Case Based Pediatrics Chapter

Case Based Pediatrics Chapter

Some Hasidic Jews practice “metzitzah b’peh,” in which the mohel — the specially trained person performing the circumcision — uses oral suction “to draw blood from the area of the circumcision wound.” “Some Jewish religious authorities maintain that [metzitzah b’peh] is the proper means, and some deem it the only acceptable means, under Jewish law,” to draw off the blood. Herpes can also spread to internal organs, such as the liver and lungs. The residents evaluate this data in an effort to formulate a plan for improvement of our clinical practices and overall efficiency. Vision is normally measured using a Snellen chart. This site uses cookies to track user behaviour on this site, without linking to personally identifiable data. Nichole Lopez: Yes, she came down with us from upstate, at the time she had a son named J***l, he had something wrong with his legs requiring him to use assistance walking and she had a baby named B***l. My daughter has chlamydia, can she pass it to the younger kids through kissing, or bath towels?

Please make sure if you choose to have a vaginal birth that the doctors don’t use a device called a fetal scalp monitor. Oh. Howe said. Theranos does that, she says, with as little as a finger prick’s worth of blood, a much smaller amount than traditional blood tests, and at a fraction of the cost. Planned home birth for LOW RISK women in the USA increases the risk of intrapartum and neonatal death at least 3-5 times compared to low risk women giving birth in a hospital. Lungs show good aeration. Abdomen is soft and without masses.

Pulses are 1+ throughout with 3-4 sec capillary refill. Neuro exam shows decreased tone and a weak, intermittent cry. Twenty percent of the U.S. I also told them they must have the Courage and the Kindness to tell families the whole truth when things go wrong, and that this truth has to include both the known facts and their opinions to be meaningful. The transparency of the first case investigation helped to strengthen trust between Rockland County Health Department and the Orthodox community and helped to expedite testing when two additional cases emerged in 2014. CBG (capillary blood gas) pH 7.31, pCO2 43, pO2 44, BE-4. CSF: 2430 RBCs, 20 WBCs, 1% PMN, 17% lymphs, 82% monos, glucose 39, protein 133, gram stain shows no organisms.

who assisted in drafting guidelines on the management of H.S.V. What other tests would you obtain? What would your assessment be for this infant? What would your recommendations be (if any) for further evaluation or treatment? If you were to treat this infant, how long would you treat her? The evaluation and management of the neonate at risk for sepsis is potentially a source of frustration for students and practitioners. The convention in the past has often been to evaluate and empirically treat all neonates felt to be at significant risk, especially as relates to maternal factors and the receipt of maternal antibiotics in labor.

Due to evolutions in health care and the advent of intrapartum prophylaxis for group B streptococcal sepsis (mothers are routinely screened for group B strep and if found to be positive, they are given ampicillin prior to delivery), more attention has come to focus (very appropriately) on the clinical evaluation of the infant as a major part of the decision to evaluate and treat with antibiotics. This factor; however, remains fraught with a degree of uncertainty related to the nonspecific manifestations of infection in the newborn, the sometimes rapid progression of sepsis in the newborn, and the lack of laboratory tools which have high positive predictive accuracy. The approach in this section of neonatal sepsis will be to: 1) incorporate the evolutionary changes in management which are based on more recent evidence; 2) to emphasize the lack of a gold standard underlying the variations in practice (i.e., clinical sepsis with a negative blood culture is still more often diagnosed than blood culture proven sepsis); and 3) to suggest (based on interpretation of older and recent evidence) newer concepts which place more reliance on tests with high negative predictive accuracy and the efficacy of intrapartum antibiotics (1-7). It was like an ocean of worry that I had built up all 9 months of my pregnancy flooding me and knocking me down, when I heard those words: “I think it’s herpes”. These are necessary and basic to understanding the problem of neonatal sepsis and perinatal infections. However, the evaluation and management will de-emphasize empiric treatment for risk alone, and variation in practice will be seen as a necessary consequence of our lack of knowledge and the inherent variation in individual practitioner’s tolerance of degree of risk and uncertainty. Table 3.

The regulation never faced that legal scrutiny, because the consent form was officially scrapped this year, and the legal case was dropped. . City officials said that in return for repealing the regulation, they hoped to win the cooperation of the ultra-Orthodox community, including parents who, in several recent cases, have refused to identify a mohel suspected of infecting a child with herpes. . Apnea and dusky episodes for no clear reason. . Note that this case is not relevant to the controversy about male circumcision bans generally (in the unlikely scenario that such a ban would be enacted in any American jurisdiction), or for that matter less restrictive regulations of male circumcision.

. . A trial frame worn by the patient is usually used instead of the instrument containing the lenses the patient sits behind (phoropter). . . . If the herpes virus is not active, then a vaginal birth is perfectly fine you will be treated like any other low risk woman.

Marie70 34 weeks ago. “It takes a real breadth of knowledge to run an imaging center like this one,” McGinley told the youngsters. Waldo Concepcion, the chief of clinical transplantation surgery at Stanford University Medical Center, spends most of his time performing kidney transplants on children, a procedure he believes is often preventable. . . Clinical appearance; doesn’t look “good”. .

. . . Tachypnea, temperature instability, look of distress. Table 4. The most important risk factors for neonatal sepsis: . .

. . Prematurity . . . . Untreated maternal chorioamnionitis.

