Periodic fevers are defined as uniform periods of fever that recur regularly in individuals who are healthy between attacks. Parents may organize life eg holidays around expected attacks and don’t have any concerns otherwise cf child with recurrent respiratory and gastrointestinal infections after starting nursery who “always has something”.
Recurrent bacterial infections esp recurrent/chronic pneumonia or otitis media may indicate a humoral immune defect. Similarly, recurrent documented viral or fungal infections may indicate a cell mediated immune defect.
Arbovirus, spread by ticks, big problem in forested regions of Europe and vaccine available.
In Scotland, “Louping ill” is tick born encephalitis affecting sheep – v rarely humans too.
Since 2019, 3 cases of TBE in England (virus had been found in ticks in Southern England before), and recently 1 in Scotland. Patient had a dozen or so ticks that were only removed after a day.
Lyme disease is the other important tick borne infection.
Chandler classification describes the potential sequence of events:
Preseptal (periorbital) cellulitis, in other words, anterior to the eye. Usually caused by skin organisms entering via superficial trauma
Orbital cellulitis – surrounding the eye
Subperiosteal orbital abscess – penetration into bone of orbit
Orbital abscess
Cavernous sinus thrombosis
In older children, more likely to start with sinusitis, then eroding through into orbit. Differentiating between these types is difficult without imaging.
Different organisms cf skin commensals of preseptal cellulitis eg Haemophilus, streptococci including pneumococcus, anaerobes.
In a large US review of 220 children and young adults, 98% were investigated by CT. High rate of steroid use – previous studies have suggested better outcomes, but no obvious benefit in terms of treatment success here. Various antibiotic regimens, various durations. More treatment failures if treated for more than 3 weeks but these will be the most severe/complex cases.
Management
Jointly managed by ophthalmology, ENT and paediatrics. Ophthalmology are best at performing eye movement assessment, but it is ENT who tend to do any surgery (usually endoscopic sinus surgery).
Red flags:
Severe proptosis,
worsening visual acuity,
elevated intraocular pressure,
colour indiscrimination,
intracranial involvement,
inability to perform a reliable serial ophthalmologic examination,
poor response to a trial of intravenous antibiotics for 24 to 48 hours
These are indications for surgery.
The size of any subperiosteal abscess on CT is a new prognostic factor: diameter >10mm and volumes ≥500mm3 (although volume measurements not routinely reported) are thought typically to require immediate surgical intervention, with the remainder going to surgery only in the event of clinical deterioration, lack of clinical improvement after 48 hours of antibiotics, or worsening abscess on imaging.
Treatment duration – most people would agree to IV treatment until clear improvement, followed by oral antibiotics for a total of 14 days.
Doesn’t seem to be associated with severity of initial illness.
Long COVID is less common if you are vaccinated already. In a community based study of adults aged 18 to 69 years infected with SARS-CoV-2 before vaccination against covid-19, the odds of experiencing long covid symptoms decreased by an average of 13% after a first covid-19 vaccine dose, with a further 9% decrease in the odds of long covid after a second dose. [https://doi.org/10.1136/bmj-2021-069676]
If you already have long COVID, further COVID immunisations seem to be beneficial, rather than harmful:
In a non-controlled study of 900 social media users with long COVID, more than half experienced an improvement in symptoms after vaccination compared with 7% who reported a deterioration.19
A study of 44 vaccinated patients and 22 unvaccinated controls previously admitted to hospital with covid-19 in the UK, which inevitably had limited power to detect clinically relevant effects, found no evidence for vaccination being associated with worsening of long covid symptoms or quality of life.20
A French study of 455 self-selected participants found reduced long COVID symptom burden and double the rate of remission at 120 days in vaccinated participants compared with unvaccinated controls.
All about symptoms, excluding treatable conditions, then self management. For adults:
=enterobius. Common in young children, probably due to hygiene issues. Also called pinworms. Small (1-2cm), like white threads. Can be intensely itchy, usually in night when worms emerge to lay eggs.
Mebendazole effective at killing live worms in gut, not effective if eggs in vagina. Licensed from age 2 but can be used off license below that. Does not kill eggs however, and main issue is reinfection so consider treating whole family, with repeat doses after 2 weeks when any eggs will have hatched. NHS Inform advice on hygiene:
Lifespan of threadworms is approximately 6 weeks, so follow hygiene measures for at least this length of time.
