june board review
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ID Part Deux. June Board Review. Test Question. I will watch the summer olympics this year. A. True B. False. Bronchiolitis. Intro. Bronchiolitis is caused by inflammation of the bronchioles by an acute viral infection - PowerPoint PPT PresentationTRANSCRIPT
JUNE BOARD REVIEW
ID Part Deux
Test Question I will watch the summer olympics this
year.A. TrueB. False
Bronchiolitis
Intro Bronchiolitis is caused by inflammation of the
bronchioles by an acute viral infection *Most common lower respiratory tract
infection in infants and children under 2 Infectious agents:
RSV (most common)AdenovirusMetapneumovirusInfluenza virusParainfluenza virus
*Epidemiology of RSV *Know the mode of transmission
Direct or close contact with contaminated secretions○ Large droplets at short distances○ Fomites
RSV can persist on environmental surfaces for several hours○ ½ hour on hands
*Epidemiology of RSV *Incubation period
Ranges from 2 to 8 days *Period of communicability
Usually 3 to 8 days○ Shedding can last longer in young infants and
immunosuppressed people (3 to 4 weeks) *Age of onset
Most infants infected during 1st year of lifeVirtually all by 2 years of age
*Peak seasonWinter and early spring
Question #1 All of the following patients are at high
risk for morbidity and mortality from RSV infection EXCEPT:A. A premature infantB. A 1-month-old with unrepaired congenital
heart diseaseC. A 4-month-old ex-32 WGA with BPDD. A full-term infant with hyperbilirubinemiaE. A 2-month-old with cerebral palsy
*Epidemiology of RSV *Risk factors for morbidity and mortality
PrematurityUnrepaired congenital heart disease
○ Pulmonary overcirculationChronic lung diseaseAirway abnormalities
○ Laryngomalacia○ Tracheomalacia○ Cleft lip/palate
Neurologic abnormalities
*Clinical Manifestations History of recent upper respiratory tract symptoms
followed by cough, tachypnea, and increased work of breathing
Physical findings:Nasal congestionRhinorrheaCoughTachypneaIncreased respiratory effort
○ Nasal flaring, grunting, retractionsCrackles, wheezes, upper airway noiseApnea
○ May be only presenting sign in young infants
Course Characteristic pattern Expect worsening symptoms
Peak symptomatology on day 3 to 4“Day of illness” important for anticipatory
guidance, admission/discharge decisions, etc.
Diagnosis Based on history and
physical Routine lab and radiologic
studies are not recommended CXR not routinely
recommended○ Often are abnormal
appearing (hyperinflation, atelectasis, infiltrates)
○ Do not correlate with disease severity
○ Do not guide management○ May prompt unnecessary
antibiotics for PNA which is rare in viral bronchiolitis
Diagnosis Viral studies are not recommended for
diagnosis *Know the laboratory diagnosis of RSV
Viral antigen detection ○ Enzyme immunoassay technique○ Sensitivity mostly 80 to 90%○ From nasopharyngeal specimens
Viral culture○ Requires 1 to 5 days○ From nasopharyngeal secretions○ Sensitivity varies among laboratories
Question #2 A 3-month-old male ex-38 WGA comes to the emergency
room with a history of upper respiratory symptoms for 3 days, fever, decreased appetite and increased work of breathing. On PE his vitals are T 99 RR 45 HR 185 BP 90/65 and Sat 96% on room air, he has nasal congestion, mild retractions, and course breath sounds He has an older sister in pre-K.
