JUNE BOARD REVIEW

ID Part Deux

Test Question

I will watch the summer olympics this year.A. TrueB. False

Bronchiolitis

Intro Bronchiolitis is caused by inflammation of the

bronchioles by an acute viral infection *Most common lower respiratory tract

infection in infants and children under 2 Infectious agents:

RSV (most common)AdenovirusMetapneumovirusInfluenza virusParainfluenza virus

*Epidemiology of RSV

*Know the mode of transmissionDirect or close contact with contaminated

secretions○ Large droplets at short distances○ Fomites

RSV can persist on environmental surfaces for several hours○ ½ hour on hands

*Epidemiology of RSV *Incubation period

Ranges from 2 to 8 days *Period of communicability

Usually 3 to 8 days○ Shedding can last longer in young infants and

immunosuppressed people (3 to 4 weeks)

*Age of onsetMost infants infected during 1st year of lifeVirtually all by 2 years of age

*Peak seasonWinter and early spring

Question #1

All of the following patients are at high risk for morbidity and mortality from RSV infection EXCEPT:A. A premature infantB. A 1-month-old with unrepaired congenital

heart diseaseC. A 4-month-old ex-32 WGA with BPDD. A full-term infant with hyperbilirubinemiaE. A 2-month-old with cerebral palsy

*Epidemiology of RSV

*Risk factors for morbidity and mortalityPrematurityUnrepaired congenital heart disease

○ Pulmonary overcirculationChronic lung diseaseAirway abnormalities

○ Laryngomalacia○ Tracheomalacia○ Cleft lip/palate

Neurologic abnormalities

*Clinical Manifestations History of recent upper respiratory tract symptoms

followed by cough, tachypnea, and increased work of breathing

Physical findings:Nasal congestionRhinorrheaCoughTachypneaIncreased respiratory effort

○ Nasal flaring, grunting, retractionsCrackles, wheezes, upper airway noiseApnea

○ May be only presenting sign in young infants

Course

Characteristic pattern Expect worsening symptoms

Peak symptomatology on day 3 to 4“Day of illness” important for anticipatory

guidance, admission/discharge decisions, etc.

Diagnosis Based on history and

physical Routine lab and

radiologic studies are not recommended CXR not routinely

recommended○ Often are abnormal

appearing (hyperinflation, atelectasis, infiltrates)

○ Do not correlate with disease severity

○ Do not guide management○ May prompt unnecessary

antibiotics for PNA which is rare in viral bronchiolitis

Diagnosis Viral studies are not recommended for

diagnosis *Know the laboratory diagnosis of RSV

Viral antigen detection ○ Enzyme immunoassay technique○ Sensitivity mostly 80 to 90%○ From nasopharyngeal specimens

Viral culture○ Requires 1 to 5 days○ From nasopharyngeal secretions○ Sensitivity varies among laboratories

Question #2 A 3-month-old male ex-38 WGA comes to the

emergency room with a history of upper respiratory symptoms for 3 days, fever, decreased appetite and increased work of breathing. On PE his vitals are T 99 RR 45 HR 185 BP 90/65 and Sat 96% on room air, he has nasal congestion, mild retractions, and course breath sounds He has an older sister in pre-K.

Of the following the MOST appropriate next step in management is:A. Start albuterol nebsB. Give Orapred 2mg/kgC. IVFs with normal salineD. Supplemental oxygenE. Nasal decongestants

Management

*Plan the management of RSV infectionSupportive careHydrationOxygenationOther measures (bronchodilators,

corticosteroids, antiviral agents, CPT, nasal suction, decongestant drops) have been shown to have impact on duration of illness, severity of clinical course, or subsequent outcomes

Management

Hydration↑ RR, secretions, fever, poor feeding →

dehydrationMay require IV fluids or NG feedsBronchiolitis causes ADH release → risk for

hyponatremia○ Use isotonic fluids

Management

OxygenationResults from impaired diffusion, V/Q mismatch,

plugging of bronchiolesGoal is to maintain normal satsNo clear consensus on pulse ox range

○ Aim for sats between 90 to 92%Monitoring

○ Schedule spot checks○ Continuous pulse ox only for those with previous O2

requirement, risk for apnea, or with underlying cardiopulmonary conditions

Managment

BronchodilatorsAAP does not recommend routine useA monitored trial may be considered, but

only continued if clinical response is documented○ Diminished work of breathing○ Decrease in RR○ Improvement in hypoxemia

