Children’s Health – Febrile Illness, Infectious Diseases, Dermatology and Haematology / Oncology

What is intussusception

• involves a section of the bowel sliding or folding into itself in a telescoping motion.

• Often, the ileum enters the caecum.

Epidemiology of intussusception

• most often occurs in infants between 3 months and 2 years of age

• More common in boys

• Associated with viral illness, Henoch-Schonlein purpura, Cystic fibrosis, Intestinal polyps, Meckel diverticulum

 

Intussusception may be associated with other conditions:

• Viral illnesses

  • Henoch-Schonlein purpura

• Cystic fibrosis

• Intestinal polyps

  • Meckel diverticulum

 

The typical presentation of intussusception is an infant under 2 years, with an acute onset of:

• Severe, colicky abdominal pain

• Bilious (green) vomiting

• Redcurrant jelly stool (a mix of blood, mucus and stool) is a later sign

 

Exam buzz words for intussusception

• If “redcurrant jelly stool” and a “sausage-shaped” mass in the abdomen appear in your exams, think of intussusception.

• Recent viral infection now has obstruction in bowels

 

Diagnosis of intussusception

• USS

  • Target or doughnut sign

Treatment of intussusception

• Therapeutic enema (contrast, water or air pumped into colon)

• Surgical reduction

  • Bowel resection if gangrene or perforation

What is meningitis

inflammation of the meninges

The causes of bacterial meningitis include:

• Neisseria meningitidis

• Streptococcus pneumoniae (pneumococcus)

• Haemophilus influenzae

• Group B streptococcus (GBS) (particularly in neonates as GBS may colonise the vagina)

• Listeria monocytogenes (particularly in neonates)

What kind of bacteria is Neisseria meningitidis

• gram-negative diplococcus bacteria

• they are circular bacteria (cocci) that occur in pairs (diplo-)

 

What is meningococcal meningitis

• when the bacteria infects the meninges and the cerebrospinal fluid

 

What is meningococcal septicaemia

• when the meningococcus bacterial infection is in the bloodstream

• cause the classic non-blanching rash

 

The most common causes of viral meningitis are:

• Enteroviruses (e.g., coxsackievirus)

  • Herpes simplex virus (HSV)

• Varicella zoster virus (VZV)

 

Diagnosis of viral meningitis

• Viral PCR testing can be performed on a CSF sample

 

Treatment of viral meningitis

• Aciclovir is used to treat HSV and VZV

 

 

Typical symptoms of meningitis are:

• Fever

• Neck stiffness

• Vomiting

• Headache

• Photophobia

• Altered consciousness

• Seizures

 

Treatment of bacterial meningitis

• Antibiotics

• Steroids (reduce frequency and severity of hearing loss and neurological complications)

 

Which types of meningitis are notifiable

• Bacterial meningitis and meningococcal infection are notifiable diseases to the UK Health Security Agency.

 

Post-Exposure Prophylaxis for meningitis

• risk is highest with close prolonged contact within 7 days before the onset of the illness

  • usual choice is a single dose of ciprofloxacin given as soon as possible after the diagnosis

Complications of meningitis

• Hearing loss (a key complication)

• Seizures and epilepsy

• Cognitive impairment and learning disability

• Memory loss

• Focal neurological deficits, such as limb weakness or spasticity

 

 

What fluids given to children in septic shock

• For children under 16, the NICE guidelines recommend an initial 10 mL/kg bolus of a glucose-free crystalloid containing sodium of between 130-154 mmol/L (e.g., 0.9% sodium chloride), up to a maximum of 250 mL

  • Vasopressors

Their physical observations can be used to calculate the Paediatric Early Warning Score (PEWS) using age-specific ranges:

• Temperature

  • Respiratory rate

• Heart rate

• Oxygen saturation

• Capillary refill time and blood pressure

• Consciousness level

Key factors to consider when assessing a child for suspected sepsis include:

• History of fever

• Recent presentations (e.g., to their GP or A&E)

• Poor oral intake

• Reduced urine output

• Reduced consciousness

• Reduced body tone (floppy)

• Weak cry or inconsolable

• Skin colour changes (cyanosis, mottled, pale or ashen)

• Non-blanching rashes (meningococcal disease)

• Skin breaks that could lead to infection (e.g., cuts)

 

Immediate management of paediatric sepsis

• Giving oxygen if the patient has evidence of shock or oxygen saturations are below 94%

• Obtaining IV access (cannulation)

• Blood tests, including a FBC, U&E, LFT, CRP and clotting screen

• Blood gas for lactate and glucose

• Blood cultures, ideally before giving antibiotics, provided it does not cause a delay

• Urine sample for dipstick testing and sent to the lab for microscopy, culture and sensitivities

• IV antibiotics within 1 hour for suspected sepsis with high-risk features, according to local guidelines

