Pediatric Examination and Board Review (101 page)

(A) retropharyngeal abscess

(B) splenic rupture

(C) glomerulonephritis

(D) peritonsillar abscess

(E) rheumatic fever

4.
If this patient’s rapid strep test was positive, what is your
first
choice of medication?

(A) cephalexin

(B) penicillin

(C) azithromycin

(D) ceftriaxone

(E) prednisone

5.
If she came back after taking the prescribed antibiotic for 10 days, still had a sore throat, and similar findings on examination, what would you do next?

(A) reculture for group A streptococcus

(B) monospot test

(C) diagnose her as a group A streptococcus carrier

(D) admit for IV antibiotics

(E) A and B

6.
If her repeat throat culture grew group A streptococcus, what medication would you start her on?

(A) acetaminophen or ibuprofen

(B) penicillin

(C) azithromycin

(D) ceftriaxone

(E) prednisone

7.
Her mother wants to know if her 6-year-old brother, who is at home, should also be tested for group A streptococcus. He has no symptoms and is otherwise healthy. Which is the next appropriate step for you to take for her brother?

(A) rapid strep test

(B) throat culture for strep

(C) no tests

(D) prophylactic oral antibiotics

(E) prophylactic IM ceftriaxone

8.
One week later, her 2-year-old brother developed a fever of 101°F (38.3°C) axillary, serous rhinitis, and mild cough. On examination, he was found to have a temperature of 100.5°F (38°C) rectally, a normal respiratory rate, nasal congestion, and yellowish discharge in both nares. The oropharynx was moist and normal appearing, and the lungs were clear. What test(s), if any, would you do?

(A) rapid strep test

(B) monospot

(C) rapid flu test

(D) CBC with differential leukocyte count

(E) no tests

9.
A 6-month-old male infant presents to your office with a diaper rash for 8 days. His parents have tried OTC diaper creams but none seem to be helping. He is eating normally, has regular soft bowel movements, and has had no other symptoms except irritability for 2 days when he has a bowel movement and when they are cleaning him afterward. On examination you note bright erythema perianally extending about 3 cm outward but no other finding. His genitals appear normal, and the rest of his examination is normal. What is the likely etiology of this rash?

(A)
Candida albicans

(B) group A streptococci

(C) group B streptococci

(D) seborrheic dermatitis

(E) pinworm infestation

10.
What is the most worrisome complication of the disease from question 9?

(A) rheumatic fever

(B) abscess

(C) impetigo

(D) glomerulonephritis

(E) severe diarrhea

11.
What lab test can you do to confirm your suspicion raised in question 9?

(A) KOH prep

(B) skin culture

(C) throat culture

(D) urinalysis

(E) stool studies

12.
What do you recommend to the parents for treatment in question 9?

(A) watchful waiting

(B) continue OTC diaper creams only

(C) topical antibiotics

(D) topical steroids

(E) penicillin orally

13.
A 15-year-old girl whom you saw in your office last week and diagnosed with group A streptococcus pharyngitis has returned. She stopped taking her antibiotics after 3 days because her sore throat resolved. It has now returned, and she feels more pain than before. She reports a fever of 104°F (40°C) last night and this morning is having difficulty opening her mouth to eat and severe pain on swallowing water. On examination she is ill appearing. Her temperature is 102°F (38.8°C) and she has very tender anterior and posterior cervical lymph nodes bilaterally. She cannot open her mouth for you to examine her oropharynx. Her abdominal examination is normal. What is the likely diagnosis?

(A) group A streptococcal pharyngitis

(B) EBV mononucleosis

(C) retropharyngeal abscess

(D) peritonsillar abscess

(E) gonococcal pharyngitis

14.
What is the study to best diagnose the problem from question 13?

(A) radiograph of lateral neck

(B) CT

(C) MRI

(D) throat culture

(E) fine-needle aspiration

15.
All of the following are useful treatment measures for the diagnosis in question 13 except

(A) parenteral antibiotics

(B) oral steroids

(C) surgical drainage

(D) patient-controlled analgesia (PCA) pump

(E) all are appropriate treatment measures

16.
A 21-month-old girl is brought in by her mother because of fever (101°F-103°F [38.3°C-39.4°C]) and anorexia for 2 days. She has not urinated in 12 hours. She has no other symptoms, specifically no cough, rhinorrhea, rash, vomiting, or diarrhea. On examination, she appears quite ill, has an axillary temperature of 102.5°F (39.1°C), heart rate of 140, and a capillary refill of 3 seconds. She holds her head hyperextended and resists examination of her oral cavity. She has tender bilateral cervical lymphadenopathy and has mild stridor. The rest of her examination is normal. What is the most likely diagnosis?

