Pediatric emergency medicine trisk 583

Schistosomiasis— Sub-Saharan Africa Katayama fever Schistosoma— Sub-Saharan Africa swimmer’s itch (freshwater), digger’s itch (saltwater) High fever, urticaria, eosinophilia weeks after contact with freshwater in endemic areas Pruritic rash after skin is penetrated by schistosomal cercaria Laboratory findings include anemia, thrombocytopenia, hypoalbuminemia, and hypergammaglobulinemia Untreated visceral infection is nearly always fatal Diagnosis of the cutaneous form is through identification of leishmanial organisms via Wright or Giemsa stain of tissue samples Visceral disease is diagnosed via bone marrow (iliac crest in children), spleen, or less commonly, liver aspirations Treatment is always indicated for the mucosal and visceral cases The drug of choice for visceral and mucosal disease is liposomal amphotericin B Miltefosine can be used to treat all three forms and is FDA approved for patients ≥12 years old Sodium stibogluconate, an antimonial, has also been used in the treatment of leishmaniasis, but has multiple potential adverse events including cardiotoxicity (EKG changes findings include STelevation or depression, T-wave inversion, and QT-interval prolongation), hepatitis, pancreatitis, nephrotoxicity with proteinuria, phlebitis, myelosuppression, and optic atrophy Treatment of localized cutaneous disease depends on the type and characteristics of the lesion Those that are rapidly selfhealing can remain untreated Systemic treatment is recommended for large or multiple cutaneous lesions Diffuse cutaneous disease is resistant to treatment Expert consultation through the CDC Division of Parasitic Diseases and Malaria: (404) 718-4745 or (770) 488-7100 is strongly suggested Standard isolation precautions are recommended Cutaneous Larva Migrans CLM is caused by the larval form of canine and feline hookworms (Ancylostoma species), found in fecal material in soil or sand These nematodes can penetrate intact skin; infection is most common in tropical regions, especially on beaches While most common in travelers returning from the Caribbean, Latin America, Asia, and Africa, the infection is also seen in the southeastern United States Patients present with itchy papules at the entry site with a migratory, raised, erythematous, serpiginous pattern as the larvae migrate The feet and buttocks most commonly are affected The parasites enter the bloodstream and have a maturation phase in the lungs With a large inoculation, eosinophilic pneumonitis (Löeffler syndrome) can be seen Eosinophilia can also be seen with invasive enteritis, but is not a feature of isolated CLM The diagnosis is clinical; biopsy is not recommended, but pathology may demonstrate an eosinophilic infiltrate Serologies and EIAs are not commercially available While usually a self-limited disease, albendazole or ivermectin can be used for treatment Patients with substantial eosinophilia should be monitored for manifestations of mast cell degranulation after treatment, and some may require corticosteroids along with antiparasitic therapy Contact precautions are recommended for the incontinent child Filariasis Filariases are mosquito-borne infections caused by the nematodes (roundworms) Wuchereria bancrofti, Brugia malayi, or Brugia timori ( e-Table 94.25 ) The incubation period ranges from to 12 months depending on the species W bancrofti ’s clinical manifestations include acute adenolymphangitis (ADL), hydrocele, lymphedema, elephantiasis, chyluria, and tropical pulmonary eosinophilia (TPE) ADL is characterized by malaise, fever, chills, and enlarged painful lymph nodes, usually in the lower limb Hydrocele (unilaterally or bilateral) is the most common chronic manifestation of W bancrofti Chronic lymphedema may progress to elephantiasis and typically involves the lower extremities Edema usually becomes nonpitting with skin thickening and loss of skin elasticity Secondary bacterial and fungal infections are common Chyluria is seen when dilated lymphatics rupture and drain into the urinary excretory system It is typically recurrent and lasts for days to weeks TPE is the result of immune hyperresponsiveness to microfilaria in the lung Patients with TPE typically present with nocturnal coughing and wheezing and extreme peripheral eosinophilia (counts >3,000 cells/mm3) If left untreated, TPE may progress to chronic interstitial fibrosis and permanent lung damage Brugian filariasis (caused by both B malayi and B timori ) is very similar to Bancroftian filariasis, except that hydroceles, genital manifestations, and chyluria are less common, and that the elephantiasis is usually limited to the lower legs in Brugian filariasis Lymphatic filariasis may be diagnosed via microscopic detection of microfilaria on blood smears obtained at night In addition, adult worms or microfilaria may be detected with skin biopsy, and ultrasonography can sometimes be used to detect adult worms Nocturnal microfilaria of W bancrofti and B malayi may be provoked to enter the bloodstream during the day with a one-time dose of diethylcarbamazine citrate (DEC) Blood examination