The common cold

The common coldViral illness that symptoms of rhinorrhea and

nasal obstruction are prominent .

The most common pathogens are the rhinoviruses .

Coronaviruses and RSV are occasional . Influenza , parainfluenza , Adenoviruse and

Entroviruses are uncommon

EpidemiologyYoung children have an average of 6-7 colds

per year.The incidence of illness higher in the daycare

group in the first 3 yr of life

Colds occur year round. Incidence is greater from the early fall until the late

spring.The highest incidence of rhinovirus infection occurs in

the early fall and in the late spring .

pathogenesisViruses are spread by small-particle aerosols, large-

particle aerosols ,and direct contact .

Direct contact is an efficient mechanism for RSV and rhinoviruses.

Infections with rhinoviruses and adenoviruses result in development of serotype-specific protective immunity.

Re-infection with parainfluenza viruses and RSV occurs and protective immunity to these pathogens dose not develop.

Clinical manifestation

The onset of symptoms that typically occurs 1-3 days after viral infection are :

sore throat , nasal obstruction and rhinorrhea . and by the 2- 3 day of illness nasal symptoms predominate .

Cough is associated with approximately 30% of colds .

Influenza viruses , RSV ,and adenoviruses associated with fever and other constitutional symptoms .

( low – grad fever, sneezing )

Clinical manifestation

The usual cold persists about 1 wk ( 10% last 2 wk)

Increased nasal secretion is obvious .Change in the color or consistency of the secretions is

common and is not indicative of sinusitis or bacterial superinfection .

Persistent rhinorrhea following a cold suggests sinusitis or bacterial superinfection .

Condition may mimic common cold

Allergic rhinitis Prominent itching and sneezing and nasal eosinophilia

Foreign body Unilteral,foul-smelling dischargewith

Sinusitis Headache,facial pain,or periorbital edema persistence of

rhinorrhea or cough for longer than 10-14 days

Condition may mimic common cold

Streptococcal nasopharyngitis Nasal dischar that excoriates the nares

Pertussis Onset of persistent or paroxysmal cough

Congenital syphilis Persistent Rhinorrhea (snuffles) with onset in the first 3 mo of life

Rhinorrhea

Rhinorrhea is a common manifestation of : infectious , allergic , mechanical condition . Infectious rhinitis : mucopurulent discharge with PMN .

Allergic rhinitis : lack of fever ,eosinophils in discharge . ( allergic shiners , nasal polyps , pale edematous nasal

mucosa ,transverse crease on the nasal bridge ) .

Less common causes are : foreign body, choanal atresia vasomotor rhinitis , CSF fistula , diphtheria , tumor , congenital syphilis.

treatmentSymptomatic treatment for : Fever , Nasal obstruction, rhinorrhea, Sore

throat, cough.Antibacterial therapy is not benefit in the

treatment of the common cold.Antiviral treatment

specific antiviral therapy is not currently available for rhinovirus.

Ribavirin which is approved for treatment of RSV infections has no role in the treatment of the common cold .

treatment Topical or oral adrenergic agents may be

used as nasal decongestant 1. not approved <2yr .2. prolonged use should be avoided to prevent of

rhinitis medicamentosa.

oral adrenergic agents are less effective than the topical and are associated with systemic effects

( hypertension , palpitation)

treatment Rhinorrhea the first - generation antihistamines reduce

rhinorrhea that related to the anticholinergic rather than the antihistaminic properties .( by 25- 30% )

Sore throat is not severe but mild analgesics is occasionally

indicated particulary if there is associated myalgia or headache.

Cough may be result of viruse- induced reactive

airway disease (bronchodilator)

Treatment Cough Cough suppression is generally not necessary .

but in some patients is due to upper respiratory tract irritation and post nasal drip .

(first generation antihystamin may be helpful )

Vitamin c , guaifenesin , inhalation of warm , humidified air have all been found no more effctive than placebo.

Echinacea is a popular herbal treatment .

prevention Chemoprophylaxis or immunoprophylaxis is

generally not available for common cold .

– Chemoprophylaxis or immunoprophylaxis against influenza may be useful.

– Cold can prevented by interrupting the chain spread of virus .with good hand washing

Complications The most common complication of a cold is

otitis media ( 5-30%)Symptomatic treatment has no effect on the

development of acute otitis media .or sinusitis

Exacerbation of asthma

Sinusitis is a relatively frequent complication (0.5 -2% in adult and 5-13% in

children)1. Rhinorrhea or daytime cough

persists without improvement for 10-14 days

2. or if signs ( fever , facial pain , facial swelling) develop.

sinusitisSuppurative infection of the paranasal sinuses. Complicates the common cold and allergic rhinitis .

