RTIs Paed

Common cold

defintion organisms and transmission natural history cinical manisfestatiions management complications preventing

is a viral illness in which the symptoms of rhinorrhoea and nasal obstruction are prominent and systemic symptoms and signs such as myalgia and fever are absent or mild

Rhinoviruses are the most common pathogens. Others are adenovirus, parainfluenza virus and respiratory syncitial virus. Spread is by physical contact and air borne droplets. Common cold is self limiting, and usually lasts for 7-8 days, but may persist up to two weeks in 10% of patients

Clinical Manifestations

There are four distinct clinical stages

1. Prodromal stage: Lasts for a few hours. Experiences feeling of tickling sensation of the throat.

2. Stage of irritation: Mucous membrane will become red. A watery discharge is present (rhinorrhoea) and it will last for 1-4 days with nasal obstruction and sneezing. Cough is associated in only 30% of cases.

3. Stage of secondary infection: after two to three days the mucosa becomes oedematous and bluish with more nasal obstruction and thick mucopurulent secretions.

4. Stage of resolution: Complete recovery occurs.

Management

Management of common cold is primarily symptomatic.

1. Nasal obstruction

Topical vasoconstrictor agents like oxymetazoline and xylometzoline are not recommended below two years of age.

• Even if indicated in those over 2 years of age, prolonged use should be avoided (preferably, less than seven days to avoid rebound phenomena).

2. Rhinorrhoea

The first generation antihistamines (sedating antihistamine) reduce rhinorrhoea by 25 - 30%. e.g.

Chlorpheniramine maleate: oral

Child 1 month- 2years 1mg every 12 hours

Child 2-6 years 1mg every 6 hours C

hild 6-12 years 2mg every 6 hours

3. Cough

Cough suppressives are generally not necessary

• Antibiotics are not indicated.

+ Use of paracetamol is not routinely recommended in an uncomplicated common cold. Vitamin C, inhalation of warm humidified air (steam inhalation), guaifenesin have no proven benefit.

Complications

Usually complete resolution without complications occurs. However, if the body resistance is low, secondary invasion by other organisms may occur.

Otitis media (5 -30%)

2. Acute sinusitis (5 -13%)

3. Pneumonia

4. Exacerbation of asthma

Bronchiolitis

DEf viruses causing epidemiliogy clinical features natural history riskfactorsforsecereillness Accessig severity criteria for admissionns DDiagosis and investigations Management DD and treatmtn differece criteria fordischarge Followup adprevention Prophylaxcis

Objectives

Definition

Epidemiology

Clinical features

Investigations

Management

Acute bronchiolitis is the commonest lower respiratory tract infection in infancy.

Respiratory syncytial virus is responsible for most cases and other agents include parainfluenza and adenoviruses.

Acute bronchiolitis is characterized by bronchiolar obstruction with oedema, mucus and cellular debris. Immunological factors also play a significant role in this and impairment of the normal pulmonary gas exchange results in hypoxaemia and hypercapnia.

Definition

Bronchiolitis is an acute viral respiratory infection involving terminal and respiratory bronchioles in children

Initiated by URTI, any of different viruses

RSV, Rhinovirus, Human metaneumovirus,adeno,Influenza A/B,Human boca virus

Seen in children <2 yrs of age ,peak incidence 3-6 months

Self limiting

Clinical features - Symptoms

Bronchiolitis is a clinical diagnosis. It starts as an upper respiratory tract infection with low grade fever and rhinorrhoea. The infant then develops wheezy cough, nasal flaring, tachypnoea and hypoxia. It interferes with the feeding of the child.

Physical examination is characterized by recessions of the suprasternal, subcostal and intercostal regions, and bilateral fine crepitations. Severe disease is characterized by cyanosis, apnoea and even a silent chest.

Apnoea may be the presenting feature especially in very young, premature or low birth weight infants

Predisposing factors for severe illness

Preterm

<12 months

Post natal smoke exposure

Breast feed < 2 months

Failure to thrive

Chronic Lung disease

Congenital heart disease

Immunodeficiency

Chronic Neurological disease

May consider early escalation of care and eary hospitalisation since these children are more prone for severe disease , and will rapidly deteriorate!

Natural History

How to assess severity?

Indications for hospital referral for acute bronchiolitis

DIagnostic studies / Investigations

For children with mild bronchiolitis, no investigations are indicated, since they will not influence the management

For moderate to severe infection, investigations such as pulse oximetry, full blood count and chest radiograph may be considered [C/D]. The white blood cell and differential counts are usually normal. The chest radiograph may show hyperinflated lung fields and patchy shadows with pushed down diaphragm and rather horizontal ribs and normal sized heart