should be performed 30 to 60 minutes after administration of DEC PCR and immunologic testing are also available The drug of choice for lymphatic filariasis is DEC (2 mg/kg/dose three times daily after food for 12 days; there is no maximum adult dose) Ivermectin (150 μg/kg; there is no maximum adult dose) is effective against the microfilaria of W bancrofti but has no effect on the adult worm Consequently, combination therapy with DEC-ivermectin or ivermectin-albendazole is needed for suppression of microfilaremia TPE is treated with DEC for 12 to 21 days DEC is no longer commercially available in the United States but can be obtained through the CDC (404-718-4745) Paradoxical worsening, including encephalopathy, can occur during treatment, especially in patients with high organism burdens Standard precautions exist for isolation of patients with lymphatic filariasis There is no human-to-human transmission of microfilaria and adult worms with the exception of transfusion with infected blood Onchocerciasis (river blindness) is caused by Onchocerca volvulus and transmitted by Simulium blackflies Approximately 18 million people worldwide are infected, over 500,000 have severe visual disability Clinical manifestations may be dermatologic or ocular Skin manifestations present as a pruritic rash with multiple papules that may resolve spontaneously or continue to spread Painless, firm, mobile granulomas may develop in subcutaneous tissue, but rarely cause morbidity Ocular lesions involve both the anterior and posterior segments Anterior segment lesions result from an acute inflammatory reaction around microfilariae and are reversible with therapy Posterior segment lesions involve the optic nerve and chorioretinitis and may result in blindness Diagnosis can be made clinically Laboratory confirmation may be sought via PCR or microscopic examination of skin snips for microfilariae The diagnosis is primarily clinical, as microfilariae may not be present in patients with lymphedema Treatment is with ivermectin in a single dose of 150 μg/kg (there is no maximum adult dose) DEC can cause adverse ophthalmic reactions and is contraindicated in onchocerciasis Standard precautions should be used SEXUALLY TRANSMITTED INFECTIONS STIs are the most commonly reported infections in the United States and represent an important pediatric problem, particularly during infancy or adolescence This chapter focuses on HIV, syphilis, HSV outside the neonatal period, and neonatal chlamydia and gonorrheal infections and nongenital gonorrheal infections STIs causing pelvic inflammatory disease and cervicitis are covered elsewhere (Chapter 92 Gynecology Emergencies ) and management of STIs in the abused child is discussed in Chapter 87 Child Abuse/Assault In these children, the most common pathogens are Trichomonas, C trachomatis, and Neisseria gonorrhea, and one study in sexually abused girls found that 8% of girls had one or more STIs As many adolescents with one STI can be infected with more than one pathogen, identification of one STI should prompt diagnostic evaluation for others The manifestations, diagnosis, and treatment of common STIs are described in Table 94.22 Chlamydia, Neonatal C trachomatis can cause a number of syndromes in infants: conjunctivitis, trachoma, and pneumonia Chlamydia is the most common STI in the United States, and adolescent females comprise the most at-risk group Vertical transmission occurs in up to 50% of infants born to infected mothers Chlamydia conjunctivitis is characterized by a serous, slightly purulent eye discharge that can be first noticed within days to several weeks after delivery There is conjunctival injection and lid edema The drainage typically lasts to weeks Approximately 30% of children with neonatal chlamydia conjunctivitis also will have chlamydial pneumonia Chlamydia conjunctivitis and trachoma are not prevented by erythromycin that is given in the immediate newborn period to prevent ophthalmia neonatorum (see below) Trachoma is a sequela of chronic chlamydial eye infection and is characterized by corneal neovascularization which can result in blindness While rare in the United States, trachoma is the leading infectious cause of blindness globally, estimated to impact up to 80 million persons C trachomatis pneumonia occurs most commonly from weeks to months after birth and is characterized by an afebrile illness with repetitive, paroxysmal cough similar to pertussis In contrast to pertussis, leukemoid reactions are rare, but eosinophilia can be seen Upper respiratory tract symptoms are common from chlamydial colonization of the nasopharynx Radiographic findings may include hyperinflation and patchy interstitial infiltrates The diagnosis is made on the basis of direct fluorescent antibody (DFA) testing, the only FDA-approved test for the detection of C trachomatis from nasopharyngeal and conjunctival specimens The treatment of chlamydia ... STIs are the most commonly reported infections in the United States and represent an important pediatric problem, particularly during infancy or adolescence This chapter focuses on HIV, syphilis,