Transcript BOARD REVIEW id part 1

Karen Estrella-Ramadan
07/03/12
BOARD REVIEW
ID PART 1
Question 1
 A family comes to your office for consultation regarding a
3-week trip to India they are planning to take in 3 months.
The children, a 9-year-old boy and a 7-month-old girl, are
well, and their immunizations are up to date.
Of the following, the MOST appropriate prophylaxis to
provide in preparation for travel is:
A. chloroquine for both children
B. hepatitis A vaccination for both children
C. measles vaccination for the girl
D. polio vaccination for the boy
E. typhoid vaccine for both children
C
 Measles: common in many parts of the world,
including India. Measles vaccine is
recommended for 6- to 11-month-old
children, and the 7-month-old girl in the
vignette should be given a dose of measles
vaccine. She still will require two doses of
measles-containing vaccine after 1 year of
age because the immune response may be
suboptimal at her young age. If the 9-yearold boy is up to date on immunizations, he
requires no additional measles vaccination.
 Chloroquine : NO, because South and Southeast Asia, sub-
Saharan Africa, and tropical areas of South America are
resistant to it. In these areas use atovaquone/proguanil and
mefloquine. Doxycycline can be used in children older than
8 years of age.
 Travelers' Health – CDC
 Hepatitis A: is a concern, but NOT approved in kids <1y/o.
Iunder this age may use: Immunoglobulin IM.
 The boy must get vaccine 2-4 wks before departure if hadnt got
it, and then sec dose in 6-12months.
 Polio : NO, both are UTD in vaccines
 Typhoid: may be indicated for a trip to Indica longer than 2
wks, but neither of the two licensed vaccines is indicated in
children younger than 2 years of age
Question 2
 You are called by a nurse who has sustained a needle stick injury
while drawing blood from a patient's central line. The patient is a
14-year-old male who recently was diagnosed with acute
myelocytic leukemia. He has received several blood product
transfusions for anemia and thrombocytopenia. You obtain
human immunodeficiency virus and hepatitis C serologies.
A.
B.
C.
D.
E.
Of the following, the additional serologic test that MUST be
obtained for the nurse is for:
Cytomegalovirus
hepatitis A
hepatitis B
measles
tetanus
C
 Requires a serologic test for hepatitis B.

Hepatitis B virus (HBV) is a DNA hepadnavirus that is comprised of an outer
lipoprotein envelope containing hepatitis B surface antigen (HBsAg) and an
inner nucleocapsid consisting of hepatitis B core antigen.
 ONLY antibody to HBsAg (anti-Hbs) provides protection from HBV
infection
 Transmitted through: blood or body fluids (wound exudates, semen,
cervical secretions, and saliva)
 Blood and serum highest concentrations of virus; salivalowest.
 Serology is the most common diagnostic test used to detect and
diagnose hepatitis B.


In addition, hybridization assays and gene amplification techniques (eg,
polymerase chain reaction) are available to detect and quantitate HBV
DNA.
 Cytomegalovirus, hepatitis A, and measles
are NOT transmitted parenterally.
 Tetanus is acquired through contamination
of wounds with soil or excrement that contain
the tetanus organism. Needlestick injury is
not a usual pathway for acquiring tetanus.
Question 3

A 15-year-old girl presents to the emergency department with right upper
quadrant pain for 2 days that is severe enough to keep her out of school. Her
appetite is decreased and she has nausea but no vomiting or diarrhea. She has
mild discomfort with urination but no vaginal discharge. The only medication
she is taking is combined oral contraceptive pills. Her last menstrual period was
heavier that usual. Laboratory tests reveal:
WBC: 7.4x103/mcL (7.4x109/L) with N: 64% L: 26%
Total bilirubin, 0.4 mg/dL (6.9 mcmol/L)
ALT: 14 units/L
AST: 16 units/L
Urine has 7 WBC.
Abdominal US: reveals a normal liver, spleen, gallbladder, and kidneys.
1.
2.
3.
4.
5.
Of the following, the MOST likely diagnosis is
Cholecystitis
Fitz-Hugh-Curtis syndrome
hepatitis A infection
infectious mononucleosis
pyelonephritis
2
 ALL adolescents should be asked annually about:
sexual behaviors , unintended pregnancy and sexually
transmitted infections (STIs), including HIV.
 Document screening and LMP
 Fitz-Hugh-Curtis syndrome or perihepatitis presents as
RUQ pain that results from inflammation of the liver
capsule from ascending pelvic infection. Although
typically associated with salpingitis, it can exist without
other signs of pelvic inflammatory disease and may
mimic other abdominal emergencies.

 Lab r/o hepatitis, including that caused by
mononucleosis, and biliary tract obstruction.
 The absence of fever and the location of pain for
this girl make pyelonephritis unlikely.
 Pyuria raises the possibility of urethritis, which
commonly occurs with Neisseria gonorrhoeae and
Chlamydia trachomatis infections. C trachomatis
can cause inflammation of the genital tract
without the classic symptoms and signs of pelvic
inflammatory disease. Often, heavier menstrual
flow may be the only symptom.
Question 4





A 15-year-old boy comes to the emergency department because of
cramping abdominal pain, diarrhea, and body aches. Physical
examination reveals no icterus or organomegaly, although he has
increased bowel sounds and mild diffuse abdominal tenderness. His
genitalia are at Sexual Maturity Rating 4. Among the results of
laboratory tests obtained are:
Total bilirubin, 0.6 mg/dL (10.3 mcmol/L)
ALT: 18 units/L
AST: 22 units/L
Alkaline phosphatase: 360 IU/L
A.
B.
C.
D.
E.
Of the following, the MOST likely explanation for the results of these
laboratory tests is:
bone malignancy
infectious hepatitis
inflammatory bowel disease
physiologic growth spurt
viral gastroenteritis
D
 An increased serum alkaline phosphatase value on a LFT
panel in an adolescent, often is the result of rapid bone growth
during the pubertal growth spurt. Therefore, it is important to
correlate the value with the Sexual Maturity Rating (SMR)
rather than with chronologic age.





