Pediatric Examination and Board Review (186 page)

4.
Endoscopy is performed on a 10-year-old girl with persistent epigastric abdominal pain and vomiting. A duodenal ulcer is found. Infection with
Helicobacter pylori
is confirmed by culture and histologic examination of duodenal biopsy samples. Treatment for this girl should include which of the following?

(A) omeprazole

(B) omeprazole and metronidazole

(C) clarithromycin and lansoprazole

(D) amoxicillin, clarithromycin, omeprazole, and bismuth subsalicylate

(E) amoxicillin, clarithromycin, and omeprazole

5.
A 5-year-old boy returns from Mexico with family after visiting with relatives that lived in a rural area. He has a fever of 103°F (39.4°C), anorexia, and decreased activity 2 weeks after returning home. His mother reports that he does not want to walk. On physical examination there is limitation of movement, swelling, and tenderness of the left knee joint. He also has splenomegaly. A definitive diagnosis can be made by

(A) culture of blood

(B) enzyme immunoassay on acute serum

(C) PCR of serum

(D) urine for antigen detection

(E) serum antibody by enzyme immunoassay

6.
A 14-year-old boy develops severe conjunctivitis with pain followed by the development of enlarged painful preauricular lymph nodes. He reveals that 1 week ago he went hunting with his father and killed a number of squirrels. Which of the following should be considered in the differential diagnosis of the adolescent’s illness?

(A)
Coccidioides immitis

(B)
Francisella tularensis

(C)
Bartonella quintana

(D)
Mycobacterium tuberculosis

(E)
Anaplasma phagocytophilum

7.
Kingella kingae
can be a normal inhabitant of the oropharynx of humans. The most common clinical infection caused by
K kingae
in children is

(A) endocarditis

(B) intervertebral diskitis

(C) occult bacteremia

(D) pneumonia

(E) septic arthritis

8.
Legionella pneumophila
can rarely cause community-acquired pneumonia in healthy children, and infection usually resolves without treatment. However,
Legionella pneumophila
is likely to cause severe and fatal disease in children with

(A) neoplasm receiving chemotherapy

(B) chronic persistent asthma

(C) X-linked agammaglobulinemia

(D) IgA deficiency

(E) cyanotic congenital heart disease

9.
A 7-year-old girl from North Carolina develops fever to 102°F (38.8°C) in July associated with severe headache and myalgias. On the fifth day of fever the child develops a macular blanching rash that starts on the wrists, ankles, and forearms (
Figure 105-1
). The rash then spreads centrally over the next 24 hours, and scattered petechiae are noted. Laboratory evaluation reveals a leukocyte count of 12,000/mm
³
, hemoglobin of 12.0 g/dL, and platelet count of 100,000/mm
³
. The serum sodium is 130 mEq/L. The etiologic agent of this child’s illness is

(A) Epstein-Barr virus

(B)
Neisseria meningitidis

(C)
Rickettsia akari

(D)
R rickettsii

(E)
Anaplasma phagocytophilum

FIGURE 105-1.
See color plates.

10.
The treatment of choice for this infection in this 7-year-old girl is

(A) azithromycin

(B) chloramphenicol

(C) doxycycline

(D) rifampin

(E) ceftriaxone

11.
An 8-year-old boy has a fever of 102°F (38.8°C) associated with headache, anorexia, and vomiting. He remembers being bitten by a tick 9 days before his illness. On physical examination, he is alert. The temperature is 102°F (38.8°C), and a blanching macular rash involving the trunk is present. The leukocyte count is 3500/mm
³
; the platelet count is 120,000/mm
³
, the hemoglobin 12 g/dL, and the aspartate aminotransferase (AST) is 110 U/L. The most likely diagnosis is

(A) babesiosis

(B) ehrlichiosis

(C) rickettsialpox

(D) Rocky Mountain spotted fever

(E) leptospirosis

12.
The treatment of choice for this infection in this 8-year-old boy is

(A) azithromycin

(B) chloramphenicol

(C) cefepime

(D) gentamicin

(E) doxycycline

13.
A 9-day-old male term infant develops a watery eye discharge that becomes purulent. The conjunctiva of the right eye becomes injected and the eyelid is swollen. A DFA test of a conjunctival specimen confirms the diagnosis of
C trachomatis
infection. Treatment with systemic oral antibiotic therapy is recommended because

(A) there is often coinfection with
N gonorrhoeae
(B) topical ophthalmic therapy does not eliminate nasopharyngeal carriage

(C) there are no topical ophthalmic antibiotics active against
C trachomatis

(D) resistance develops rapidly when ophthalmic antibiotics are used

(E) adherence with ophthalmic antibiotic therapy is less than with oral antibiotic therapy

14.
A 5-year-old boy has an illness that includes a 2-week history of cough, sore throat, and fever. The coughing persists, and bilateral rales are heard on auscultation of the lungs. A chest radiograph reveals bilateral infiltrates. The most likely etiology of the following choices for this pneumonia is

(A)
Chlamydia pneumoniae

(B)
Chlamydia trachomatis

(C) influenza A

(D) Epstein-Barr virus

(E)
Histoplasma capsulatum

15.
Mycoplasma pneumoniae
is a well known to cause lower respiratory tract disease, primarily in schoolage children and young adults. Severe and fatal pneumonia caused by
M pneumoniae
has been described in children with the following disorder

(A) hypogammaglobulinemia

(B) asthma

(C) cystic fibrosis

(D) prematurity

(E) chronic kidney disease

16.
Appropriate antimicrobial therapy for a 5-year-old child with pneumonia caused by
M pneumoniae
or
C pneumoniae
is

(A) azithromycin

(B) ciprofloxacin

(C) doxycycline

(D) ceftriaxone

(E) meropenem

17.
A 6-year-old boy develops fever, headache, vomiting, and muscle pain. You obtain a history from his mother that he handled a dead rat in the alley of the family’s apartment 2 weeks ago. On physical examination the child has a fever of 102°F (38.8°C) and a maculopapular rash involving the extremities, including the palms and soles. There is no evidence of any bite wound. The causative agent of this child’s illness is likely

(A)
Ehrlichia chaffeensis

(B)
R rickettsia

(C)
Spirillum minus

(D)
Streptobacillus moniliformis

(E)
Leptospira interrogans

18.
The treatment of choice for the infection in the 6-year-old boy just described should include

(A) doxycycline

(B) erythromycin

(C) aztreonam

(D) vancomycin

(E) penicillin

ANSWERS

1.
(A)
The most common clinical presentation of cat-scratch disease is unilateral regional lymphadenitis. The lymphadenitis usually involves nodes that drain the site of inoculation, but in up to 20% of cases additional lymph node groups are involved (see
Figure 105-2
). At a particular site of lymphadenitis, multiple nodes are involved about half the time. The most common site is the axilla followed by cervical, submandibular, and inguinal nodes. Most patients with catscratch disease are afebrile. However, systemic catscratch disease can occur in which the presentation includes prolonged fever of 1-3 weeks, malaise, myalgias, and arthralgias. Weight loss, abdominal pain, generalized lymphadenopathy, hepatomegaly, and splenomegaly can occur. Ultrasound of the liver or spleen can identify multiple microabscesses. Encephalopathy is the most serious complication of catscratch disease, occurring in up to 5% of patients.

FIGURE 105-2.
Characteristic regional (axillary) lymphadenopathy in a patient with cat-scratch disease. (Reproduced, with permission, from Fauci AS, Kasper DL, Braunwald E, et al. Harrison’s Principles of Internal Medicine, 17th ed. New York: McGraw-Hill; 2008: Fig. 153-1.)