Management

1.Humidified oxygen via head box or nasal prongs to maiantain sats > 92%

2.Heated humidified high flow nasal cannulae HHHFNC

3.Fluid and nutrition

4.Nasal suction

5.Chest physiotherapy

6.Anti viral therapy – in highly selected cases only

Supportive therapy and oxygen supplementation remains the mainstay of treatment [D]. Humidified oxygen is administered via face mask (4L/min) or nasal prongs (2L/ min) if saturation is less than 92% to overcome the hypoxia [D]. Although bronchodilators are claimed not to improve oxygen saturation or duration of hospital stay [A], a trial of nebulization with a bronchodilator can be given [D]. If there is no positive response, it should be discontinued. Multiple studies have failed to demonstrate efficacy of corticosteroids in bronchiolitis [B].But if there is an apparent improvement after nebulization the infant may have wheezing due to early asthma and may show some response to steroids [D]. The use of nebulized adrenaline has shown some benefits in outpatient settings but it lacks convincing evidence to be used in inpatient settings [B]. Like bronchodilators, a trial of two doses of adrenaline 3ml 1:1000 nebulized 30 minutes apart in moderate to severe bronchiolitis may be appropriate to assess the response [D]. There is no benefit in using antibiotics in hospitalized infants with bronchiolitis [B]. It may be used when secondary bacterial infection such as Staphylococcus or Streptococcus is suspected [D]. This is rare. Use of ribavarin, a guanosine analogue with a broad spectrum antiviral activity has not been supported by evidence to be beneficial [A].

Differential diagnosis

Criteria for discharge

Clinically stable and improving

When the infant is feeding well and oxygen saturation is maintained over 92% without administered oxygen, the baby could be considered for discharge. A review visit may be arranged in one week

Feeding adequately

Family have ability to return or seek assistance

Family confident to manage at home

Sats in air > 94%

Not in severe distress

Follow up and prevention

Mostly for complicated patients

Children with haemodynamically significant heart lesions or chronic lung disease will benefit from palivizumab in the first year of life

Hand Hygiene

Encourage breast feeding

Avoid exposure to tobacco smoke

RSV Prophylaxis

There is no effective vaccine for RSV.

Question

A 3 month old Baby born to non consanguneous parents presented to the emergancy department with a history of 2 days runny nose ,and mild cough .He was warm to touch , but was able to complete the breast feed . Mother complaints regarding a ‘blocked nose ‘during feeds . On examination the RR 45/min , HR 120/min , Sats 97%

1 As the admitting offer what steps would you take ?

2 2 days later you see the same baby at the paediatric ward admitted due to breathing difficultyand is unable to feed , describe your management options ?

3.The house officer informs you that he had attended to the delivery of the baby as he was born early, what differnece would it make to your answer in Q1?

CROUP (acute laryngotracheobronchitis)Croup Def and intro Epid Clinical features. 7 Diagnosis and investigations Mx 7 Scheme of management 7

Croup is a viral infection of the upper respiratory tract infection commonly seen in preschool children aged 6 months to three years with a peak incidence at 1 - 2 years. The condition is usually mild and self limiting, although it may occasionally cause severe respiratory obstruction. Secondary bacterial infections are common after five days of illness.

Clinical features

It starts with rhinorrhoea, mild cough and low grade fever which may last up to three days. Then the child develops characteristic features of barking cough, hoarseness and inspiratory stridor. Crying or agitation aggravates the symptoms.

The child may prefer the upright position. Physical examination reveals hoarse voice, tachypnoea and moderately inflamed pharynx.

Decreased oxygen saturation is a late sign in severity of croup. Since it is an upper respiratory tract infection, gas exchange in the alveoli is usually unaffected.

Investigations

It is mainly a clinical diagnosis. Lateral x- ray of the neck for soft tissues may occasionally be warranted in patients with stridor where the diagnosis is uncertain.

Management

Management of the airway is important. Children with croup should be kept calm and distressing procedures (e.g. intravenous cannulation) should be kept to a minimum. They should be allowed to adopt the position they like most

Oxygen must be given via a face mask in moderate to severe croup [D].

In severe croup nebulize with adrenaline 5ml of 1: 1000 (0.5ml/kg to a maximum dose of 5ml) [A/B] which can be repeated twice with a 30 min gap in between.

Still if there is no improvement, the situation should be reviewed urgently.

Be cautious when nebulizing with adrenaline in a child who has congenital heart disease since it can precipitate tachyarrythmias.

Dexamethasone and budesonide are effective in relieving the symptoms of croup as early as 30 minutes after treatment The use of systemic corticosteroids has been associated with reduction in disease severity, number of readmissions, the length of hospital stay and the number of co-interventions

Dexamethasone is given orally 0.6mg /kg as a single dose orally or nebulized with budesonide 2 mg

Antibiotics are not indicated unless there is a high degree of suspicion of secondary bacterial infection

Scheme of management

Bacterial TracheitisTracheatis Pathophisology Epidemiology Prognosis. Organisms Clinical manifestations Diagnosis and investigations Management Antibiotics

Definition

Bacterial tracheitis is an uncommon infectious cause of acute upper airway obstruction. It is characterized by a diffuse inflammatory process of the larynx, trachea, and bronchi with adherent or semi adherent mucopurulent membranes within the trachea. Signs and symptoms usually are intermediate, between epiglottitis and croup.