The highest mean SAP concentrations in girls occur at SMR 2 and in boys
at SMR 3, coinciding in each instance with peak height velocity and
presumed maximum osteoblastic activity. (high as 500 UI/L)
Osteoblasts, by creating a local environment of alkalinity via alkaline
phosphatase, help build bone.
With increasing SMR or age, the SAP values in both sexes decrease
markedly.
The normal range for children and adolescents varies with age, sex,
sexual maturity, and reference laboratory.
The isoenzyme test can reveal whether an elevation of SAP is from bone
or liver, but this test is not widely available.
 Pathologic causes of increased SAP include:





Liver or biliary disease
Pregnancy
drugs (eg, phenytoin)
skeletal disease
endocrine disorders such as hyperPTH.
Normal concentrations of liver enzymes suggest a nonhepatic
cause of SAP elevation and rule out infectious hepatitis and
inflammatory bowel disease with hepatic involvement.
Bone pathology (eg, osteosarcoma) presents with higher SAP
values than reported for this boy along with other symptoms (eg,
limb pain) and signs (eg, swelling).
Elevated SAP concentrations do not occur in viral gastroenteritis.
Question 5
 You are evaluating an 18-month-old boy in the
emergency department who appears "toxic" and is
sitting uncomfortably and leaning forward in his
mother's lap. His temperature is 40.0°C, heart rate is
140 beats/min, respiratory rate is 35 breaths/min,
blood pressure is 90/60 mm Hg, and oxygen
saturation on room air is 94% by pulse oximetry. He
is drooling from the corners of his mouth, and his cry
appears muffled. The nurse shows you the lateral
neck radiograph that was just obtained.
Of the following, the MOST appropriate next step in
the treatment of this patient is
A. administration of intramuscular penicillin
B. blood cultures and a complete blood count
C. emergent otolaryngology and anesthesia
consultation
D. intramuscular administration of
dexamethasone
E. throat culture
C
 Epiglottitis is a medical emergency. The incidence of this
disease has significantly decreased since the introduction
of the Haemophilus influenzae type b vaccine, and the most
common infectious pathogens now are Streptococcus
pneumoniae, group A beta-hemolytic Streptococcus, and
Staphylococcus aureus.
 Often, the infection involves the entire supraglottic area,
not just the epiglottis, and is called supraglottitis.
 Typically between 2 and 8 years of age, usually present with
the rapid onset of fever, sore throat, and the "four Ds"
(drooling, dysphagia, dysphonia, and dyspnea), "tripod
position." Clinicians must be vigilant for atypical
presentations, especially among children younger than 2
years of age.







AIRWAY!!! Direct examination of the
airway under anesthesia
An ETT that is 0.5 to 1 mm smaller
than usual for age generally is needed.
Cultures of the supraglottic area can
be obtained at the time of intubation
and broad-spectrum antibiotics: CTX.
Lateral radiographs are diagnostic but
should be deferred until personnel
and equipment ready for airway
security. As well as lab work, throat cx
or IM meds.
Neither penicillin nor dexamethasone
is indicated for the initial treatment of
epiglottitis
Rifampin for 4 days for alll close
contacs
Children >2y/o no need for vaccine
Question 6

A 13-year-old girl who plays soccer presents with a temperature to 38.9°C
for 2 days, dysphagia, malaise, and nausea. She has had no cough or
rhinorrhea. Physical examination reveals erythema of the tonsils with
petechial hemorrhages, petechiae on the soft palate, mild enlargement of
the cervical lymph nodes, and vague discomfort in the epigastric area. On
evaluation, you palpate a spleen tip. You obtain a rapid streptococcal
antigen test and a throat culture. The rapid streptococcal antigen test is
negative and you recommend antipyretics and rest. She returns to the clinic
48 hours later because her symptoms have not improved. The throat culture
is negative, but the girl reports continued fever, increasing malaise, and
some vomiting. Findings on the physical examination have not changed,
and there are no signs of serious bacterial infection or dehydration.
Of the following, the MOST efficacious next test for this patient is:
A.
CBC
B.
Epstein-Barr virus titers
C.
rapid influenza test
D.
spot test for infectious mononucleosis
E.
viral culture for adenovirus
D

Criteria for streptococcal pharyngitis
fever, sore throat, tender cervical
lymphadenopathy, and NO cough.

70% of cases of exudative pharyngitis
are due to virus.

Petechiae on the soft palate may be a
sign of group A streptococcal
pharyngitis, but macules, vesicles,
and other lesions of the palate also
are seen in EBV, coxsackie and adeno

Adenovirus : 25% of exudative
pharyngitis, often with conjunctivitis.

Enterovirus: pharyngitis,
gastrointestinal complaints, and
vesicular lesions of the pharynx, often
including the palate.

Arcanobacterium haemolyticum :
bacterial cause of pharyngitis similar
to by group A Streptococcus.
Adolescents.
 EBV: pharyngitis + more serious illness  hepatosplenomegaly,
hepatitis, or significant lymphadenopathy.
 Abdominal pain may be seen with streptococcal disease, EpsteinBarr virus infection, and a variety of other illnesses.
 R/o Kawasaki disease in the child who has fever and oral mucous
membrane changes, especially with rash and adenopathy, as well as
adenovirus and common rhinoviruses and influenza.





For the girl described in the vignette, the heterophile antibody rapid
mononucleosis spot test is likely to be helpful because it is widely
available and results can be obtained quickly.
If results are negative and clinical suspicion for this infection remains
high, Epstein-Barr virus titers may be obtained.
Standard adenovirus culture takes time, no fastest than 2 days , not
readily available, and it can be in tonsills for months post infection.
A haemolyticum may be cultured with conventional throat culture,
but the laboratory must be informed
The absence of cough or coryza in this patient makes Flu less likely.
CBC not specific
Question 7

A.
B.
C.
D.
E.
A 7 year-old-girl presents to your office with a 1-day history of a
temperature of 38.9°C. Notable findings from her past medical history
include static encephalopathy, seizure disorder, and recurrent urinary
tract infections. She is receiving intermittent straight catheterization
and trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis. Her
medications also include phenytoin, albuterol via nebulizer, ipratropium,
and ranitidine. Urinalysis reveals more than 100 white blood cells per
high-power field and is positive for leukocyte esterase and nitrites.
Of the following, the BEST option for oral empiric therapy pending
culture results is
Amoxicillin
azithromycin
ciprofloxacin
Nitrofurantoin
trimethoprim-sulfamethoxazole
C

Recurrent UTI under TMP-SMX prophylaxis resistant pathogen , making
ciprofloxacin,, the best option for therapy, pending cx and sensitivities.

Azithromycin is not indicated for treatment of UTIs.

Amoxicillin and nitrofurantoin not for resistant pathogen and no TMT-SMX because
of resistance in this child

Studies in young animals demonstrated arthropathy, but no increase incidence in
pediatric pts

The Committee on Infectious Diseases of the AAP suggest that fluoroquinolone use in
pediatrics be restricted to situations in which the pathogen is multidrug-resistant and
there is no safe and effective alternative or when parenteral therapy is not feasible
and there is no effective alternative oral agent. Such situations might include UTIs
caused by multidrug-resistant gram-negative rods, including Pseudomonas
aeruginosa; gastrointestinal and respiratory tract infections caused by resistant gramnegative organisms; and chronic or acute osteomyelitis caused by P aeruginosa. In
addition, a fluoroquinolone may be indicated for treatment or prevention of anthrax
and for treatment of mycobacterial infection with sensitive strains.
Be aware of interactions: antiacids containing aluminum , Mg or Calcium—decrease
absorption of cipro, NSAIDS potentiate CNS side effects

Cipro increases warfarin, inhibit K channels in heart and can cause long QT interval,
hypo or hyperglicemia in pts with insulin
Question 8
 An 18-month-old boy is brought to the clinic with fever and
irritability. His mother explains that he has had a fever for
the past week and a red rash on his extremities. On physical
examination, he has a temperature of 39.2°C; he is irritable;
his eyes are injected without discharge and his lips are dry,
red, and cracked. All other findings are within normal limits.
Of the following, the MOST appropriate next step in this
patient's care is to:
A. administer intravenous antibiotics
B. administer intravenous gamma globulin
C. obtain blood cultures
D. obtain electrocardiography
E. perform a lumbar puncture and culture the cerebrospinal
fluid
B
PLUS 4out of 5:

Vasculitis of small- and medium-sized blood vessels, including the coronary
arteries.

