PEDIATRIC INFECTIOUS DISEASES
JI Agaloos, JI Mangabat, JI Mathew, JI Mapalo
Outline
I. Pharyngotonsillitis A1. Epstein Barr Virus
A. Viral Pharyngitis ● also known as Infectious Mononucleosis
A.1. EBV ● Mode of transmission: oral contact
A.2. Streptococcal Tonsillitis-Pharyngitis ● Common among adolescents
B. Other Causes of Pharyngotonsillitis → Younger children: asymptomatic, abdominal complaints
B.1. Periodic Fever With Aphthous Ulcers, Pharyngitis, ● Clinical Manifestation
→ fever, general malaise, headache, pharyngitis, dysphagia
and Adenopathy
and odynophagia
II. Complications
● Exam Findings
A. Group A β-Hemolytic Streptococcus May Be Complicated → normal-sized or hypertrophic tonsils
by Suppurative and Nonsuppurative Sequelae → palatal petechiae
A.1. Croup → large tender cervical lymph nodes
A.2. Supraglottitis → Tonsils: green or gray exudate
A.3. Bacterial Tracheitis → rash (rare)
A.4. Pertussis → splenomegaly and hepatomegaly
A.5. Bronchiolitis → atypical presentations: attributed to acute infection with
CMV
I. PHARYNGOTONSILLITIS
A. Viral Pharyngitis
● The most frequent cause of viral pharyngitis in children is
the “common cold” or URI.
VIRAL PATHOGENS
● Rhinovirus
● Influenza Virus
● Parainfluenza Virus
● Adenovirus
● Coxsackievirus
● Echovirus
● EBV
● Reovirus
● RSV
● URI-associated pharyngitis
→ mild, preceded by other symptoms (rhinorrhea and
congestion)
→ Mild to moderate sore throat, dysphagia, hoarseness and
low-grade fever ● Management
→ severe throat pain (atypical) → based on symptoms
● Exam Findings → Recovery: weeks
→ Oropharyngeal erythema → Pain control: NSAIDs
→ Tonsillar hypertrophy without exudate → Antibiotics: not indicated unless treatment for concomitant
→ Pharyngitis due to adenovirus: higher fevers, bacterial infection is required
conjunctivitis ▪ Contraindicated: β-lactam antibiotics (amoxicillin and
→ Coxsackievirus: Herpangina ampicillin) because of the risk of precipitating a rash
▪ Small vesicles with erythematous bases that become ▪ EBV-associated rash: morbilliform rash (involving the
ulcers trunk and sparing the extremities); resolves within 1 to
▪ spread over anterior tonsillar pillars, palate and 6 days
posterior pharynx → Mononucleosis-associated mild upper airway obstruction
▪ sometimes with associated cutaneous rash ▪ Tx: oral or parenteral corticosteroids
→ Hand-foot-and-mouth disease → Severe obstruction
▪ Caused by Coxsackievirus A16, Enterovirus 71 ▪ Nasopharyngeal airway
▪ associated with high fever and malaise ▪ Tonsillectomy, intubation or tracheotomy (rare)
▪ followed by vesicular eruptions in the mouths causing
oral throat pain & A2. Streptococcal Tonsillitis-Pharyngitis
▪ maculopapular rash or vesicles on the palms of the ● Group A Beta-Hemolytic Strep (GABHS) is the most
hands, soles and buttocks common bacterial cause of acute pharyngitis
▪ highly contagious ● Implicated in up to 37% of all children with acute pharyngitis
→ “Cold sore” ● Disease of childhood and adolescence
▪ caused by Herpes simplex virus (HSV) → Peak incidence: 5-6 years of age
▪ exudative or nonexudative pharyngitis ● Most common presentation
▪ older children and young adults → fever
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PEDIATRIC INFECTIOUS DISEASES
JI Agaloos, JI Mangabat, JI Mathew, JI Mapalo
→ sudden throat pain
→ odynophagia
● Associated symptoms
→ Malaise, dysphagia, otalgia, headache, nausea and
abdominal pain
● Physical exam findings
→ oropharyngeal erythema
→ enlarged tonsils with or without exudate
→ swollen uvula
→ palatal petechiae
→ enlarged tender cervical lymphadenopathy
→ scarlatiniform rash
● Atypical presentation in children <3 years of age
→ Mucopurulent rhinorrhea and excoriated nares without
significant pharyngitis
● Scarlet fever
→ variation of GABHS pharyngitis
● Treatment
→ associated with descending erythematous rash (neck to
→ 10-day course of penicillin or amoxicillin: first-line
trunk and extremities)
treatment for acute GABHS
→ develops within the first 24 hours of illness, fades within a
→ for those who are penicillin allergic: first-generation
week
cephalosporin, clindamycin, clarithromycin or
→ Strawberry tongue: enlarged papillae on the tongue with
azithromycin are first-line treatments
or without a white membrane
→ Acetaminophen or NSAIDs are recommended for
management of symptoms
● Throat culture
▪ Aspirins should be avoided
→ Diagnostic test of choice for GABHS infection
▪ Steroids are not indicated
→ Sensitivity: 90-97%; specificity: 90%
→ Penicillin Failure (7-37%)
→ results can take 18-48 hours to obtain and this delay can
▪ Theories include:
affect follow-up treatment
− A protective effect for GABHS by β- lactamase-
producing bacteria in the tonsils
● Rapid antigen detection tests
− lack of other bacteria that inhibit GABHS virulence
→ Sensitivity: 86%; Specificity 95%
− poor penetration of the pharyngeal tissues by
→ American guidelines: all children and adolescents who
penicillin
have a negative rapid antigen detection test should
− antimicrobial resistance to penicillin
undergo throat culture
→ Tonsillectomy
→ In addition, these patients should also have a monospot
▪ Considered in the treatment of children with recurrent
and CBC to evaluate for other causes.