Of the following the MOST appropriate next step in management is:A. Start albuterol nebsB. Give Orapred 2mg/kgC. IVFs with normal salineD. Supplemental oxygenE. Nasal decongestants
Management *Plan the management of RSV infection
Supportive careHydrationOxygenationOther measures (bronchodilators,
corticosteroids, antiviral agents, CPT, nasal suction, decongestant drops) have been shown to have impact on duration of illness, severity of clinical course, or subsequent outcomes
Management Hydration
↑ RR, secretions, fever, poor feeding → dehydration
May require IV fluids or NG feedsBronchiolitis causes ADH release → risk for
hyponatremia○ Use isotonic fluids
Management Oxygenation
Results from impaired diffusion, V/Q mismatch, plugging of bronchioles
Goal is to maintain normal satsNo clear consensus on pulse ox range
○ Aim for sats between 90 to 92%Monitoring
○ Schedule spot checks○ Continuous pulse ox only for those with previous O2
requirement, risk for apnea, or with underlying cardiopulmonary conditions
Managment Bronchodilators
AAP does not recommend routine useA monitored trial may be considered, but
only continued if clinical response is documented○ Diminished work of breathing○ Decrease in RR○ Improvement in hypoxemia
Managment Steroids
Based on current evidence, corticosteroids should not be used to treat bronchiolitis
RibavirinShould not be used routinelyMay be considered in special situations:
○ Organ transplant, malignancy, congenital immunodeficiencies
Very expensive
Management CPT
Bronchiolitis (V/Q mismatch) is unaffected by regional CPT
Nasal suctionMay increase comfort and improve feedingMost beneficial before feedings and in response
to copious secretions Nasal decongestants
No proven efficacy, potential harmful side effectsShould not be used in children under 2
Question #3 The major benefit of palivizumab
prophylaxis is:A. Decreased hospitalization rateB. Improved treatmentC. Increased cost-effectivenessD. Lower mortality rateE. Shorter duration of illness
*Prevention *Identify patients who may benefit from
prophylaxisPalivizumab (Synagis)
○ Monoclonal antibody (IgG) against RSVCandidates
○ History of prematurity○ Infants with chronic lung disease○ Infants with hemodynamically significant
congenital heart disease
Prevention
•Effectiveness of palivizumab beyond the second year is unknown•Prophylaxis should be administered in 5 monthly doses beginning in November•Not overall cost-effective
Question #4 It’s December and a mom is in your office with
her 6 week-old daughter is worried about RSV. Her older son who is now 4-years-old had it as a baby and had to be hospitalized. She asks you if there is anything she can do at home to help prevent her daughter from catching it.
All of the following are ways to reduce the risk of RSV EXCEPT:A. Avoid tobacco smokeB. Encourage breastfeedingC. Washing hands with soap and water thoroughlyD. Vitamin C supplementsE. Alcohol-based hand sanitizer after contact
Prevention Strict hand hygiene and isolation policies Avoidance of tobacco smoke
Independent risk factor for contracting bronchiolitis
Encouragement of breastfeedingContains immune factors that can prevent
RSVNeutralizing activity against RSV
Prognosis Most recover without sequelae A portion develop recurrent wheezing
40% have subsequent wheezing episodes through 5 years of age
10% have subsequent wheezing episodes after 5 years
Question #5 An 11-month-old boy presents to your office with a 5-day
history of fever, nasal congestion, conjunctivitis, and the development of a rash over the past 24 hours. The rash began on his head and neck and spread to his trunk and extremities. The family recently returned from a trip to Ireland. His past medical history is unremarkable, and his immunizations are up to date.
Of the following, the BEST test for diagnosing this child’s condition is:A. Measles IgM serologyB. Nasal aspirate for viral cultureC. Rubella IgM serologyD. Skin biopsyE. Throat culture for Group A Streptococcus
Measles (Rubeola)
Transmission *Transmission:
Direct droplet contactAirborne spread
Incubation period: 8-12 days Period of communicability: 1-2 days
before any symptoms appear until 4 days after the rash appears
*Clinical Presentation Exposure Fever, malaise Coryza, cough,
conjunctivits Koplik spots Exanthum Exanthem: red/ purple papules appear at
hairline, then spread downward (@ toes by day 3)Coalescence common on face and upper bodyFades in same fashion (headtoe)
24h8-12d
48h 2-3d
Measles
Koplik spots
*Control Measures Isolation (airborne precautions) Immunization/ Immune globulin
First determine who is susceptible○ <2 doses of MMR vaccine after the first birthday○ Low titers in response to vaccine administration○ No documentation of measles by a physician ○ Immunocompromised patients
If susceptible:○ MMR vaccine within 72hours of exposure○ IM Immune globulin within 6 days of exposure:
Household contacts if vaccine not given within 72h Immunocompromised patients Infants <12mo***
*Complications OM Bronchopneumonia Laryngotracheobronchitis Diarrhea Acute encephalitis Subacute sclerosing panencephalitis
(SSPE)
Rubella (German measles)
Transmission *Transmission:
Person-to-person spread via droplet inhalation *Incubation period: 2 to 3 weeks *Period of communicability: several days
before to 2 weeks after the onset of the rash
In 2005, the CDC announced that rubella had been eliminated from the USBut, it’s still on the Boards!!