. . . . Untreated maternal prolonged rupture of membranes. . .

. . Maternal fever, untreated. . . . .

Untreated positive maternal GBS screen. Table 5. Equivocal risk factors (i.e., they overlap or may result in similar manifestations): . . . Thank God i don’t have any great secuels of SJS, but I have really dry eyes and some scars on them but nothing that couldn’t be treated. Fetal distress.

Vishnevetsky joins a select group of 100 junior and senior high school students who have achieved high grade-point averages and are involved in numerous co-curricular and extracurricular activities. Holmes says the company’s era of secrecy is over, and it’s inviting outsiders, including reporters, to try the tests for themselves. . . Depression at birth (needs resuscitation, low 5 minute Apgar). . .

. . Meconium staining. . . . .

Case Based Pediatrics Chapter
Hypoglycemia. . . . . Any unusual finding which may be due to infection. Although we have gained more knowledge about risk factors and have more antibiotics at our disposal, there is still NO GOLD STANDARD for the diagnosis of neonatal infection.

There are still many unknowns in neonatal sepsis which continue to elude us, and compel the diagnosis of neonatal infection to be made clinically more often than not. Table 6. The Unknowns in Neonatal Sepsis: . . . . 1.

How effective is GBS prophylaxis as prescribed? >95% . . . . 2. How sensitive are blood cultures (i.e., how often are they positive) ?

. . . . 3. Can an elevated l/T ratio (immature to total granulocyte ratio) indicate acute OR resolving inflammatory response? Wednesday, Feb.

. . . 4. Will ampicillin resistant organisms be seen with more use of intrapartum ampicillin prophylaxis? . .

. . 5. What is the minimum duration of antibiotic treatment to effectively treat sepsis? . . .

. 6. Is neonatal infection with a positive blood culture the same as neonatal sepsis? . . . .

7. When does neonatal sepsis become SIRS (systemic inflammatory response syndrome), i.e., overwhelming sepsis? . . . . 8.

What is the immunologic competence level of a given infant at risk (i.e., will the infant be able to respond positively with appropriate antibiotics)? . . . . 9. Does intrapartum treatment of the mother for chorioamnionitis also treat the fetus effectively?

Because we have many unknowns and the worst case scenario for neonatal infection is sepsis and perhaps overwhelming sepsis or death from SIRS, pediatricians have tended to err on being conservative in the evaluation for sepsis. This intention paradoxically results in a more “aggressive” approach to the patient in terms of tests and/or treatment. This paradox is underscored by the lack of a gold standard for diagnosing sepsis in the newborn, and complicated by the recent increase of intrapartum antibiotics prescribed to women in labor. Table 7. The full sepsis work-up. . .

. . 1. CBC differential, platelet count. . . .

. 2. Blood, urine, and CSF cultures. . . . .

3. CXR. Add a tracheal aspirate for gram stain and culture if the patient is intubated. . . . .

4. Equivocal: gastric aspirate for gram stain and culture. . . . . 5.

Start broad spectrum antibiotics while awaiting culture results. For a partial sepsis work-up, one could pick any one or more of the above items. For a totally asymptomatic infant with high risk factors, none of the steps might be elected (practice variation). This is based on the premise that the clinical appearance and serial monitoring of the infant is just as accurate as any laboratory test for indicating the presence of infection, given any set of risk factors in an infant with a relatively normal exam. This wide variation of practice suggests that the unknowns in neonatal sepsis (see above) are quite important to practical management. This may lead one to be more or less restrictive in practice, and requires one to have thorough knowledge of the predictive accuracy of the objective tools available in the assessment of neonatal sepsis. From an outcomes point of view, one would expect that if certain practices were inappropriate, there would be a higher rate of readmission within two weeks of discharge from the normal nursery for those regimens which were “least restrictive.” Such evidence has not emerged from this institution, based on a review of early discharge from the nursery in the mid-1990’s, when the most common cause for readmission was jaundice (infection and sepsis were not found).

The highest degree of controversy surrounds the group of infants who are asymptomatic with some risk factors for sepsis, especially those whose mothers received intrapartum antibiotics. In these infants, there is the fear of partially treated sepsis, prompting evaluation and treatment of these infants based on their risk factors and discounting the maternal antibiotics. However, the asymptomatic state could also be interpreted as adequate prophylactic treatment for neonatal bacteremia. In 1990, Wiswell et al., reported on a survey of academic infectious disease departments with respect to management of this scenario. They concluded that there is no consensus regarding management of pretreated, healthy appearing, term gestation neonates (8). In contrast, Teji et al (1994) surveyed neonatologists in Midwestern states of the U.S. with regard to the management of PROM (prolonged rupture of membranes) without chorioamnionitis, chorioamnionitis without treatment prior to delivery, and chorioamnionitis with treatment prior to delivery.

One hundred thirty seven responses were received and prematurity and severity of maternal illness significantly influenced the decision to treat empirically, irrespective of screening test results (9). More recently, Eichenwald (1997) has suggested a very reasonable scheme for evaluation of the asymptomatic term infant, based on a protocol developed by the Joint Program in Neonatology in Boston (Table 8) (10). However, the question persists and evolves regarding the benefits and risks of routine therapy of high risk neonates vs. clinical observation and selective therapy of only those infants who manifest symptoms. This evolution is highlighted by the recent reports of ampicillin-resistant organisms in neonatal sepsis (11-13) and the dramatically increased incidence of Candida species sepsis in very premature infants in NICU settings over the last decade, of which one very important contributor is the prior use of antibiotics.