Managment

SteroidsBased on current evidence, corticosteroids

should not be used to treat bronchiolitis Ribavirin

Should not be used routinelyMay be considered in special situations:

○ Organ transplant, malignancy, congenital immunodeficiencies

Very expensive

Management

CPTBronchiolitis (V/Q mismatch) is unaffected by

regional CPT Nasal suction

May increase comfort and improve feedingMost beneficial before feedings and in response

to copious secretions Nasal decongestants

No proven efficacy, potential harmful side effectsShould not be used in children under 2

Question #3

The major benefit of palivizumab prophylaxis is:A. Decreased hospitalization rateB. Improved treatmentC. Increased cost-effectivenessD. Lower mortality rateE. Shorter duration of illness

*Prevention

*Identify patients who may benefit from prophylaxisPalivizumab (Synagis)

○ Monoclonal antibody (IgG) against RSVCandidates

○ History of prematurity○ Infants with chronic lung disease○ Infants with hemodynamically significant

congenital heart disease

Prevention

•Effectiveness of palivizumab beyond the second year is unknown•Prophylaxis should be administered in 5 monthly doses beginning in November•Not overall cost-effective

Question #4 It’s December and a mom is in your office with

her 6 week-old daughter is worried about RSV. Her older son who is now 4-years-old had it as a baby and had to be hospitalized. She asks you if there is anything she can do at home to help prevent her daughter from catching it.

All of the following are ways to reduce the risk of RSV EXCEPT:A. Avoid tobacco smokeB. Encourage breastfeedingC. Washing hands with soap and water thoroughlyD. Vitamin C supplementsE. Alcohol-based hand sanitizer after contact

Prevention

Strict hand hygiene and isolation

policies Avoidance of tobacco smoke

Independent risk factor for contracting bronchiolitis

Encouragement of breastfeedingContains immune factors that can prevent

RSVNeutralizing activity against RSV

Prognosis

Most recover without sequelae A portion develop recurrent wheezing

40% have subsequent wheezing episodes through 5 years of age

10% have subsequent wheezing episodes after 5 years

Question #5 An 11-month-old boy presents to your office with a 5-

day history of fever, nasal congestion, conjunctivitis, and the development of a rash over the past 24 hours. The rash began on his head and neck and spread to his trunk and extremities. The family recently returned from a trip to Ireland. His past medical history is unremarkable, and his immunizations are up to date.

Of the following, the BEST test for diagnosing this child’s condition is:A. Measles IgM serologyB. Nasal aspirate for viral cultureC. Rubella IgM serologyD. Skin biopsyE. Throat culture for Group A Streptococcus

Measles (Rubeola)

Transmission

*Transmission:Direct droplet contactAirborne spread

Incubation period: 8-12 days Period of communicability: 1-2 days

before any symptoms appear until 4 days after the rash appears

*Clinical Presentation Exposure Fever, malaise Coryza, cough,

conjunctivits Koplik spots Exanthum Exanthem: red/ purple papules appear at

hairline, then spread downward (@ toes by day 3)Coalescence common on face and upper bodyFades in same fashion (headtoe)

24h8-12d

48h 2-3d

Measles

Koplik spots

*Control Measures Isolation (airborne precautions) Immunization/ Immune globulin

First determine who is susceptible○ <2 doses of MMR vaccine after the first birthday○ Low titers in response to vaccine administration○ No documentation of measles by a physician ○ Immunocompromised patients

If susceptible:○ MMR vaccine within 72hours of exposure○ IM Immune globulin within 6 days of exposure:

Household contacts if vaccine not given within 72h Immunocompromised patients Infants <12mo***

*Complications

OM Bronchopneumonia Laryngotracheobronchitis Diarrhea Acute encephalitis Subacute sclerosing panencephalitis

(SSPE)

Rubella (German measles)

Transmission

*Transmission:Person-to-person spread via droplet inhalation

*Incubation period: 2 to 3 weeks *Period of communicability: several days

before to 2 weeks after the onset of the rash

In 2005, the CDC announced that rubella had been eliminated from the USBut, it’s still on the Boards!!