The morbidity and mortality is related to the potential for acute upper airway obstruction. Morbidity is related predominantly due to induced hypoxic insults. Mortality can rise up to 20% in the acute phase. The patients do generally well if the airway is managed adequately and antibiotic therapy initiated very early

Aetiology

Staphylococcus aureus ( most common )

Haemophilus influenzae type B (HiB)

Moraxella catarrhalis •

Streptococcal species, especially Streptococcus pyogenes

Klebsiella species

Pseudomonas species

Anaerobes (Peptostreptococcus, Bacteroides, Prevotella)

Clinical manifestations

Occur in children from 3 weeks to 16 years, with a mean age of 4 years.

Tracheitis is a potentially life-threatening infraglottic infection where most children will need eventual intubation (57-100%), and is similar in many ways to epiglottitis.

Ill child

Increasing deep or barking croup-like cough following a previous upper respiratory tract infection

• Worsening or abruptly occurring inspiratory stridor (with or without expiratory stridor)

• High fever

Variable degrees of respiratory distress increasing in severity over time o Chest wall indrawing o Dyspnoea o Nasal flaring o Cyanosis

No drooling

No specific position of comfort (The patient may lie supine.)

Differnetial diagnosis

Angioedema

Candidiasis

Croup

• Epiglottitis

• Peritonsillar abscess

• Retropharyngeal abscess

Diagnosis

Mainly a clinical diagnosis which is made based on evidence of bacterial upper airway disease and an absence of the classic findings of epiglottitis.

Obtain bacterial culture and Gram stain of tracheal secretions. (can be obtained during intubation)

Obtain blood cultures, though they often do not yield a microbiologic diagnosis.

Imaging Studies

Radiographs of the lateral neck o In ward, and only in a stable patient o Not definitive, not essential o May reveal subglottic narrowing, clouding of tracheal air column, or irregular tracheal margin o Concretions of epithelium and inflammatory cells possibly appearing as a foreign body

Management

Once bacterial tracheitis is made as the provisional diagnosis, the child may need PICU management.

Airway

Maintenance of an adequate airway is of primary importance.

Check oxygen saturation and give oxygen if saturation is less than 92%.

• Avoid agitating the child. If the patient’s respiratory status deteriorates, usually due to movement of the membrane, bag-valve-mask ventilation should be effective.

The child should be in an intensive care unit at this stage and need ENT/ Anaesthetic referral. Most patients require eventual intubation (57-100%)

Intravenous Access

Once the airway is stabilized, obtain intravenous access for antibiotics administration

Antibiotics

Cloxacillin and a third-generation cephalosporin, (x) or chloramphenicol and clindamycin for patients who are allergic to penicillin

Acute Epiglottitis Acute epiglottis Definition Epidemiology Clinical course and features Management Household prophylaxis Immunisation process,

It is an airway emergency seen mainly in the age group of 2-6 years. This grave illness is most commonly caused by H.influenzae and carries a high risk of complete obstruction of the upper airway. Incidence can be reduced by over 97% with proper immunization of infants with Haemophilus influenzae type b vaccination

Symptoms

Illness starts as a sore throat and rapidly progresses within hours to a very toxic level evidenced by high fever, irritability and dyspnoea. Dysphagia and drooling of saliva may be observed by the parents. The child prefers to sit forward with open mouth and extended neck.

Clinical features

Usually the child is ill and has a characteristic posture, muffled voice, intercostal and subcostal recessions. Cyanosis and deteriorating level of consciousness are precursors of impending respiratory arrest.

Treatment

The diagnosis is mainly clinical.

Get help immediately, if available, call the consultant anaesthetist, ENT surgeon and the consultant paediatritian.

Any disturbing procedure can be disastrous as it may precipitate a laryngeal spasm and respiratory arrest. Do not attempt to place the child supine on the bed. Keep the child on the mother’s lap. Refrain from cannulation at this point.

Give high flow humidified oxygen by a face mask.

Intubate the child under anaesthesia by the most competent person. Failing this, do a tracheostomy. Indirect laryngoscopy during the procedure may show a large, cherry red, swollen epiglottis

In the absence of a skilled hand cricothyrodostomy with a wide bore needle (blood needle 16G) may be life saving, in a sudden event of a respiratory arrest

Check the adequacy of ventilation and gain intravenous access.

White blood cell count shows increased count with a left shift. Blood cultures are positive for H. influenzae in 50% of patients.The radiological confirmation by x- ray lateral neck for soft tissues should not be done since it may precipitate a sudden obstruction of the upper airway.

Third generation cephalosporins, ceftriaxone or cefotaxime are preferred over ampicillin and chloramphenicol since 30% of H.influenzae strains are resistant to the latter drugs. Usually there is a rapid response to antibiotics and early extubation is possible after 2

If there is a child under 4 years at home who has not completed Hib vaccination, Rifampicin 20mg / kg daily for 4 days should be given for all household contacts including the index case, to eradicate carrier state.

Immunisation

Haemophilus influenzae type b vaccination (Hib) is administered at 2nd, 4th and 6th months of life and a booster at 18 months. If immunization is started between 6 months and 1 year of age the child should receive two doses, 1-2 months apart and a booster at 18 months. If immunization is started after 1 year of age only one dose is enough.