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Case Based Pediatrics Chapter

Case Based Pediatrics Chapter

Conjunctivitis Conjunctivitis, sometimes referred to as pink eye, is an infection or inflammation of the conjunctiva the thin, protective membrane that covers the surface of the eyeball and inner surface of the eyelids. Many industrial workers exposed to chemical fumes may also be affected. Feline patients may additionally be infected with secondary pathogens including Calicivirus, Chlamydophila felis, mycoplasma sp and/or bacterial pathogens. Infection is the most common cause. In this case, the smallpox virus is the causative agent of this form of conjunctivitis. Inflammation of the conjunctive caused by an allergy is called allergic conjunctivitis. Viral conjunctivitis is highly contagious from onset of disease to almost week after the eyes have become white.

Conjunctivitis in newborn babies can be caused by germs called chlamydia or gonorrhoea. For the multicenter trial, the researchers recruited 128 patients (76 females, 52 males) with a clinical diagnosis of acute viral conjunctivitis in a prospective, sequential manner within 7 days of developing a red eye. No, I did not discover the cure, But i found the way to contain it and prevent further damage. Signs include edema, erythema, warmth and pain of the eyelid. As a matter of fact rubbing the eyes with contaminated hands is a very common mechanism of catching the common cold and the flu. The percentage of patients experiencing postherpetic neuralgia decreased during follow-up. Like driftwood flowing in a river s current the bacteria or virus particles are washed down into the throat as the tears drain from the eye.

Once in the throat they are home free to cause illness. The most effective treatment for herpes is to apply ice on the affected area to soothe and numb the area. Cultures from conjunctiva and blood can be obtained, but the yield is not high. Molluscum contagiosum is a common viral skin infection that can spread to the eyes. To diagnose and determine what bacteria leading to pink eye, an intensive laboratory test is required. If herpes virus is suspected, a special antiviral medication and referral to an ophthalmologist is required. You rub your eyes.

When the orbital structures posterior to the orbital septum are infected, it implies orbital cellulitis (as opposed to periorbital cellulitis). HIV-constructive sufferers with suppressed immune techniques —usually a CD4 cell count much less that one hundred—who have been receiving long-time period acyclovir for the therapy and prevention of recurrent herpes flare-ups have been identified to develop drug-resistant herpes. Of all the viruses that can cause conjunctivitis adenovirus the ever-present virus that lurks in our nose throat and upper respiratory airway is probably the most common. Diagnostic imaging also helps in detecting infections extending from periorbital sites which are not uncommon. You may also have other allergic reactions, such as a runny or itchy nose. Draining of abscesses may be necessary for the patient to improve. Otolaryngology consultation should be sought if sinusitis is present to consider draining the sinuses as well.

This may be indicated by eye pain, reduced vision, or swelling around the eye. But in some cases, quite rare, films can be more dense, which complicates removal of the conjunctiva. Treatment option depends on the cause of inflammation. They are not considered infectious, unless eyelid cellulitis ensues. This then causes an allergic response and symptoms of conjunctivitis. The 10-minute test detects MMP9 levels greater than 40 ng/mL. The conjunctiva is a thin layer of non-keratinized mucous membrane which covers the surface of the eyeball (bulbar conjunctiva) and inner layers of the eyelids (tarsal or palpebral conjunctiva).

Conjunctivitis describes inflammation of the conjunctiva and is a nonspecific entity. However the virus continues to run its course in some individuals being a major cause of severe corneal scarring that could require transplantation. Watery and thin mucus discharge accompanied by red and swollen eyelids are signs of viral conjunctivitis, usually caused by adenovirus. When an infected person sneezes zillions of contaminated droplets enter the immediate airspace. These particles are picked up by air currents and can easily drift into another person s airspace and then inhaled. Majority of sufferers aren’t able to eliminate herpes symptoms rapidly as a result of they fight merchandise that don’t work. Treatment is supportive, with cool compresses and artificial tears.

Conjunctivitis may take up to 21 days to resolve. Viral conjunctivitis is very contagious, especially for the first few days. Patients should be told to wash their hands, avoid touching their eyes, sharing towel, bedsheets or pillow cases. If your eye is red swollen itchy painful or has a watery discharge it’s important that you see your eye doctor right away. Children should stay away from school for at least the first 3 to 7 days. Herpes simplex can cause conjunctivitis indistinguishable from other viral conjunctivitis, but herpetic skin vesicles along the eyelids should raise the suspicion. Topical antiviral therapy and sometimes systemic antiviral therapy are recommended.

Purulent discharge is an important sign of bacterial conjunctivitis. If the onset is hyperacute, i.e., within 12 hours, a smear should be taken from the eye to rule out gonococcal conjunctivitis. Otherwise, a routine culture should be taken and a topical broad-spectrum antibiotic, such as erythromycin ointment or sulfacetamide drops can be used for 5 to 7 days. Chlamydial inclusion conjunctivitis is a sexually transmitted infection, typically occurring in teenagers and young adults. Do not share towels, pillows or utensils. For the treatment of this form of viral conjunctivitis in children using antimetabolites in the form of eye drops or ointments topically, for example, solution idoxuridine 0,1 (6 to 8 times daily) or acyclovir ointment 3 (2-3 times a day). In case the eye does not look normal, a few tests are done including culture of the drainage to test bacteria and viruses, and Slit-lamp examination to identify the damage to the surface of the eyeball.