• IV fluids for shock or signs of poor perfusion

 

Additional investigations for paediatric sepsis may be performed depending on the suspected infection:

• Chest x-ray if pneumonia is suspected

• Abdominal and pelvic ultrasound if intra-abdominal infection is suspected

• Lumbar puncture if meningitis is suspected

• Meningococcal PCR blood test if meningococcal disease is suspected

• Serum cortisol if adrenal crisis is suspected

 

What is acute gastritis

• stomach inflammation

  • presents with epigastric discomfort, nausea and vomiting

What is gastroenteritis

• inflammation all the way from the stomach to the intestines

• presents with pain, nausea, vomiting and diarrhoea

 

Viral gastroenteritis is common. It is highly contagious. Specific viruses include:

• Rotavirus

  • Norovirus

• Adenovirus (tends to cause respiratory symptoms)

How do strains of E.coli cause gastroenteritis

• E. coli 0157 produces the Shiga toxin.

• The Shiga toxin causes abdominal cramps, bloody diarrhoea and vomiting.

  • It also destroys blood cells, leading to haemolytic uraemic syndrome (HUS).

Why are antibiotics avoided in E.coli gastroenteritis

• use of antibiotics increases the risk of haemolytic uraemic syndrome.

• Therefore, antibiotics should be avoided if E. coli gastroenteritis is a possibility

 

What is the most common cause of traveller's diarrhoea

Campylobacter Jejuni

What type of bacteria is Campylobacter Jejuni

 

• Gram-negative that is curved or spiral shaped

How is campylobacter jejuni spread

• Raw or improperly cooked poultry

• Untreated water

• Unpasteurised milk

 

Symptoms of campylobacter jejuni

• Abdominal cramps

• Diarrhoea often with blood

• Vomiting

• Fever

 

In patient with a severe campylobacter infection, what antibiotics are used

• Clarithromycin first line

• Azithromycin and ciprofloxacin

 

What is the Shigella and how is it spread

• spread via faeces, either person-to-person or through contaminated drinking water or food

 

Treatment of Shigella gastroenteritis

• Shigella can produce the Shiga toxin, which can cause haemolytic uraemic syndrome.

• Treatment of severe cases is with azithromycin or ciprofloxacin

 

How is salmonella spread

• eating raw eggs or poultry or food contaminated with the infected faeces of small animals

 

Symptoms of salmonella

• Watery diarrhoea w/wo mucus or blood

• Abdominal pain

• Vomiting

 

What type of bacteria is bacillus cereus and how is it spread

• Gram positive

• Contaminated cooked food

 

What is Yersinia Entercolitica and how is it spread-

• Yersinia enterocolitica is a gram-negative bacillus

• Pigs are key carriers, and eating raw or undercooked pork can cause infection

• It is also spread through contact with infected humans, animals or faeces

What is Giardiasis-

• type of microscopic parasite.

• It lives in the small intestines of mammals.

• This is called faecal-oral transmission

• Treatment is with tinidazole or metronidazole

 

Management of gastroenteritis-

• Food poisoning is a notifiable disease.

  • The UK Health Security Agency (UKHSA) should be notified

• Dehydration is the primary concern of suspected cases

• microscopy, culture and sensitivities to establish the causative organism.

 

 

Post-Gastroenteritis Complications-

• Lactose intolerance

• Irritable bowel syndrome

• Reactive arthritis

• Guillain–Barré syndrome

  • Haemolytic uraemic syndrome.

The presentation of UTI in infants is non-specific:

• Fever

• Lethargy

• Irritability

• Vomiting

• Poor feeding

  • Urinary frequency

Signs and symptoms of UTI in older infants and children are more specific:

• Abdominal pain, particularly suprapubic pain

• Dysuria (painful urination)

• Urinary frequency

• Urinary urgency

• Urinary incontinence

• Nocturnal enuresis (bedwetting)

• Fever

  • Vomiting

The diagnosis of an acute upper urinary tract infection (pyelonephritis) is made if there is either:

• Fever over 38°C

  • Loin pain or tenderness

Diagnosis of UTI in children

• Dipstick

• MSU

• USS

• DMSA scan

• MCUG scan

 

 

Management of UTI in children

• Children under 3 months with a fever should have a full septic screen

  • Uncomplicated lower urinary tract infections are treated with 3 days of oral antibiotics

Typical antibiotic choice for UTI in children

• Trimethoprim (first-line if low risk of resistance)

• Nitrofurantoin (first-line)

• Cefalexin

• Amoxicillin

 

 

NICE (2019) recommends an ultrasound scan (in UTI) for:

• All children under 6 months with their first UTI (within 6 weeks)

• Recurrent UTIs (within 6 weeks)

• Atypical UTIs (e.g., very unwell or atypical organisms) (during the illness)

 

What is DMSA scan

• is recommended 4-6 months after the infection to assess for damage from recurrent or atypical UTIs.