Bacterial SinusitisSinusitis Definition Classification Misdiagnosis Development of paranasal sinuses Pathogenesis Usual bacteria Predisposing factors 8 Clinical manifestation signs and symptoms 4 signs Diagnosis DD Facial pain? If persisting? Investigations 8 Prognosis Aims of treatment Mx of acute sinusitis Not working stuff 4 Mx of recurrent sinusitis Mx of chronic Complications of sinusitis Follow up Indications for referral 5 Main dd Less than 1 year

Definition

Sinusitis is infectious or non infectious inflammation of one or more sinuses. The inflammation can be caused by infectious (bacterial, viral, fungal) or non infectious (allergic) triggers.

Classification of bacterial sinusitis

Acute bacterial sinusitis

Infection lasts less than four weeks and symptoms resolve completely with treatment (duration range 10-30 days)

Subacute bacterial sinusitis

Infection lasting four to twelve weeks yet resolves completely with treatment

Recurrent acute bacterial sinusitis

Episodes last less than four weeks and are separated by intervals of at least ten days during which the patient is totally free of symptoms.

Chronic bacterial sinusitis

Symptoms last more than twelve weeks with or without treatment.

Differentiation between acute and chronic sinusitis has clinical significance

....

Rhinitis and Rhinosinusits are often misdiagnosed as sinusitis

Rhinitis

It is the inflammation of the nasal mucosa. The most common causes are viral or allergy.

Rhinosinusitis

Inflammation of the nasal mucosa and the lining of the sinuses.

...

An understanding of the development of the paranasal sinuses is important

1. Maxillary and ethmoidal sinuses are present at birth.

2. Sphenoidal sinuses develop by the age of five to six years.

3. Frontal sinus is the last to develop at eight to ten years of age

Goals of these guidelines

To increase the accuracy in the diagnosis of bacterial sinusitis.

To optimizes the management of sinusitis and decrease the duration for recovery.

To reduce antibiotic usage in ill-defined upper respiratory tract infections.

To optimize the appropriate use of laboratory investigations and timely referral.

Aetiology and pathogensesis

The majority of cases follow a viral upper respiratory tract infection which involves whole upper respiratory epithelium including the paranasal sinuses. Such infections cause hyperaemia and oedema of the mucosa, which blocks the ostia. There will be a cellular infiltration and an increase in mucous production.The infection will also paralyze the cilia, leading to stasis of secretions predisposing to secondary bacterial infection.

The usual bacteria

Predisposing factors

Clinical Manifestations

Diagnosis

Diagnosis is mainly dependant on the clinical picture.

Differentiation of bacterial sinusitis from viral upper respiratory tract infection is largely determined by duration and severity of symptoms.Persistent symptoms of upper respiratory tract infections without improvement after 10- 14 days is more suggestive of bacterial sinusitis.

Symptoms of acute sinusitis usually disappear within two to four weeks

In case of persisting symptoms, one should suspect: • Complications of acute sinusitis, • Subacute sinusitis • Chronic sinusitis

Facial pain alone is not diagnostic of bacterial sinusitis in children

Investigations

Management

The aims of treatment are

to resolve and limit the course of the acute infection

to prevent complications

to correct any precipitating factors.

Studies indicate that up to 60% of cases of acute sinusitis will resolve spontaneously without antibiotic

Acute sinusitis

Recurrent sinusitis

Management is similar to acute bacterial sinusitis. If the duration between two episodes is less than 6 weeks, consider second line antimicrobial agents and if it is 6 or more weeks first line antibiotics are indicated.

Chronic sinusitis

Complications of sinusitis

Periorbital /orbital cellulitis

Meningitis

Intracranial abscess

Intracranial venous thrombosis

Sepsis

Follow up

A follow up examination at the completion of treatment is not routinely recommended. If patient shows no improvement after 72 hours following treatment with adjunctive therapy and the first line antibiotics, consider second line agents in the treatment.

If there is deterioration at any time patient should be reassessed for: 2 • Acute complication of sinusitis • Other diagnoses • Adherence to treatment

Indications for referral to ENT specialists

Sinusitis unresponsive to medical therapy after a 3 week trial of a second line agent and a full course of nasal steroid therapy with evidence of disease on the sinus CT scan.

Recurrent sinusitis - 3 or more episodes in a 6 month period despite adequate medical treatment as outlined above and evidence of disease on the sinus CT scan.

Patient with known immune compromisation or ciliary motility problem.

• Orbital or cranial complications of sinus infections.

Recurrent nasal polyps unresponsive to medical therapy and evidence of disease on the sinus CT scan.

• Any evidence of tumour noted on examination or CT

Background notes

It may be difficult to distinguish children with uncomplicated viral upper respiratory infections or adenoiditis from those with an episode of acute bacterial sinusitis. Most viral infections of the upper respiratory tract involve the nose and the paranasal sinuses (viral rhinosinusitis).

Bacterial sinusitis does occur rarely in children less than 1 year of age, their exclusion reflects, in part, the difficulty in conducting clinical investigation in this age group. This is a consequence of the small size of the paranasal sinuses and the difficulty in safely performing sinus aspiration.

