1. Cases for the Pediatric IV Module

2. CASE I “Kizzin Cuzzins”

3. 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

4. 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?

5. 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 C; CR-120/min.; RR-
33/min.; appeared acutely ill and toxic.

6. 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

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

8. 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

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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. Herpes simplex Infection
Herpetic gingivostomatitis in adult

17. 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

18. 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

19. 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

20. Streptococcal Tonsillopharyngitis
Exudative Tonsillitis
Cervical lymphadenitis

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

22. 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

23. Tonsillopharyngeal Diphtheria

24. 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)

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

26. 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

27. 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

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

29. 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

30. Question 6: What complications of Diphtheria can be anticipated?

31. 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)

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

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

34. 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

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

36. 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

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

38. 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

39. 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

40. CASE 1 “Kizzin Cuzzins”