Disclaimer. This is a broad survey and cannot cover all differential diagnoses or each condition in thorough detail

Transcription

1 Objectives Pediatric Infections: Differentiating Benign from Serious Eileen Klein, MD, MPH Rashes Infectious vs non-infectious Viral vs bacterial Respiratory and GI illnesses When do you treat When do you refer The Red eye When should you worry Disclaimer This is a broad survey and cannot cover all differential diagnoses or each condition in thorough detail Goal is to give participants the tools to differentiate sick versus not sick for a number of pediatric problems

2 Common feature of all photos? Petechiae Differential Diagnosis Petechiae Infectious Viral Oral Streptococcal pharyngitis Sepsis Non infectious Traumatic (cough, vomit, injury) HSP ITP Leukemia 2

3 Viral Rash Combination rash Main rash is: Blanching Erythematous Maculopapular Child is generally not ill appearing Associated viral symptoms (URI, diarrhea, etc) Need to consider sepsis if ill appearing Streptococcal Pharyngitis Viral vs bacterial Bacterial more common age 4-14 Centor Criteria History of Fever Tonsillar exudates Tender cervical nodes Absence of cough If all 4 then 40-60% positive predictive value If 0 then 80% negative predictive value Children less than 3 should not be tested Common carriers and low risk of rheumatic fever Sepsis You are likely to see children early Fever and petechiae red flag Early sign of sepsis Tachycardia Out of proportion to fever/fussiness Have low threshold for referral SCH - part of national collaborative aiming to decrease mortality from sepsis 3

4 Traumatic petechiae Common with cough/vomit Usually located on face Increase concern if fever and below nipple line Think about other etiologies (e.g. sepsis) Consider abuse if in pattern (e.g. hand print) Journal of Pediatrics Henoch-Schonlein Purpura (HSP) Unique feature - Palpable purpura Vasculitis (i.e. systemic) Is a CBC needed? Short term complications Leg swelling/pain and abdominal pain Intussusception (ileo-ileal) Not treated (steroids may help abdominal pain) Long term complications Need to follow BP and urine for kidney disease Idiopathic Thrombocytopenic Purpura (ITP) Autoimmune disease Often self limited Treatment: Treat if platelets less than 20 IVIG (first line) Rho Immune globulin (If Rh+) Steroids (may need bone marrow first) Splenectomy if refractory to therapy Risk of spontaneous bleed if platelets less than

5 Leukemia Leukemia cells can be found in rash Leukemic infiltrates Get CBC if concern for low platelets Associated with: Pallor Hepatosplenomegaly Decreased energy Often not very ill appearing Urticaria - etiology Urticaria - management Idiopathic Viral infection Allergic reaction Food Drug Contact Insect bite Skin involvement only Make sure not anaphylaxis (needs epinephrine) Airway or mucous membrane involvement Treatment Antihistamine Give on regular basis at least for several days Symptoms may wax and wane for weeks! Dermatology if persists more than 6 weeks (consider photo consult if unsure of diagnosis) Also Urticaria 5

6 Periorbital Cellulitis vs Allergic Reaction Hard to differentiate if: Unilateral Afebrile Not pruritic or hard to tell Treatment Antibiotics, antihistamines or both Close follow up Viral Exanthem Blanching erythematous maculopapular rash Other viral symptoms (URI, diarrhea, etc) Immunization status (measles and rubella) Common viral rashes Erythema infectiosum (parvovirus) Slapped cheek appearance followed by diffuse rash Roseola (HHV) Fever followed by rash Self limited (days) - Key is parental reassurance Drug Eruption Medication history Evaluate severe reaction (e.g. Stevens Johnson) Most common: Drug induced exanthem Antibiotics common (especially bactrim) 1-2 weeks after treatment started May be 2-3 days if previously exposed May take 2 weeks to resolve! 6

7 Cellulitis vs Fasciitis Clinical measures Intense pain with light touch (out of proportion) Rapid progression Dusky skin discoloration (late sign) Laboratory measures Laboratory risk indicator for necrotizing fasciitis LRINEC score arrows point to lower risk CRP ( ) WBC ( ) Hemoglobin ( ) Sodium ( ) Creatinine ( ) Glucose ( ) Score of 6 or higher is very concerning URI when is it more? Upper Airway Disease that needs treatment Sinusitis Croup Peritonsillar/Retropharyngeal Abscess Lower Airway Disease Wheezing Bronchiolitis Pneumonia What about persistent Cough? Upper Airway Disease Sinusitis (treatment with Amoxicillin) Persistens symptoms Severe symptoms Worsening symptoms Croup (See SCH guidelines) Dexamethasone Racemic epinephrine Peritonsillar/Retropharyngeal abscess Trismus Neck stiffness and fever is not torticollis Lower Airway Disease Tachypnea (afebrile) indicates lower airway Often difficult to differentiate Wheeze/Bronchiolitis/Pneumonia Patient age helps as does history of wheeze Tips for identifying wheezes X-rays usually not needed Fever may be the tipping point Hypoxia helps to determine need to refer Persistent Cough with URI Diarrhea When to worry 50% resolve after 12 days 90% resolve after 25 days Some last longer than 25 days! Honey can help sleep and nighttime cough Don t give honey to young children Pediatrics Sep;130(3): doi: /peds BMJ Dec 11;347:f7027. doi: /bmj.f Aug 6. Culture if: Severe acute symptoms Blood (found in bacterial and viral infections) Long duration (greater than 7-10 days) Don t treat with antibiotics (need culture result) Refer if: Bloody (make sure to guaiac) with concern for HUS Recurrent and bloody (concern for IBD) Dehydration 7

8 Conjunctivitis - What else could it be Viral vs Bacterial conjunctivitis May be allergic also pruritic (antihistamine) Not painful Sometimes hard to differentiate Most get treated (return to daycare/school) Ointment more effective Drops more tolerated (e.g., Polytrim) Tips for putting in drops Other causes of red eye Traumatic Iritis (inflammation in anterior chamber) Painful (photophobia) Often hours after trauma Needs ophthalmologist/slit lamp exam Corneal abrasion or Foreign body History is key (ie, exposure, sensation of object) Fluorescein exam Eyelid eversion Eye pain low threshold for referral! Putting it all together ae.medseek.com/.../graphics/images/en/19662.jpg 8

9 Take Home Points Consider sepsis if fever and petechiae Urticaria can last a long time! Think about necrotizing fasciitis with cellulitis URI associated cough can last a long time! No antibiotics for diarrhea (culture) Eye pain is a red flag Use your colleagues they are a great resource! Thank You! Thank you you 9