Accordingly, the gold standard for the diagnosis of acute bacterial sinusitis is the recovery of bacteria in high density (>104 colony-forming units/ml) from the cavity of a paranasal sinus.Although sinus aspiration is the gold standard for the diagnosis of acute bacterial sinusitis, it is an invasive, time-consuming, and potentially painful procedure that should only be performed by a specialist (otolaryngologist). It is not a feasible method of diagnosis for many

It is recommended that the diagnosis of acute bacterial sinusitis be based on clinical criteria in children less than 6 years of age who present with upper respiratory symptoms that are either persistent or severe.

The ethmoid and maxillary sinuses form in the third to fourth gestational month and, accordingly, are present at birth. The sphenoid sinuses are generally pneumatized by 5 years of age; the frontal sinuses appear at age 7 to 8 years but are not completely developed until late adolescence.

Bacterial infections of the paranasal sinuses do not usually involve the nose.

Although bacterial sinusitis does occur rarely in children less than 1 year of age, their exclusion reflects, in part, the difficulty in conducting clinical investigation in this age group.

ACUTE PHARYNGITISAcute pharyngitis Definition Causes Transmission Epid and incidence Immunity Clinical manifestations 3 DD. Bacterial vs viral Diagnosis and investigations Treatment Red flags bbbnbbnn klopp Anti microbials

Introduction

Upper respiratory infection is a common problem. One third of such illnesses feature sore throat (pharyngitis) as the primary illness.

Aetiology

Transmission of typical viral and Group A beta haemolytic Streptococcus (GABHS) pharyngitis occurs mostly by hand contact with nasal discharge, rather than by oral contact.

The guidelines for the management of pharyngitis will mainly focus on infectious rather than the non infectious causes.

Streptococcal pharyngitis is uncommon before 2-3 years of age.

Colonization with GABHS could be asymptomatic or can cause an acute illness.

M protein is the major virulent factor of GABHS; thus, type specific immunity will develop later

Clinical manifestations

Epstein - Barr virus (EBV) pharyngitis is associated with, tonsilar enlargement and exudates, cervical lymph nodes enlargement, hepatosplenomegaly, rash and fatigue.

Clinical DIagnosis

The clinical presentations of streptococcal and viral pharyngitis show considerable overlap.

Pharyngitis is more likely to have a bacterial aetiology in the absence of rhinorrhoea, cough and conjunctivitis

Throat culture remains the gold standard for diagnosis of streptococcal pharyngitis.

False positives are due to misidentification of other organisms

False negatives are due to either inadequate throat swab specimen or use of antibiotics prior to culture

EBV infection may show lymphocytosis in the full blood count and atypical lymphocytosis in the blood picture. Though it is costly, EBV IgM antibodies are useful in diagnosing acute infection.

Treatment

ACUTE TONSILLITIS

Acute tonsilitis definition organisms differinciating incidence precaution clinical manifestations investigations management , ideal, precaaution complications

Definition

Inflammation of tonsil(s).

Causative organisms

Clinical Manifestation

There may be a prodromal illness with pyrexia, malaise, and headache which precedes the predominant symptom of sore throat by one day

Investigations

Management

Most of the cases diagnosed as tonsillitis do not need antibiotics since only 30% are bacterial in origin [A].5 But when the child presents with a severe clinical picture antibiotics may be prescribed empirically.

The mainstay of treatment is supportive.

Complications

CHRONIC TONSILLITIS

Chornic tonsillitis Definiition clinical features Investigations Management Indications for management

Chronic inflammation of the tonsil(s) usually starts as an acute inflammation.

Clinical features

Symptoms

Repeated attacks of sore throat with imperfect remission indicates chronic inflammation

Pain around the neck

Odynophagia (painful swallowing)

Fever

Cough and irritation of the throat.

In hypertrophic tonsillitis breathing problems and snoring are present.

Halitosis (bad breath.)

Foreign body sensation in the throat

Signs

1. Tonsils of any size.

2. Debris in the tonsillar crypts.

Investigations

Usually throat swabs for cultures becomes negative for Group A Beta Haemolytic Streptococci

Management

Management is mainly surgical

Indications for tonsillectomy

Whooping cough/PertussisPertussis Intro and Epid Aetiokogy and dd Clinical features Transmission Complication Case Definition Investigation and nuances Treatment description Chemoprophylscis and types Complete immunisation Moh stuff

Pertussis is the preferred term as whoop may not be a feature. Pertussis is a prolonged severe respiratory illness in infants and unimmunized children below 5 years. The challenge in providing effective treatment and chemoprophylaxis of pertussis lies in the early recognition and reporting of cases.

Aetiology

Clinical features

Only 30- 50% children have the characteristic paroxysmal cough and the inspiratory whoop.

Young infants present with apnoea, post tussive vomiting, poor feeding or bradycardia.

Period of communicability is from before the onset of symptoms to three weeks after the onset of cough.

Complications

Common complications seen in infancy are as follows,

Secondary bacterial pneumonia (commonest cause of mortality) •Apnoea

Convulsions

Encephalopathy

Pneumothorax

Otitis media

Recommended case definition WHO

Microbiology

If pertussis is suspected per nasal swab for culture should be taken prior to antibiotics. Nasopharyngeal aspiration can be done if the facilities are for available, culture and PCR. PCR will differentiate B. pertussis from parapertussis infection.