The maxillary , ethmoid , and sphenoid sinuses present at birth .

The frontal sinus develops at 1 year of life . And may not appear at air-filled spaces until 10 years of age.

sinusitis increased incidence of sinusitis ;

Cyanotic heart disease CF immunoglobulin deficiency HIV nasoteracheal intubation immotile cilia syndrome dental infection immunocompromised children following organ

transplantation.

Etiology of sinusitisCulture of the nasal mucosa is not helpful in

identifying the responsible bacteria .

If necessary , anteral puncture for maxillary sinusitis is the diagnostic procedure of choice .

Obstruction to mucociliary flow predisposes to bacterial proliferation.

Etiology of sinusitisThe bacterial producing acute sinusitis are :

Pneumococci , non typable H.influenzae M.catarrhalis , anaerobic bacteri

and rarely streptococci and staphylococci.

Nasocomial sinusitis may occurs by: gram- negative bacteria ( klebsiella, pseudomonas ,

entrobacter)

Clinical manifestations of sinusitis

Persistent mucopurulent rhinorrhea .

cough (at night ) .nasal stuffiness, nasal quality to the

voice .

facial swelling , tenderness , pain .

headache.

diagnosis of sinusitisCT reveals clouding , thickened

mucosa , or an air- fluid level .

Sinus aspiration usually is not needed in uncomplicated sinusitis

treatment of sinusitisAmoxicillin or amoxicillin/clavulanate is

usually effective in uncomplicated sinusitis .

Complications should be treated with : drainage and if indicated broad-spectrum

parentral antibiotics .

Long of treatment 14-21 days

complicationsOrbital cellulitis . Epidural or subdural empyema .brain absecess . dural sinus thrombosis .osteomyelitis and meningitis .sinusitis may also exacerbate bronchoconstriction

in asthmatic patients

دارد درد گوش مشكل كودك ؟آيا دارد؟ وجود گوش درد آيا ميشود؟ خارج ترشح گوش از آيا

مدت؟ چه براي

: معاينه . كنيد نگاه چرك خروج نظر از را گوش

. كنبد معاينه را گوش

: گوش حاد عفونت هاي نشانهاز 1. كمتر چرك روز 14خروجاست 2. قرمز معاينه در گوش وپرده گوش درد

درمان:مدت به بيوتيك روز 10آنتي

روز دو برگردد فوري زماني چه كه مادر به توصيه. كند مراجعه پيگيري جهت بعد

otitis

مزمن عفونت هاي نشانهاز بيش ازگوش چرك روز 14خروج

درمان: از بيش چرك غير 6خروج در ارجاع هفته

گوش كردن خشك به توصيه اينصورت بمدت بيوتيك روز 14آنتي پيگيري .2جهت كند مراجعه بعد روز

Otitis mediaSuppurative infection of the middle ear cavity and is

the most common between 6 months and 2 years of age .

High –risk populations:HIV. Cleft palate .Down syndrome . more common in boys . in patients of low socioeconomic status . In formula – fed infants . in the winter months.Day care

Pathogenesis Otitis mediaWhen the eustachian tube is blocked

by:

1. local infection .2. Pharyngitis.3. Hypertrophied adenoids .

Pathogenesis otitis mediaAir trapped in the middle ear is reabsorbed ,

creating negative pressure in this cavity , that permit reflux of bacteria .

This bacteria plus obstruction of the flow of secration from the middle ear and leads to middle ear effusion.

The most common bacterial pathogens are : pneumococci ,nontypable H. influenzae .M.catarrhalis .

and less frequently group A streptococci and highly resistant S .pneumoniae

Clinical manifestation Usually occur 1-7 days after nasopharyngitis .

Patients often Febrile( 30% -50% ) and , irritable ,Vomiting ,diarrhea ,bulging of

funtanel ,vertigo ,tinnitus , and draining ear may be seen .

Otoscopic examination:Erythematous TM ,loss of identifiable landmarks .Perforation of TM also may occur and usually is

associated with acute relief of pain .

treatment otitis media

Oral antibiotics frequent used are :

amoxicillin , amoxicillin/clavulanate trimethoprim/sufamethoxazole . erythromycin /sulfisoxazole .

Oral cphalosporins(cefaclor ,cefuroxime , cefexim ) also been approved for otitis caused by:

β-lactamase- producing organisms .

treatment otitis mediaFor Highly resistant pneumococci higher doses of

amoxicillin/clavulanate or clindamycin or a single dose of parenteral ceftriaxone may be efficacious .

Tympanocentesis may be needed in patients: who are difficult to treat . or do not respond to therapy.

