Pediatrics Aquifer Cases Questions & Answers
definition of fever of unknown origin
fever over 8 days with no apparent origin after workup
meningeal signs in an infant
Fever
Hypothermia
Bulging fontanelles
Lethargy
Irritability
Restlessness
Paroxysmal crying (crying when picked up)
Poor feeding
Vomiting and/or
Diarrhea
Kernig's sign
resistance to extension of the child's leg from a flexed position
Brudzinski's sign
flexion of the hip and knee in response to flexion of the neck by the examiner
Opisthotonos
increased extensor tone of neck and spine leads to hyperextension of the entire spine
Presentation of roseola
A high fever is often the only symptom in the first few days of illness and typically lasts
for 3 to 5 days.
Some patients develop a rash as the fever resolves; the rash can persist from 1 to 4
days.
When does HSV gingivostomatits usually occur?
10 months and three years
What's different about meningitis in babies?
In very young children, the absence of meningeal signs cannot rule out this diagnosis.
Presentation of sepsis in a baby
Early in sepsis an elevated heart rate may be the only vital sign abnormality. Late signs
include evidence of end-organ hypoperfusion: poor perfusion (delayed capillary refill),
low blood pressure, altered mental status and other evidence of organ failure.
Presentation of UTI in a baby
UTI commonly presents as fever and no focus on physical examination and a relatively
unremarkable review of systems.
Normal WBC count for babies
6-17 cells x103/µL
Why not use ampicillin for UTI/
Resistance rates of E. Coli to Ampicilin (A) are rising, so ampicillin alone would not be
appropriate for empiric therapy. Amp/Gent is okay for pyelo and enterococcus.
What antibiotic for UTI in babies?
Ceftriaxone
Why not ciprofloxacin for UTI in babies?
,Ciprofloxacin is not ideal given its high cost and potential for adverse reactions in
children. It is approved for children older than 1 year for complicated UTI with resistant
organisms.
Oral antibiotics for baby UTIs
Keflex, Bactrim, nitrofurantoin (only cystitis, not pyelo)
What to do after first episode of pyelo? Second episode?
first episode of pyelonephritis - renal and bladder ultrasound. second episode - voiding
cystourethrogram
Adenovirus presentation
May cause upper respiratory tract infection, pharyngitis, conjunctivitis, tonsillitis, or otitis
media
Potential for more severe infections in immunocompromised hosts
Kawasaki disease presentation
Fever for at least 5 days
Cervical adenopathy - unilateral and large
Nonpurulent conjunctivitis
Nonspecific ("polymorphic") rash
Swelling and erythema of extremities
Mucosal inflammation
Meningitis in babies - presentation
Fever
Chills, malaise
Rash (often petechial)
May lead to shock and DIC (often rapidly progressing)
Measles presentation
After a prodrome of fever (over 38.3 C, or 101 F), cough, coryza, and conjunctivitis, this
maculopapular rash starts on the neck, behind the ears, and along the hairline.
The rash spreads downward, reaching the feet in two or three days.
The initial rash appears on the buccal mucosa as red lesions with bluish white spots in
the center (known as Koplik spots). These have frequently disappeared by the time the
patient presents to medical attention
Rocky mountain spotted fever presentation
Fever
Headache
Rash (typically starts on ankles and wrists and progresses centrally and to palms and
soles; may be macular or papular at first, quickly becoming petechial; in 5% of cases,
there may be no rash)
Myalgias
Scarlet fever (GAS) presentation
Fever
A diffuse, erythematous, finely papular rash (described as having a "sandpaper" texture)
is pathognomonic
Rash often begins at neck, axillae, and groin and then spreads over trunk and
extremities, typically resolving within four or five days
Enteroviral infection (Coxsackievirus, echovirus, enterovirus) - presentation
, Fever lasting 3-5 days
Nonspecific rash (which may include the palms and soles)
May also cause conjunctivitis, oral ulcers, diarrhea, aseptic meningitis
Erythema infectiosum presentation
(Fifth disease) Low grade fever followed by a rash, which starts as a facial erythema to
the face ("slapped cheek" appearance), which can spread to the trunk and extremities
and appears lacy
Can lead to pain and swelling of the extremities, as well as development of transient
pure red cell aplasia which can lead to severe anemia in patients with underlying
hemolytic disease.