(A) group A streptococcal pharyngitis

(B) EBV mononucleosis

(C) retropharyngeal abscess

(D) peritonsillar abscess

(E) gonococcal pharyngitis

17.
What is the most concerning possible complication in this child from question 16?

(A) febrile seizure

(B) airway occlusion

(C) dehydration

(D) sepsis

(E) aspiration pneumonia

18.
On arrival in the emergency department, the child from question 16 is examined by an otolaryngologist who notes a right-sided anterior bulge in the posterior oropharynx. Which of the following is the first step of your management?

(A) airway securing and monitoring

(B) placement of IV and nothing by mouth (NPO) order

(C) surgery consult

(D) radiographs

(E) IM dexamethasone

ANSWERS

1.
(C)
Although bacteria are the etiology in only 5-10% of cases of pharyngitis, this presentation is most likely group A beta-hemolytic streptococcal pharyngitis. It is most common among school-age children and causes rapid-onset pharyngitis with associated symptoms of fever, headache, neck tenderness, abdominal pain, and emesis. Viral pharyngitis is more common in conjunction with other upper respiratory tract symptoms (congestion, rhinorrhea, cough, ear pain). Coxsackie virus is an enterovirus that can cause typical symptoms of the common cold, ulcerative pharyngitis, and handfoot-mouth disease. EBV mononucleosis can cause exudative pharyngitis, and often splenomegaly is found on examination. Group B streptococcus does not cause pharyngitis; it is a major cause of perinatal infections and urinary tract infections among pregnant women.

2.
(C)
If you are suspicious of streptococcal pharyngitis, a rapid latex test can be performed in your office. Several rapid tests are available, and all require vigorous swabbing of the palate and tonsils, and/or the posterior pharynx. Sensitivities and specificities are similar and approximately 80-90% and 95%, respectively. Because of the high specificity, a positive latex test does
not
require a confirmatory throat culture. Conversely, a negative rapid test should prompt a throat culture to screen for group A streptococci. Starting antibiotics without documenting group A streptococci by latex or throat culture is not appropriate.

3.
(B)
All of these are possible complications of group A streptococcal pharyngitis except splenic rupture, which is associated with trauma to the enlarged and friable spleen associated with EBV mononucleosis. A retropharyngeal abscess presents as high fever, drooling, trismus (inability to open jaw), painful pharyngitis, and, sometimes, a toxic appearance. Rheumatic fever in children younger than 3 years old is uncommon. With improved testing and treatment, rheumatic fever in the United States today is uncommon (0.3% in nonepidemics, 3% in epidemics), although it may still occur in association with group A streptococcal outbreaks. All the complications previously listed are usually preventable by timely testing and antibiotic treatment.

4.
(B)
Penicillin is still the antibiotic of choice for group A streptococcal pharyngitis. Oral (phenoxymethyl) penicillin or IM benzathine penicillin are acceptable. Other beta-lactams such as amoxicillin are also acceptable. Azithromycin or erythromycin have activity against group A streptococci (although rare resistance is reported) but should be reserved for penicillin-allergic patients. Firstgeneration oral cephalosporins (cephalexin, cefadroxil) can be used against group A streptococci but are more expensive and have wider antimicrobial spectra. They should also be reserved for allergic patients. IV or IM cephalosporins are not indicated. Steroids have no role in treating group A streptococci pharyngitis.

5.
(E)
Reculturing this patient for group A streptococci is an appropriate next step. Posttreatment throat cultures should be reserved only for those patients who are still symptomatic or for those patients who are at very high risk for rheumatic fever. Those who are asymptomatic at the end of treatment but still culture positive should not receive additional antimicrobial treatment because carriage of group A streptococci in the pharynx can continue for several weeks after active infection. One might also consider the possibility of concomitant EBV pharyngitis because approximately 10% of patients with mononucleosis are group A streptococcus positive. This patient may also be a group A streptococcal carrier and have prolonged viral pharyngitis, although a second round of treatment for another positive throat culture is warranted before entertaining the carrier diagnosis. Treating with a different oral or IV antibiotic is unnecessary even if the patient is still positive for group A streptococci.

6.
(B)
For a persistent symptomatic patient with a positive group A streptococcal culture, the same antibiotic is recommended (penicillin). In this case, continued infection should be ruled out with a second course of penicillin. A persistently positive test for group A streptococci after a
second
course of penicillin suggests that the patient is a group A streptococci carrier and has another etiology for her pharyngitis.