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Herpes simplex virus
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- Transmission occurs via contact with mucosal secretions from anogenital or oral mucosa or from contact with ulcerative lesions
- HSV-1 is more likely to cause oral infections where as HSV-2 is more likely to cause genitourinary infections however both serotypes can cause infections in either area
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Herpes simplex virus: presentation
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- Prodromal features last 5-7 days and mimic flu
- Primary infection presents with crops of painful blisters in a symmetrical distribution over the anogenital mucosa. Tender lymphadenopathy and local oedema
- Dysuria
- Vaginal or urethral discharge
- In secondary infection, presentation is unilateral and usually less severe with each successive infection
- Primary infections can last several weeks whereas recurrent infections don’t tend to last more than a few days
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Herpes simplex virus investigations
A
- Can be done clinically
- Viral culture and PCR amplification can be used to identify most cases of infection
- Serological tests can take up to 12 weeks to become positive so a negative test before 3 months does not rule out infection
- Urine dipstick/ MSU
- Pelvic USS
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Q
Herpes simplex virus complications
A
- Chronic pelvic pain, Damage to fallopian tubes, risk of infertility, ectopic pregnancy.
- Herpes keratitis: inflammation of the cornea in the eye
- Herpetic whitlow: painful skin lesion on finger or thumb
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Q
Herpes simplex virus management
A
- Management is usually supportive however antiretroviral therapy can be given
- Aciclovir 400 mg three times daily; OR
- Valaciclovir, 500 mg twice daily for five days.
- Antiretroviral therapy does not alter the course of the infection or stop recurrence but reduces the severity and duration of the flares
6
Q
Pregnancy and genital herpes
A
- Risk of neonatal herpes simplex infection contracted during labour and delivery: has a high morbidity and mortality
- Primary genital herpes (<28 weeks gestation): aciclovir is given during the initial infection and prophylactic aciclovir is given from 36 weeks onwards. If women is asymptomatic at delivery and is 6 weeks from initial infection can have vaginal delivery otherwise C-section
- Primary genital herpes (>28 weeks gestation): given aciclovir in initial infection then regular prophylactic aciclovir. Always have C-section
- Recurrent genital herpes: infection prior to pregnancy has low risk of transmission even if lesions are present. Regular prophylactic aciclovir is given from 36 weeks
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Q
HPV
A
- Spread through sexual contact
- Asymptomatic but can cause genital warts
- Vaccine given to 12-13 girls and boys
- Can cause: cervical cancer (Herpes 16,18 and 33), anal cancer, penile cancer, vulval cancer, vaginal cancer, some types of head and neck cancer
- Can prevent transmission with barrier contraception
- Is tested during cervical cancer screening
- No treatment
8
Q
Genital warts
A
- Small rough lumps on the skin around the genital area can bleed or itch
- Caused by Herpes 6 and 11
- First line: topical podophyllum or cryotherapy (solitary or keratinised wart)
- Often resistant to treatment and recurrence is common
9
Q
Indications for splenectomy
A
- Indications for emergency splenectomy include trauma and rupture (e.g. in EBV infection).
- An elective splenectomy is done in cases of hypersplenism, where there is increased uptake of platelets in the spleen, which leads to sequestration of cells in the spleen
- Indications for elective splenectomy include haemolytic anaemia (hereditary or immune) and idiopathic thrombocytopenic purpura.
10
Q
Whats Hyposplenism and blood film post splenectomy
A
Hyposplenism: dysfunctional spleen i.e. in coeliac
Blood film post splenectomy: Howell-Jolly bodies and Pappenheimer bodies
11
Q
Splenectomy susceptible to infections
A
- Reduce response against encapsulated organisms (Haemophilus, pneumococcus and meningococcus)
- Particularly high risk in the first 2 years
- Require low dose prophylactic antibiotics often for life. Normally phenoxymethylpenicillin also known as penicillin V (clarithromycin or erythromycin if patients are allergic to penicillin).
11
Q
Vaccines in splenectomy
A
- Pneumococcal vaccination (with regular boosters every 5 years).
- Seasonal influenza vaccination (yearly, typically every autumn).
- Haemophilus influenza type B vaccination (one-off).
- Meningitis C vaccination (one-off).