80% of cases occur in children <4y/o

> in winter and spring, > in males

All ethnicities

Phases: ACUTE: 1-2 wks after onset of fever and is when the diagnostic
criteria typically are present.
SUBACUTE: 2 to 8 weeks after disease onset, and patients may
demonstrate desquamation of the fingers and toes.
 Coronary aneurysms may develop, particularly in those who have not
been treated with intravenous gamma globulin during the acute phase.
CONVALESCENT: lasts for months following the illness
Because the child in the vignette is in the acute phase of KD, he should be
treated with intravenous gamma globulin at a dose of 2 g/kg. If his fever
persists, a second dose of gamma globulin may be administered. In
addition, high-dose aspirin therapy (80 to 100 mg/kg per day) is
administered until the patient is afebrile for 48 hours, at which time the
dose is decreased to 3 to 5 mg/kg per day for 6 to 8 weeks or until the
platelet values normalize. NO ABX, NO LP , NO EKG
Question 9





A 16-year-old girl comes to your office in August for evaluation of fever,
headache with retro-orbital pain, and marked achiness of her joints and
muscles. She returned 1 week ago from a church mission trip to El
Salvador. A number of other people on the trip were diagnosed with a
viral syndrome. Findings on physical examination are normal except for:
T 39.1°C, HR: 104:
Conjunctival injection without discharge
Erythema of the pharynx without exudate
Mild, tender hepatomegaly
Maculopapular rash on the trunk and scattered petechiae
Laboratory results include:
WBC: 3.2x109/L, Hb: 14, hct: 41.8%, platelets: 78
AST: 212 units/L, ALT: 187 units/L, Total bilirubin: 0.8 mg/dL
BUN: 18.0 mg/dL, creatinine: 0.8 mg/dL
Of the following, the MOST likely diagnosis is:
A. dengue fever
B. Epstein-Barr virus infection
C. hepatitis A infection
D. Malaria
E. typhoid fever
A
•break-bone fever."
•Dx: serology
•Dengue virus is the
most common
arthropod-borne
(arbo) virus disease
in the world,
•Dengue fever has
been reported in
Southeast Asia, the
South Pacific Islands,
Latin America, and
the Caribbean.
•Humans: accidental
hosts
retro-orbital pain, conjunctival injection, pharyngeal erythema,
hepatomegaly with mild elevation of liver enzyme values,
thrombocytopenia, and recent travel to El Salvador
A
 Arbovirus: US: summer and autumn
CNS involvement: West Nile virus, eastern and western equine
encephalitis virus, St Louis encephalitis virus, LaCrosse
encephalitis virus, and Japanese encephalitis virus.
Other arthropod-borne illnesses include hemorrhagic fevers and
febrile illnesses, often with rashes or hepatitis. Dengue fever is
the most prominent of such infections. Others include Colorado
tick fever and yellow fever





Infectious mononucleosis or acute Epstein-Barr virus infection can cause
many of the symptoms and laboratory abnormalities (thrombocytopenia,
elevated liver enzymes) described in the vignette, but the absence of
splenomegaly and exudative pharyngitis and the extent of the myalgias and
arthralgias are less typical of this condition.
Similarly, the degree of systemic complaints is not consistent with hepatitis
A infection.
Malaria can present with many of the features described for this girl, but the
degree of myalgias and arthralgias is somewhat severe for non-falciparum
malaria, which are the types seen in Central America. In addition, anemia,
hypersplenism, and pallor would be present in malaria.
Furthermore, the viral illnesses reported in other members of the group are
more consistent with a viral diagnosis than malaria.
Typhoid fever also may manifest many of the complaints described for this
girl, but the rash of typhoid (rose spots) is much more subtle, and abdominal
pain generally is more prominent.
BOARD REVIEW
ID PART 2
QUESTION 10:
A 15-year-old boy presents to the clinic because of a persistent cough.
According to his mother, his cough has been present for approximately 2
weeks, but it seems to be getting worse. He does not cough all the time, but
the coughing episodes tend to come in bursts.This morning she became
very worried because he passed out during a coughing spell. Physical
examination reveals a healthy-appearing male in no apparent distress. He is
afebrile, and his vital signs are normal. He has petechiaeon his face but no
other skin lesions. His lungs are clear.
Of the following, the MOST appropriate antimicrobial agent to prescribe for
this patient is:
A.
B.
C.
D.
E.
azithromycin
Clarithromycin
Doxycycline
Erythromycin
trimethoprimsulfamethoxazole
0%
A.
0%
0%
B.
C.
0%
0%
D.
E.
10
Countdown
Pertussis
(bordetella pertussis)
 Incubation: 3-12 days.
 A 6wk duration, with 3 stages lasting each one 1-2 wks.

Stage 1: (catarrhal): URI symptoms
 Very contagious

Stage 2: paroxysms of intense coughing lasting up to several minutes.
 Infants >6mo and toddlers: “whooping cough” cough, f/u by loud whoop
as inspired air goes through a still partially closed airway.
 <6mo: apneic episodes and are at risk for exhaustion.
 Older children: Posttussive vomiting and turning red with coughing

