QUESTION: 231

An 11-month-old girl presents to your office with a fever of 39°C she has had for 2 days. She has also vomited frequently and had decreased fluid intake. She looked tired and ill but on examination, had no apparent source of infection. She appeared to be 510% dehydrated.

Her urine culture is positive at 24 hours. Which of the following is the most likely organism?

Klebsiella
Escherichia coli
Staphylococcus saprophyticus
Proteus
Enterococcus

Answer(s): B

Explanation:

Urine for urinalysis and culture must be properly obtained. Catheterization is the most reliable method of the choices offered. Suprapubic tap is considered the "gold-standard" but is not always technically feasible, especially in an outpatient office setting. Amidstream, clean catch specimen would be acceptable in an older, toilet-trained child. "Bagged" specimens are not recommended because of possible skin or fecal contamination of the specimen. Similarly, obtaining a sample from a diaper or potty would be unacceptable.
Urinalysis includes dipstick method and microscopic examination. Leukocyte esterase (an enzyme in WBC) and nitrites suggest probable infection. Microscopic analysis of unspun urine for WBC (>10/ highpower field) or bacteria is also predictive of infection. RBCs are often present in a UTI. The patient is vomiting and dehydrated; this may indicate possible pyelonephritis. The most appropriate course would be IV hydration and empiric treatment with antibiotics (ceftriaxone) while awaiting cultures. Children with pyelonephritis are at increased risk of renal scarring, especially younger children, and should be treated early. E. coli is the most common organism cultured; others include Proteus, Klebsiella, S saprophyticus, and Enterococcus. The occurrence of a UTI in a girl under age 35 years and in a boy of any age may be a marker for an underlying congenital anatomic abnormality, in particular, vesicourethral reflux. Radiologic investigation with renal ultrasound and VCUG is recommended

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QUESTION: 232

An 11-month-old girl presents to your office with a fever of 39°C she has had for 2 days. She has also vomited frequently and had decreased fluid intake. She looked tired and ill but on examination, had no apparent source of infection. She appeared to be 510% dehydrated.

After the infection has been treated, which one of the following tests should be considered ?

no tests are needed
renal ultrasound
voiding cystourethrogram (VCUG)
renal ultrasound and a VCUG
radionucleotide renal scan

Answer(s): D

Explanation:

Urine for urinalysis and culture must be properly obtained. Catheterization is the most reliable method of the choices offered. Suprapubic tap is considered the "gold-standard" but is not always technically feasible, especially in an outpatient office setting. Amidstream, clean catch specimen would be acceptable in an older, toilet-trained child. "Bagged" specimens are not recommended because of possible skin or fecal contamination of the specimen. Similarly, obtaining a sample from a diaper or potty would be unacceptable.
Urinalysis includes dipstick method and microscopic examination. Leukocyte esterase (an enzyme in WBC) and nitrites suggest probable infection. Microscopic analysis of unspun urine for WBC (>10/ highpower field) or bacteria is also predictive of infection. RBCs are often present in a UTI. The patient is vomiting and dehydrated; this may indicate possible pyelonephritis. The most appropriate course would be IV hydration and empiric treatment with antibiotics (ceftriaxone) while awaiting cultures. Children with pyelonephritis are at increased risk of renal scarring, especially younger children, and should be treated early. E. coli is the most common organism cultured; others include Proteus, Klebsiella, S saprophyticus, and Enterococcus. The occurrence of a UTI in a girl under age 35 years and in a boy of any age may be a marker for an underlying congenital anatomic abnormality, in particular, vesicourethral reflux. Radiologic investigation with renal ultrasound and VCUG is recommended

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QUESTION: 233

A 10-year-old boy comes to your office in the winter with a sore throat he has had for 2 days. In addition, he has had fever, headache, and abdominal pain. He does not have any allergies to medications. On examination, he has a temperature of 38.6°C, an ery thematous pharynx, and tender cervical adenopathy. Arapid screening test for group Astreptococcus is performed and is positive. Which of the following would be the most appropriate antimicrobial agent?

erythromycin
penicillin
trimethoprim-sulfamethoxazole
azithromycin
cefaclor

Answer(s): B

Explanation:

Penicillin remains the drug of choice for treatment of streptococcal pharyngitis. Amoxicillin, macrolides, and cephalosporins are acceptable alternatives.

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QUESTION: 234

A 10-year-old boy comes to your office in the winter with a sore throat he has had for 2 days. In addition, he has had fever, headache, and abdominal pain. He does not have any allergies to medications. On examination, he has a temperature of 38.6°C, an ery thematous pharynx, and tender cervical adenopathy. Arapid screening test for group Astreptococcus is performed and is positive. Which of the following would be the most appropriate antimicrobial agent?

The same child returns to your office the next day. He has taken the medication you prescribed. He is feeling a little better. His fever has resolved, but he has developed a rash. His examination is unchanged, except that he is afebrile and has a fine, papular rash over his body, which is accentuated in his axilla and groin.

Which of the following is the most likely cause of his rash?

allergic reaction to the antibiotic
rash from the antibiotic seen in patients with mononucleosis
scarlet fever
serum sickness
viral exanthem typical of enterovirus

Answer(s): C

Explanation:

Scarlet fever is caused by toxins made by group A Streptococci. It is usually seen in patients with strep throat. The rash is popular and described as sandpaper like. Sometimes it is easier to feel it than to see it.
An allergic rash would be urticarial. More than 80% of patients with EBV infection develop a maculopapular rash if given amoxicillin. This patient's clinical course is not typical for EBV which presents more gradually, and patients often have posterior cervical adenopathy and splenomegaly. Patients with serum sickness often have urticarial rashes, sometimes progressing to angioedema. They may also have arthritis, myalgias, and lymphadenopathy. The rash in enteroviral infections is typically macular.

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