Pediatric Examination and Board Review (106 page)

12.
(E)
In addition to those listed, other manifestations of
Bartonella henselae
infection include encephalitis, fever of unknown origin, pneumonia, thrombotic thrombocytopenic purpura (TTP), erythema nodosum, and osteolytic lesions. Parinaud oculoglandular syndrome presents as conjunctivitis and preauricular or submandibular lymphadenopathy that is ipsilateral to the primary infection.

13.
(A)

14.
(A)
Antibiotics are usually reserved for disseminated cat-scratch disease. Getting rid of the cats/kittens will not help this episode, although patients should be instructed to avoid rough play with cats and kittens to avoid scratches, and, if scratched, should wash the wound immediately. Incision and drainage as well as surgical excision should be avoided.

15.
(D)
Thyroglossal duct cysts appear during childhood and often enlarge rapidly in the setting of an infection. They are located in the midline, between the hyoid bone and the suprasternal notch, and move up when the patient sticks the tongue out or during swallowing (see
Figure 64-2
). The lump could represent thyroid tissue, although unlikely given this history, but must be ruled out before surgery is undertaken to excise the cyst.

FIGURE 64-2.
Midline mass in an adolescent demonstrating a thyroglossal duct cyst. (Reproduced, with permission, from Tintinalli, JE, Kelen GD, Stapczynski JS. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 6th ed. New York: McGraw-Hill; 2004: Fig. 243-6.)

16.
(E)
This most likely is a branchial cleft cyst, located at the anterior border of the sternocleidomastoid (SCM) muscle. When superinfected, like this one, it enlarges and may drain purulent fluid.

17.
(E)
Typically, ultrasound is the preferred modality to begin the evaluation of branchial clefts in children. CT is often performed as well.

18.
(A)
2-3% are bilateral.

S
UGGESTED
R
EADING

Behrman RE, Kliegman RM, Jenson HB, et al.
Nelson Textbook of Pediatrics
. Philadelphia, PA: WB Saunders; 2007.

Chesney PJ. Nontuberculous mycobacteria.
Pediatr Rev.
2002; 23(9):300-308.

Peters TR, Edwards KM. Cervical lymphadenopathy and adenitis.
Pediatr Rev.
2000;21(12):399-404.

Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds.
Red Book 2009 Report of the Committee on Infectious Diseases.
28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009.

CASE 65: A 3-MONTH-OLD BOY WITH APNEA

A 3-month-old boy is brought to your emergency department on Thanksgiving after Mom noted that he “stopped breathing.” He was in his usual state of health until 3 days before presentation when he developed nasal congestion and mild cough. The cough worsened, resulting in decreased intake, and, according to Mom, progressed toward an increased effort of breathing. The night of admission Mom observed a particularly harsh coughing spell, followed by a period where no breathing was noted for approximately 20-30 seconds. Mom denies any color changes, abnormal movements, loss of tone, emesis, or fever. After the breathing resumed, the infant was breathing abnormally fast, and Mom continued to note an increased effort to breathe. She brought him to the emergency department and noted no further episodes on the way.

Past medical history and family history are unremarkable. Immunizations are up to date and he takes no known medications. The infant lives at home with his mom, dad, and 3-year-old sister, all of whom are healthy. There are no smokers in the home. He attends day care.

On your examination, he is resting quietly, with vital signs of T (temperature) 100.7°F (38.2°C) rectally, heart rate (HR) 144, respiratory rate (RR) 62, BP 100/70, and oxygen saturation of 90% on room air (RA). He appears mildly dehydrated but not toxic. The right TM has decreased mobility with poor landmarks, and nasal congestion and discharge are noted. The lung examination reveals tachypnea with subcostal retractions and nasal flaring. He has diffuse wheezes and crackles through both lung fields. A wet cough is noted. Neurologically he has no focal deficits and is alert and responsive. The remainder of the examination is benign.

He is placed on 1 L oxygen by nasal cannula and given an albuterol nebulizer treatment with no apparent response. Chest radiograph demonstrates right middle lobe atelectasis with hyperinflation but no focal infiltrates.

SELECT THE ONE BEST ANSWER

1.
Which of the following is the most likely etiology for this patient’s symptoms?

(A)
C trachomatis
(B) pertussis

(C) respiratory syncytial virus (RSV)

(D) reactive airway disease

(E) none of the above

2.
Which of the following would be most useful in directing the immediate course of action for this patient?

(A) CBC with differential

(B) rapid enzyme immunoassay for RSV

(C) EEG

(D) viral culture of nasopharyngeal aspirate

(E) none of the above

3.
Which of the following has been proven unquestionably useful for the patient’s therapy?

(A) nebulized albuterol

(B) nebulized budesonide

(C) oral prednisolone

(D) aerosolized ribavirin

(E) none of the above

4.
Which of the following is not an important issue with regard to the infection control of RSV?

(A) prevention of fecal-oral spread

(B) good handwashing

(C) institution of hospital contact isolation

(D) parental education

(E) patient cohorting in hospital

5.
Which of the following patients is not at increased risk for RSV complications?

(A) a 6-year-old status post bone marrow transplant

(B) a 7-month-old, former 30-week premature infant without chronic lung disease

(C) an 8-month-old with diagnosed chronic lung disease

(D) a full-term infant with congenital heart disease

(E) a 9-month-old, former 27-week premature infant without chronic lung disease

6.
Which of the following is false regarding the epidemiology of RSV?

(A) peak months are November through May in temperate climates

(B) the virus can remain viable on countertops for hours

(C) peak age of onset is birth to 2 months

(D) spread is via ocular or nasal direct contact with large droplets in secretions

(E) the virus can be shed for 3-8 days

7.
True or False: Prior infection with RSV confers lifelong immunity.

(A) True

(B) False

8.
True or False: Most children have been infected with RSV by 4 years old.

(A) True

(B) False

9.
For an infant who presents with a staccato cough without fever, what is the most diagnostically useful finding on CBC?

(A) absolute lymphocytosis

(B) neutropenia

(C) thrombocytopenia

(D) eosinophilia

(E) normocytic anemia

10.
True or False: Newborns of mothers with untreated
C trachomatis
during pregnancy should be treated empirically for a chlamydia infection in addition to receiving eye prophylaxis given primarily for gonorrhea.

(A) True

(B) False

11.
If a newborn does acquire
C trachomatis
during delivery, what are the chances that the infant will eventually have a symptomatic infection?

(A) 25-50% for pneumonia

(B) 50-75% for conjunctivitis

(C) 5-20% for pneumonia

(D) 5-20% for conjunctivitis

(E) 50-75% for pneumonia

12.
Which of the following statements is true regarding the treatment of infant chlamydial infections?