Everyone in the household must follow the advice outlined below.
Wash all night clothes, bed linen, towels and soft toys (normal temperatures OK but make sure the washing is well rinsed [presumably at start of treatment; dilution more important than soap?]
Vacuum and dust the whole house esp bedrooms – repeat regularly
Avoid shaking out clothes/bedding that may be contaminated with eggs, to prevent eggs being transferred to other surfaces
Don’t eat food in the bedroom
Keep fingernails short
Discourage nail-biting and sucking fingers/thumbs
Wash hands frequently and scrub under your fingernails esp before eating, after going to the toilet, and before and after changing your baby’s nappy
wear close-fitting underwear at night and change your underwear every morning
bathe or shower regularly – it’s particularly important to bathe or shower first thing in the morning: make sure you clean around your anus and vagina to remove any eggs
don’t share towels
keep toothbrushes in a closed cupboard and rinse them thoroughly before use!
Eggs probably become unviable after a few days if not in warm and moist environment… Children may of course pick up another threadworm infection from school/nursery…
Sometimes you just have to keep repeating treatment over months/years! Mebendazole is harmless (v little systemic absorption), although symptoms may be caused by clearance of large worm burdens.
Typically P. aeruginosa. A biofilm producing gram negative bacterium important in multiresistant infections, particularly in the immunocompromised and in cystic fibrosis.
Pretty ubiquitous in the environment, especially in lakes and rivers. Often found in vases of cut flowers, and in spa/whirlpool baths, where it is associated with folliculitis.
The ability to make biofilms makes infection difficult to treat, as the biofilm prevents penetration by antibiotics. The biofilm allows the bugs to survive in low nutrient environments.
Antibiotic resistance is a major issue, with specific anti-pseudomonal antibiotics often required viz tobramycin, ceftazidine.
Ingesting pseudomonas doesn’t pose much of a hazard, unless you are on antibiotics already and have a disturbed intestinal flora. Aerosolizing pseudomonas on the other hand can be lethal to mice.
Upper, lower, atypical, recurrent – all have specific definitions;
Diagnosis is ideally by culture – minimum of 1.25 ml, pref 2.5ml of urine in a 7ml red top boric acid container. White top only acceptable if received at lab on same day or day before, within hospital. Collection method important, ideally clean catch.
But given delay in getting culture result, urinalysis more practical, if less sensitive/specific. Nitrites have high positive predictive value so treatment usually started pending culture. Microscopy (for white cells and bacteria) is routinely done in infants under 3 months but needs to be requested between 3 months and 3 years. Greater than 100 wcc or 1000 organisms considered “numerous”, above 40 wcc or 500 organisms “moderate”.
Contains a range of different sugars, aromatic oils, also pollens and bee proteins. Royal jelly and beeswax related, of course.
High fructose content can cause GI intolerance in some.
Allergic reactions can happen, often unrecognised, mostly due to specific pollens (depending on what flowers the bees feed on), in minority to bee proteins. Commercial honey tends to contain v low amounts of pollen, due to production techniques. IgE test for honey is available, but you may need to skin prick test with the specific honey if negative.
Honey eaten all year round is rumoured to prevent hay fever symptoms because of the pollens it contains, but this has not been proven, although it’s a nice idea related to immunotherapy. Depends on getting the right pollens of course – bees don’t like grass and birch flowers, probably. In some it may just trigger allergy symptoms.
Cross reaction between honey and bee venom is reported, not surprisingly, but not automatic.
Plant toxins can be present in sufficient quantities in honey to cause poisoning eg rhododendrons (some species).
Botulism reported in infants – failure to thrive, hypotonia, cranial nerve palsies. Clostridium and other bacteria cannot grow in honey due to the high sugar content, but spores can be present. So advice is not to give honey to infants.
Has Victorian connotations as fatal epidemics of Scarlet fever swept through slums in the pre-antibiotic era.
Group A streptococcus pyogenes is still carried in up to 20% of young children’s throats. Disease peaks in winter and spring (cool conditions, and more time indoors?). Spread easily through saliva.
Scarlet fever (scarlatina is usually used for mild cases) is when an exotoxin is produced, that causes fever and rash. Characteristic features are:
Strawberry tongue – progresses from white coated, to red, beefy tongue as coating lifts.
