Pediatric Examination and Board Review (107 page)

(A) azithromycin for 5 days is the treatment of choice

(B) erythromycin should not be given to children younger than 6 weeks because of the risk of pyloric stenosis

(C) topical erythromycin alone is adequate for the treatment of conjunctivitis

(D) oral erythromycin should be given for both conjunctivitis and pneumonia

(E) none of the above

13.
Which of the following (A-D) is not a clinical presentation of an apparent life-threatening event (ALTE)?

(A) limpness

(B) gagging

(C) cyanosis

(D) plethoric color changes

(E) all of the above could be a clinical presentation of an ALTE

14.
Which of the following is a potential diagnosis to explain an ALTE?

(A) gastroesophageal reflux

(B) anemia

(C) pertussis

(D) bronchiolitis

(E) all of the above

15.
A 2-week old infant has an apneic event. The infant was born via uncomplicated vaginal delivery and had an unremarkable postnatal course. Mom denies any complications of pregnancy or infections. All appropriate bacterial cultures are pending, and an EEG demonstrates sharp spikes in the temporal lobe. What is the most appropriate next step to help in diagnosis?

(A) send CSF for viral culture

(B) send CSF for a specific polymerase chain reaction (PCR) test

(C) send serum for a specific PCR test

(D) obtain a pH probe study

(E) obtain a head CT

16.
What would be the appropriate therapy for herpes simplex virus meningoencephalitis?

(A) acyclovir PO for 4 weeks

(B) acyclovir IV for 3 weeks

(C) ganciclovir IV for 3 weeks

(D) oseltamivir IV for 4 weeks

(E) foscarnet IV for 3 weeks

17.
What is the most important goal of hospitalization for an ALTE?

(A) obtaining definitive diagnosis

(B) establishing home apnea monitoring

(C) educating family on infant cardiopulmonary resuscitation (CPR)

(D) involving child protective services

(E) all of the above

ANSWERS

1.
(C)
The patient described in the vignette most likely has an infectious etiology for his respiratory symptoms. The most likely of the infectious choices in this scenario is RSV. The most common cause of respiratory tract infection in infants and young children, RSV peaks between November and May. Hypoxia and wheezing following congestion and cough are classic clinical features of RSV infection. Chlamydia infects younger patients (2 months) who usually have a staccato cough with, possibly, a history of conjunctivitis. Pertussis, although common in young infants, is less frequently seen after the 4-month immunization visit and tends to present with a paroxysmal cough without wheezing. Both chlamydia and pertussis, like RSV, however, can cause apnea, although chlamydia does so rarely. Reactive airway disease is less likely with a negative family history of asthma, no prior episodes, and lack of response to bronchodilators.

2.
(B)
With clinical suspicion high for RSV, the most rapid diagnostic tool would be a rapid RSV screen by immunoassay. A positive test would prevent further unnecessary laboratory testing and antibiotic use, as well as allow for proper infection control steps. The sensitivity and specificity of the rapid tests exceed 90%. Although a viral culture would confirm any screen, results take several days and RSV is not recoverable on routine viral culture media. A CBC could suggest concern for other infectious causes (eg, lymphocytosis in pertussis or eosinophilia in
Chlamydia
) but is not specific. An EEG is often included in the workup of apnea but would not be warranted until an infectious cause is ruled out.

3.
(E)
The only uncontroversial method for RSV treatment is supportive care. Careful attention should be paid to oral intake because increased respiratory rate can prevent adequate nutritional intake, and IV fluids may be necessary. Supplemental oxygen may be necessary for persistent desaturation. Multiple studies have investigated the role of bronchodilators, steroids, and antivirals, with no consistent results. Although some studies have shown a correlation with ribavirin use and certain relevant clinical outcomes, these studies are also contradictory and inconclusive. Bronchodilators and steroids have shown inconsistent benefit at best and are not cost effective for the minimal improvement they may offer.

4.
(A)
RSV is transmitted via large-droplet secretions via nasal or ocular contact. Respiratory isolation is not necessary, although the remaining answers are all mainstays for prevention of community and nosocomial transmission.