Stage 3: chronic cough, which may last for weeks.
 Older children, adolescents, and adults may not exhibit distinct
stages. Symptoms in these patients include uninterrupted
coughing, feelings of suffocation or strangulation, and
headaches.
 Dx: cough for >2wks + paroxysmal cough,
posttussive vomiting, or inspiratory whoop
 Cx: nasopharyngeal swab for (15-30”) or until
cough
A
 Any patient who has episodic coughing that ends with
syncope or vomiting consider pertussis
 Complications in adolescents: urinary incontinence, sleep
interruption, rib fractures, and pneumonia.
 Despite vaccination: increase incidence in adolescents
 AAP: booster Tdap
 If received only tetanus toxoid or only Td, GIVE Tdap if the
interval since the Td is > 2 years or if the adolescent is living in
a setting of increased disease, immunosupression or risk to
transmit to a vulnerable contact
 Tx of pertussis after cough started
DOESNT affect the course of the illness
but limits the spread of disease to others.
 Macrolides: abx of choice
 Azithromycin
 Doesn’t interact with drugs metabolized by citP450
 Less side effects compared to other abx from same
family
 TMT-SMX: if allergic to macrolides or
macrolide-resistant isolate (child >2mo)
 Doxycycline is not recommended for the
treatment of pertussis.
Question 11
You are speaking to the mother of a child who attends a junior high school where
one of the students was diagnosed with meningococcal disease 24 hours ago.
Her child does not have any classes with the index patient and, except for passing
him in the hall during lunch 3 days ago, has had no other contact with the patient.
The child's mother is frantic because the school sent home a notice asking
parents to bring their children to the public health department or their private
physician to receive antibiotic prophylaxis.
Of the following, the MOST appropriate advice for this parent is that her child:
A. does not require antibiotic prophylaxis and does not need to be seen
does not require antibiotic prophylaxis but needs to be evaluated to
determine if she is developing symptoms of meningococcal disease
C. needs to be seen to obtain nasopharyngeal cultures for
meningococcal organisms and if the cultures are positive, may
require antibiotic prophylaxis
D. requires antibiotic prophylaxis and should be seen immediately
E. should be seen immediately to determine if she needs to be
hospitalized and treated for possible meningococcal disease
B.
0%
A.
0%
0%
B.
C.
10
0%
0%
D.
E.
Countdown
A
 Classroom contacts of students who have meningococcal disease,
are considered CASUAL contacts (no history of direct exposure to
the index patient's oral secretions), and the use of prophylactic
antibiotics is NOT recommended.
 Prophylaxis:
 Close contacts of all persons who have invasive meningococcal
disease, whether sporadic or in an outbreak, SHOULD receive
chemoprophylaxis within 24 hours of diagnosis of the primary
case, regardless of vaccination status.
 Close contacts include ALL household contacts, child care and
nursery school contacts during the previous 7 days, persons who
have had direct contact with the patient's oral secretions, and
persons who frequently eat or sleep in the same dwelling as the
index patient.
 In view of this and the fact that the contact is asymptomatic, she
does not require medical evaluation at this time, and
nasopharyngeal cultures are not indicated.
 Because secondary cases of meningococcal
disease can occur several weeks after the onset of
disease in the index case, the use of
meningococcal vaccine is a possible adjunct to
chemoprophylaxis if the serogroup is contained in
the vaccine.
 Other infections can spread easily in the household
setting and may require the use of postexposure
prophylactic immunoglobulin, antibiotics, or
vaccines to prevent development of disease in
individuals exposed to the index case, such as:
Question 12
A 2-year-old girl presents to the emergency department with a simple febrile seizure.
After the recovering from their shock, the parents, who are medical students, ask you
whether genetic predisposition or particular infectious agents confer risk for febrile
seizures.You respond that several genes appear to increase risk for febrile and
nonfebrileseizures, but certain infectious agents also may be more likely than others to
trigger febrile seizures.
Of the following, the agent that is MOST associated with febrile seizures is:
A.
B.
C.
D.
E.
Aspergillus fumigatus
Escherichia coli
group A beta-hemolytic
Streptococcus
human herpesvirus type 2
human herpesvirus type 6
0%
A.
0%
0%
B.
C.
0%
0%
D.
E.
10
Countdown
E
 Febrile sz:
 Common: 1mo to 5 years, often: presenting between 6
months and 3 years of age.
 > benign
 Predispositions are not fully characterized but include both
genetic factors and types of infections
 URI, AOM, roseola (HHV 6)
 HSV 2, group A beta-hemolytic streptococcal
infection, aspergillosis, and Escherichia coli infections
have NOT been linked to febrile seizures.
Question 13
 A 9-year-old girl presents to the ED because of
fever, a macular rash on her trunk and arms, and
pain in her knees and ankles. Her mother
explains that she recently had pharyngitis. You
note a murmur on physical examination and
order electrocardiography and
echocardiography. The echocardiogram
demonstrates mitral regurgitation.
Of the following, the MOST likely diagnosis for this
girl is:
A. acute rheumatic
B.
C.
D.
E.
fever
cat-scratch
disease
Epstein-Barr
viral infection
Lyme disease
SLE
0%
A.
0%
0%
B.
C.
0%
0%
D.
E.
10
Countdown
A

The girl described in the vignette has three of the five major Jones criteria
for the diagnosis of acute rheumatic fever.
 Complications::
 Carditis: lead to mitral and ocassional aortic regurgitation and
stenosis.
 Migratory arthritis and chorea will resolve with no problems

Best evidence of strep infection: elevated ASO or antiDNAase B titer.

Tx: steroids if severe carditis leading to CHF.; unclear if reduces long term
valve dysfunction.
ASA can shorten acute symptoms, but unclear if decrease the risk of serious
lifelong rheumatic heart disease.

The MOST important chronic therapeutic intervention is antibiotic
prophylaxis to prevent group A streptococcal pharyngitis, which can lead to
a recurrent bout of acute rheumatic fever. Serious valve damage is unusual
after the initial attack of acute rheumatic fever but becomes more likely
with subsequent attacks.
 Administration of intramuscular benzathine penicillin every 21 to 28 days

Rheumatic fever prophylaxis must continue into adulthood.
Jones criteria: ARF
(2 major OR 1 major and 2 minor, + evidence of a preexisting Group A hemolytic streptococcal
infection)
Why not?
 Cat-scratch disease : by Bartonella. Most commonly in
children 1 to 2 weeks following a cat scratch or bite.
Common findings are lymphadenopathy, headache,
chills, and abdominal pain. The disease usually resolves
spontaneously, with or without treatment, in 1 month.
Cardiac valve involvement and electrocardiographic
changes are rare.
Why not?
 EBV infection  infectious mononucleosis, which
develops when a person initially is exposed to the virus
during or after adolescence. Symptoms : fever,
pharyngitis, hepatitis, and lymphadenopathy. Usually,
laboratory tests are needed for confirmation. Serologic
results include an elevated white blood cell count, an
increased percentage of certain atypical white blood
cells, and a positive reaction to a "mono spot" test.
Pericarditis and myocarditis are infrequent findings.
The young age of the patient in the vignette is highly
unusual for symptomatic Epstein-Barr virus infection,
as are the electrocardiographic changes, rash, and
arthritis.
Why not?
 Lyme disease results in fever, rash, malaise, and
muscle soreness. Although neurologic disorders and
arthritis can occur, these are invariably late findings.
In addition, the morphology of the rash distinguishes
this condition from acute rheumatic fever, and the
Jones criteria are not fulfilled. Carditis is a rare
manifestation of Lyme disease. The most common
abnormality is atrioventricular block of various
degrees, although other rhythm abnormalities have
been reported. Pericarditis, myocarditis,
cardiomyopathy, and degenerative valvular disease
have been associated with Borrelia burgdorferi
infection.
Why not?
 Systemic lupus erythematosus (SLE) can
present with rash, carditis, and arthritis.
However, evidence of a preexisting group A
hemolytic streptococcal infection would not
be expected. Of course, this laboratory
finding could be present in a patient who has
SLE, but these two diagnoses can be
distinguished by the additional laboratory
findings in SLE, including antinuclear
antibody, anti-double-stranded DNA
antibodies, and low complement values.
Question 14
 A 14-year-old otherwise healthy boy developed
an oval pink, scaly lesion on his back about 1
week ago. He presents today with widespread,
moderately pruritic, scaling macules involving his
trunk and upper extremities but sparing the
scalp, face, palms, and soles. He admits to being
sexually active but has no other known
exposures and takes no medications. Aside from
the rash, physical examination findings are
normal.
Of the following, the MOST appropriate next step in
management is to:
A. obtain serology for
B.
C.
D.
E.
Mycoplasma and Legionella
obtain serology for syphilis
perform a skin biopsy
prescribe a course of
azithromycin
prescribe a topical antifungal
cream
0%
A.
0%
0%
B.
C.
0%
0%
D.
E.
10
Countdown