*Postnatal Clinical Presentation Exposure Tender adenopathy (post-
auricular, posterior cervical, and occipital); malaise, HA, low-grade fever, sore throat Exanthem (+/- Forchheimer spots)
Exanthem: rose-pink maculopapules on face that spread quickly to involve trunk and then extremitiesDay 2: rash on face disappears, truncal rash
coalesces Day 3: rash disappears
14-21 d
1-5 d
Rubella
Forchheimer Spots
Question #6 All of the following are sequelae of
congenital rubella syndrome, EXCEPT:A. Sensorineural hearing lossB. CataractsC. Radiolucenicies in the metaphyses of
long bonesD. Heart diseaseE. Craniofacial abnormalities
*Congenital Rubella
Highest rate of infection 1st and 3rd trimesters, morbidity associated with 1st trimester infectionPresentation:
Blueberry muffin lesions Radiolucencies in
metaphyseal long bones PDA (or ASD/VSD) Sensorineural deafness Cataracts/ glaucoma HSM IUGR
Question #7 A mother of one of your patients is in her first trimester
of pregnancy and just found out that her internationally adopted niece has contracted rubella. She wonders when it will be safe for her to be around her niece again. You tell her:A. She should stay out of contact until the LAD resolvesB. She should stay out of contact until the fever resolvesC. She should stay out of contact until the exanthem
resolvesD. She should stay out of contact until the exanthem
appearsE. She does not need to worry…contracting rubella in this
stage of her pregnancy is unlikely to cause any sequelae
*Control Measures Primary focus: preventing CRS
Maintaining elevated vaccine coverage rates in children and adolescents
Providing adequate surveillance systemsTimely investigations during outbreaks
○ Active cases should be reported to local public health authorities
Susceptible individuals should be kept out of contact with anyone infected with rubella○ Despite widespread vaccination, some women of
childbearing age may be susceptible
Meningococcal disease
Neisseria meningitidis *Know the epidemiology of Neisseria meningitidis
Five serotypes: A, B, C, Y, and W-135○ B, C, and Y cause most cases in North America○ More than 50% of cases in infants caused by
serogroup B → *NOT preventable with vaccines*Leading cause of bacterial meningitis in young
childrenMost often occurs in kids 2 and younger
○ Peak in kids under 1○ Another peak in adolescents age 15 to 18
*Epidemiology Asymptomatic colonization of the upper
respiratory tract is how the organism is spread10 to 40% of adolescents and adults are carriers
Transmission occurs from person to person through droplets from respiratory tractRequires close contactOutbreaks get media coverage
○ Less than 5% of cases associated with outbreaks
Incubation period is 1 to 10 days
Question #8 You are discussing with medical students the
risk factors that increase the likelihood that transmission from carriers will result in meningococcal disease.
Of the following groups, the risk of disease is HIGHEST among:A. School childrenB. Vaccinated students living in college dormsC. Healthy nonsmoking adultsD. Household contacts of an index caseE. Toddler in child care centers
*Risk factors Environmental factors
Crowded living conditions○ College dorms, military barracks
Secondary infection among household contacts is up to 800 times that in the general population
Active and passive tobacco smoke *Understand which patients are at increased risk
of invasive and recurrent meningococcal diseaseTerminal complement deficiencyHypogammaglobulinemiaAnatomic or functional asplenia
Clinical Syndromes *Know the major clinical syndromes of
Neisseria meningitidisSevere meningococcal septicemiaMeningococcal meningitis
Systemic manifestations of the organism reproducing in the blood50% have isolated meningitis10 to 15% have severe meningococcal
septicemia40% have a mixed picture
*Severe Meningococcal Septicemia Characterized by sudden onset, rapid
progression, and absence of localizing findings
More severe than meningitis Fatality rate is high (40 to 50%) Most patients have no
immunocompromise
*Severe Meningococcal Septicemia Symptoms and physical findings
High fever, shaking chills, myalgias, extremity or back pain
Deteriorate within 6 hoursRash
○ Classically petechial○ Often become hemorrhagic○ Coalesce to form widespread purpura
Purpura fulminans○ Aggressive spread of purpura to large areas with iscemic
necrosis○ Likely to have sudden drops in blood pressure and acute
adrenal hemorrhage (Waterhouse-Friderichsen)
Rash
*Severe Meningococcal Septicemia Early diagnosis and treatment still evades
clinicians Look for early clues
TachycardiaRash
○ Typically present in 24 hours○ Fever and petechial rash is SMS until proven otherwise
True rigorsSevere pain in neck, back, and extremitiesVomitingConcern of parentExposure
Meningococcal Meningitis *Signs and symptoms of typical bacterial
meningitis1 to 3 day non-specific prodrome with low-grade
fever and URI symptomsCushing triad can occur (bradycardia, HTN, resp.
depression) as ICP risesMeningismusMental status changesSudden and severe headache with photophobiaGI complaintsMyalgias
Question #9 You are working in the ER and see a 14-month-old boy,
previously healthy and fully immunized, who has had cold symptoms for the past 2 days. Late this morning, he developed a temp of 101, malaise, and discomfort. On PE you see scattered petechiae over his trunk. He is alert, but very fussy.
