Pediatric Examination and Board Review (124 page)

(E) all of the above

9.
The wet preparation shows large amounts of white blood cells and flagellated organisms. With the information you have so far (including history and physical examination), this patient most likely has

(A) trichomonal vaginitis

(B) herpes simplex infection

(C) chlamydial cervicitis

(D) a UTI

(E) all of the above

10.
The following laboratory tests should now be performed except

(A) rapid plasma reagin (RPR)

(B) blood culture

(C) HIV test

(D) urine culture

(E) pregnancy test

11.
Concerning chlamydia infections, which of the following statements is false?

(A) cervical ectopy is a risk factor for infection

(B) most chlamydia infections are asymptomatic

(C) retesting is recommended 4-6 months after treatment of chlamydia cervicitis

(D) 15% of all
C trachomatis
infections occur in young women aged 15-19 years

(E) there is a high rate of concurrent disease in adolescents with urinary tract symptomatology and
C trachomatis

12.
Regarding trichomonal vaginitis, which of the following statements is/are true?

(A) up to 90% of women infected with
T vaginalis
present with vaginal discharge

(B) partners of patients with trichomonal infection should be treated

(C) most recurrences of trichomonal vaginitis are a result of resistance to treatment

(D) trichomonal infections in males are symptomatic in most cases

(E) all of the above

13.
Regarding the clinical manifestation of primary herpes infections in adolescents, which of the following statements is false?

(A) the incubation period is 2-12 days

(B) reepithelization occurs 15-20 days after the initial outbreak

(C) lesions shed the virus for 3-5 days

(D) cervicitis is present in up to 90% of first episodes but is less common in recurrent disease

(E) constitutional symptoms may include headaches, fever, malaise, myalgia, nuchal rigidity, and photophobia

14.
The following laboratory tests are useful for the diagnosis of herpes simplex virus (HSV) infections except

(A) Tzanck smear

(B) wet mount

(C) Pap smear and colposcopy

(D) viral culture

(E) serology

15.
In gonorrhea, all of the following are true except

(A) females have a 50% chance of contracting gonorrhea from an infected male after a single sexual encounter

(B) males have a 25% chance of contracting gonorrhea from an infected female

(C) the incubation period is 2 weeks

(D) adolescent girls aged 15-19 years have the highest rates of gonorrhea infection

(E) most gonorrhea infections in adolescent girls are asymptomatic

16.
Which of the following features gathered by history is associated with an increased risk of PID?

(A) use of barrier methods (eg, condoms)

(B) age younger than 24 years or smoking

(C) birth control pills

(D) use of an intrauterine device (IUD)

(E) B and D

17.
All of the following clinical signs are considered as minimal diagnostic criteria for the diagnosis of PID except

(A) lower abdominal tenderness

(B) fever

(C) adnexal tenderness

(D) cervical motion tenderness

(E) all are required to made a diagnosis of PID; no exception

18.
Assuming her pregnancy test is negative, there is no suspicion of PID, and there are no known allergies, what would be the treatment of choice in this 14-yearold adolescent girl?

(A) ceftriaxone 125 mg intramuscularly (IM) single dose, doxycycline 100 mg orally twice a day for 7 days, acyclovir 400 mg orally 3 time a day for 5 days, metronidazole 2 g single dose orally, and symptomatic treatment for pain relief

(B) ciprofloxacin 500 mg single dose orally, doxycycline 100 mg orally twice a day for 7 days, valacyclovir 1 g orally twice a day for 7-10 days, and symptomatic treatment for pain relief

(C) ceftriaxone 125 mg IM single dose, azithromycin 1 g single dose orally, metronidazole 2 g single dose orally, valacyclovir 1 g orally twice a day for 7-10 days, and symptomatic treatment for pain relief

(D) metronidazole 2 g single dose orally, ceftriaxone 250 mg IM single dose, azithromycin 1 g, valacyclovir after herpes genitalis is confirmed by viral culture

(E) ceftriaxone 250 mg single dose orally, erythromycin base, 500 mg 4 times a day, acyclovir 200 mg orally 5 times a day, metronidazole topically for 5 days, and symptomatic treatment for pain relief

19.
What other management recommendations would you offer at this visit?

(A) partner needs treatment for trichomonas, chlamydia, and gonorrhea

(B) test for HIV and syphilis

(C) counseling to address runaway behavior and substance use

(D) discuss contraceptive options and STD prevention

(E) all of the above

ANSWERS

1.
(E)
Dysuria is a common symptom in adolescent girls and may be secondary to infection, trauma, or chemical irritation. The differential diagnosis includes bacterial UTI, chlamydia and gonorrhea urethritis, candida and trichomonal vulvovaginitis, bacterial vaginosis, herpes simplex infections, traumatic urethritis, vulvovaginal chemical irritation, and vulvar dermatoses. In one study of adolescents with a presenting complaint of dysuria, UTI alone was found in only 17% of the cases, and UTI and vaginitis were the diagnoses in another 17%. Of the remaining two-thirds, the diagnoses were candida vaginitis, bacterial vaginosis, trichomoniasis, gonorrhea, and chlamydia or herpesvirus infection. These data underscore the importance of obtaining a detailed gynecologic and sexual history in young adolescents with dysuria.