This pt has: PYTIRIASIS ROSEA!






INFLAMMATORY SKIN CONDITION, MOSTLY ADOELSCENTS, OF UNKNOWN
ETIOLOGY
PRODROME: URI
LATER: HERALD PATCH: 2-10cm oval, red flat, scale, can get confused with tinea
corporis or atopic dermatitis.
THEN: 2-21 days after the appearance of the herald patch, crops of 5- to 10-mm
oval, salmon-colored thin plaques appear. These range in number from less than
50 to more than 200 on the body. They are classically distributed along Langer's
lines, producing a Christmas (fir) tree pattern on the back . They also may appear
transversely across the lower abdomen and back, circumferentially around the
shoulders, or in a V-shaped pattern on the upper chest.
 African-american: more in face
RESOLVES: in 2-12wks
? Association with HHV-7, Legionella, Mycoplasma.
B

Among the most important differential diagnoses for pityriasis rosea is
secondary syphilis, especially is rash on palms and soles.


In rare occasions when rash doesn’t resolve, consider skin bx.
TX for pytiriasis rosea;



Pruritus: emollients
No evidence of improvement with topical antifungal
? With macrolides help decrease duration of disease
Question 15:
A 14-month-old boy presents to the emergency department for evaluation of respiratory
distress, recent fever, cough, and congestion. He has received all of his vaccinations.
Physical examination shows tachycardia, poor perfusion, and hepatomegaly. CXR
documents an enlarged heart with hazy lung markings. Electrocardiography reveals sinus
tachycardia. Echocardiography identifies severe left ventricular dilation and systolic
dysfunction, with mitral regurgitation.You suspect dilated cardiomyopathy.
Of the following, the MOST likely cause is:
A.
B.
C.
D.
E.
bacterial pneumonia leading to bacterial
myocarditis
congenital coronary artery anomaly
Duchenne muscular dystrophy
previously undetected supraventricular
tachycardia
viral myocarditis due to enterovirus
0%
A.
0%
0%
B.
C.
0%
D.
0%
10
E.
Countdown
E
 Myocarditis, most often is due to infection from common viruses.
 Inflammationmyocite necrosis dilated cardiomyopathy
 Symptoms: fever, chest pain, abd pain, peripheral edema, resp
distress, liver congestion, palpitations.
 Toddlers: decrease po, cough, malaise
 Complications: CHF, poor cardiac output, arrhythmias,
pericarditis, death
 Suspicion: elevated ESR, CRP, troponin, echo cardio + for LV
dilatation, myocardial edema.
 Gold standard: myocardial bx.

ETIOLOGY:
INFECTIOUS:
 Enterovirus, coxsackievirus, adenovirus, parvovirus B19, HIV and
cytomegalovirus.
 Bacterial causes are rare, except for patients who have immunodeficiency
(Brucella, Corynebacterium diphtheriae, Haemophilus influenzae, and
Borrelia burgdorferi (Lyme disease) as well as Fungal pathogens
TOXINS:
 ethanol,CO, anthracyclines chemotherapy, some antipsychotics (eg,
clozapine), and immunologic reactions to acetazolamide and
amitriptyline
AUTOIMMUNE: sleroderma, SLE
 Treatment: symptomatic: inotropes, afterload reduction, diuretics
 High inflammatory markers: IVIG and steroids
 Maintenance: ACE-captopril
 CHF: heart transplant
 Congenital coronary anomalies can cause
myocardial dysfunction and subsequent isquemia
such as:
 coronary fistula
 Anomalous coronary artery arising from the pulmonary
artery
 Will present with similar symptoms but no URI prodrome
 Duchenne muscular dystrophy results in a dilated
cardiomyopathy, but changes until late childhood or
early adolescence.
 Supraventricular tachycardia (in addition to all forms
of atrial tachyarrhythmia) can cause a dilated
cardiomyopathy if it is chronic
Question 16:
A 17-year-old girl has been hospitalized for 3 weeks due to complicated peritonitis
following a ruptured appendix. She has undergone laparotomyand drainage of intraabdominal abscesses and improved while receiving intravenous ampicillin,
gentamicin, and clindamycin. Her nasogastrictube was removed last week, and she
has been tolerating a bland diet.Today, however, she complains of abdominal pain
and distention and has had three episodes of diarrhea. Physical examination reveals
a febrile adolescent who has a diffusely tender abdomen.
Of the following, the stool test MOST likely to establish the diagnosis is:
A.
B.
C.
D.
E.
bacterial culture
evaluation for ova and parasites
fecal occult blood
toxin assay
viral culture
0%
A.
0%
0%
B.
C.
10
0%
0%
D.
E.
Countdown
D






Long course of IV abx + abd pain+ diarrhea = colitis sec to Clostridium
difficile.
 Dx: stool for C difficile toxins (A and B).
 If sample will not be tested promptly, store it at 4°C (deteriorates at
room temperature)
 Endoscopy: Pseudomembranes and friable colorectal mucosa.
Occult blood would not be diagnostic
A stool study for ova and parasites would not be useful because a patient
who has been hospitalized for a prolonged period of time is unlikely to have
developed a gastrointestinal tract infection due to a parasite.
Nosocomial viral infections of the gastrointestinal tract do occur, and a stool
viral culture may be appropriate but in this case, hx is more related to C diff.
The spectrum of illness caused by C difficile ranges from asymptomatic
carriage to watery diarrhea to pseudomembranous colitis.
Asymptomatic carriage can occur at any age but is common in newborns
and <1y/o .
C diff


Symptoms: fever, abdominal pain and cramps, and diarrhea and appear systemically ill.
Complications: Toxic megacolon and intestinal perforation



Risk factors : Abx therapy (especially beta-lactam drugs, clindamycin, fluoroquinolones,
and macrolides ), BUT CAN HAPPEN WITH ANYONE), underlying bowel disease,
gastrointestinal tract surgery, prolonged nasogastric tube insertion, repeated enemas, and
renal insufficiency. Prolonged hospitalization, rooming with an infected patient, and being
on the same hospital ward as a symptomatically infected patient
Prevention: hand hygiene, limiting antibiotic use, properly disposing of contaminated
materials, and adequately cleaning contaminated surfaces.





likely to be fatal in infants who have underlying gastrointestinal disease (Hirschsprung disease or
inflammatory bowel disease) or are immunocompromised.
Alcohol-based hand hygiene products and many common hospital disinfectants do not eradicate C
difficile spores;
USE SOAP AND WATER
Diluted bleach solutions are best for cleaning and decontaminating surfaces.
Excluded pt from group activities for the duration of the diarrhea.
Tx: Metronidazole orally or intravenously is effective and the drug of choice.