Case Based Pediatrics Chapter
Trachoma can present in a similar fashion to chlamydial conjunctivitis, but this principally occurs in immigrants from underprivileged countries. Antihistamine eye drops or mast cell stabiliser eye drops (described above) do not work in this type of conjunctivitis. Trachoma is classically acquired by workers in rug factories where the occupational risk of poor air quality (dust and rug fibers presumably) places the factory workers at risk for trachoma. Allergic conjunctivitis is the most common non-infectious conjunctivitis. Itching, watery discharge, chronicity, red eyes and a history of allergies are typical symptoms. Some allergic conjunctivitis are seasonal, but others can be year-long. If the inciting agent can be identified, such as cat fur and animal dander, it should be eliminated.

Cool compresses help decrease itchiness, and are preferable to rubbing the eyes. Over-the-counter artificial tears and vasoconstrictor drops (naphazoline/pheniramine) can be used for mild cases. Topical mast-cell stabilizers (cromolyn, Alomide) work well as preventive measures if the patient’s allergies are seasonal. Topical antihistamines have a faster onset of action. In severe cases, topical corticosteroids may be needed, but patients must be monitored for side effects associated with prolonged topical steroid use, such as cataracts, and glaucoma. Concomitant oral antihistamines are helpful if the patient has systemic allergies. Acute allergic conjunctivitis frequently presents with impressive edema of the conjunctiva.

The conjunctiva can become so edematous that it lifts off the sclera and frequently protrudes out. The pale, watery edema resembles a lychee fruit (without the skin). Topical vasoconstrictors and antihistamines are used to treat this. When an eye is exposed to acidic or basic chemicals, copious irrigation with water or normal saline should be started as soon as possible. Litmus paper can be used to test the tears for neutrality. If the cornea has been burned with the chemical, an ophthalmology consult needs to be obtained. Otherwise, the conjunctivitis can be treated with frequent artificial tears and moisturizing eye ointments.

Occasionally, prolonged exposure to topical eye medications can cause conjunctivitis, especially the aminoglycosides, such as gentamicin and tobramycin, and certain glaucoma medications. Additionally, patients may have allergic reactions to other topical antibiotics such as sulfonamides. 1. Herpes simplex conjunctivitis: . . . .

. a. may be chronic. . . . .

. b. may be associated with skin vesicles. . . . .

. c. may recur. . . . .

. d. all of the above. 5. A four month old male has congenital tear duct obstructions and has symptoms of chronic tearing and mucus. His primary care physician prescribes topical sulfacetamide drops three times a day to clear up the mucus, but after using the drops for one month, his eyelids are more erythematous than ever and the conjunctiva is more swollen and he constantly rubs his eyes. What should be done?

2. The answer is all of the above. Although a skin laceration is easily diagnosed, a sinusitis needs to be confirmed with a CT scan. A chalazion is usually diagnosed by history or a fluctuant skin mass in the eyelid. A dental infection involving the upper teeth can easily spread itself into the orbit. 3. Topical corticosteroid is the only choice that is not appropriate for a primary care physician to prescribe.

The rest of the choices are appropriate, although most chalazia do not require oral antibiotics. 5. The baby is probably developing an allergic reaction to the long-term use of topical sulfacetamide. The eyedrops should be discontinued right away and patient can be treated with tear duct massage and another antibiotic eyedrop on an as-needed basis.

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Case Based Pediatrics Chapter

Case Based Pediatrics Chapter

Encephalitis is a rare condition. In fact, if a mother has an illness, her breast milk will contain antibodies to it, that will help protect her baby from those same illnesses. TL;DR Breast milk can transmit HIV and active, untreated tuberculosis, can carry HPV but transmission risk is unclear, and has not been demonstrated to transmit hepatitis, chlamydia, gonorrhea, syphilis, or herpes. Similar to unprotected sex, privately donating breastmilk or cross-nursing is another activity that involves biological fluids. As I talk to older doctors and learn about those early days of “VD,” I envy the simplicity of them. All other prenatal labs are pending. Glycoprotein B (gB)498-505-and herpes simplex virus (HSV)-2-specific CD8 + T cells induced in the draining lymph nodes following intravaginal lipopeptide immunization.

The editorial was based on research concerning mothers who buy breast milk online and feed it to their children. HCV is transmitted through parenteral exposures to contaminated blood, usually through use of injection drugs (sharing of needles or works) and to a lesser extent through exposures in health-care settings as a consequence of inadequate infection-control practices. He is quickly positioned, dried, and stimulated. Performance is measured by the infant’s growth, absorption of nutrients, gastrointestinal tolerance, and reactions in blood. You note his skin is mildly jaundiced with raised red/purple lesions. Cover up any cuts or abrasions of your own and get those around you to do the same. Exam: VS T 37.5, P120, RR 40, BP 60/36, oxygen saturation 100% in room air.