throat infection
▪ Children who undergo tonsillectomy for recurrent
● Cultures alone cannot differentiate the acute and carrier
tonsillitis have been shown to have an increased risk of
states of GABHS
postoperative hemorrhage.
→ 20% school-age children are chronic carriers
→ up to 25% of household contacts of symptomatic GABHS
patients are carriers
→ Guidelines: Patients with frequent sore throat and positive
studies for GABHS may either have frequent GABHS or
are GABHS carriers with requents viral pharyngitis.
B. Other Causes of Pharyngotonsillitis
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PEDIATRIC INFECTIOUS DISEASES
JI Agaloos, JI Mangabat, JI Mathew, JI Mapalo
▪ Pharyngitis.
ORGANISMS
● Other symptoms:
→ Headache
● Mycoplasma pneumoniae ● Yersinia enterocolitica
→ Diarrhea
● Chlamydia pneumoniae ● Helicobacter pylori
→ Arthralgia
● Treponema pallidum, ● Group B, C, and G
→ Rash
● Neisseria gonorrhoeae Streptococcus
→ Chills
● Neisseria meningitides ● Fusobacterium species
→ Abdominal pain
● Arcanobacterium ● Peptostreptococcus
● Typical age of onset: Between 2 and 5 years of age.
haemolyticum species
● Laboratory tests reveal
● Francisella tularensis
→ Mild leukocytosis
● Thrush is quite common in infants, it typically is not painful; → Elevated erythrocyte sedimentation rate.
● Candidiasis: Causes significant throat pain. ● Etiology:
→ Unknown, with no identified familial pattern or genetic
B1. Corynebacterium diphtheriae etiology.
● Infection has declined markedly since the introduction of ● Differential diagnosis:
diphtheria vaccination in the 1920s. → Hyper-IgD syndrome
● C. diphtheriae causes an early exudative pharyngotonsillitis → Cyclic neutropenia
with a thick pharyngeal membrane and produces a lethal → Familial Mediterranean fever
exotoxin that can damage cells in distant organs. ● Treatment:
● Infection can spread to the throat, tonsils, palate, ear, skin, → Corticosteroids
and larynx with associated severe upper airway obstruction. ▪ Prednisolone
− Reduce symptoms and resolve fevers within 24
hours for a majority of patients
Corynebacterium diphtheriae → H2-receptor antagonist
▪ Cimetidine
Characteristics ● gram-positive pleomorphic aerobic − Successfully used for treatment
bacillus: “Chinese character” − Prophylaxis in a minority of patients.
● Best identified: Tellurite media. → NSAIDs:
● Toxigenic strains infected with a ▪ Generally ineffective
bacteriophage
II. COMPLICATIONS
Early diagnosis ● CRITICAL A. Group A β-Hemolytic Streptococcus May Be
and isolation Complicated by Suppurative and Nonsuppurative
Sequelae
● 5% to as high as 20% in children under ● Suppurative complications:
Mortality 5 years of age. → Cervical lymphadenitis
→ Peritonsillar abscess
Treatment ● Antitoxin → Parapharyngeal abscess.
