Cases for the Pediatric IV Module

CASE I “Kizzin Cuzzins”

Topics for Case 1 Grp A B-hemolytic Streptococcus C. diphtheriae Grp C B-hemolytic Streptococcus N. gonorrheae S. aureus Candida Albicans Adenovirus Epstein Barr virus Coxsackie virus (Herpangina) Herpes simplex virus Parainfluenza virus Influenza virus Mumps

Questions/Tasks How would you approach the problem of sore throat? What are the etiologic agents of Tonsillopharyngitis in children? What is/are the distinguishing feature/s of Tonsillopharyngeal diphtheria? What differentiates the ‘bull-neck” appearance of Diphtheria from Mumps? What laboratory tests/procedures is/are indicated to confirm the diagnosis of Diphtheria? What complications of Diphtheria can be anticipated? 7. Give the curative and preventive principles of therapy for diphtheria 8. What is the drug of choice and acceptable alternative therapies for Streptococcal tonsillopharyngitis? 9. What is the rationale and goals of treatment of Grp A B-hemolytic Streptococcal tonsillopharyngitis? 10. What are the indications for removal of the tonsils and adenoids?

Case 1 – “Kizzin Cuzzins” Em-em, 9 years old; female Chief complaint: high fever and sore throat with difficulty of swallowing accompanied by vomiting and chilly sensation. Mother Had “colds” characterized by watery nasal discharge, sneezing and an itchy throat 3 days earlier PE: Temp. 39.40C; CR-120/min.; RR- 33/min.; appeared acutely ill and toxic.

Case 1 – “Kizzin Cuzzins Posterior pharynx, palatine tonsils and uvula acutely inflamed, bright red and edematous; tonsils markedly enlarged (“kissing”) with several discrete white to gray exudates noted over each tonsillar area. Right tympanic membrane was dull and slightly edematous

Question 1: How would you approach the problem of sore throat?

Approach The best presenting manifestation for this patient is sore throat. “Sore throat” is one of the most common complaints of children seen for medical treatment. Infection may involve the pharynx diffusely (acute pharyngitis) or localized predominantly to the palatine tonsils (acute tonsillitis). The diagnosis is made by carefully visualizing the throat. Erythema, exudates and swollen tonsils are all signs of infection. The clinician faces the basic problem of differentiating self-limiting viral infections from bacterial infections that require antibiotic tx

Question 2: What are the etiologic agents of Tonsillopharyngitis in children?

Etiologic agents Eichenwald estimates that 80 –90% of ATP’s are due to viral agents. Adenovirus, Parainfluenzae and influenzae etc. have implicated in infections of the pharynx and tonsils. Enteroviruses, EBV, Herpes simplex virus may also present as oral lesions GABHS is the most common cause of bacterial infection in the pharynx Others: Group C;S. aureus, Gram (-) organisms, M. pneumoniae and rarely N. gonorrhea and Corynebacterium diphtheriae. ( see p.1396 NELSON) Candida occur in the immunocompromised or those chronically treated with antibiotics

Common Etiologic Agents for Acute Pharyngitis Types of Pharyngeal Lesions: (in diminishing frequency) Erythematous – S. pyogenes, Adenovirus, C.pneumoniae Follicular – Adenovirus, S. pyogenes (to a much lesser degree) Exudative – C. diphtheriae, EBV, S. pyogenes Ulcerative – Herpes simplex, Enterovirus Petechial – S. pyogenes, EBV Modified from: Cherry JD, Textbook of Pediatric Infectious Disease 4th edition

Epstein-Barr virus infection Infectious mononucleosis The tonsils are swollen and covered with uniform white exudates. Uvula looks swollen and the patient’s speech is nasal The typical exudate are patches forming thick plaques of opaque white membrane Anginose variety of Infectious Mononucleosis

Epstein-Barr virus infection Infectious Mononucleosis Moderate leukocytosis develops between the 1st and 2nd week – the result of an absolute increase in circulating lymphocytes many of which are abnormal A large number of atypical mononuclear cells in peripheral blood is one of the characteristics of the disease Atypical lymphocytes

Herpangina (Enterovirus) Caused by type A coxsackievirus Characterized by an acute onset with high fever, sore throat and dysphagia. Throat is inflamed and small discrete vesicles surrounded by a band of erythema may be seen scattered over the palate, fauces and pharynx

Herpes simplex Infection Herpetic stomatitis: Presents as vesicular (ulcerative) eruptions but tend to affect the anterior half of the buccal cavity whereas herpangina is confined to the posterior Herpetic gingivostomatitis

Herpes simplex Infection Herpetic gingivostomatitis in adult

Thrush Oral Candidiasis: May occur in infants as a result of cross-infection from the mother or other infants esp. in bottle-fed babies In adults, infection is usually endogenous & found in dehydrated or debilitated patients or when the bacterial flora is disturbed by antibiotic therapy

