis and pneumonia in adults • C. pneumoniae is primarily a human respiratory pathogen • Transmission probably occurs from person to person through respiratory droplets
Clinical Manifestation • Pneumonia usually occurs as a classic atypical (or nonbacterial) pneumonia characterized by mild to moderate constitutional symptoms • Fever, malaise, headache, cough, and often pharyngitis • Severe pneumonia with pleural effusions and empyema has been described • Milder respiratory infections have been described, which can manifest as a pertussis-like illness
Treatment Erythromycin (40 mg/kg/day PO divided twice a day for 10 days) Clarithromycin (15 mg/kg/day PO divided twice a day for 10 days) Azithromycin (10 mg/kg PO on day 1, and then 5 mg/kg/day PO on days 2-5)