○ Within 48 hours of onset of disease, ● Non-Suppurative complications:
● Antibiotic → Rheumatic fever
○ Erythromycin or penicillin G ▪ Episode of pharyngeal GABHS infection
− Polyarthritis
Prevention ● Vaccines − Carditis
○ Diphtheria-tetanus toxoid − Sydenham chorea
○ Diphtheria-tetanus pertussis − Truncal rash
▪ Treatment
B2. Periodic Fever With Aphthous Ulcers, Pharyngitis, − Penicillin prophylaxis
and Adenopathy (PFAPA) → Poststreptococcal glomerulonephritis
● Most common cause of pediatric recurrent fever. ▪ May be seen after pharyngeal or skin infections
● Prodromal phase: ▪ Typically an acute nephritic syndrome develops 1 to 2
→ Malaise weeks after a streptococcal infection.
→ Irritability ▪ Treatment
→ Fatigue. − Penicillin management may not decrease the attack
● Prodromal phase that may precede the onset of fever. rate
● Fever: − No evidence that antibiotic therapy affects the
→ 3 to 6 days (38.5° to 41°C) natural history of glomerulonephritis.
→ Occurs every 2 to 8 weeks with asymptomatic intervals. → Pediatric autoimmune neuropsychiatric disorders
● Strict criteria include: associated with streptococcal infections (PANDAS)
→ Periodic fevers with at least one of the following three
symptoms: A1. Croup
▪ Aphthous stomatitis ● Also known as Laryngotracheobronchitis
▪ Cervical adenitis ● Most common infectious cause of stridor in children
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PEDIATRIC INFECTIOUS DISEASES
JI Agaloos, JI Mangabat, JI Mathew, JI Mapalo
● Group most commonly affected: children 6 months to 3 yrs → Classic endoscopic findings of croup:
old ▪ edema
● Can occur any time of the year ▪ narrowing of the vocal folds and subglottis
● Most common etiologic agent: Parainfluenza viruses type ● Consider life-threatening airway infections as alternative
1,2, and 3 diagnoses in acute settings
→ Influenza A and B, RSV, and adenovirus → can cause croup → e.g. epiglottitis
symptoms ● Atypical Croup is considered if it
● MOT: direct contact and exposure to nasopharyngeal → occurs in infants younger than 6 months of age
secretions or through airborne droplets over short distances → lasts more than 7 days
● Incubation period: 2 to 6 days (parainfluenza type 1) → is unusually severe
● Preceded by 1 to 2 days of a nonspecific viral prodromal → does not respond to appropriate treatment
URI with low-grade fever ● Common etiologies of recurrent croup
● Mean duration: 2-3 days ▪ congenital subglottic narrowing
→ resolution of symptoms within 2 days ▪ gastroesophageal reflux disease
● Evolves into a triad of ● Management
→ hoarseness → typically self limited
→ stridor with a distinct expiratory component (seal-like → patients who present for medical evaluation can be
barking cough) managed with:
→ varying degrees of upper airway obstruction ▪ systemic glucocorticoids
● Croup most often presents with only mild symptoms, but it − low dose oral administration: preferred in
can also cause severe, life-threatening airway obstruction. ambulatory settings
− IV administration: preferred for severe disease in
inpatient settings
▪ racemic epinephrine
− second line therapy even though the effect is more
rapid due to its short duration of action and its side
effects (tachycardia, agitation, hypertension)
▪ inspired mixture of helium and oxygen (heliox)
● Admission should be considered:
→ if initial therapy is ineffective
→ in those children with severe symptoms (decreased level
of consciousness, worsening work of breathing, infants
younger than 6 months
● Signs indicating severe airway obstruction → when social circumstances raise concerns about follow-
→ biphasic stridor up and appropriate access to care
→ retractions ● Endotracheal intubation → may be necessary In patients with
→ high respiratory rate persistent severe airway compromise
→ oxygen desaturations
→ altered consciousness A2. Supraglottitis
● The infection causes inflammation of the larynx, trachea, ● Also known as Acute epiglottitis
bronchi, bronchioles, and lung parenchyma. ● It is a cellulitis of the supraglottic structures associated with
→ Obstruction caused by swelling and inflammatory profound edema, most noticeably of the epiglottis.
exudates develops and becomes pronounced in the ● Epiglottis enlarges → curls posteriorly and inferiorly → limits the
subglottic region patency and ease of visualization of the airway
▪ narrowest portion of the airway in children ● Predominant Cause: Haemophilus influenzae
▪ the only complete cartilaginous ring ● After introduction of the conjugated H. influenzae type B (HIB)
● Stridor does not occur until airway obstruction is already vaccine → decline in cases of epiglottitis and other invasive H.