Ballard exam: 38-40 weeks gestation. Growth parameters: weight 1.845 kg (50%ile). He is a well developed, well nourished term male infant who appears sleepy and lethargic. When he does awake, he is difficult to console and displays a weak, high pitched cry. (2) Hep C is also the most common chronic bloodborne viral infection in the United States, and many people are not aware of their infected status. But, she wondered, what else could she have? His anterior fontanelle is soft, but full.

After you get chickenpox, the virus remains inactive (becomes dormant) in certain nerves in the body. The abdomen is soft and non-tender. Acute hepatitis C is a reportable condition in 49 states, and matching viral hepatitis and HIV surveillance registries can facilitate early detection of social networks of HCV transmission among HIV-infected MSM. Neurologically, the infant has decreased tone throughout his extremities and he is difficult to arouse. Sucking at the breast promotes good jaw development as well. You obtain an extra tube of CSF to be held in the lab. IV access is obtained and the infant is immediately given ampicillin and gentamicin.

IV fluids are also started in light of his decreased level of consciousness and poor appetite. Prior to transfer to the pediatric wards, the patient develops rhythmic right-sided tonic-clonic movements. After administering IV phenobarbital, the seizures stop. You then order IV acyclovir and call the lab to run PCR for herpes simplex virus and enterovirus on the extra tube of CSF. This clinical presentation is consistent with a perinatal infection, possibly due to herpes simplex virus. HIV-1 and HIV-2: When most people think of HIV, they’re thinking of HIV-1. There are different stages of cancerous changes, and the treatment chosen will vary depending upon the stage.

A congenital infection is an infection seen in the newborn infant that was acquired transplacentally during the first, second, or early third trimester. These drugs can also help prevent the virus reactivates in people who have frequent repeated outbreaks. The incidence of congenital infection in the fetus and newborn infant is relatively high at 0.5-2.5%. However, heterosexual and homosexual persons, especially those with concurrent HIV infection or with more than one partner, should protect themselves and their partners against transmission of HCV, HBV, HIV, and other pathogens by use of male latex condoms. Despite the diversity of these organisms, many produce similar syndromes in the newborn infant. Lactation also stimulates the uterus to contract back to its original size. However, the majority of affected infants are entirely asymptomatic.

The incidence of congenital rubella syndrome is 0.5 per 1000 live births. Infants are usually born small for gestational age. Common clinical findings include: purpura, thrombocytopenia, hepatosplenomegaly, cardiac defects, eye defects (glaucoma and cataracts), pneumonia and meningoencephalitis. Diffuse purpuric lesions on the skin resembling a “blueberry muffin”, represent cutaneous extramedullary hematopoietic tissue that may be seen in this and other congenital infections. Congenital rubella infection can be diagnosed with an elevated anti-rubella IgM titer in the perinatal period or high anti-rubella IgG titers throughout the first year of life. Virus can also be isolated from a throat swab, CSF or urine. Common long term problems seen in infants with congenital rubella include communication disorders, hearing defects, mental and/or motor retardation, microcephaly, learning deficits, balance and gait disturbances, and behavioral problems.

Case Based Pediatrics Chapter
That’s where its true danger lies. Annually, approximately 40,000 infants are born with congenital CMV infection in this country. People with an active CMV infection can sometimes the virus in their body fluids scales, such as urine, saliva, blood, tears, semen and breast milk. Congenital CMV infection may be the result of a newly acquired maternal infection or a reactivated old maternal infection. Routine testing for HCV infection is not recommended for all pregnant women. Ninety percent of infected newborns are surprisingly asymptomatic at birth. Even though a nursing mother works up a big appetite and consumes extra calories, the extra food for her is less expensive than buying formula for the baby.

The diagnosis of congenital CMV infection is best made by isolating the virus in urine culture. Periventricular calcifications can be seen on cranial ultrasound. Of the affected infants that survive the neonatal period, 1/3 will have hearing loss, one third will have neuromuscular disorders (seizures or spasticity) and a few will have vision problems secondary to chorioretinitis. Although there is no specific therapy for congenital CMV infection, trials examining the effectiveness of ganciclovir, alpha interferon and CMV immune globulin are underway (1). The incidence of congenital toxoplasmosis infection varies with geographic location and local dietary habits. Maternal toxoplasma infection is usually due to ingestion of tissue cysts found in raw or undercooked meats or consumption of water or other foods containing oocysts from infected cats. Congenital infection with Toxoplasmosis gondii occurs during maternal parasitemia.

In the neonate, the primary focus of toxoplasma infection is in the central nervous system, leaving necrotic, calcified cystic lesions dispersed within the brain. Finally, he convinced her to call 911 and tell the operator that her 3-day-old baby was having a seizure. Approximately 85% of infants with congenital infection have normal examinations and are asymptomatic. Those infants that exhibit illness at birth frequently present with fever, hepatosplenomegaly, jaundice, rash and pneumonitis. The classic triad of toxoplasmosis, chorioretinitis, hydrocephalus and intracranial calcification occurs in only a small proportion of symptomatic patients. Abnormal laboratory findings include anemia, thrombocytopenia, eosinophilia, and abnormal CSF studies. Seizures, mental retardation, spasticity, and relapsing chorioretinitis are common long-term complications of congenital toxoplasmosis, even if not present at birth.