Roseola presentation
HSV6 - "Exanthem subitum." Also called sixth disease
Erythematous macules start on trunk and spread to arms and neck (less commonly face
and legs)
Rash is typically preceded by 3 to 4 days of high fevers, which end as the rash appears
Usually occurs in children under age 2 years
What is LAD like in Kawasaki disease?
Unilateral, with nodes larger than 1.5cm, nonfluctuant
Causes of unilateral cervical LAD
Reactive cervical adenitis, Kawasaki disease, bacterial cervical adenitis, cat scratch
disease, mycobacteria
Strawberry tongue - three associations
GAS pharyngitis, Kawasaki disease, toxic shock syndrome
Heart sequelae of Kawasaki disease
Aneurysm of coronary arteries during the subacute phase (4 weeks of onset)
Three phases of Kawasaki disease
Acute phase: onset through ~10 days. Fever and clinical findings are present, with
serologic evidence of systemic inflammation (elevated acute phase reactants).
Subacute phase: 10 days through ~3 weeks. Fever resolves and clinical findings largely
subside (often with peeling of hands and feet). Serologic evidence of inflammation
continues.
Convalescent phase: 3 weeks through 6-8 weeks. All clinical findings have resolved.
Continued serologic evidence of inflammation.
What does CBC/CMP show in Kawasaki disease?
Elevated WBC with neutrophil predominance, normochrom, normocyt anemia,
thrombocytosis
Low albumin, elevated liver enzymes
What does UA show in Kawasaki disease?
Sterile pyuria secondary to sterile urethritis
Five complications of Kawasaki disease
Aseptic meningitis or other CNS, coronary artery aneurysm, liver dysfunction, arthritis,
hydrops of the gallbladder
Treatment of Kawasaki disease
High dose ASA (80-100mg/day) - no effect on aneurysms, only fever and antiplatelet
effects
IVIG 2g/kg single dose
definition of fever of unknown origin
fever over 8 days with no apparent origin after workup
meningeal signs in an infant
Fever
Hypothermia
Bulging fontanelles
Lethargy
Irritability
Restlessness
Paroxysmal crying (crying when picked up)
Poor feeding
Vomiting and/or
Diarrhea
Kernig's sign
resistance to extension of the child's leg from a flexed position
Brudzinski's sign
flexion of the hip and knee in response to flexion of the neck by the examiner
Opisthotonos
increased extensor tone of neck and spine leads to hyperextension of the entire spine
Presentation of roseola
A high fever is often the only symptom in the first few days of illness and typically lasts
for 3 to 5 days.
Some patients develop a rash as the fever resolves; the rash can persist from 1 to 4
days.
When does HSV gingivostomatits usually occur?
10 months and three years
What's different about meningitis in babies?
In very young children, the absence of meningeal signs cannot rule out this diagnosis.
Presentation of sepsis in a baby
Early in sepsis an elevated heart rate may be the only vital sign abnormality. Late signs
include evidence of end-organ hypoperfusion: poor perfusion (delayed capillary refill),
low blood pressure, altered mental status and other evidence of organ failure.
Presentation of UTI in a baby
UTI commonly presents as fever and no focus on physical examination and a relatively
unremarkable review of systems.
Normal WBC count for babies
6-17 cells x103/µL
Why not use ampicillin for UTI/
Resistance rates of E. Coli to Ampicilin (A) are rising, so ampicillin alone would not be
appropriate for empiric therapy. Amp/Gent is okay for pyelo and enterococcus.
What antibiotic for UTI in babies?
Ceftriaxone
Why not ciprofloxacin for UTI in babies?
,Ciprofloxacin is not ideal given its high cost and potential for adverse reactions in
children. It is approved for children older than 1 year for complicated UTI with resistant
organisms.