significant influenzae diseases
● Diagnosis → median age of disease in children shifted from 3 years to
→ History and physical examination is sufficient for 6 to 12 years
diagnosis ● Other cases can be attributed to:
→ Useful adjunct: AP and Lateral radiographs → lack of immunization with the H. influenzae type B (Hib)
▪ AP View: Classic “steeple sign” in subglottic area vaccine
− not pathognomic for croup → failure of antibody production, especially in those with
→ Flexible fiberoptic laryngoscopy immunodeficiency
▪ useful but must be performed w/ extreme caution to ● Atypical cases may be due to
avoid inducing acute airway obstruction in children with → Kawasaki disease
moderate to severe obstructive symptoms → Posttransplant lymphoproliferative disorder
→ Direct laryngoscopy and bronchoscopy is warranted in
patients with:
▪ severe airway obstruction
▪ an uncertain diagnosis
▪ risk factors for other airway pathology
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PEDIATRIC INFECTIOUS DISEASES
JI Agaloos, JI Mangabat, JI Mathew, JI Mapalo
● Signs and Symptoms: − development of an air leak around the endotracheal
→ Hallmark features: tube
▪ dysphagia → Antibiotic Therapy
▪ drooling ▪ Broad-spectrum coverage using a second- or third-
▪ respiratory distress generation cephalosporin
− rapid in onset and progressive over hours ▪ Epiglottic abscess: incision and drainage should be
→ Children are toxic and anxious in appearance with: performed after intubation
▪ high fever − after extubation, patients can be converted to an
▪ clinical evidence of major upper airway obstruction oral regimen (7 to 10 days)
→ The child exhibits shallow respiration, inspiratory stridor, ● Complications
retractions, and drooling. → infectious:
→ Throat pain and dysphagia are severe ▪ bacteremia, pneumonia meningitis, cervical adenitis,
▪ limited speech, muffled voice pericarditis, septic arthritis, and otitis media
→ Cough and hoarseness are uncommon → noninfectious:
→ Stridor and retractions → late and concerning signs ▪ death or hypoxic central nervous system damage
▪ impending complete obstruction secondary to airway obstruction
→ Patient usually prefers to sit leaning forward or in the
“tripod” position A3. Bacterial Tracheitis
▪ seated, with the hands braced against the bed and the ● Rare but potentially life-threatening disease that can occur
head held in the sniffing position to maximize airflow). in isolation or as a secondary infection of viral croup.
● Diagnosis ● More likely than croup or epiglottitis to cause respiratory
→ Radiographs failure in pediatric critical care patients though historically,
▪ swelling and rounding of the epiglottis (thumbprint this was considered uncommon.
sign) with thickening and bulging of the aryepiglottic ● Common etiologies:
folds on lateral films → with variability in severity of disease by organism
▪ should not be done on patients with an obstructed airway→ ▪ Staphylococcus aureus
proceed directly to the OR ▪ Moraxella catarrhalis
→ Direct Examination of the larynx ▪ Streptococcus pneumoniae
▪ child who presents with moderate to severe symptoms ▪ H. influenzae
▪ reveals obscured cartilaginous landmarks and an ● primarily occurs during autumn and winter
edematous, erythematous epiglottis with variable ● seen in a wider range of ages than typical croup, with a
degrees of obstruction of the airway mean age of 5 years at time of diagnosis.
→ Child should be allowed to remain in the most ● infectious inflammatory process involves the subglottis and
comfortable position trachea
● Management → marked edema followed by diffuse mucosal ulceration
→ Tracheotomy: historically been the safest intervention and pseudomembrane formation with copious exudative
→ Endotracheal intubation: the current standard approach sloughing that further contributes to airway obstruction.
▪ Induction of general anesthesia: nonirritating inhalation ● onset of bacterial tracheitis is variable.
agent → typical presentation characterized by a several-day
▪ Muscle relaxants: avoided prodromal period of upper respiratory symptoms that precede the
▪ Nasotracheal intubation: preferred to reduce the rapid onset of high fever, stridor, barky cough, increasing
chance of accidental extubation respiratory distress, and toxic appearance.
− adequate sedation or restraint to prevent accidental → Some children become acutely ill and have severe
extubation post operatively respiratory decompensation within hours of the onset of illness,
▪ Criteria for extubation include: whereas others have a more subacute presentation.
− decreased erythema and swelling of the epiglottis → Suspicion should be raised in patients who do not respond
on laryngoscopy or worsen with standard croup treatment or who appear toxic.