Viral vs. Bacterial tonsillopharyngitis Features Acute Streptococcal Non-GBS (Viral) Time course of onset Presenting Sx: Gen. Toxicity/malaise Abdominal pain Vomiting Headache Fever Respiratory tract: Cough Hoarseness Nasal congestion Conjunctivitis Sudden Moderate to severe Common Moderate to high Rare Gradual Mild to moderate Low to mod.high Ambulatory Pediatrics, Green and Haggerty

Viral vs. Bacterial tonsillopharyngitis Features Acute Streptococcal Non-GBS (Viral) Pharynx: Sore throat Tonsillar erythema Exudate Petechial on soft palate Very common Moderate to extensive Small to extensive (if extensive rule out Diphtheria) Common Minimal to moderate None to small (except EBV - may have extensive exudates) Rare Ant.cervical nodes: Enlarged Tender -palpation Age Moderate to severe Generally > 3 yrs. Any age Ambulatory Pediatrics, Green and Haggerty

Streptococcal Tonsillopharyngitis Exudative Tonsillitis Cervical lymphadenitis

Question 3: What is/are the distinguishing feature/s of Tonsillopharyngeal Diphtheria?

Tonsillopharyngeal Diphtheria The membrane of diphtheria tends to be darker, grayer, more fibrous and adherent than in other conditions . When forcibly removed, bleeding is likely to occur Knowledge of the child’s immune status is helpful in differentiating

Tonsillopharyngeal Diphtheria

Diphtheria Epidemiology In many developing tropical countries where immunization is not routinely performed, the disease is still common and results in considerable morbidity and a significant mortality. The organism produces an exotoxin which is species specific however only strains infected with a bacteriophage carrying tox gene are toxigenic 88 cases (National Epidemiology Center, DOH 2003)

Question 4: What differentiates the “bull-neck” appearance of Diphtheria from Mumps?

Diphtheritic cervical adenitis vs Mumps Diphtheria -the neck is swollen due to cervical adenitis and periglandular edema. At this time, patient is very ill, toxic, lethargic, drowsy but often afebrile

Mumps Rapid onset of parotitis appearing 2-3 wks. following contact. Prodromal sx of malaise, myalgia, headache and pain over parotid glands. Constitutional sx become more intense in next 1-3 days and parotid swelling displaces the earlobe outwards and upwards. Pain is aggravated by chewing and tasting sour fluids Orifices of Stensen’s & Wharton’s ducts are erythematous and pouting

Question 5: What laboratory tests/procedures is/are indicated to confirm the diagnosis of Diphtheria?

Diphtheria The diagnosis of diphtheria must be made early and on clinical grounds so that treatment can be given early and progress of the disease halted. If clinical index of suspicion is high, treatment must be initiated even before laboratory confirmation Confirmation -positive identification of C.diphtheriae on selective media Schick test is useful for determining immune status to diphtheria

Question 6: What complications of Diphtheria can be anticipated?

Diphtheria Complications: Myocarditis Neuritis Glomerulonephritis 2/3 of patients develop myocarditis but in only 10-25% is this clinically important. Occurs between D10 and D20 Neuritis affects 75% of patients with severe disease. Affects cranial & peripheral nerves: palate (3 wks); oculomotor (4 wks); respiratory (7 wks) and peripheral nerves (10 wks)

7. Give the Curative and Preventive principles of therapy of Diphtheria

Question 8: What is the rationale and goals of treatment of Group A B-hemolytic Streptococcal tonsillopharyngitis?

Rationale and goals of Tx Prevent rheumatic fever Prevent suppurative complications Abatement of clinical symptoms Reduce transmission of group A streptococcus Minimize adverse effects of inappropriate antibiotic therapy Recommendations of Infectious Diseases Society of America, CID 25:574,1997

Question 9: What is the Drug of choice and acceptable alternative therapies for Streptococcal tonsillopharyngitis

DOC for Streptococcal tonsillopharyngitis Except in penicillin-allergic patients, Penicillin V is the drug of choice (there has been no documented reports of resistance) Erythromycin most widely recommended for penicillin-allergic patients

Question 10: What are the indications for removing the tonsils and adenoids?

Tonsillectomy and Adenoidectomy DEFINITE: Obstructive tonsils/adenoids causing obstructive apnea or cor pulmonale Malignancy Persistent or recurrent tonsillar hemorrhage RELATIVE: Peritonsillar abscess Recurrent documented tonsillitis Chronic otitis media with effusion Bluestone CD: Current indications for Tonsillectomy & Adenoidectomy Ann. Otol.Rhinol. Laryngol, 101:58-64,1992

Key Learning Points for Sore throat Not all ‘streptococcal-looking” pharyngitis is due to streptococcus Streptococcal sore throat in infants is rare. Adenovirus is a more common etiology of pharyngitis of this age Treatment of Strep throat helps prevent rheumatic fever and may speed up recovery from pharyngitis Streptococcal tonsillopharyngitis relapses should be treated with alternatives to penicillin if the patient did have good compliance with the initial PCN course

CASE 1 “Kizzin Cuzzins”