*Postnatal Clinical Presentation

Exposure Tender adenopathy (post-auricular, posterior cervical, and occipital); malaise, HA, low-grade fever, sore throat

Exanthem (+/- Forchheimer spots) Exanthem: rose-pink maculopapules on face

that spread quickly to involve trunk and then extremitiesDay 2: rash on face disappears, truncal rash

coalesces Day 3: rash disappears

14-21 d

1-5 d

Rubella

Forchheimer Spots

Question #6

All of the following are sequelae of congenital rubella syndrome, EXCEPT:A. Sensorineural hearing lossB. CataractsC. Radiolucenicies in the metaphyses of

long bonesD. Heart diseaseE. Craniofacial abnormalities

*Congenital Rubella

Highest rate of infection 1st and 3rd trimesters, morbidity associated with 1st trimester infectionPresentation:

Blueberry muffin lesions Radiolucencies in

metaphyseal long bones PDA (or ASD/VSD) Sensorineural deafness Cataracts/ glaucoma HSM IUGR

Question #7 A mother of one of your patients is in her first

trimester of pregnancy and just found out that her internationally adopted niece has contracted rubella. She wonders when it will be safe for her to be around her niece again. You tell her:A. She should stay out of contact until the LAD resolvesB. She should stay out of contact until the fever resolvesC. She should stay out of contact until the exanthem

resolvesD. She should stay out of contact until the exanthem

appearsE. She does not need to worry…contracting rubella in this

stage of her pregnancy is unlikely to cause any sequelae

*Control Measures

Primary focus: preventing CRSMaintaining elevated vaccine coverage rates

in children and adolescentsProviding adequate surveillance systemsTimely investigations during outbreaks

○ Active cases should be reported to local public health authorities

Susceptible individuals should be kept out of contact with anyone infected with rubella○ Despite widespread vaccination, some women

of childbearing age may be susceptible

Meningococcal disease

Neisseria meningitidis *Know the epidemiology of

Neisseria meningitidisFive serotypes: A, B, C, Y, and W-135

○ B, C, and Y cause most cases in North America○ More than 50% of cases in infants caused by

serogroup B → *NOT preventable with vaccines*Leading cause of bacterial meningitis in young

childrenMost often occurs in kids 2 and younger

○ Peak in kids under 1○ Another peak in adolescents age 15 to 18

*Epidemiology Asymptomatic colonization of the upper

respiratory tract is how the organism is spread10 to 40% of adolescents and adults are carriers

Transmission occurs from person to person through droplets from respiratory tractRequires close contactOutbreaks get media coverage

○ Less than 5% of cases associated with

outbreaks

Incubation period is 1 to 10 days

Question #8

You are discussing with medical students the risk factors that increase the likelihood that transmission from carriers will result in meningococcal disease.

Of the following groups, the risk of disease is HIGHEST among:A. School childrenB. Vaccinated students living in college dormsC. Healthy nonsmoking adultsD. Household contacts of an index caseE. Toddler in child care centers

*Risk factors Environmental factors

Crowded living conditions○ College dorms, military barracks

Secondary infection among household contacts is up to 800 times that in the general population

Active and passive tobacco smoke *Understand which patients are at increased risk

of invasive and recurrent meningococcal diseaseTerminal complement deficiencyHypogammaglobulinemiaAnatomic or functional asplenia

Clinical Syndromes

*Know the major clinical syndromes of Neisseria meningitidisSevere meningococcal septicemiaMeningococcal meningitis

Systemic manifestations of the organism reproducing in the blood50% have isolated meningitis10 to 15% have severe meningococcal

septicemia40% have a mixed picture

*Severe Meningococcal Septicemia Characterized by sudden onset, rapid

progression, and absence of localizing findings

More severe than meningitis Fatality rate is high (40 to 50%) Most patients have no

immunocompromise

*Severe Meningococcal Septicemia Symptoms and physical findings

High fever, shaking chills, myalgias, extremity or back pain

Deteriorate within 6 hoursRash

○ Classically petechial○ Often become hemorrhagic○ Coalesce to form widespread purpura

Purpura fulminans○ Aggressive spread of purpura to large areas with iscemic

necrosis○ Likely to have sudden drops in blood pressure and acute

adrenal hemorrhage (Waterhouse-Friderichsen)

Rash

*Severe Meningococcal Septicemia Early diagnosis and treatment still evades

clinicians Look for early clues

TachycardiaRash

○ Typically present in 24 hours○ Fever and petechial rash is SMS until proven otherwise

True rigorsSevere pain in neck, back, and extremitiesVomitingConcern of parentExposure

Meningococcal Meningitis *Signs and symptoms of typical bacterial

meningitis1 to 3 day non-specific prodrome with low-grade

fever and URI symptomsCushing triad can occur (bradycardia, HTN, resp.

depression) as ICP risesMeningismusMental status changesSudden and severe headache with photophobiaGI complaintsMyalgias

Question #9 You are working in the ER and see a 14-month-old boy,

previously healthy and fully immunized, who has had cold symptoms for the past 2 days. Late this morning, he developed a temp of 101, malaise, and discomfort. On PE you see scattered petechiae over his trunk. He is alert, but very fussy.