A woman’s nipples may become sore or cracked. Antenatal ultrasound can suggest the diagnosis of congenital toxoplasma infection when bilateral, symmetric ventricular dilatation, intracranial calcifications, increased placental thickness, hepatomegaly and ascites are noted. Postnatal diagnosis is also made by detection of anti-Toxoplasma IgM antibodies in the infant’s serum. Treatment, antenatally and postnatally, consists of pyrimethamine and sulfadiazine. Spiramycin may also be used, if available. Historically, prognosis in untreated infants is poor. However, with recent advances in antenatal diagnostic capabilities and available medical therapies, the frequency of major neurologic sequelae has decreased (2).

Syphilis is caused by the spirochete Treponema pallidum. Transplacental transmission usually occurs during the second half of pregnancy. Unlike half of all babies born with herpes, she survived. Because congenital syphilis is associated with significant neurodevelopmental morbidity, it is imperative that both maternal status and infant risk for syphilis be checked in all pregnancies. Early features of congenital syphilis include hepatosplenomegaly, skin rash, anemia, jaundice, metaphyseal dystrophy, periostitis and CSF abnormalities including elevated protein and mononuclear pleocytosis. However, in some cases, the infant is asymptomatic and may not develop any signs or symptoms of congenital infection for weeks or months. “Snuffles” is obstruction of the nose with initial clear discharge progressing to purulent or sanguineous discharge.

It is seen in infants with congenital syphilis usually after the newborn period. Most La Leche League chapters allow women to come to a few meetings without charge. However, this test is not always positive early on in life, thus repeat testing at 3 to 4 week intervals is frequently indicated. Treatment for both the pregnant mother and baby is penicillin G. Despite antibiotic therapy, it is recommended that infants undergo repeat blood and CSF testing during the first 12-15 months of life until negative or stable low titer levels are achieved. Vision, hearing and developmental evaluations are also indicated before three years of age in infants with congenital syphilis (3). One to two-thirds of adults in the United States are seropositive for human parvovirus B19.

However, the overall risk of fetal infection from human parvovirus B19 is low. Fetal infection with the virus can result in neonatal nonimmune hydrops fetalis and fetal aplastic crisis (i.e., severe anemia resulting in high output congestive heart failure and hydrops), but has not been shown to cause congenital anomalies. B19 is known to have an affinity for progenitor erythroid cells in the bone marrow. Many people with the infection have mild symptoms or none at all. The diagnosis of B19 infection can be made either serologically (anti-human parvovirus B19 IgG and IgM levels) or by viral culture. Antenatal treatment of infected infants with hydrops includes fetal transfusion and maternal digitalization. No specific antiviral treatment is currently available.

Perinatally acquired infections are those that are acquired either around the time of delivery or during the first week of extrauterine life. Common pathogens include bacteria, such as group B streptococci, E. Another reason for originally producing low-iron formulas was that human milk contains low amounts of iron–less than a milligram per liter. Infants with perinatally acquired viral infections are often normal at birth, developing illness later in life (1). A few pathogens like cytomegalovirus (CMV) can cause both congenital and perinatally acquired infection in the newborn with striking contrasts in presentation. The infant in Case 1 presents with growth restriction, anemia, thrombocytopenia, extramedullary hematopoiesis, and intracranial calcifications, all indicative of a chronic process; namely, congenital CMV infection that was transmitted transplacentally during the first or second trimester of pregnancy. In contrast, the infant in Case 2 acquired CMV infection after birth resulting in illness several weeks later.

Perinatally, CMV can be transmitted through breast milk or vaginal secretions. Premature infants however, are particularly susceptible to transmission through transfusion of blood products. The resulting syndrome is characterized by shock, pneumonitis and lymphocytosis as described above (4). The role of ganciclovir in perinatally acquired CMV infection is unclear.

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Case Based Pediatrics Chapter

Case Based Pediatrics Chapter

Recurrent HSV-1 ocular disease results from reactivation of latent virus in trigeminal ganglia (TG), often following immunosuppression or exposure to a variety of psychological or physical stressors. Long-term cytomegalovirus infection leads to significant changes in the composition of the CD8+ T-cell repertoire, which may be the basis for an imbalance in the cytokine production profile in elderly persons. Herpes genitalis is one of the most important sexually transmitted diseases; furthermore, there are severe diseases associated with HSV (e.g., encephalitis). It was also shown that mice passively immunized with rabbit antibody to herpes simplex virus, following the inoculation of herpes simplex virus by the maxillary gingiva route, developed a latent infection in the trigeminal ganglia. We applied nested polymerase chain reaction (PCR) assays to detect HSV-1 and VZV genome in trigeminal ganglia and olfactory bulbs which were obtained from 109 human corpses at forensic postmortems. HSV-1 latency was found in 72.5% of trigeminal ganglia and in 15.5% of olfactory bulbs. There were 129 eyes of 128 patients who visited the Cornea Service in our university hospitals at Osayasayama, Sakai and Nara over 13 years and were diagnosed with herpetic keratitis and followed up for at least one year.