Oral vancomycin for patients who have severe disease or can be used alone for those who do not
respond to metronidazole. Therapy should be administered for at least 10 days.
Question 17:
A 3-year-old boy developed a petechial rash beginning on his wrists
and ankles 5 days after a family camping trip in the Chesapeake
Bay area. A latex agglutination assay confirms the diagnosis of
Rocky Mountain spotted fever.
Of the following, the MOST appropriate antibiotic choice for
treating this child is:
A.
B.
C.
D.
E.
Amoxicillin
Azithromycin
Chloramphenicol
Doxycycline
trimethoprimsulfamethoxazole
0%
A.
0%
0%
B.
C.
10
0%
0%
D.
E.
Countdown
D
Doxycycline is the treatment of choice
for Rocky Mountain spotted fever (RMSF)
 Amoxicillin, azithromycin, and trimethoprim-
sulfamethoxazole are not active against Rickettsia
rickettsii, the etiologic agent of RMSF.
 Other uses for tetracyclines: chlamydial infections
(eg, nongonococcal urethritis, pelvic inflammatory
disease), Lyme disease, community-acquired MRSA
Legionnaires disease, Mycoplasma infections,
leptospirosis, chloroquine-resistant malaria, and
traveler's diarrhea.
Question 18:
A 9 y/o boy has complained of stomach cramps and diarrhea for the past 3
days. Five days ago, he visited a dairy farm with his 4th grade class and drank
unpasteurized milk. A fecal sample brought in by the parents demonstrates
mushy stool, with flakes of mucus and blood. Findings on PE include a HR of
110, dry lips, mild and diffuse nonspecific abdominal tenderness; and active
bowel sounds.You hospitalize the boy for administration of IVF and send a stool
specimen for culture.
Of the following, aTRUE statement about AGE is that:
A.
B.
C.
D.
E.
Cats and dogs are not at risk for human infection with
enteric pathogens
Erythromycin shortens the duration of Campylobacter
gastroenteritis
Rotavirus is a common cause of bloody diarrhea in infants
and children
The incubation period for calicivirus (norwalk) is 5-7 days
TMP-SMX is the tx of choice for Giardia lambia infection
0%
A.
0%
0%
B.
C.
10
0%
0%
D.
E.
Countdown
B

Acute onset of symptoms, unpasteurized milk consumption and stool findings= acute bacterial
colitis
 Common pathogens: Campylobacter, Salmonella, Shigella, Yersinia, E. coli, C. diff.
 > bacterial gastroenteritis have an incubation time of 1-7 days after exposure
 Transmission:
Or
Campylobacter: improperly cooked poultry and …
•Erytho or azithro decrease duration of illness
•If stool + for C fetus: septisemia-meningitis: IV abx




Cats and dogs: giardia
 Tx with metronidazol or nitazonamide
Rotavirus: no blood, infants
Norwalk: incubation 12hrs-4 days
Other diff dx: IBD, HSP, vasculitis. Meckel and polyps: blood but painless
BOARD REVIEW
ID PART 3
Question 19
A 5 y/o girl has been bitten on the hand by her cat. Within
24hrs of the bite, she developed pain, edema and erythema at
the bite site.
Of the following, the MOST likely organism to cause the
wound infection is:
Alpha-hemolytic
streptococcus
2. Bacteroides
3. Fusobacterium
4. Pasteurella multiocida
5. Staphyloccus aureus
1.
0%
1
0%
0%
2
3
0%
0%
4
5
10
Countdown
D
 Bites: > dogs then cats
 But higher rate of infection (sharp teeth=puncture
wound=deep inoculation)
 Tx:
 careful cleaning
 tetanus prophylaxis if required
 evaluation for need for rabies prophylaxis
 use of abx if wound is infected
Pasteurella multiocida
 Infection: quick <24hrs, erythema, tenderness and
edema
 Tx: Augmentin-cover also for anaerobes and S. aureus
 DON’T USE: cephalexin, clinda, cefaclor, cefadroxil=
resistant
 If allergy to PCN: use TMP-SMX, cefuroxime
Tetanus prophylaxis
Wound
Tetanus (3 doses)
Tetanus unknown
contaminated
None (if last
tetanus was <5yrs
ago)
TIG + Tdap
clean
None ( if last
Tdap
tetanus was <10yrs
ago)
Dtap if < 7y/o
Rabies prophylaxis
 Transmitted to humans and domestic animals
from infected bats, raccoons, skunks, foxes,
and coyotes.
 Mice and rabbits: rare
 Transmission: contamination of mucosa or skin
lesions by saliva or neural tissue from the infected
animal.
 Incubation period of the virus ranges from a few
days to years but usually is 4 to 6 weeks.
In cases where animal testing is not possible
 Give: rabies immune globulin (RIG) and rabies
vaccine ideally within 24 hours of exposure
 Give RIG within 7 days:
 Protect against rabies between exposure and
antibody production
 Total: 20 IU/kg of RIG, > around the wound,
remaining, give IM at a distant site from the
vaccine.
 Rabies vaccine
 1 mL IM dose in the deltoid muscle or the
anterolateral thigh on the day of exposure or first day
of postexposure prophylaxis (day 0) and is repeated on
days 3, 7, and 14 after the initial dose in
immunocompetent individuals.
 For immunosuppressed individuals, an additional 1.0mL dose of vaccine should be provided on day 28 of
postexposure prophylaxis.
 Documentation of seroconversion 1 to 2 weeks after the
completion of prophylaxis is reserved for
immunosuppressed persons.
 Animal Bite Report Form
Question 20
You are asked to attend the delivery of a
term infant because the baby is SGA and
prenatal US revealed periventricular
cerebral calcifications. The infant’s bwt: 2
kg. On PE, you note HSM and a petechial
rash on face and trunk.
Of the following the BEST laboratory test for dx the
cause of these findings is:
Nasopharyngeal cx for HSV
2. RPR for syphilis
3. Serum IgG for rubella
4. Serum IgM for toxoplasmosis
5. Urine cx for cytomegalovirus
1.
0%
1
0%
0%
2
3
0%
0%
4
5
10
Countdown
E
 All viral specimens: transported on ice
 Easy to identify: adeno, HSV, VZV, CMV, entero,
rhino, influenza, parainfluenza, RSV
 Newborns: asymptomatic: HSV, syphillis
 Cerebral calcifications:
 NONE: Rubella-Cataracts + glaucoma tx: none
 PERIVENTRICULAR: CMV-chorioretinitis tx? gancyclovir
 DIFFUSE: toxoplasmatx with pyrimethamine, sufadiazine,
leucovorin
 All have HSM and petechial rash
 No hearing loss in toxo
 Dx: CMV with urine cx
Question 21
You are called to help manage a 2y/o girl who has relapse ALL
and has developed enteroccal bacteremia. Initial susceptibility
testing reveals that the pathogen is resistant to vancomycin.
Upon further investigation, you discover that the infecting
organism is Enterococcus gallinarum.
Of the following, the MOST effective antimicrobial agent for
this infection is:
Ampicillin
2. Ciprofloxacin
3. Linezolid
4. Ticarcillin
5. Vancomycin
1.
0%
1
0%
0%
2
3
0%
0%
4
5
10
Countdown
A
 Ampicillin is the most active B-lactam
antimicrobial agent against most
enterococcal isolates
 Enteroccus SHOULD BE considered resistant
to cephalosporins, aminoglycosides,
ciprofloxacin and TMT/SMX
 E. gallinarum and Ecasseliflavus: vancomycin
resistant
 Linezolid: can be used for vanco-resistant
bacteria but few data in children
Question 22
Among the following, the condition that is MOST likely
to predispone a pediatric patient to the development of
systemic candidiasis is?
History of atopy
2. Hx of prematurity
3. Immunosupression
4. Presence of indwelling urinary
catheter
5. Recent tonsillectomy
1.
0%
1
0%
0%
2
3
0%
0%
4
5
10
Countdown
C
 Of the opportunistic infections in children,
candida is the most common
 Candidiasis: blood + disseminated infection
 Candidemia: blood + localized to central venous
catheter
 Risk factors:





Immunosupression: cellular (CHEMO PTS)
Broad spectrum abx
Extensive burns
Long term TPN
Prematurity + comorbilities + poor nutritional status+
abx
 Alone NO RISK
 No RISK:
 Atopy
 Indwelling urinary catheter: bacterial
 Sx: exc if extensive and pt immunodepressed
Question 23
A woman suffers a brief flu-like illness during he 34th wk of
pregnancy and goes to labor. She delivers a 2.2kg baby who
rapidly develops hypotension, respiratory distress and apnea.
Finding include: fine, white nodules on the fetal surface of the
placenta and thrombocytopenia.
The most likely etiology of these findings is?
C. botulinum
2. E. coli
3. GBS
4. Listeria
5. S. aureus
1.
0%
1
0%
0%
2
3
0%
4
10
0%
5
Countdown
D
 Listeria: Gram + nonspore-forming rod
 Early: 1 wk: sepsis: shock, hypothermia, rsp distress,
lethargy, apnea, metab acidosis, leukocytosis or
neutropenia, thrombocytopenia)
 Late: 2wks: meningitis
 “flu-like illness” on mother 1-2 wks prior to delivery+
nodules in placenta (microabscess)
 Hx of miscarriages or stillbirths in mother
 In severe cases baby develops microabscess in internal
organs as well as on skin
 Tx: ampicillin + gentamycin for 14 days
 NO CEPHALOSPORINS: resistant
GBS

Gram + diplococci

NO active disease in mom, prolonged asymptomatic carriage

Risk factors:








PT <37wk
prolonged ROM > 18hrs
infants born to women with high genital GBS inoculum
intrapartum fever
Chorioamnionitis
GBS bacteriuria during the current pregnancy
previous infant with invasive GBS disease.
A low or an undectable maternal concentration of type-specific serum antibody to
capsular polysaccharide of the infecting strain. =

~ to listeria with acute and late onset (but this also includes: osteomyelitis,
septic arthritis, cellullitis)

SCREENING: 35-37wk (vaginal and rectal)

Chemoprophylaxis: with Penicillin G 5 million U initially, then 2.5 to 3.0
million U, every 4 hours, until delivery
 Remember:
 If GBS status is unknown at onset of labor or ROM,
give intrapartum prophylaxis to ALL women with
gestation less than 37 weeks, duration of
membrane rupture 18 hours or longer, or
intrapartum temperature of 38.0°C (100.4°F) or
greater
 + GBS bacteriuria is enough for tx
 No prophylaxis in C/S
Management of Neonates for Prevention of Early-Onset Group B
Streptococcal (GBS) Disease. RED BOOK guidelines
a full workup: CBC, blood cx. CXR,
LP –if septic
dLimited evaluation includes: blood cx. CBC
f If sepsis
g If ≥37
develop, do full workup + abx
weeks' gestation, observation may occur at home after 24 hours if other
Question 24
A 2y/o F who has congenital hydrocephalus and a VPS has a T .102,
irritability, vomiting for 3 days. She now has nucchalrigidity.
Examination of CSF taken from the shunt reveals WBC 50, N: 65%
and L 35% and a few Gram + cocci in clusters.
The best abx to given this pt is?
Cefotaxime
2. Cefuroxime
3. Nafcillin
4. Penicillin
5. vancomycin
1.
0%
1
0%
0%
2
3
0%
0%
4
5
10
Countdown
E
 Pt has a shunt-related ventriculitis
 Staphylococcus epidermidis (coagulase neg) or S.
aureus (coagulase positive)
 VANCOMYCIN: bacteridal exc for enterococci
Question 25
Physical exam of a 6wk old afebrile infant reveals a RR 74, and few
crackles on inspiration. The 17y/o mother reports that the infant
has had a loud cough but otherwise has been well except for some
yellow eye drainage last week. The mother recently was treated
for an “infection” in the genital area.
Among the following, the MOST likely cause of the infant’s
findings is?
B0rdetella pertussis
2. Chlamydia trachomatis
3. Influenza type A virus
4. RSV
5. Streptococcus pneumoniae
1.
0%
1
0%
0%
2
3
0%
4
10
0%
5
Countdown
B
 Infants < 3months old with cough WITHOUT fever
and a purulent eye discharge should be suspected of
chlamydia trachomatis infection until proven
otherwise