Benefit of antibiotic treatment just ½ day symptoms! But without treatment would need to exclude from nursery/school for 14 days!!! Else after 24hrs antibiotics.
No resistance to penicillin and low MIC so preferred. 10 day course of whichever antibiotic recommended (for clearance from throat, as opposed to clinical improvement), with exception of azithromycin (5 days).
Other antibiotics eg clindamycin may be chosen however if invasive disease.
Currently not an outbreak in Scotland but surging numbers in England (esp West Midlands and London) October 2023-January 2024, with worldwide outbreaks – Kazhakstan, Yemen, Ethiopia, Pakistan.
Extremely infectious – in a vulnerable population, you can expect 15-20 more cases per index case (R0 number). Incubation period is 7-21 days, typically 10-12 days. Infectious period is 4 days before to 4 days after onset of rash. Starts with a prodrome of cough, coryza, conjunctivitis and fever lasting 2-6 days (peaks at day 4-5). Then the rash appears: brick red, maculopapular, starts behind ears, spreads from face on to trunk and then everywhere including palms/soles. Discrete spots may then coalesce. With time the rash may darken (“stain”) and may desquamate. The child is typically irritable – compare other common childhood rashes.
Koplik’s spots are pathognomic but easily missed as they appear early in the illness, disappearing within a few days of the rash starting. They are grey or white spots on the buccal mucosa opposite the 2nd molars.
Case definition is:
a fever (temperature 38ºC or higher) and
generalised maculopapular rash lasting three days or longer and
either cough, coryza or conjunctivitis.
Diagnosis is by oral fluid test else throat swab (or urine) for PCR. Send blood for IgG/M too.
Complication
Significant effect on immune function.
Measles pneumonia most common cause of mortality.
Encephalitis well recognised. Roald Dahl’s daughter Olivia died of it in the 60s and he was a strong supporter of immunisation thereafter.
Management
Check vulnerable contacts. Risk window is 4 days prior to rash, to 4 days after onset of rash (peak infectivity before rash appears).
Immunosuppressed (biologics or chemo) Group A – may have had good immune response to vaccination earlier in life. Check Measles IgG if in doubt. Susceptibility depends on age, history of previous measles infection, vaccine status. See table 3 below.
Immunosuppressed Group B – known vulnerable else unlikely to have adequate antibody levels. Check Measles IgG and treat if negative or unable to check (some will just need IVIG regardless).
Pregnant women – even equivocal measles IgG considered protected (neutralisation assays show detectable antibody). Check if only one measles vaccine given or unvaccinated (allow 6 days for result). HNIG used.
Infants under 6 months get HNIG as little transplacental transfer of measles antibody, and wane. 6-8 months old with household contact considered high risk and should get HNIG, for other exposure can get MMR.
From 9 months onwards, MMR, ideally within 3 days. Beyond 3 days may still help protect against other potential exposures in outbreak.
immunosuppressed but also infants and pregnant women. There is not an explicit definition for close contact. Ideally vaccination should be offered within 3 days.
Pregnant vaccinated women should be fine, if in doubt do rapid antibody levels, give HNIG (Human Normal Immunoglobulin, NOT MMR) if necessary, repeat serology at 3/52.
Infants under 6/12 should get HNIG, unless mother has had natural measles (or born before 1970!). Else MMR, unless 6-8/12 old and a household contact or high risk.
IVIG/HNIG should be given within 72 hours of exposure (up to 6 days). Protects for 3 weeks, after which another dose required if further exposure. Dose for IM is 0.6mg/kg up to a maximum of 1,000mg
Respiratory protective equipment should be worn when caring for confirmed or suspected cases viz FFP3 respirator.
[HPA Guidance 2024]
Vaccination
Measles now endemic again in England and many European countries, with cases increasing year on year with only a slight reversal during lockdown. Before vaccines, pretty much inevitable part of childhood.
Andrew Wakefield in 1998 didn’t help – no immediate problem with his false paper (due to herd immunity), first death not until 2006, at which point rate 13x higher than pre-Wakefield. Vaccine hesitancy continues to be one of the biggest global health challenges of our time.
MMR clinical symptoms occur 7-14 days post-vaccination. Very rare after booster. Tends to be mild fever, rash and conjunctivitis.
Porto Outbreak
March-April 2018, 96 confirmed cases in a hospital in Porto, Portugal. Mostly vaccinated Health care workers!!!