Of the following, which is the GOLD standard to make the bacteriologic diagnosis in this case?A. PCRB. Culture of normally sterile siteC. Gram stainD. Antigen detectionE. Antibody titers

Diagnostic studies *Know the diagnostic tests for invasive

meningococcal diseaseGram stain

○ Of CSF is highly sensitive and specificCulture of sterile site

○ Gold standard○ Can culture aspirate of purpuric lesion

Antigen detection○ In CSF can support diagnosis, but high false-negative

ratesPCR

○ Useful in patients who have already received abx○ Use in UK, but not widely in US

Diagnostic Studies

Lab tests may return too late or may fall within normal range in a precipitous course

CSFWBC elevated, low glucose, elevated

proteinHowever, a negative LP result is an ominous

finding in a patient with invasive meningococcal disease

Question #10 You admitted a patient to the hospital with rapid onset of

fever, petechial rash, myalgias, and mental status changes. You are worried about invasive meningococcal infection. You intubate the patient, begin IVFs, draw blood cultures and start ceftriaxone. The patient is placed on droplet precautions. The blood culture grows N. meningitidis the next day. The nurse asks how long the patient needs to be in respiratory isolation.

Of the following, the BEST answer is until the child:A. completes 1 day of antimicrobial therapyB. defervecesC. is clinically stableD. is extubatedE. is proven not to have meningitis

*Management

*Plan the treatment of a Neisseria meningitidus infectionFirst step is recognition and aggressive

treatmentRefer to emergency care facility

IVFsLarge isotonic fluid bolusesGiving 60 to 100 ml/kg in first hour assoc.

with improved survival

*Management Vasoactive agents

Consider inotropic/vasoactive agents such as dopamine or dobutamine

Works best when intravascular fluid volume is maximized

AirwayLarge volume IVFs may lead to pulm edema

CorticosteroidsPhysiologic doses of hydrocortisone may be

beneficial in those with SMS and poor response to vasopressors

Dexamethasone in MM

*Management

Antibiotics

•Patients treated with penicillin require oral rifampin to eradicate nasal pharyngeal carriage state•Require isolation and droplet precautions for 24 hours after start of antibiotics

Vaccine *Recognize that vaccines are

not available against N. meningitidis

serogroup BMeningococcal conjugate vaccine (MCV4)

○ Protects against A, C, Y, W-135 capsular groups○ Recommended at 11 to 12 years of age

Booster at 16

○ Unvaccinated adolescents through age 18 should receive a dose at earliest opportunity

○ Age 2 to 55 for those at high riskVaccine for infants under investigation

Question #11 A 2-year-old boy is diagnosed with meningococcal

meningitis. IV penicillin was administered on admission, droplet precautions were begun immediately, and he received oral rifampin the next morning. No special resuscitative measures were ever required. To reduce the risk of secondary cases, prophylaxis with oral rifampin is necessary for:A. Physicians who examined the patientB. Nurses who delivered routine bedside careC. Grandparents who live out of state and visited him in

the hospitalD. Laboratory personnel who drew blood samplesE. His companions in child care

Treatment of contacts

*Know that certain close contacts of patients with N. meningitidis require chemoprophylaxisHousehold contactsChild care or pre-school contactDirect exposure to index case’s oral secretions (7

days before onset of illness)○ Kissing, toothbrushes or utensils, mouth-to-mouth

Slept in the same dwelling during 7 days beforePassengers seated directly next to index case on

flight longer than 8 hours

Treatment of Contacts

*Know what to recommend to a parent when it is reported that a child has been exposed to meningitis in schoolLow riskNo history of direct contact to index patient’s

oral secretionsNO chemoprophylaxis is recommended for

school or work○ Only child care centers

Treatment of Contacts

Rifampin Ciprofloxacin Azithromycin Ceftriaxone

Hepatitis B

The Virus

Hepadnavirus family HBcAg: protein that

forms the nucleocapsid

that encloses the viral

DNA HBeAg: secreted soluble

antigen believed to induce

tolerance HBsAg: surface antigen

Epidemiology One third of the world’s population is

infected (!)Endemic areas: Africa, Eastern Europe, the

Middle East, Southeast and Central Asia, the Pacific Islands, and the Amazon Basin of South America