2.
(A)
E coli
is responsible for up to 90% of UTIs in this age group. In most series,
S saprophyticus
is the second most common pathogen identified. In chronic or recurrent infections,
Klebsiella
species, enterococci,
Proteus
species, or
Pseudomonas aeruginosa
may be found. The incidence of group B streptococci as a causative agent for UTI increases among pregnant adolescent girls.

3.
(E)
Gonococcal and nongonococcal urethritis (NGU), prostatitis, and chemical irritation secondary to spermicides are the leading causes of dysuria in adolescent boys. The most common etiologic agents of NGU are
C trachomatis, Ureaplasma urealyticum, Gardnerella vaginalis
, HSV,
Staphylococcus saprophyticus, E coli
, and
T vaginalis
.

4.
(C)
Additional risk factors for UTI in girls include delayed postcoital micturition, pregnancy, and anatomic abnormalities such as vesicourethral reflux, urethral stenosis, neurogenic bladder, and nephrolithiasis.

5.
(D)
In evaluating an adolescent girl with dysuria, answers A, B, C, and E, should be investigated. In addition, the patient should be interviewed about

• Onset of symptoms (acute onset suggests cystitis, whereas a gradual onset is more typical of urethritis)

• Concurrent diagnoses: diabetes mellitus, HIV, pregnancy, recent use of steroids

• Symptoms of urethritis in the male partner

• Internal versus external dysuria (in the latter, the pain is triggered as urine passes over the affected skin or mucosa)

• Menstrual history including date of last menstrual period

• Use of douches, deodorant soaps, and bubble bath

• Past history of UTI, vesicoureteral reflex, and/or other abnormalities of the urinary tract

• Terminal dysuria or hematuria, which would strongly favor the diagnosis of UTI

6.
(E)
Weight, temperature, and BP should be documented. A general physical examination with special attention to the skin, the head, eyes, ears, nose, throat, neck, abdomen, and extremities will all be necessary. In this case, it is important to look for rashes suggestive of STDs and to perform a throat and neck examination looking for signs of infection (eg, oral sores, exudates, and lymphadenopathy). The eyes should be inspected for iritis and conjunctivitis complicating some STDs, and a musculoskeletal examination may be helpful to screen for STD-associated arthritis. An abdominal examination should be done looking for tenderness, guarding, masses, and visceromegalies. The costovertebral angles should be evaluated for tenderness and Tanner stage should be recorded. A thorough pelvic examination will be needed to establish the diagnosis; a rectal examination would only be indicated in selected cases.

7.
(D)
The presence of clusters of exquisitely tender vesicular and ulcerative lesions is highly suggestive of herpes infection. However, in view of the yellowish, foamy discharge found at the introitus and in the cul-de-sac, other STDs, such as gonorrhea, chlamydia, and trichomoniasis, need to be ruled out. A GC/chlamydia probe, wet prep, and herpes culture will be necessary to confirm the diagnoses. In the absence of symptoms or signs suggesting monilial vaginitis or vulvitis, a KOH prep will not be helpful. HIV testing is indicated in view of her clinical picture and sexual history.

8.
(E)
The clinical appearance of the discharge provides important clues to the diagnosis. Leukorrhea is a normal finding in adolescent girls and is a result of the progressive estrogenization of the vaginal mucosa, which starts a few months before menarche and continues throughout the reproductive years. There is a normal, cyclic variation in the appearance of leukorrhea throughout the month. A thick, curdy, “cottage cheese” white discharge with underlying erythema and friability of affected tissue suggests
Candida
infection; a thin, grayish, foul-smelling discharge is consistent with bacterial vaginosis.
Trichomonas
vaginitis usually has a frothy, malodorous yellow or white discharge.

Microscopic examination of the wet preparation is a helpful technique, which often provides timely information in the office setting. Normal findings include sheets of epithelial cells such as those seen in leukorrhea. Epithelial cells covered with refractile bacteria attached to their surface are known as “clue cells,” characteristic in bacterial vaginosis (see
Figure 75-1
). Typically, leukocytes are absent in this condition. In contrast, large numbers of leukocytes are usually seen both in trichomonal infections and in mucopurulent cervicitis. The presence of flagellated organisms will confirm the diagnosis of trichomoniasis. It is important to remember, however, that the sensitivity of the wet preparation to identify trichomonas can be as low as 50-60% and therefore almost half of patients with this diagnosis may be missed with this technique. Newer, liquid-based trichomonas culture tests exist with sensitivities higher than 90%. In this case, with a clinical picture suggestive of several coexisting genital infections and a friable cervix, the wet preparation is likely to show all the elements listed.