• A radioactive material (DMSA) is injected, and a gamma camera is used to determine how well the kidneys take up the material

 

What is the MCUG scan

• used to test for vesicoureteral reflux (VUR) in infants under 6 months with recurrent or atypical UTIs

• It involves catheterising the child, injecting contrast into the bladder and taking a series of x-rays to determine whether the contrast is refluxing into the ureters

 

What is the vesicoureteral reflux

• involves urine flowing back into the ureters from the bladder.

• This predisposes patients to develop upper urinary tract infections and subsequent renal scarring

• Diagnosed by MCUG

 

Less severe VUR may resolve as the child gets older. Management depends on the severity and may involve:

• Avoiding constipation

• Avoiding an excessively full bladder

• Prophylactic antibiotics

• Surgical input from paediatric urology

 

What is intussusception

• involves a section of the bowel sliding or folding into itself in a telescoping motion.

• Often, the ileum enters the caecum.

 

Epidemiology of intussusception

• most often occurs in infants between 3 months and 2 years of age

• More common in boys

• Associated with viral illness, Henoch-Schonlein purpura, Cystic fibrosis, Intestinal polyps, Meckel diverticulum

 

Intussusception may be associated with other conditions:

• Viral illnesses

• Henoch-Schonlein purpura

• Cystic fibrosis

• Intestinal polyps

• Meckel diverticulum

 

The typical presentation of intussusception is an infant under 2 years, with an acute onset of:

• Severe, colicky abdominal pain

• Bilious (green) vomiting

• Redcurrant jelly stool (a mix of blood, mucus and stool) is a later sign

 

Exam buzz words for intussusception

• If “redcurrant jelly stool” and a “sausage-shaped” mass in the abdomen appear in your exams, think of intussusception.

• Recent viral infection now has obstruction in bowels

 

Types of vaccines

• Inactivated vaccine

• Subunit and conjugate vaccines

• MRNA vaccines

• Live attenuated vaccines

  • Toxoid vaccines

Examples of inactivated vaccines

• Inactivated polio vaccine

• Injected influenza vaccine

• Hepatitis A

  • Rabies

What are inactivated vaccines

• giving an inactive version of the pathogen.

  • They cannot cause an infection and are safe for immunocompromised patients

What are Subunit and conjugate vaccines

• contain parts of the pathogen required to stimulate an immune response.

• They cannot cause infection and are safe for immunocompromised patients

 

Examples of subunit and conjugate vaccines

• Pneumococcus

• Meningococcus

• Hepatitis B

• Pertussis (whooping cough)

• Haemophilus influenza type B

• Human papillomavirus (HPV)

• Shingles (Shingrix)

 

What are MRNA vaccines

• deliver mRNA that codes for specific viral proteins into the body’s cells

•  The cells translate that mRNA into antigen proteins,

 

What are live attenuated vaccines

• contain a weakened version of the pathogen.

• They can rarely cause disease, particularly in immunocompromised patients.

 

Examples of live attenuated vaccines

• Measles, mumps and rubella vaccine: contains all three weakened viruses

• BCG (contains live attenuated Mycobacterium bovis)

• Chickenpox (contains weakened varicella-zoster virus)

• Nasal influenza (not the injected flu vaccine)

• Rotavirus vaccine

 

What are toxoid vaccines

• contain an inactivated toxin that is normally produced by a pathogen

• They cause immunity to the toxin, not the pathogen itself.

 

Examples of toxoid vaccines

• Diphtheria

• Tetanus

 

How is HPV spread

• Sexual activity

 

What does the HPV vaccine prevent

• HPV infections

• cancer affecting the cervix, mouth, anus, penis, vulva and vagina

  • genital warts

Which vaccine is given for HPV under NHS

• Gardasil 9,

• which protects against strains 6, 11, 16, 18, 31, 33, 45, 52 and 58

 

When is the BCG vaccine given

• offered at around 28 days old to newborns who are at higher risk of tuberculosis

•  It may also be given to children arriving from areas of high TB prevalence or in close contact with people who have TB.

 

What is post vaccination fever

• Fever can appear with vaccines.

• Most common with the MenB vaccine given at 8 weeks, 12 weeks and 12 months.

• Fever tends to peak around 6 hours post vaccine but can appear up to 48 hours after the vaccine.

 

What is Non-Blanching Rashes

• Caused by bleeding under the skin.

• Petechiae are small (< 3mm), non blanching, red spots on the skin caused by burst capillaries.

• Purpura are larger (3 – 10mm) non-blanching, red-purple, macules or papules created by leaking of blood from vessels under the skin.