Tachypnea, resp distress, crackles, NO wheezing
“Staccato cough”
50% purulent conjuntivitis
50% otitis
LAB: eosinophilia, increased serum Igs
TX: Infants with chlamydial conjunctivitis or pneumonia
 oral erythromycin base or ethylsuccinate for 14 days or
 azithromycin for 3 days
 Who to screen for chlamydia?- high risk
 Women with mucopurulent cervicitis
 Sexually active women <20y/o
 > than 1 sexual partner in 3 months
 Women who used barrier contraception
inconsistently while in a nonmonogamous
relationship
 Men with dysuria + urethral d/c 7-14 days after
contact
Question 26
A 15 mo F who recently returned from visiting her grandmother
in the Caribbean is found to have ascarisis.
Of the following the best treatment is?
Iodoquinol
2. Metronidazol
3. Praziquantel
4. Pyrantel pamoate
5. thiabendazole
1.
0%
1
0%
0%
2
3
0%
0%
4
5
10
Countdown
D
 1 dose of pyrantel pamoate
 Also willl work: mebendazole x 3d OR albendazole
1 dose but NOT studied in kids < 2y/o
 Iodoquinol: entamoeba histolytica
 Metronidazole: Giardia lambdia, E.
hystolytica, trichomocnas vaginalis
 Praziquantel: schistosoma, tapeworm
 Thiabendazole: strongyloides, cutaneous
larva migrans
Question 27
A 9 mo boy was exposed 5 days ago to a child who has confirmed
rubeola.
Among the following, the intervention that is MOST likely to
prevent measles in the exposed child is administration of?
Acyclovir
2. IM immunoglobulin
3. IV immnunoglobulin
4. MMR vaccine
5. MMR vaccine + IM
immunoglobulin
1.
0%
1
0%
0%
2
3
0%
0%
4
5
10
Countdown
B
 The risks for complications as
a result from measles is high
among infants <1y/o
 Immunoglobulin given within
6 days of exposure can
prevent or modify the
disease.
 Prefer IM (0.25ml/kg)
 IV: has same concentration,
but higher cost
 In an outbreak situation or if
the exposure to measles
occurred within the previous
72hrs, administer MMR
vaccine to infants as young as
6mo old.
Question 29
During an emergent evaluation of a 7y/o girl with slurred speech, ataxia and
gralized hypotonia, you note brief rapid, jerking movements of the limbs and
face. She is alert and oriented. Examination of the cranial nerves is normal. Deep
tendon reflexes are 2+ and symmetrical in the upper and lower extremities.
Which of the following cutaneousfindings is most likely to be identified in pts
with similar signs and symptoms?
1.
2.
3.
4.
5.
A blotchy, gralized erythematous, blanching macular
rash
Erythematous, nontender, circumscribed patches over
the cheeks, sparing the perioral region
Several patches of grouped thick-walled vesicles on an
erythematous base, some of which have become
ulcerated in appearance
Generalized desquamation of the skin characterized by
large, thin flakes, especially prominent in the groin and
axilla
A gralized purpuric and petechial rash
0%
1
0%
0%
2
3
10
0%
0%
4
5
Countdown
D
 Girl with sudden onset of chorea + hypotonia +
speech difficulty= sydenham chorea
 Uncontrollable, with complete inability to ambulate
 Sudden decrease in school performance (dramatic




change in handwritting)
facial grimmacing
thrusting tongue movements
Uncharacteristic irritability, emotional lability
Can present inmmediately after strep infections or
months later
 Skin characteristics (desquamation in groin and
axilla) follows 5-7 days after sandpaper rash
Measles
Erythema
infectiosum-5th
disease
Meningococcimia
Herpetic whitlow
Scarlet fever
Question 30
A 15y/o F with turner syndrome and a hx of bicuspid valves presents with
fever, extreme fatigue, anorexia and malaise. Her Temp 101.5. On PE, a
previously noted systolic ejection click is associated with a new harsh
ejection murmur. Additional clinical findings include mucous membrane
and extremity petechiae and blanching painless erythematouslesions on
the palms and soles.
Which of the following is the most likely cause of this pt’s clinical signs and
symptoms?
1.
2.
3.
4.
5.
S. pneumoniae
Viridans streptococci
E. coli O157:H7
Neisseria meningitides
H. influenzae type b
0%
1
0%
0%
2
3
0%
0%
4
5
10
Countdown
B
 Subacute bacterial endocarditis
 S. aureus >> s. viridans>> coagulase neg staph>>
GBS and GAS
 If suspicion: f/u blood cx for 7 days (fastidious
bacteria or fungi)
 At least 3 blood cx
 > of SBE in children >2y/o have a preexisting
structural cardiac abnormality (bicuspid aortic
valves, septal defects, coarctation of aorta, TOF, a
prosthetic valve) and present with new or
worsening murmur.
Skin manifestations
Osler nodes: painful nodules on the
pulp of finger or toes
Roth spots: edematous hemorragic lesions
within retina
Janeway lesions: red macular blanching palms
and soles-painless
Splinter hemorrhages:
non blanching, linear red-brown
beneath nail beds
Question 31
A 6y/o girl presents with the sudden onset of brief, purposeless movements of
her arms and legs associated with generalized hypotoniaand irritability. Results
of laboratory evaluation include includea markedly elevated ASO
(antistreptolysin) level.
Which of the following is most likely to be identified in this patient?
1.
2.
3.
4.
5.
Repetitive hand wringing and sighing respirations
Involuntary apposition of the thumb and visible contraction of
the muscles of the thenar eminence upon percussion of the
thenar eminence with a reflex hammer
Intermittent episodes of painful blanching, followed by
cyanosis and then hyper-erythema of the fingers and toes
Delayed relaxation of the fingers when asked to grip the
examiner’s fingers and release rapidly
Repetitive relaxation and tightening of the hand when asked
to shake hands with the examiner
0%
1
0%
2
10
0%
3
0%
0%
4
5
Countdown
E
 Recent GAS
Sydenham chorea:
 “milkmaid’s grip”
 Relaxation and tightening
handshake
 “spooning”
 “darting tongue’
 Inability to protrude the
tongue for more than a
few seconds
 “pronator sign”
 Outward movement of the
arms and palms when held
above the head
 Hand wringing and sighing respirations:
 Rett
 Involuntary apposition of thumb+contraction
thenar eminence muscles upon percussion
with hummer +delayed relaxation:
 myotonic dystrophy
 Intermittent episodes of
blanchingcyanosishyperemia:
 Raynaud phenomena
Question 32
A 4y/o boy presents with a 1 wk hx of painful bowel movements that
have caused him to attempt to withhold his stool and refrain from
using the bathroom. He complains of persistent perirectal pain and
mild associated pruritus. On PE, a flat, well demarcated, tender,
intensely erythematousand moist perianaleruption, associated
with a perianalfissure is noted.
Which of the following is the most appropriate next step in the
treatment of this patient?
1.
2.
3.
4.
5.
Oral penicillin
Oral polyethylene glycol
Topical nystatin powder
Topical acyclovir cream
Topical corticosteroid cream
0%
0%
1
2
0%
0%
0%
0%
3
4
5
6
10
Countdown
A
 Perianal streptoccal dermatitis
 Associated constipation
 Voluntary whitholding
 Peaks at 4-5y/o
 > in boys
 Associated with symptomatic or asymptomatic
GAS colonization in the throat
 Unexpected flare of psoriasis
 Tx: oral penicillin