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PEDIATRIC INFECTIOUS DISEASES
JI Agaloos, JI Mangabat, JI Mathew, JI Mapalo
● The presentation differs from supraglottitis by → Symptoms may persist for as long as 10 weeks. Younger
→ absence of preferred posture, dysphagia, or drooling. children and previously vaccinated individuals may not
→ Leukocytosis often prominent. have the classic whooping.
→ blood cultures are usually negative, but tracheal cultures → Any person with a prolonged cough should be evaluated
reliably reveal the bacterial pathogen. for pertussis.
● Radiographs- only in a stable patient. ● Unvaccinated neonates and infants - highest risk
● Plain radiographic imaging of the upper airway - “steeple” sign of → minimal initial symptoms, present with history of mild
the upper trachea or subglottis on an anterior view. → diffuse congestion or cough, which can progress to gasping,
haziness with soft tissue irregularities within the lumen on a lateral apnea, hypoxia, cyanosis, pneumonia, and even death (in
view 1%)
● endoscopic examination of the airway is the gold standard ● Treatment: symptomatic relief and prevention of spread of
for diagnosis. disease.
● similar management with epiglottitis in the OR. ● Antimicrobials, (macrolides) - do not improve symptoms
● Direct laryngoscopy and rigid bronchoscopy and suction after the catarrhal phase, can reduce transmission.
removal of copious secretions and pseudomembranes both ● Patients can be contagious for 6 weeks after infection.
therapeutic in relieving obstructive symptoms and ● Young infants often require hospitalization for supportive
diagnostic( culture and Gram stain.) care.
● Intubation may be necessary, ● chemoprophylactic treatment regardless of previous
● 53% and 91% - proportion of pediatric patients with vaccination in close contacts.
bacterial tracheitis requiring intubation. ● booster immunizations are now recommended for older
→ endotracheal tube half to one size smaller than what is children and adults due to concern about waning immunity
typical for the patient’s age used from standard infant vaccination.
→ tracheotomy is rarely necessary,. A5. Bronchiolitis
● frequent saline administration and suctioning via the ● Between 2% and 3% of children younger than 12 months in
endotracheal tube aids in the evacuation of secretions. the United States are diagnosed and hospitalized.
● Repeat rigid bronchoscopy may be necessary to handle ● Infectious bronchiolitis
unusually tenacious secretions. → viral inflammatory process in the bronchioles of the lower
● Milder disease - empiric therapy with a third-generation respiratory tract, most commonly caused by RSV.
cephalosporin and penicillinase-resistant penicillin. → children under 2 years of age.
● for communities with high MRSA: Clindamycin or → Typical symptoms: those of an URI with expiratory
vancomycin may be preferred wheeze or crackles, tachypnea, nasal flaring, and
● For toxic patients: vancomycin with or without clindamycin. retractions.
● Extubation safely performed → Examination may reveal both inspiratory and expiratory
→ when the child’s temperature has returned to normal, sounds on lung auscultation, these should be
→ a leak is present around the endotracheal tube, differentiated from frank stridor of the upper airway.
→ markedly decreased secretions. → Radiologic findings may include air trapping,
● average intubation duration - 3 days, hyperinflation, centrilobar thickening, and bronchiolar
→ up to 7 days in more severe cases. dilation
● Oral antibiotics to complete a 10- to 14-day course of ● foreign body should be in the differential diagnosis.
therapy. ● CT is preferred over plain radiographs.
● Pneumonia - most common complication of bacterial ● Symptoms usually self-limited, and although inhaled
tracheitis (50%) of children. bronchodilators may improve symptoms, use of antibiotics,
● severe cases of airway obstruction -Severe hypoxia, death steroids, and oral bronchodilators is not well supported
after respiratory arrest. ● Palivizumab
A4. Pertussis → monoclonal antibody injection used to curb serious RSV-
● least well-controlled vaccine-preventable disease in the associated lower respiratory tract infection
United States. → should not be used broadly for RSV prophylaxis;
● Children are most at risk, under 1 year of age have the however, its use in very specific subpopulations of infants
greatest morbidity and mortality. or toddlers may be beneficial.
● School-age children (7 to 10 years old) - higher incidence ● Vigilant measures to prevent nosocomial spread to other
group. hospitalized patients is important.
● Increased rates due to waning immunity and lack of
education about booster vaccination.
● Classic pertussis - due to Bordetella pertussis bacterium;
→ milder forms occur with B. parapertussis, B. holmesii, and
B. bronchiseptica.
● Spread by aerosolized mucus from coughing and sneezing.
● Classic symptoms:
→ initial (catarrhal) phase similar to a viral URI that lasts 7 to
10 days
→ followed by the development of severe paroxysms of
coughing
→ classic inspiratory “whoop,” a form of stridor.
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