 

Causes of non-blanching rash

• Meningococcal septicaemia or other bacterial sepsis

• Henoch-Schonlein purpura (HSP)

• Idiopathic thrombocytopenic purpura (ITP)

• Acute leukaemias

• Haemolytic uraemic syndrome (HUS)

• Mechanical (strong coughing, vomiting, breath holding)

• Traumatic (non-accidental injury)

• Viral illness (influenza and enterovirus)

 

Investigations in non-blanching rash

• Full blood count: Anaemia can suggest HUS or leukaemia. Low white cells can suggest neutropenic sepsis or leukaemia. Low platelets can suggest ITP or HUS.

• Urea and electrolytes: High urea and creatinine can indicate HUS or HSP with renal involvement.

• C-reactive protein (CRP): This is a non-specific indication of inflammation or infection and can be useful but not definitive in excluding sepsis.

• Erythrocyte sedimentation rate (ESR): This is a non-specific indication of inflammatory illness such as a vasculitis (HSP) or infection.

• Coagulation screen, including PT, APTT, INR and fibrinogen can diagnose clotting abnormalities.

• Blood culture: This can be useful but not definitive in diagnosing or excluding sepsis.

• Meningococcal PCR: This can confirm meningococcal disease, although this should not delay treatment.

• Lumbar puncture: To diagnose meningitis or encephalitis.

• Blood pressure: Hypertension can occur in HSP and HUS. Hypotension can occur in septic shock.

• Urine dipstick: Proteinuria and haematuria can suggest HSP with renal involvement, or HUS.

 

What is Viral Exanthemas

an eruptive widespread rash

Originally there were six “viral exanthemas” known as first, second, third, fourth, fifth and sixth disease:

• First disease: Measles

• Second disease: Scarlet Fever

• Third disease: Rubella (AKA German Measles)

• Fourth disease: Dukes’ Disease

• Fifth disease: Parvovirus B19

  • Sixth disease: Roseola Infantum

What is measles

• caused by the measles virus.

• highly contagious via respiratory droplets

• Measles is a notifiable disease and all cases need to be reported to public health.

 

How is measles spread

highly contagious via respiratory droplets

Symptoms of measles

• fever, coryzal symptoms and conjunctivitis.

• Koplik spots are greyish white spots on the buccal mucosa.

  • Rash

What rash is seen in measles

• The rash starts on the face, classically behind the ears

• erythematous, macular rash with flat lesions

 

Management of measles

• self resolving after 7 – 10 days of symptoms.

• Children should be isolated until 4 days after their symptoms resolve.

• Measles is a notifiable disease and all cases need to be reported to public health.

 

Complications of measles

• Pneumonia

• Diarrhoea

• Dehydration

• Encephalitis

• Meningitis

• Hearing loss

• Vision loss

• Death

 

What is scarlet fever

• associated with group A streptococcus infection, usually tonsillitis

• a highly contagious bacterial infection

 

What rash is seen in scarlet fever

• a red-pink, blotchy, macular rash with rough “sandpaper” skin

• starts on the trunk and spreads outwards.

 

Presentation of Scarlet Fever

• red, flushed cheeks

• a red-pink, blotchy, macular rash with rough “sandpaper” skin

• Fever

• Lethargy

• Flushed face

• Sore throat

• Strawberry tongue

• Cervical lymphadenopathy

 

Management of Scarlet fever

• phenoxymethylpenicillin (penicillin V) for 10 days

• Scarlet fever is a notifiable disease and all cases need to be reported to public health

 

What is rubella

• caused by the rubella virus.

• It is highly contagious and spread by respiratory droplets

How is rubella spread

• It is highly contagious and spread by respiratory droplets

 

What rash is seen in rubella

• milder erythematous macular rash compared with measles

• starts on the face and spreads to the rest of the body.

• The rash classically lasts 3 days

 

Presentation of rubella

• Rash

• mild fever, joint pain and a sore throat

• Lymphadenopathy

 

Management of rubella

• Self-limiting

• Notifiable disease

• Children should stay off school for at least 5 days after the rash appears.

• Children should avoid pregnant women.

 

Complications of rubella

• thrombocytopenia and encephalitis.

  • Rubella is dangerous in pregnancy and can lead to congenital rubella syndrome

What is Parvovirus B19

•  slapped cheek syndrome and erythema infectiosum.

• It is caused by the parvovirus B19 virus.

 

Presentation of parvovirus B19

• mild fever, coryza and non-specific viral symptoms such as muscle aches and lethargy

• rash appears quite rapidly as a diffuse bright red rash on both cheeks

• A few days later a reticular mildly erythematous rash affecting the trunk and limbs appears that can be raised and itchy

 

Management of parvovirus B19

• self limiting over 1-2 weeks

 

 

Complications of parvovirus B19

• Aplastic anaemia

• Encephalitis or meningitis

• Pregnancy complications including fetal death

• Rarely hepatitis, myocarditis or nephritis