Of the following, which is the GOLD standard to make the bacteriologic diagnosis in this case?A. PCRB. Culture of normally sterile siteC. Gram stainD. Antigen detectionE. Antibody titers
Diagnostic studies *Know the diagnostic tests for invasive
meningococcal diseaseGram stain
○ Of CSF is highly sensitive and specificCulture of sterile site
○ Gold standard○ Can culture aspirate of purpuric lesion
Antigen detection○ In CSF can support diagnosis, but high false-negative rates
PCR○ Useful in patients who have already received abx○ Use in UK, but not widely in US
Diagnostic Studies Lab tests may return too late or may fall
within normal range in a precipitous course
CSFWBC elevated, low glucose, elevated
proteinHowever, a negative LP result is an ominous
finding in a patient with invasive meningococcal disease
Question #10 You admitted a patient to the hospital with rapid onset of
fever, petechial rash, myalgias, and mental status changes. You are worried about invasive meningococcal infection. You intubate the patient, begin IVFs, draw blood cultures and start ceftriaxone. The patient is placed on droplet precautions. The blood culture grows N. meningitidis the next day. The nurse asks how long the patient needs to be in respiratory isolation.
Of the following, the BEST answer is until the child:A. completes 1 day of antimicrobial therapyB. defervecesC. is clinically stableD. is extubatedE. is proven not to have meningitis
*Management *Plan the treatment of a Neisseria
meningitidus infectionFirst step is recognition and aggressive
treatmentRefer to emergency care facility
IVFsLarge isotonic fluid bolusesGiving 60 to 100 ml/kg in first hour assoc.
with improved survival
*Management Vasoactive agents
Consider inotropic/vasoactive agents such as dopamine or dobutamine
Works best when intravascular fluid volume is maximized
AirwayLarge volume IVFs may lead to pulm edema
CorticosteroidsPhysiologic doses of hydrocortisone may be
beneficial in those with SMS and poor response to vasopressors
Dexamethasone in MM
*Management Antibiotics
•Patients treated with penicillin require oral rifampin to eradicate nasal pharyngeal carriage state•Require isolation and droplet precautions for 24 hours after start of antibiotics
Vaccine *Recognize that vaccines are not available against N. meningitidis serogroup B
Meningococcal conjugate vaccine (MCV4)○ Protects against A, C, Y, W-135 capsular groups○ Recommended at 11 to 12 years of age
Booster at 16○ Unvaccinated adolescents through age 18 should
receive a dose at earliest opportunity○ Age 2 to 55 for those at high risk
Vaccine for infants under investigation
Question #11 A 2-year-old boy is diagnosed with meningococcal
meningitis. IV penicillin was administered on admission, droplet precautions were begun immediately, and he received oral rifampin the next morning. No special resuscitative measures were ever required. To reduce the risk of secondary cases, prophylaxis with oral rifampin is necessary for:A. Physicians who examined the patientB. Nurses who delivered routine bedside careC. Grandparents who live out of state and visited him in the
hospitalD. Laboratory personnel who drew blood samplesE. His companions in child care
Treatment of contacts *Know that certain close contacts of patients
with N. meningitidis require chemoprophylaxisHousehold contactsChild care or pre-school contactDirect exposure to index case’s oral secretions (7
days before onset of illness)○ Kissing, toothbrushes or utensils, mouth-to-mouth
Slept in the same dwelling during 7 days beforePassengers seated directly next to index case on
flight longer than 8 hours
Treatment of Contacts *Know what to recommend to a parent
when it is reported that a child has been exposed to meningitis in schoolLow riskNo history of direct contact to index patient’s
oral secretionsNO chemoprophylaxis is recommended for
school or work○ Only child care centers
Treatment of Contacts Rifampin Ciprofloxacin Azithromycin Ceftriaxone
Hepatitis B
The Virus Hepadnavirus family HBcAg: protein that forms the nucleocapsid that encloses the viralDNA HBeAg: secreted solubleantigen believed to inducetolerance HBsAg: surface antigen
Epidemiology One third of the world’s population is infected
(!)Endemic areas: Africa, Eastern Europe, the Middle
East, Southeast and Central Asia, the Pacific Islands, and the Amazon Basin of South America