Oral antibiotics for baby UTIs
Keflex, Bactrim, nitrofurantoin (only cystitis, not pyelo)
What to do after first episode of pyelo? Second episode?
first episode of pyelonephritis - renal and bladder ultrasound. second episode - voiding
cystourethrogram
Adenovirus presentation
May cause upper respiratory tract infection, pharyngitis, conjunctivitis, tonsillitis, or otitis
media
Potential for more severe infections in immunocompromised hosts
Kawasaki disease presentation
Fever for at least 5 days
Cervical adenopathy - unilateral and large
Nonpurulent conjunctivitis
Nonspecific ("polymorphic") rash
Swelling and erythema of extremities
Mucosal inflammation
Meningitis in babies - presentation
Fever
Chills, malaise
Rash (often petechial)
May lead to shock and DIC (often rapidly progressing)
Measles presentation
After a prodrome of fever (over 38.3 C, or 101 F), cough, coryza, and conjunctivitis, this
maculopapular rash starts on the neck, behind the ears, and along the hairline.
The rash spreads downward, reaching the feet in two or three days.
The initial rash appears on the buccal mucosa as red lesions with bluish white spots in
the center (known as Koplik spots). These have frequently disappeared by the time the
patient presents to medical attention
Rocky mountain spotted fever presentation
Fever
Headache
Rash (typically starts on ankles and wrists and progresses centrally and to palms and
soles; may be macular or papular at first, quickly becoming petechial; in 5% of cases,
there may be no rash)
Myalgias
Scarlet fever (GAS) presentation
Fever
A diffuse, erythematous, finely papular rash (described as having a "sandpaper" texture)
is pathognomonic
Rash often begins at neck, axillae, and groin and then spreads over trunk and
extremities, typically resolving within four or five days
Enteroviral infection (Coxsackievirus, echovirus, enterovirus) - presentation
, Fever lasting 3-5 days
Nonspecific rash (which may include the palms and soles)
May also cause conjunctivitis, oral ulcers, diarrhea, aseptic meningitis
Erythema infectiosum presentation
(Fifth disease) Low grade fever followed by a rash, which starts as a facial erythema to
the face ("slapped cheek" appearance), which can spread to the trunk and extremities
and appears lacy
Can lead to pain and swelling of the extremities, as well as development of transient
pure red cell aplasia which can lead to severe anemia in patients with underlying
hemolytic disease.
Roseola presentation
HSV6 - "Exanthem subitum." Also called sixth disease
Erythematous macules start on trunk and spread to arms and neck (less commonly face
and legs)
Rash is typically preceded by 3 to 4 days of high fevers, which end as the rash appears
Usually occurs in children under age 2 years
What is LAD like in Kawasaki disease?
Unilateral, with nodes larger than 1.5cm, nonfluctuant
Causes of unilateral cervical LAD
Reactive cervical adenitis, Kawasaki disease, bacterial cervical adenitis, cat scratch
disease, mycobacteria
Strawberry tongue - three associations
GAS pharyngitis, Kawasaki disease, toxic shock syndrome
Heart sequelae of Kawasaki disease
Aneurysm of coronary arteries during the subacute phase (4 weeks of onset)
Three phases of Kawasaki disease
Acute phase: onset through ~10 days. Fever and clinical findings are present, with
serologic evidence of systemic inflammation (elevated acute phase reactants).
Subacute phase: 10 days through ~3 weeks. Fever resolves and clinical findings largely
subside (often with peeling of hands and feet). Serologic evidence of inflammation
continues.
Convalescent phase: 3 weeks through 6-8 weeks. All clinical findings have resolved.
Continued serologic evidence of inflammation.
What does CBC/CMP show in Kawasaki disease?
Elevated WBC with neutrophil predominance, normochrom, normocyt anemia,
thrombocytosis
Low albumin, elevated liver enzymes
What does UA show in Kawasaki disease?
Sterile pyuria secondary to sterile urethritis
Five complications of Kawasaki disease
Aseptic meningitis or other CNS, coronary artery aneurysm, liver dysfunction, arthritis,
hydrops of the gallbladder
Treatment of Kawasaki disease
High dose ASA (80-100mg/day) - no effect on aneurysms, only fever and antiplatelet
effects
IVIG 2g/kg single dose