Simultaneous latency of VZV and HSV genome occurs in 48.8% of trigeminal ganglia. Laboratory testing reveals a mild leukocytosis with the presence of atypical lymphocytes. HSV-specific CD8+ T cells can block HSV-1 reactivation from latency in ex vivo TG cultures in part through production of IFN-&#947. Morbidity does not influence the T-cell immune risk phenotype in the elderly: Findings in the Swedish NONA Immune Study using sample selection protocols. To evaluate the frequency of neurological HSV diseases, 2,406 cerebrospinal fluid samples (CSF) from 2,121 patients suspected of meningitis or encephalitis were tested for HSV DNA by the polymerase chain reaction. The Epstein-Barr virus (EBV) causes a broad spectrum of disease in humans with several clinical syndromes. Perhaps the best known is the one illustrated in the case above, the syndrome of infectious mononucleosis.

This is an acute illness that results from primary infection with the virus. Our question is: Is this long administration really necessary? The name is derived from the mononuclear lymphocytosis with atypical appearing lymphocytes that accompany the illness. The EBV virus is ubiquitous, infecting more than 95% of the world’s population. Its clinical manifestations depend on the age when the infection is first acquired. Herpes simplex virus type 1 DNA is present in specific regions of brain from aged people with and without senile dementia of the Alzheimer type. These are often asymptomatic or indistinguishable from other childhood illnesses.

Among affluent communities, however, primary infection may be delayed until adolescence or young adulthood. This is when the classic syndrome of infectious mononucleosis often manifests. Almost all adults over age forty have been infected with EBV and show serologic evidence of prior infection. 1) Positive HSV DNA in the human cornea. EBV is also known as human herpes virus-4 or HHV-4. Like other herpes viruses, it establishes a lifelong latent infection. The virus is transmitted in oral secretions and is acquired from close contact such as kissing or exchange of saliva between children.

It initially infects epithelial cells in the oropharynx, where viral replication occurs and lysis of the epithelial cell results in release of new virions into the circulation. The virus then infects B lymphocytes in the peripheral blood and the reticuloendothelial system, including the liver, spleen, and lymph nodes. It is in these cells where the virus establishes latency, via formation of a viral episome. The host mounts a cell-mediated immune response to control the number of proliferating infected B lymphocytes. The atypical lymphocytes seen in infectious mononucleosis are activated CD8 T-cells, which exhibit suppressor and cytotoxic functions in response to the infected B cells. The results of multiplex real-time PCR showed HSV-1, HHV-6 and HHV-7 DNA present in tear fluid both before and after PEA or PKP. Reactivation may occur intermittently with viral shedding in oral secretions of affected individuals.

The incubation period of infectious mononucleosis is 30-50 days. The onset of symptoms is often insidious, with a prodrome of malaise, headache, fatigue, fever, sore throat, anorexia, and myalgia. Patients seek medical attention with worsening sore throat and fever. On physical exam, the most common finding is lymphadenopathy, which is present in 90% of cases. It often occurs in the cervical region, particularly the posterior cervical chain, but may also be generalized with involvement of submandibular, epitrochlear, axillary, and inguinal lymph nodes. Lymph nodes are not spontaneously painful but may be mildly tender to palpation. Fever and pharyngitis occur in most patients.

Immunoresponse involved in herpetic keratitis. Abdominal exam may reveal splenomegaly in 60% and hepatomegaly in 10%. Patients treated with ampicillin/amoxicillin for presumed bacterial infection characteristically develop a maculopapular rash, which may be useful in diagnosis, but it is also an annoying adverse effect that often results in an inappropriate diagnosis of penicillin allergy. The diagnosis of infectious mononucleosis may be made by clinical history, physical exam, and typical laboratory findings. Greater than 90% of patients will have leukocytosis, with white blood cell counts ranging from 10,000 to 20,000. Atypical lymphocytes usually account for 20-40% of the total number. These cells appear larger, with eccentrically placed nuclei and a larger amount of cytoplasm compared to typical lymphocytes.

Mild elevation of liver enzymes occurs in 50%. EBV-associated infectious mononucleosis is associated with the transient production of heterophil antibodies. These are IgM antibodies from the patient’s serum that cause agglutination of red cells from sheep or horse serum. The most widely used test is the Monospot (trademark), a qualitative rapid slide test which detects horse red cell agglutination (i.e., the modern equivalent of the heterophil antibody). The sensitivity and specificity of this test is greater than 95% for diagnosing EBV-associated infectious mononucleosis. Children with symptomatic primary EBV infection are often heterophil negative. Ten percent of EBV-associated infectious mononucleosis may be heterophil- negative.

Certain organisms may cause an infectious mononucleosis-like syndrome but are not associated with formation of heterophil antibodies, such as cytomegalovirus, T. gondii, adenovirus, viral hepatitis, HIV, and rubella. The host also produces antibodies specific to the EBV virus. These are unnecessary for the diagnosis of infectious mononucleosis when the Monospot test is positive. These may be useful to clarify the diagnosis of heterophil-negative cases, or for atypical EBV infections when the Monospot test is often negative. Multiple EBV-specific antibody tests are available, including tests for viral capsid antigen (VCA), early antigen (EA), and EBV nuclear antigen (EBNA). The presence of IgM antibodies against viral capsid antigen signifies acute infection, while the presence of IgG antibodies signifies recent or past infection.