Culture and PCR are most sensitive when cough has been present for less than 2 weeks, but after that time false negative results can occur. PCR may be able to identify the organisms up to 3-4 weeks or longer after the onset of cough.

Treatment

The aim of treatment is limiting the spread.

There is no benefit, if treatment (or chemoprophylaxis for contacts) is started after 21 days of onset of symptoms.

• After 5 days of antibiotics it is considered to be safe to allow the patient to mix with the others.

• Children should refrain from attending school or nursery until the completion of antibiotics for 5 days.

• It is recommended that infants and children who have recovered from microbiologically confirmed pertussis complete their immunization, since natural immunity doesn’t confer life long immunity.

Chemoprophylaxis

Erythromicin is given for 14 days. Same dose schedule as treatment Azithromicin and Clarithromycin can be given alternatively

Complete immunisation

Complete immunization includes 3 primary injections and a booster for those under 5. Most adults and older children may be partially immunized since vaccination provides protection for about 2-3 years.

Notification

Pertussis is notifiable on clinical suspicion

Bronchiectasis

Definition

Dilatation of bronchi associated with a persistent variable inflammation of the lung.

Aetiology

Whooping cough or measles

Inhaled foreign body or tuberculosis (may lead to localized bronchiectasis)

Cystic fibrosis

Kartagener syndrome

Immunodeficiencies

Allergic bronchopulmonory aspergillosis

Congenital -Williams Campbell Syndrome, tracheobronchomegaly

Miscellaneous –alfa 1 antitrypsin deficiency

Yellow nail syndrome

Gastro oesophageal reflux

Clinical features

Symptoms

Recurrent episodes of malaise

Volume and the purulence increase during exacerbations

During exacerbations wheezing occurs in the majority

Signs

Halitosis

Clubbing in more severe cases

Basal coarse crepitations •

Productive sputum – purulent sputum indicate severe disease activity.

Haemoptysis

Chronic cough and wheezing with clubbing in the absence of cyanotic heart disease needs exclusion of bronchiectasis

Investigations

CXR will show dilated bronchi or multiple cysts. Presence of tramline shadows indicate bronchial wall oedema. 37% sensitivity at lung level. High resolution Computed Tomography (HRCT) is the investigation of choice in the diagnosis of bronchiectasis. It should be considered in all patients with a chronic productive cough and recurrent chest infections.

Sputum examination may reveal major pathogens such as Staphylococcus aureus , Peudomonas, Haemophilus influenzae and anaerobes

Further investigations

Following investigations will be helpful in detecting an aetiology.

Bronchoscopy if foreign body is suspected

Immune screen (can be done at MRI Colombo)

Cilliary studies

Mantoux testing and Acid Fast Bascilli

Sweat test

Alfa 1 antitrypsin

Aspergillus precipitins

Treatment

Postural drainage.

Antibiotics

Haemophilus influenzae and Streptococcus pneumaniae accounts for 70 -80 % of infections. Morexella catarrhalis is also common .Chronic colonization with mucoid Pseudomonas aeruginosa is common in severe disease.

Short courses (10 -14 days) for clearly defined infective episodes. In the absence of pseudomonas amoxicillin is the antibiotic of choice. If treatment fails resistance due to beta lactamase is suspected and alternatives include Co amoxiclav or quinolones. Morrhexella catarrhalis is usually resistant to amoxicillin

Prophylactic therapy for frequent recurrent exacerbations

Continuous therapy for persistent infection

Bronchodilators are useful if there is a demonstrable airflow limitation.

Surgery such as segmental or lobar resection should be considered when localized severe disease persists despite adequate medical management

Lung abscess

Definition

Lung abscess is necrosis of the pulmonary tissue and formation of cavities containing necrotic debris or fluid caused by microbial infection

Primar Lung abcess

In a previously healthy child, caused by aspiration or secondary to pneumonia

Secondary lung abcess

Abscess is caused by a preexisting condition (eg.foreign body obstruction, tracheo-oesophageal fistula, gastro-oesophageal reflux) spread from an extrapulmonary site such as empyema , bronchiectasis, and/or an immunocmpromised state, due to post operative complication of tonsillectomy and adenoidectomy, and aspiration following seizures and neurological disease.

Aetiology

Majority have mixed aerobic and anaerobic bacterial pathogens.

Anaerobes consist of 90% of the isolated organisms; • Peptostreptococcus, bacteroides, fusobacterium species, and microaerophilic streptococcus.

Aerobes up to 50%; • Staphylococcus aureus, streptococcus pyogenes, streptococcus pneumoniae (rarely), klebsiella pneumoniae, haemophilus influenzae, actinomyces species

Nonbacterial pathogens; • These microorganisms may include parasites (eg, Paragonimus, Entamoeba), fungi (eg, Aspergillus, Cryptococcus, Histoplasma, Blastomyces, Coccidioides), and Mycobacteria

Clinical Manifestations

Onset may be acute or insidious. Following symptoms may be elicited in the history.