5.
(B)
Infants born after a 29-32 week gestation who do not have chronic lung disease are not at increased risk after 6 months of age.

6.
(C)
Peak age of onset is 2-5 months.

7.
(B)
False. Reinfection often occurs with RSV, although subsequent infections tend to be less severe.

8.
(A)
True. Most children in the United States will be infected by the age of 2 years, although more than 75% of hospital admissions for RSV will be in children younger than 1 year.

9.
(D)
Patients with
C trachomatis
pneumonia often have eosinophilia on CBC. Although this is not diagnostic, it is highly suggestive of such an infection in a child who fits the classic clinical picture (staccato cough, afebrile pneumonia, 1-3 months of age).

10.
(B)
False. There are no studies that prove the efficacy of empirical treatment of a newborn born to a
Chlamydia
positive mother. Treatment is based on development of symptoms (conjunctivitis, pneumonia).

11.
(C)
The risk of an infant acquiring
Chlamydia
pneumonia is 5-20%. The risk of conjunctivitis is greater, 25-50%, although chlamydial conjunctivitis does not present before day of life 5.

12.
(D)
Oral erythromycin is currently the recommended therapy for both conjunctivitis and pneumonia caused by
C trachomatis
. Topical therapy for conjunctivitis is ineffective. Azithromycin has not been approved for children younger than 6 months. Although an association between erythromycin and pyloric stenosis has been reported in infants, such an association has not been proven, and thus erythromycin is still recommended for therapy even for infants younger than 6 weeks.

13.
(E)
An ALTE is defined as any episode that is frightening to the observer. All of the preceding symptoms can be included in that definition. Most ALTE patients require admission and observation/ workup.

14.
(E)
All of the above are potential etiologies for ALTE. The workup of ALTE is focused on historical and physical findings directing the investigation. A large percentage of patients have no identifiable cause for the ALTE and have no repeat events either in the hospital or after discharge.

15.
(B)
The patient described above has an ALTE secondary to seizure activity consistent with neonatal herpes infection. Confirmation of a herpes CNS infection could be achieved by CSF PCR. A CSF viral culture is rarely positive, although it should be attempted. CT scans demonstrate changes that are consistent but not diagnostic. After obtaining CSF for PCR, antivirals targeting herpes should be used pending the result.

16.
(B)
Acyclovir is the drug of choice for CNS HSV infection in neonates. The dose is 20 mg/kg per dose 3 times per day for 14-21 days.

17.
(C)
The most important discharge goal for ALTE is to educate parents on infant CPR. Home monitoring has not been proven to reduce the incidence of SIDS and often causes more parental stress. Most cases of ALTE are of unknown etiology. Although child protective services may be warranted in some cases of ALTE when the clinical history is suspicious, most cases only require parental education.

S
UGGESTED
R
EADING

Meissner HC, Long SS; American Academy of Pediatrics Committee on Infectious Diseases and Committee on Fetus and Newborn. Revised indications for the use of palivizumab and respiratory syncytial virus immune globulin intravenous for the prevention of respiratory syncytial virus infections.
Pediatrics.
2003;112:1447-1452.

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.

RSV pages. Centers for Disease Control and Prevention Web site.
http://www.cdc.gov/rsv/index.html
. Accessed June 2010.

CASE 66: A 2-YEAR-OLD BOY WHO NEEDS A CHECKUP

A 2-year-old boy presents for a routine health supervision visit. He is a new patient to your clinic and arrives with few medical records. Mom reports that he has been well his whole life, although his previous doctor mentioned that he was “behind on the things he does.” She does not have any concerns. He started day care 4 months prior and is starting to attempt toilet training. Bowel movements are every other day and can be hard. His diet consists of eating most foods, with minimal vegetables, but limited “junk food,” and he drinks 4-5 glasses of whole milk per day. Developmentally he can brush his teeth with help but does not dress/undress himself. He can build a tower of 6 cubes, climbs steps, but does not kick a ball. He has a 20-word vocabulary and is just starting to combine 2-word phrases. Family history is negative for any chronic illness.