12
Q
Congenital Hypothyroidism
A
- Screened on newborn blood test
- Symptoms: prolonged neonatal jaundice, poor feeding, constipation, increased sleeping, reduced activity, slow growth and development
- Child is born with underactive thyroid. Two types:
- Dysgenesis: underdeveloped thyroid gland
- Dyshormogenesis: fully developed gland doesn’t produce enough hormones
13
Q
Acquired Hypothyroidism (paediatrics)
A
- Most common type is Hashimotos thyroiditis associated with anti-TPO antibodies
- Associated with other autoimmune condition particularly type 1 diabetes and coeliac disease
- Symptoms: fatigue, low energy, poor growth, weight gain, poor school performance, weight gain, constipation, dry skin and hair loss
14
Q
JIA
A
Juvenile idiopathic arthritis (JIA) is an umbrella term for a range of arthritis affecting children and young people where the cause is not clear. JIA is a diagnosis of exclusion for children <16 years old who have persistent joint swelling (>6 weeks). Different kinds of JIA include polyarthritis, oligoarthritis and systemic forms.
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JIA symptoms
A
- Systemic signs include: fever, malaise, salmon pink rash
- Joint involvement can be in one or multiple joints: joint pain, swelling, morning stiffness, limited range of motion
- Clinical diagnosis once other diagnoses have been excluded i.e. infection, malignancy, lupus
- Can be extremely debilitating and cause joint damage and disability if untreated
- Diagnosed clinically but can order bloods and US (synovial hypertrophy, effusion or bone erosion)
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JIA management
- Patients may need psychological support to help coming to terms with using walking aids so early on in life
- Options for medical management include:
- NSAIDs (symptom control only)
- Steroids (intra-articular or oral)
- Steroid-sparing agents e.g., methotrexate or biologics such as TNF-a inhibitors
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JIA complications
- Flexion contractures (requiring physio and splints)
- Joint destruction (requiring prostheses at young ages)
- Growth failure (from steroids and chronic disease)
- Anterior uveitis (causing visual impairment)
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Oligoarticular JIA
- Refers to cases where 4 or less joints are affected, accounts for 60% of JIA
- Tends to be large joints like knee, ankle or wrist
- Features: joint pain and swelling, usually medium sized joints I.e. knees, ankles, elbows. May develop limp. Can cause uveitis
- ANA may be positive- associated with anterior uveitis
24
Polyarticular JIA
- >5 joints
- Either RF positive or RF negative
- Symmetrical joint involvement particularly in the small joints of the hands and feet
25
Systemic onset JIA
- Known as still’s disease
- Features: pyrexia, salmon-pink rash, arthritis,
- Other features: lymphadenopathy, uveitis, anorexia and weight loss
- ANA me be positive especially in oligoarticular JIA
- Rheumatoid factor is usually negative
25
Kocker criteria for the diagnosis of septic arthritis
- Fever >38.5 degrees
- Non-weight bearing
- Raised ESR
- Raised WCC
25
Septic arthritis
- Double the amount of boys
- Most commonly affected joints are hip, knee and ankle
- Symptoms: joint pain, limp, fever, systemically unwell: lethargy
- Signs: swollen, red joint. Only minimal movement
- Joint aspiration: for culture, shows raised WBC, raised inflammatory markers, blood culture
26
Impetigo cause and features
Mainly caused by Staphylococcus aureus then streptococcus pyogenes
Features
- Presents as a pruritic rash with discrete patches that have a golden crusting
- Patients may be febrile
- Commonly occurs in infants and school age children
27
Impetigo management
- Localised non-bullous: Hydrogen peroxide 1% cream. Oral flucloxacillin may also help. If allergic to penicillin oral clarithromycin is used
- Widespread non-bullous: topical fusidic acid or oral antibiotics (flucloxacillin) for 5 days
- Bullous or systemically unwell: oral antibiotics for up to 7 days (flucloxacillin or Clarithromycin if penicillin allergic)
- It is highly infectious. Patients should not share towels and should not attend school or work until they have completed 48 hours of antibiotic treatment.
28
Bullous impetigo
forms large blisters, skin on the top of the blisters is very thin and peels off leaving large red raw areas underneath
29
Crohn's (crows NEST)
- N – No blood or mucus (these are less common in Crohns.)