Vaccine administration has greatly reduced disease burden
*Risk groupsInjection drug usersImmigrants from endemic countries
Epidemiology Transmission
Virus present to some degree in most body fluids, but highest concentration is in the serum
*Routes of transmission○ Percutaneous injection of body fluids○ Sexual contact○ Perinatal vertical transmission
*Incubation period: 2-6 mos*Period of communicability: higher chance of
transmission when patient is HBeAg+
*Clinical Manifestations Extrahepatic
Polyarteritis nodosaMembranoproliferative glomerulonephritisLeukocytoclastic vasculitisArthalgias/arthritisErythematous or urticarial rash that
precedes hepatic manifestations
*Clinical Manifestations Hepatic
Acute self-limited hepatitisAcute fulminant hepatitisChronic hepatitisCirrhosisHepatocellular carcinoma
Clinical Manifestations Acute self-limited hepatitis
Nausea, fever, abdominal pain, jaundice, fatigue, general malaise
Increased transaminasesResolution of infection within 6 months
○ HBsAb seroconversion Acute fulminant hepatitis
Associated change in mental status brought on by hepatic encephalopathy
More common presentation during infancy
Question #12 True or False: Perinatally-acquired HBV
infections are less likely to cause chronic infections than infections acquired later in lifeA. True B. False
Clinical Manifestations Chronic HBV infection
Presence of HBsAg in serum for at least 6 months or presence of HBsAg without IgM HBcAb
*The younger a person is exposed, the more likely he/she will become chronically infected○ 90% of exposed infants become chronically
infected○ 25-50% of exposed 1-5yo○ Only 6-10% of those exposed >5yo
Usually asymptomatic in childhood
Clinical Manifestations Chronic HBV infection (con’t)
Progresses through 3 phases:○ Immune tolerance
No liver inflammationHigh viral countsHBeAg+
○ Immune clearanceIncreasing liver inflammation (with resulting damage)Decreasing viral countsHBeAb seroconversion
○ Residual
Clinical Manifestations Cirrhosis/ HCC
Up to 25% of children with chronic HBV infection develop cirrhosis or HCC
Factors that contribute to risk○ Race○ Genotype of the virus○ Alcohol consumption○ Coinfection with HCV, HDV, HAV, or HIV
Question #13 You are reviewing a patient’s HBV serum
markers. You see that the patient’s HBsAb is positive, along with the total HBcAb. The HBsAg and the HBcAb IgM are both negative. Of the following, the most appropriate interpretation of these labs is:A. Immune recovery after HBV infectionB. No prior infection, not immuneC. Chronic HBV infectionD. Acute HBV infectionE. Immune after Hep B vaccination
Question #14 You are reviewing yet another patient’s HBV
serum markers. This patient has a positive HBsAg and total HBcAb, with a negative HBcAb IgM and HBsAb. Of the following, the most appropriate interpretation of these labs is:A. Immune recovery after HBV infectionB. No prior infection, not immuneC. Chronic HBV infectionD. Acute HBV infectionE. Immune after Hep B vaccination
*Serum Markers
Screening In Chronic HBV Infections Liver enzymes
Q6mos Serum AFP
Q6mos Ultrasound of the liver
Q12 mos
Treatment Goal of therapy: long-term remission
(eradication not possible with current therapies)Loss of detectable HBV in the serumLoss of HBeAg
Available therapies:Interferon
○ Stimulates host immune system to maximize its own antiviral effect
Nucleotide/side antivirals (lamivudine)○ Interferes with the reverse transcription of HBV
Question #15 A 38 wga M is born to a 24 yo G1P0 via NSVD.
Upon review of the maternal labs, you notice that Mom is HBsAg+. The baby is currently 10h old and is eating, sleeping, urinating and stooling normally. Of the following, the most appropriate course of action in this infant is:A. Immediate administration of the Hep B vaccineB. Immediate administration of HBIGC. Immediate administration of both the Hep B
vaccine and HBIGD. Start lamivudineE. No interventions are necessary in the infant
Immunoprophylaxis Two types of therapy:
HBV vaccineHBIG
CDC has set a goal for eliminating transmission of HBV in the USUniversal immunization of infants at birthPrevention of perinatal HBV transmission via routine
screening of all pregnant woman and appropriate immunoprophylaxis for exposed infants
Routine immunization of children and adolescents that have not been previously immunized
Immunization of previously unimmunized adults
THE END!!
Thank you for participating in board review this year!!