Decongestants or antihistamines are not effective alone or with antibiotics

pharyngitis

از تر باال كودك دارد؟ 2آيا درد گلو سال

دارد؟ مشكل خوردن غذا موقع آيا: كنيد سئوال دارد؟ بيني از آبريزش آيا ميكند؟ عطسه و سرفه كودك آيا است؟ قرمز او چشمهاي آيا دارد؟ صدا آياخشونت

از تر باال كودك دارد؟ 2آيا درد گلو سال

: كنيد معاينه حلق قرمزي و ،اگزودا پتشي وجود گردني آدنوپاتي لنف بدن حرارت درجه

Pharyngitis

استرپتوكوكي درد گلودرد: زير هاي نشانه از نشانه ودو تب وجود

حلق در اگزودا گردن قدامي لنفادنوپاتي كام روي ياپتشي ها لوزه قرمزي

ويرال فارنژيت: باشد داشته را زير هاي نشانه از نشانه دو

چشمها آبريزش سرفه چشم قرمزي صدا خشونتعطسه

Acute PharyngitisEtiology:

– Bacterial-– Group A streptococcus– Group C streptococcus – Corynebacterium diphtheriae – Others (less often):– Mycoplasma pneumonia , spirochetes, Chlamydia

pneumoniae.

Acute Pharyngitis(Bacterial)

• Mycoplasma pneumoniae

• Arcanobacterium haemolyticum• Francisella toleransis (gram – coccobacillus)• Chlamydia pneumoniae

Acute Pharyngitis

– Viral >90% • Rhinovirus – common cold• Coronavirus – common cold• Adenovirus – pharyngoconjunctival

fever;acute respiratory illness • Parainfluenza virus – common cold; croup• influenza virus – influenza• Coxsackievirus - herpangina• EBV, CMV – infectious mononucleosis• HIV

Acute Bacterial Pharyngitis

– Group A beta-hemolytic streptococci (S. pyogenes) ,cocci gram+ • most common bacterial cause of

pharyngitis• Uncommon<2-3 yr, peak in winter and

spring ,spread to classmates • accounts for 15-30% of cases in

children and 5-10% in adults.

Epidemiology of Streptococcal Pharyngitis

Spread by contact with respiratory secretionsPeaks in winter and springSchool age child (5-15 yr)

Patient no longer contagious after 24 hours of antibiotics

Pharyngitis: Streptococcal

Clinical Features– Fever, sore throat, headache– Pharyngeal/tonsillar inflammation (often exudates)*– Tender anterior cervical adenopathy*– Scarlatiniform rash– Absence of viral symptoms (rhinorrhea, cough, hoarseness)

Group A beta-hemolytic streptococci

Often rapid sore throat, fever, vomiting ,abdominal pains.

red pharynx, enlarged tonsil with exudatePetechiae on the soft palate, Anterior cervical lymphadenophaty ,tenderScarlet fever DD:Viral phryngitis more gradual with rhinorrhea,

cough and diarrhea

Viral phryngitis

Gingivostomatitis (HSV-1)1-5 years old,(9-36 mo)incubation 7 days

Primary HSV more sever with:(high fever,drooling, fetid breath, vesicular

lesion on the tonge ,gums ,lips and tender lymphadenopathy)

herpanginaEntroviralSudden onset high fever ,vomiting,

disphagia ,conjunctivitis, drooling and sore throat

One or more small tender papule or pinpoint vesicular lesions with erythematous base (1-2 or 3-4 mm) on the soft palatea ,uvula ,tonge that over 3-4 days rupture and produce smalll ulcers

Diagnosis

Rapid screening test: latex agglutination or ELISA

– Specificity high: usually >98%– Sensitivity variable: 68-95%

Gold standard: culture of swab of tonsils and posterior pharynx

Diffrential diagnosis

Retropharyngeal and peritonsillar abcessDiphteriaMucositis (leukemia, apelastic anemia)TrushKawasakiAutoimmune ulseration

Vincent infection

Anaerobic pharyngitis( sertain spirochetal)Fulminant,acute necrotizing ulserative

gingivitis Gray pseudomembranes on the tonsils

(false diphteria)

Noma (gangrenous stomatitis) That seen in sever malnutration or

immunodeficiency focal gingivitis progress to gangrene

Ludwig anginaAnaerobic bacteril rapidly bilateral cellulitis of the

submandibular and sub lingual spaces. glottic and lingual swelling and air way

obstraction Odontogenic origin(priapical abscess of 2 or 3 mandibular

molare)

PFAPA

Priodic fever, aphthous stomatitis ,pharyngitis, servical adenitis

Usually <5 yrLast 5 daysThere is 28 days between episode.Duration is shorter with oral prednosone.