- E – Entire GI tract
- S – “Skip lesions” on endoscopy
- T – Terminal ileum most affected and Transmural (full thickness) inflammation
- S – Smoking is a risk factor (don’t set the nest on fire)
- Also associated with weight loss, strictures and fistulas
30
Ulcerative Colitis (remember U - C - CLOSEUP)
- C – Continuous inflammation
- L – Limited to colon and rectum
- O – Only superficial mucosa affected
- S – Smoking is protective
- E – Excrete blood and mucus
- U – Use aminosalicylates
- P – Primary sclerosing cholangitis
31
Presentation of IBD
- GI: perfuse diarrhoea, abdominal pain, bleeding, weight loss, fever, tenesmus or anaemia
- Extra-intestinal: finger clubbing, erythema nodosum, episcleritis and iritis, inflammatory arthritis, primary sclerosing cholangitis (UC)
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Investigations for IBD
- Stool culture: exclude infection
- Faecal calprotectin: blood test
- Endoscopy (OGD and colonoscopy) with biopsy: gold standard
- Barium enema
- US, CT and MRI: to look for fistulas, abscesses and strictures
- AXR: will show lead pipe colon in UC
32
What colonoscopy with biopsy will show in Crohns
- Intermittent inflammation ('skip lesions')
- Cobblestone mucosa (due to ulceration and mural oedema)
- Rose-thorn ulcers (due to transmural inflammation), ± fistulae or abscesses.
- Non-caseating granulomas
- Upper GI imaging may show ‘string sign of kantour’ in the terminal ileum
33
What colonoscopy with biopsy will show in UC
- Loss of goblet cells
- Crypt abscess
- Inflammatory cells (predominantly lymphocytes)
- Continuous inflammation starting from the rectum not going beyone the submucosa
- Loss of haustral markings
- Pseudopolyps
- Barium enema: lead pipe inflammation and thumb-printing
34
Management of Crohns
- Stop smoking
- Inducing remission: first line are steroids (oral prednisolone or IV hydrocortisone). Second line are immunosuppressant medication i.e. Azathioprine, Mercaptopurine, Methotrexate
- Maintaining remission: may not need any medication. First line is Azathioprine, Mercaptopurine. Assess TPMT activity before starting, if underactivity can cause bone marrow suppression. Alternatives are methotrexate, Infliximab, Adalimub
35
Surgery in Crohns
- Rarely curative as can occur anywhere along the GI tract
- Can be used in severe stricturing or fistulating disease
- Can only have surgery on the distal ileum
36
Management of UC
- Use Truelove and Witt’s criteria for severity
- Inducing remission (mild to moderate): Aminosalicylate i.e. mesalazine topical then oral. Second line i.e. prednisolone
- Inducing remission (severe disease): first line is IV corticosteroids i.e. hydrocortisone. Second line is IV ciclosporin
- Maintaining remission: Aminosalicylate i.e. mesalazine oral or rectal, Azathioprine
37
Surgery UC
- Surgery: Panproctocolectomy which is removing the colon and rectum. They then have an ileostomy or an ileo-anal anastomosis (J-pouch).
- J pouch: where the ileum is folded back on itself and fashioned into a larger pouch that functions like a rectum. This “J-pouch” is then attached to the anus and collects stools prior to the person passing a motion
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Complications of IBD
- Fistulas: treat with fistulotomy if low or drainage if high
- Perianal abscess: given IV antibiotics and excision and drainage
- Strictures, malabsorption, perforation, nutritional deficiencies, increased risk of colon cancer, osteoporosis, intestinal obstruction
- Toxic megacolon: UC
- Primary sclerosing cholangitis: UC
38
Irritable hip (transient synovitis): pathophysiology
- temporary irritation and inflammation in the synovial membrane of the joint.
- Affects hip or knee
- Most common cause of hip pain in children aged 3-10 years
- Often have viral URTI 1-2 weeks prior
- Benign
- Children with joint pain and a fever need urgent management for septic arthritis.
38
Intussusception complications and causes
Complications: Bowel perforation, Peritonitis, Gut necrosis
Causes
- Idiopathic
- Preceding viral infection
- Lymphoid hyperplasia
- Enlarged Peyer’s patch acting as a lead point, allowing the ileum to go through the ileocaecal valve
- Pathological lead point- where an area of the bowel is caught and pulled by peristalsis
- Secondary to= Meckel’s diverticula, Intestinal polyps, Lymphoma and leukaemia, Henoch- Schonlein purpura (HSP), cystic fibrosis, polyps
38
UC characteristics
- Location: limited to the colon and rectum
- Inflammation pattern: continuous involves the entire colon
- Depth: limited to the inner lining
- Symptoms: bloody diarrhoea, abdo cramps
- Complications: toxic megacolon, colon cancer
- Endoscopy: continuous colonic inflammation, ulcers
- Treatment: medication and surgery
38
Inhaled foreign body
Common presentation in toddlers (often <3 years old), more likely if food bolus in older children
Management
- If presenting with choking symptoms assess level of obstruction: If ineffective cough, signs of choking, cyanosis, reduced consciousness then immediately begin choking algorithm
- If in respiratory distress then leave comfortable and contact ENT and anaesthetic teams
- If no respiratory distress then organise X Ray to find location of foreign body. If cant find on X-ray use endoscope
- Normally treated conservatively with observation. If high risk or large can be removed in theatre, sometimes endoscopy/bronchoscopy).