Vaccine administration has greatly reduced disease burden

*Risk groupsInjection drug usersImmigrants from endemic countries

Epidemiology

TransmissionVirus present to some degree in most body

fluids, but highest concentration is in the serum

*Routes of transmission○ Percutaneous injection of body fluids○ Sexual contact○ Perinatal vertical transmission

*Incubation period: 2-6 mos*Period of communicability: higher chance of

transmission when patient is HBeAg+

*Clinical Manifestations

ExtrahepaticPolyarteritis nodosaMembranoproliferative glomerulonephritisLeukocytoclastic vasculitisArthalgias/arthritisErythematous or urticarial rash that

precedes hepatic manifestations

*Clinical Manifestations

HepaticAcute self-limited hepatitisAcute fulminant hepatitisChronic hepatitisCirrhosisHepatocellular carcinoma

Clinical Manifestations

Acute self-limited hepatitisNausea, fever, abdominal pain, jaundice,

fatigue, general malaiseIncreased transaminasesResolution of infection within 6 months

○ HBsAb seroconversion

Acute fulminant hepatitisAssociated change in mental status brought

on by hepatic encephalopathyMore common presentation during infancy

Question #12

True or False: Perinatally-acquired HBV infections are less likely to cause chronic infections than infections acquired later in lifeA. True B. False

Clinical Manifestations

Chronic HBV infectionPresence of HBsAg in serum for at least 6

months or presence of HBsAg without IgM HBcAb

*The younger a person is exposed, the more likely he/she will become chronically infected○ 90% of exposed infants become chronically

infected○ 25-50% of exposed 1-5yo○ Only 6-10% of those exposed >5yo

Usually asymptomatic in childhood

Clinical Manifestations

Chronic HBV infection (con’t)Progresses through 3 phases:

○ Immune toleranceNo liver inflammationHigh viral countsHBeAg+

○ Immune clearanceIncreasing liver inflammation (with resulting damage)Decreasing viral countsHBeAb seroconversion

○ Residual

Clinical Manifestations

Cirrhosis/ HCCUp to 25% of children with chronic HBV

infection develop cirrhosis or HCCFactors that contribute to risk

○ Race○ Genotype of the virus○ Alcohol consumption○ Coinfection with HCV,

HDV, HAV, or HIV

Question #13 You are reviewing a patient’s HBV serum

markers. You see that the patient’s HBsAb is positive, along with the total HBcAb. The HBsAg and the HBcAb IgM are both negative. Of the following, the most appropriate interpretation of these labs is:A. Immune recovery after HBV infectionB. No prior infection, not immuneC. Chronic HBV infectionD. Acute HBV infectionE. Immune after Hep B vaccination

Question #14 You are reviewing yet another patient’s HBV

serum markers. This patient has a positive HBsAg and total HBcAb, with a negative HBcAb IgM and HBsAb. Of the following, the most appropriate interpretation of these labs is:A. Immune recovery after HBV infectionB. No prior infection, not immuneC. Chronic HBV infectionD. Acute HBV infectionE. Immune after Hep B vaccination

*Serum Markers

Screening In Chronic HBV Infections Liver enzymes

Q6mos Serum AFP

Q6mos Ultrasound of the liver

Q12 mos

Treatment Goal of therapy: long-term remission

(eradication not possible with current therapies)Loss of detectable HBV in the serumLoss of HBeAg

Available therapies:Interferon

○ Stimulates host immune system to maximize its own antiviral effect

Nucleotide/side antivirals (lamivudine)○ Interferes with the reverse transcription of HBV

Question #15 A 38 wga M is born to a 24 yo G1P0 via NSVD.

Upon review of the maternal labs, you notice that Mom is HBsAg+. The baby is currently 10h old and is eating, sleeping, urinating and stooling normally. Of the following, the most appropriate course of action in this infant is:A. Immediate administration of the Hep B vaccineB. Immediate administration of HBIGC. Immediate administration of both the Hep B

vaccine and HBIGD. Start lamivudineE. No interventions are necessary in the infant

Immunoprophylaxis Two types of therapy:

HBV vaccineHBIG

CDC has set a goal for eliminating transmission of HBV in the USUniversal immunization of infants at birthPrevention of perinatal HBV transmission via routine

screening of all pregnant woman and appropriate immunoprophylaxis for exposed infants

Routine immunization of children and adolescents that have not been previously immunized

Immunization of previously unimmunized adults

THE END!!

Thank you for participating in board review this year!!