Treatment of Streptococcal Pharyngitis

Penicillin - drug of choice (9days)Started immediately : positive rapid test, scarlrt fever, symtomatic

pharyngitis whose sibling has strereptococcal pharyngitis, history of RF– One IM of long acting penicillin (benzathine) – oral therapy for 10 days

Erythromycin - if penicillin allergic(20-40/kg/day)First –generation cephalosporin?Clindamycin or amoxicillin –vlavulanate is effective

for carriage

Suppurative Complications of Group A Streptococcal PharyngitisOtitis mediaSinusitisPeritonsillar and retropharyngeal

abscessesSuppurative cervical adenitis

Nonsuppurative Complications of Group A Streptococcus

Acute rheumatic feverAcute glomerulonephritis

– May follow pharyngitis or skin infection (pyoderma)

Strawberry Tongue in Scarlet Fever

Rash of Scarlet Fever

Bull Neck of Diphtheria

Pseudomembrane in Diptheria

croup

acute inflammation caracterized by bark like or brassy cough

croup usually affects to some degree the larynx, trachea, and bronchi

Croup may be associated with hoarseness, inspiratory stridor, and respiratory distress

Infection upper airway obstruction

Viral agents account for most upper airway obstruction

Parainfluenza viruses account for 75% of casesMost patients with croup are between 3 mo and 5yr

Recurrences are frequent from 3-6yr of age

15% patients have a strong family history of croup

Laryngo trachebronchit

The most common form of acute upper respiratory obstruction

rhinorrhea, pharyngitis,mild cough ,low-grade fever for 1-3 days before the signs and symptoms

Barking cough, hoarseness ,inspiratory stridor

Symptoms worse at night and resolve within 1 wk

Other family members have mild respiratory ill

Laryngotracheobronchit

Alveolar gas exchange is usually normal

Rarely the upper airway obstruction progress

The child who is hypoxic ,cyanotic ,pale needs immadiate management

X-Ray may show the typical sub-glotic norrowing steeple sign

Spasmodic croup most often in children 1-3yr

History of a viral prodrome and fever in patient and family absent

Occurring most frequent in the eveningThe patient is usually afebrile

The severity of the symptoms diminishes within several hours

The pathogenesis is unknown allergic reaction to viral antigen??

Acute infectious laryngitis

Viruses cause most cases

diphtheria is an exception

Sore throat , cough ,hoarseness

Respiratory distress is unusual

Inflammatory edema of the vocal cords and sub glottic tissue

Acute epiglottit

An acute fulminant course of; high fever,sore throat,dispnea, progressing

respiratory obstruction

Toxic appearance ,swalloing is difficult ,drooling, tripod position or neck hyperextention ,cyanosis

The barking cough typical of croup is rare

Stridor is a late finding

No other family members are ill with respiratory symptoms

Diagnosis of epiglottitPhlebotomy , IV line , supine position , direct inspection of oral cavity should be avoided until the airway is secure

cherry red swollen epiglottis in laryngoscopy

Laryngoscopy should be performed in an operating room or ICU

Classic radiography of epiglottit is thumb sign

Establisheing an air way by nasotracheal intubation is indicated in patient with epiglottit regardless degree of apparent respiratory distress

Differential diagnosis

Bacterial tracheitis is the most important

Diphtheric croup

Measles croup that may be fulminant

Aspiration of foregin body

Retrophryngeal or peritonsillar abscss

Extrinsic compression of the air way

Differential diagnosis( con)

Intraluminal masses

Angioedema and anaphylaxis

Endotracheal intubation

Hypocalcemic tetany , trauma ,infectious mono ,tumors

Epiglottit

A croupy cough may be an early sign of asthma

Indication for child hospitalized

Progressive stridor

Sever stridor at rest

Respiratory distress

Hypoxia

Cyanosis

Depressed mental status

Need for reliable observation

Treatment

Most children with spasmodic croup or infectious croup can be managed at home

Antibiotic are not indicated

treatment

Cool mist; moistens airway secration ,soothes inflamed

mucosa ,provide comfort child

corticosteroid 0.6 mg/ kg

Nebulized epinephrine; Stridor at rest

the need for intubation respiratory distress

hypoxia and when stridor dos not respond to cool mist

Treatment of epiglottit Artificia airway placed in ICU or operating room

All patient should receive oxygen

B/ C , LP

Ceftriaxon ,or cefotaxim for 7-10 days

Rasemic epinephrin and corticosteroid are ineffective

Acute laryngeal swelling Epinephrin 1/1000 in dosage 0.o1ml/kg

Prednisone 2-4mg/kg

Racemic epinephrin

The need for intubation Reactive mucosal swelling . severe stridor respiratory distress unresponsive to mist therapy