- NB: button battery inhalation/ingestion is an emergency and MUST be removed within 6 hours due to risk of erosion
38
Transient synovitis features
- limp/refusal to weight bear
- groin or hip pain
- a low-grade fever is present in a minority of patients
- Usually self limiting, requiring only rest and analgesia
- US: may show effusion. Clinical diagnosis
38
Crohns characteristics
- Location: any part of GI tract from mouth to anus
- Inflammation pattern: patchy skip lesions
- Depth: full thickness
- Symptoms: abdo pain, non bloody diarrhoea, weight loss
- Complications: fistulas, strictures, abscess
- Endoscopy; cobblestone appearance, deep ulcer
- Treatment approach: individual may involve medication and steroids
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Intussusception features
- intermittent, severe, crampy, progressive abdominal pain
- inconsolable crying
- during paroxysm of colicky pain the infant will characteristically draw their knees up and turn pale
- vomiting becomes billous
- bloodstained stool - 'red-currant jelly' - is a late sign
- sausage-shaped mass in the right upper quadrant
- Refuse feeds, abdominal distension
38
Intussusception investigations and examinations
Investigation: ultrasound, may show a target like mass (concentric echogenic and hypoechogenic bands). Can show complications like free abdominal air and presence of gangrene.
Examination: sausage shaped mass, absence of bowel in RLQ (‘Dance’s sign’ – only sometimes)
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Intussusception management
- Treatment with reduction by air insufflation under radiological control (air enema or water enema): First line
- Analgesia and make the patient nil by mouth
- if this fails, or the child has signs of peritonitis or is haemodynamically unstable, surgery is performed
- Fluid rescusitation
- Laparotomy if peritonism/ perforation/ failed eneema
38
Intestinal obstruction causes
Intestinal obstruction is where a physical obstruction prevents the flow of faeces through the intestines.
Causes= Meconium ileus, Hirschsprungs disease, Oesophageal atresia, Duodenal atresia, Intussusception, Imperforate anus, Malrotation of the intestines with a volvulus, strangulated hernia
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Intestinal obstruction presentations
- Persistent vomiting. This may be bilious, containing bright green bile.
- Abdominal pain and distention
- Failure to pass stools or wind
- Abnormal bowel sounds. These can be high pitched and “tinkling” early in the obstruction and absent later.
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Intestinal obstruction diagnosis
Abdominal xray. This may show dilated loops of bowel proximal to the obstruction and collapsed loops of bowel distal to the obstruction. There will also be absence of air in the rectum.
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Intestinal obstruction management
need to be referred to a paediatric surgical unit as an emergency. Initial management involves making them nil by mouth and inserting a nasogastric tube to help drain the stomach and stop the vomiting. IV fluids to correct any dehydration and electrolyte imbalances, and keep them hydrated while waiting for definitive management of the underlying cause.
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Intussusception
Intussusception describes the invagination of one portion of the bowel into the lumen of the adjacent bowel, most commonly the ileum passing into the caecum through the ileocaecal valve. Intussusception usually affects infants between 6-18 months old. Boys are affected twice as often as girls
Year 5
flashcards
Decks in class (24)
# Cards
-
Paediatrics 150
-
Paediatrics 250
-
Paediatrics 350
-
Paediatrics 450
-
Paediatrics 551
-
Paediatrics 659
-
Paediatrics 751
-
Paediatrics 850
-
Paediatrics 950
-
Paediatrics 1038
-
Repro 150
-
Repro 249
-
Repro 349
-
Repro 452
-
Repro 552
-
Repro 649
-
Repro 750
-
repro 850
-
Repro 952
-
Psych 150
-
Psych 250
-
Psych 350
-
Psych 450
-
Psych 545
