Category Archives: Infectious disease

PFAPA

General paediatrics, Immunology, Infectious disease

=periodic fever, aphthous stomatitis, pharyngitis, adenitis.

Fever every 4-6 weeks (periodic). Neutrophil count normal, cf cyclical neutropenia.

Besides mouth ulcers, sore throat and cervical lymphadenopathy, headache, musty smell (!), abdo pain.

Affected children continue to grow normally, are well between attacks, and do not suffer long-term sequelae.

Treatment with steroids or with cimetidine has been effective, and some children have had no further attacks following tonsillectomy (which suggests some relationship with strep infection but not clear).

Periodic fever

General paediatrics, Immunology, Infectious disease
Infectious causes
Mycobacteria (TB and non-tuberculous disease)
Borrelia
Leptospira
Streptobacillus moniliformis (rat bite fever)
Hepatitis B
Orbivirus
Rickettsea (typhus)
Entamoeba histolytica
Others
Cyclical neutropoenia
PFAPA
Behcet’s
Hyper IgD (HIDS)
Familial Mediterranean fever
Familial Hibernian fever/TRAPS
Cryopyrin disorder

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.

Tick borne encephalitis

General paediatrics, Infectious disease

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.

Orbital cellulitis

General paediatrics, Infectious disease, Surgical

Potentially serious infection of the eye.

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.

Often no organism is obtained, which adds to the difficulty of giving evidence based guidance. Multiple bugs not uncommon. Hence a variety of different guidelines, generally of poor quality.

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.

Long COVID

General paediatrics, Infectious disease, Mental health, OPD, Psychology

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:

https://www.yourcovidrecovery.nhs.uk/

Threadworms

Common, General paediatrics, Infectious disease, OPD

=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
  • Clean bathroom and kitchen surfaces – again, rinse cloth frequently – 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.

Pseudomonas

General paediatrics, Infectious disease

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.

[DOI: 10.1007/978-1-4419-0032-6_3]

Urinary tract infection

Common, General paediatrics, Infectious disease, Renal

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”.

Honey in medicine

Allergy, General paediatrics, Infectious disease, Neurology, Nutrition

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.

Scarlet Fever

Common, General paediatrics, Infectious disease

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.
  • Perioral pallor
  • Fiery, widespread rash – rough “sandpaper” feel characteristic
  • Pastia’s lines – lines of petechiae in creases esp wrists, elbows
  • Palatal petechiae (“Forchheimer spots”) – not specific, also measles. 
  • As rash fades, desquamation can occur, particularly on fingers/toes. Should only happen once in lifetime, as antibodies form to toxin!?

No longer notifiable in Scotland, cf England/Wales.

Complications can still be severe of course, as with any group A strep disease:

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.