Infectious mononucleosis usually resolves in 2-3 weeks, although malaise may persist for weeks to months. Treatment is primarily supportive, with rest during the acute stage of illness and symptomatic care. Contact sports should be avoided while splenomegaly is present due to the risk of splenic rupture, although the incidence of this is low at less than 0.5%. Treatment with acyclovir or corticosteroids has not been proven to be of benefit in uncomplicated cases. Corticosteroids may be considered for severe complications of EBV infection, which are rare. Complications may include marked tonsillar inflammation with impending airway obstruction, massive splenomegaly, myocarditis, autoimmune hemolytic anemia, aplastic anemia, thrombocytopenia, neutropenia, hemophagocytic syndrome, meningitis, and encephalitis. EBV infection has been identified as a possible causative agent for chronic fatigue syndrome, but there is no strong evidence to support this.

EBV has been linked with benign and malignant proliferative disorders, particularly in patients with immunodeficiencies such as HIV, transplant recipients, severe combined immune deficiency, or Wiskott-Aldrich syndrome. The absence of an intact cell-mediated immunity in these patients allows the uncontrolled proliferation of EBV-infected B lymphocytes. Examples of benign disorders include oral hairy leukoplakia, which occurs primarily in adults with HIV and presents with raised, white lesions on the tongue, and lymphoid interstitial pneumonitis, which occurs primarily in children with HIV and is characterized by the presence of diffuse interstitial pulmonary infiltrates. Examples of malignant disorders that have been associated with EBV include nasopharyngeal carcinoma, the most prevalent cancer among adult males in southern China, and African Burkitt lymphoma, the most common childhood cancer in equatorial east Africa. Genetic and environmental factors may play a role in the increased incidence of these diseases in these areas. EBV has also been associated with lymphoma in immunosuppressed patients. 1.

A 16 year old male presents with sore throat, fever, and cervical lymphadenopathy. A throat culture is done which is positive for group A streptococcus. Treatment is initiated with penicillin. He returns two days later with worsened symptoms, despite taking the medicine. Which of the following is the most appropriate step to do next? . .

. . . a. Switch to azithromycin. . .

. . . b. Obtain a CBC and Monospot. . .

. . . c. Check anti-VCA, anti-EA, and anti-EBNA titers against EBV. . .

. . . d. Assume the patient has infectious mononucleosis and start acyclovir and prednisone. 2. Which of the following is FALSE regarding EBV infection in young children?
Case Based Pediatrics Chapter

. . . . . a. Primary infection is usually asymptomatic.

. . . . . b. Heterophil antibodies are usually positive.

. . . . . c. Immunocompromised patients are at risk for lymphocytic interstitial pneumonitis .

. . . . d. Complications are less common than in adults. 4.

An 18 year old female presents with malaise, fever, sore throat, and lymphadenopathy. Her CBC reveals atypical lymphocytosis, but her Monospot test is negative. Which of the following statements is TRUE? . . . .

. a. The Monospot test is not a highly sensitive test. . . . .

. b. Her symptoms may be due to primary infection by cytomegalovirus (CMV). . . . .

. c. There is no role for EBV-specific antibodies in making the diagnosis. . . . .

. d. The atypical lymphocytes represent circulating infected B lymphocytes. 5. Which of the following statements about EBV infection is TRUE? . .

. . . a. The syndrome of infectious mononucleosis results from primary infection with the virus. . .

. . . b. Infection usually occurs via contact with the blood of an affected person. . .

. . . c. About 25% of older adults show serologic evidence of prior infection. . .

. . . d. Splenic rupture is a frequent complication in EBV-associated infectious mononucleosis. 1. The answer is b.

In this case, the group A streptococcus probably represents colonization rather than the etiology of the patient’s symptoms. Infectious mononucleosis may have a similar presentation to streptococcal pharyngitis, and must be considered if a patient is not responding clinically to treatment with antibiotics. Diagnosis may be made with a Monospot test as well as the presence of atypical lymphocytes on CBC. EBV titers are not usually needed in diagnosis, but may be considered if the Monospot is negative and EBV infection is to be ruled out. Treatment with acyclovir or corticosteroids has not been proven to be of clinical benefit in uncomplicated cases of infectious mononucleosis. 2. The answer is b.

Primary EBV infection occurs more commonly in childhood and is often asymptomatic. In children who do develop symptomatic EBV infection, heterophil antibodies are more often negative. Lymphocytic interstitial pneumonitis may occur in children with HIV. Complications occur less commonly in children than in adults. 3. The answer is d. The first three have all been found to be associated with EBV infection.

Kaposi’s sarcoma is associated with a different human herpes virus, referred to as human herpes virus-8 or HHV-8. 4. The answer is b. The Monospot test is a highly sensitive test, although ten percent of EBV-associated infectious mononucleosis may be negative. There are also a number of organisms that may cause an infectious mononucleosis-like syndrome but are not associated with formation of heterophil antibodies. The most common cause of a heterophil-negative infectious mononucleosis-like syndrome is CMV, which this patient likely has. Obtaining antibody titers specific against EBV and CMV may clarify the diagnosis.

The atypical lymphocytes that may be seen with either EBV or CMV infection represent activated T lymphocytes, which proliferate in response to infected B lymphocytes. 5. The answer is a. The syndrome of infectious mononucleosis results from primary infection with EBV, particularly when it is delayed until adolescence or young adulthood. It is usually transmitted through close contact with oral secretions of an infected individual. The virus is ubiquitous, and almost all adults over age 40 show serologic evidence of prior infection. Splenic rupture is a rare complication of EBV-associated infectious mononucleosis.

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