• Fever - low-grade in anaerobic infections and temperatures > 38.5°C in other infections.

Cough,

Shortness of breath

Chest pain,

Vomiting

Sputum production - Unless the abscess is completely walled off, the sputum is purulent and may be blood-streaked.

Weight loss, night sweats and haemoptysis.

Physical findings may be secondary to associated conditions such as underlying pneumonia or pleural effusion.

• Tachpnoea and dyspnoea

Chest wall retraction with use of accessory muscles

• Clinical findings of concomitant consolidation +/- effusion are present (eg, decreased breath sounds, dullness to percussion, bronchial breath sounds, coarse inspiratory crackles, shift of mediastinum etc.)

Digital clubbing may develop rapidly

DIagnosis

Laboratory diagnosis

A white blood cell count with differential may reveal leucocytosis and a left shift.

Obtain sputum for Gram stain, culture, and sensitivity.

If tuberculosis is suspected, acid-fast bacilli stain and mycobacterial culture should be requested.

Blood culture may be helpful in establishing the aetiology

Imaging

CXR

Early in the course, chest x-ray may show a segmental or lobar consolidation.

Parenchymal inflammation with a cavity containing an air-fluid level. • If a lung abscess fails to communicate with a bronchus, the characteristic cavity with an air fluid level will not be seen radiographically. This often leads to initial misdiagnosis since no clear abscess can be visualized

. • When the radiograph reveals multiple cavitary lesions it usually indicates that a necrotizing pneumonitis is present. This type of presentation is usually acute and fulminant and secondary to virulent aerobic bacteria such as S. aureus or K. pneumoniae.

• Changes are more common in the posterior segments of the upper lobes and the apical segments of the lower lobes

CT scan

Better anatomic definition including location and size as empyema and lung abscess are sometimes difficult to distinguish from one another by CXR

Management

Conservative management is recommended.

Antibiotic therapy

• Should be given for a total period of 4-6 weeks ( 2-3 wks of intravenous followed by oral) (x)

• Antibiotics of choice are clindamycin or ticarcillin / clavulinic acid.

• If gram negative bacteria are suspected or isolated add an aminoglycoside.

• Metronidazole is an effective drug against anaerobic bacteria. The experience with metronidazole in treating lung abscess has been rather disappointing because these infections are generally polymicrobial. A failure rate of 50% has been reported.

• Metronidazole, in combination with penicillin, is considered an appropriate treatment regimen for lung abscess because the penicillin will be active against the aerobic and microaerophilic streptococci that are often resistant to metronidazole.

Dependent drainage (with appropriate positions based on the pulmonary segment) is commonly advocated using chest physiotherapy and sometimes bronchoscopy.

Response to treatment

If there is no improvement by 7-10 days of appropriate antibiotic therapy, surgical intervention should be considered. Minimally invasive percutaneous aspiration techniques, bronchoscopic or transtracheal aspirations are useful.

Considerations in patients with poor response to antibiotic therapy include: • Bronchial obstruction with a foreign body • Infection with a resistant bacteria • Mycobacteria • Fungi.

A nonbacterial cause of cavitatory lung disease may be present, such as lung infarction, cavitating neoplasm and vasculitis. The infection of a preexisting sequestration, cyst or bulla may be the cause of delayed response to antibiotics

PLEURAL INFECTION AND EMPYEMApleural infection and empyema epid 2 definition 3 staging aeiotology common organisms clinical features examination investigations management

Parapneumonic effusion and empyema have an incidence of 3.3 per 100 000 in children. It is more frequently seen in infants and young children.

Definitions

Aetiology

In a previously well child pleural effusions are secondary to acute bacterial pneumonia and less often due to chronic infections such as tuberculosis, bronchiectasis and lung abscess. Empyema can be the presentation in a child with underlying malignancy such as a lymphoma

Common organisms

Clinical features

There are two common presentations.

1. The child has classic symptoms of pneumonia. • Fever • Poor appetite • Abdominal pain • Patient lies on the affected side to splint the involved hemithorax.

2. A diagnosed patient with pneumonia poorly responding to the appropriate antibiotics

Examination

Unilateral chest pain

• Poor chest expansion

Dullness to percussion

• Reduced or absent breath sounds

• Postural scoliosis

Investigations

1. Chest x-ray (postero- anterior) – this may show obliteration of the costophrenic angle and a rim of fluid ascending the lateral chest wall.

2. Ultra sound scan of the chest Ultra sound scan must be used to confirm the presence of pleural fluid. It is particularly useful when there is “white out” in the chest xray [D]. This can also be used to guide the chest drain insertion or thoracocentesis [C].

3. Blood culture (both aerobic and anaerobic)

4. Pleural fluid - gram stain and Acid Fast Bacilli (AFB)

5. Sputum culture – If the child is expectorating sputum (which is rare)

6. Mantoux test

7. C reactive protein – as a marker of progress (if facilities are available)

8. Bronchoscopy is not routinely recommended

Treatment

1. Humidified oxygen is administered to maintain saturation over 92%. Fluid therapy is given if the child is dehydrated or unable or unwilling to drink. All cases should be treated with intravenous antibiotics which will cover the above mentioned organisms [D].Analgesia and antipyretics are given to reduce pain. Physiotherapy is not indicated.

