A16-year-old male is brought to the emergency department with a crush injury due to a farm accident. His immunization status is unknown. The wound is heavily contaminated with soil, and you are concerned about tetanus.Which of the following is the most appropriate management step?
Answer(s): C
In patients 1118 years of age with a clean, minor wound, Tdap vaccine is required if the patient has had <3 tetanus vaccinations or if the immunization status is unknown. In contaminated wounds (dirt, feces, soil, and saliva), puncture wound, avulsions, and wounds resulting from missiles, crushing, burns and frostbite, TIG and Tdap should be given in the 1118 years age group. Waiting for immunization records is not appropriate in an emergency situation.
Children with sickle cell anemia are at increased risk of developing overwhelming infection with certain microorganisms. Which of the following is the most reasonable step to prevent such infection?
Answer(s): D
Children with sickle cell disease develop functional asplenia, presumably from repeated splenic infarction.This results in vulnerability to bacteremia and overwhelming infection, especially with encapsulated bacteria. The organism most commonly involved is S. pneumoniae. Daily prophylactic oral penicillin is indicated for young children. Because of the risk of bacteremia, these patients need careful medical evaluation when they develop fever. There are no data to support the use of gamma globulin in these children. They are not at higher risk for complications from live virus vaccines or from varicella.
Varicella vaccination is a live virus vaccine. It is generally not recommended in immunocompromised patients. Which of the following is an exception to this rule?
Answer(s): E
Varicella vaccine should not be routinely given to children with T-lymphocyte deficiency, including lymphoma, leukemia, neoplasms affecting the bone marrow or lymphatic systems, and congenital T- cell abnormalities. One exception is children with ALL, in continuous remission for at least 1 year, with a lymphocyte count >700/L and a platelet count >100 . 103/L. Another exception is HIV- infected children in CDC class 1. These children are at increased risk of morbidity from varicella and herpes zoster; therefore, the benefits outweigh the risks in these limited circumstances. Children receiving high doses of steroids should not receive the vaccine. This is defined as >2 mg/kg/day of prednisone or its equivalent, or 20 mg/ day, if their weight is >10 kg, for 14 days or more. The vaccine may be given a month after discontinuation of the therapy.
A1-year-old patient is in the office for a health maintenance visit and is ready for immunizations. The child has a mild upper respiratory infection and a low-grade fever. The mother does not want the child to receive vaccine because she has been told that the vaccine could make the illness worse. You tell her the only true contraindication to vaccination is which of the following?
Mild illness is not a contraindication to vaccination, nor is breast-feeding. Such live vaccines as MMR and varicella are not recommended for pregnant women, but may be safely given to their children. They are also not recommended in many immunocompromised children; however, it is recommended that household contacts receive the vaccinations to decrease the patient's chances of exposure. It is not necessary to restart a vaccine series if there has been a long gap between immunizations.
A 4-day-old infant presents with yellow discoloration of the skin and sclera. The baby was born at term by a normal vaginal delivery. Pregnancy was uncomplicated; there were no risk factors for sepsis and no history of maternal alcohol or drug use. The baby is breast-fed and has been nursing every 2 hours, about 10 minutes at each breast. The bilirubin level is 15 mg/dL (all unconjugated), the hematocrit is 45%, and the Coombs test is negative. Which of the following is the most likely diagnosis?
The most common causes of neonatal cholestasis are extrahepatic biliary atresia and idiopathic neonatal hepatitis. Infants usually develop icterus by 26 weeks of age. They have conjugated hyperbilirubinemia, dark urine, and acholic stools. At time of presentation, there is usually hepatomegaly, as well as pruritis, splenomegaly, and ascites. The use of RhoGAM (anti-D gamma globulin) has reduced the incidence of Rh sensitization and resulting jaundice. ABO incompatibility can also cause a milder form of isoimmune hemolytic disease and jaundice. It is more common in infants with blood types Aand B born to mothers with blood type O. Anemia is usually present; direct Coombs test is weakly positive; and indirect Coombs test is positive. Crigler-Najjar syndrome is autosomal recessive; there is usually marked hyperbilirubinemia (240 mg/dL) in an otherwise asymptomatic infant. The high levels result in kernicterus. Physiologic jaundice is the most common cause of unconjugated hyperbilirubinemia; it is characterized by peak bilirubin level of <13 mg/dL on day of life 35, decrease to normal within 2 weeks. In breast-fed infants, this is often exaggerated, with levels >13 mg/dL. This occurs in 1025% of breastfed infants, as opposed to 47% of formulafed infants. It is known as "breast-feeding" jaundice. "Breast-milk" jaundice, develops after the first week of life, peaking between the 2nd and 3rd week to 1020 mg/dL. The cause of this has not been established.
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