2. Intravenous antibiotics should be administered. Broad spectrum cover is required in hospital acquired infections, following surgery or aspiration. Whenever possible antibiotic administration should be guided by microbiological report [D]. (x) Oral antibiotic may be required for 1- 4 week or longer if there is residual infection. If a child has enlarging effusion or respiratory compromisations , intercostal tube drainage should be instituted; repeated taps are not recommended. Intrapleural fibrinolytics shorten hospital stay and are recommended for any complicated parapneumonic effusion (thick fluid with loculation) or empyema (overt pus)

3. Consider referring to a thoracic surgeon when the child has persistent pleural sepsis with pleural fluid collection despite chest tube drainage and appropriate antibiotics. The available surgical options are: (i). Video assisted thoacoscopic surgery (VATS) - achieves debridement of fibrinous pyogenic material, breakdown of loculation and drainage of pus under direct vision. (ii). Mini thoracotomy – debridement and evacuation is similar to VATS but it is an open procedure.

4. Children should be followed up after discharge until they have recovered completely and their chest radiograph have returned to near normal [D].

Acute Otitis MediaAcute otitis media Definition 4 Aetiology Examination 6 Definite diagnosis Severity DD Complications Mx, follow up and ENT OME/glue ear Definition Aetilogy Those at risk Symptoms Examination Mx Follow up ENT opinion when

Definition

Acute otitis media is a disease of infancy and early childhood defined by the presence of inflammation and fluid in the middle ear and accompanied by at least one sign of an acute illness

Aetiology

Pathogenic bacteria are isolated in 65 – 75% of cases.2 • 40% Streptococcus pneumoniae • 25 – 30% Haemophilus influenzae • 10 – 15% Moraxella catarrhalis Respiratory viruses are commonly found in association with pathogenic bacteria.3 • Respiratory syncytial virus

Clinical Manifestations

History

Local symptoms • Earache (only symptom with positive predictive value)1 • Discharge from the ear (otorrhoea)

Systemic symptoms • Fever • Symptoms of upper respiratory tract infection • Irritability • Restless sleep • Vomiting • Diarrhoea • Lethargy • Anorexia

Child under 2 years • Systemic symptoms are non specific • Tugging or rubbing of the ear indicates earache. • Evidence of conjunctival symptoms and rhinorrhoea are associated with acute otitis media

The pain will be relieved by rupture of the tympanic membrane

Examination

When AOM is suspected examination of the ear with an auriscope is mandatory. (Examination with a torch will not visualize the tympanic membrane)

To visualize the tympanic membrane, • In a young child the pinna is pulled in a horizontal and backward direction • In an older child the pinna is pulled upwards and backwards towards the occiput.

Auriscopy

Auriscopic evidence of middle ear effusion:

Otorrhoea

• Bulging of the tympanic membrane

• Opaque drum (normally shiny)

Air – fluid level behind the tympanic membrane

• Impaired drum mobility - This can be demonstrated by a pneumatic auriscope.

Auriscopic evidence of middle ear inflammation

: • Distinct erythema of the TM (excessive crying can cause mild erythema of the TM)

Differential diagnosis

(1) Otits media with effusion (Glue ear) A child with evidence of middle ear effusion with no systemic symptoms of acute illness and no signs of acute inflammation.6 (2) Meningitis Meningitis should be excluded in a young child under 2 years with non specific symptoms especially fever, lethargy and irritability associated with poor feeding and drowsiness. (3) Otitis externa A child with purulent discharge in the absence of fever and systemic symptoms. (4) Urinary tract infection (UTI) A young child with UTI can present with nonspecific systemic signs.

Complications

Management

Otitis media with effusion (OME) / Glue ear

Definition

Inflammation of the middle ear accompanied by middle ear effusion without symptoms and signs of acute inflammation

Aetiology

Clinical manifestations

History

Mostly asymptomatic.

Hearing impairment. (this is the main symptom although not identified in infants and young children)

Language and speech delay.

Behavioural symptoms such as clumsiness and inattentive behaviour.

Poor social interaction and education performance.

Auriscopy

Tympanic membrane will appear,

Retracted/concave with an abnormal colour such as yellow amber or blue opaque

Air fluid level or air bubbles may be present

Reduced motility demonstrated by a pneumatic auriscope.

Management

1) Antibiotics are not needed in most.

2) Antibiotics indicated when there is evidence of bacterial upper respiratory tract infection. Give a 2-4 week course of amoxycillin

3) No place for decongestants, mucolytics and antihistamines

4) No place for topical or oral systemic steroids

Follow up

OME is well recognized to relapse and remit. • Commonly resolves at 7-8 years. • Needs 2-3 monthly reviews

Specialised ENT Opinion sought

Children under 3 years with persistent bilateral OME should have hearing assessed. If audiometry is not possible ENT referral should be done.

If hearing loss is less than 25dB with no speech and language, development or behavioural problems child can be safely managed with watchful waiting. Audiometry should be done to exclude more serious hearing loss.