You see a 31/2-year-old child in the emergency department who has had fever for the past week. The parents relate that their son has some swollen glands, fever, and now seems to be getting a rash on his arms. On examination, you find an uncomfortable appearing young boy whose vital signs are normal with the exception of a temperature of 104°F. You note t hat he has a red posterior oropharynx with dry, cracked lips. His TMs are normal. He has mild conjunctival injection bilaterally without any discharge. His chest is clear, and his heart sounds are normal. He does not have any hepatosplenomegaly. His has a lacy, confluent macular rash on his chest and upper arms, with mild peeling of the tips of his fingers.What is the most appropriate treatment at thispoint?
Answer(s): D
Kawasaki disease (mucocutaneous lymph node syndrome) is a disease of unclear etiology. The salient diagnostic features include fever for greater than 5 days, cervical lymph node greater than 1 cm, nonpurulent conjunctivitis, oral changes (cracking lips or "strawberry tongue"), polymorphous rash to the trunk, and changes to the hands and feet (peeling of the fingers or toes or edema of the hands or feet). This may be confused with group Abeta-hemolytic streptococcal pharyngitis, which usually is not associated with conjunctivitis. Coxsackie viral infection is commonly seen as the "hand-footmouth" disease, with shallow ulcers on the palms, soles, and in the mouth. There is nominal fever associated, and conjunctivitis is uncommon. Parvovirus B-19 (erythema infectiosum, "fifth disease") is commonly called "slapped cheek" disease because of the exanthem of bright red cheeks. Adenopathy and conjunctivitis are not features of this infection. Acute phase reactions are often elevated late in the course of Kawasaki disease.The most common blood test result would be a dramatically elevated platelet count. It is usually greater than 750,000 and can be greater than 1,000,000. An ESR is also likely to be elevated, not low. Apositive rapid strep test would lead one more toward acute GAS disease. The treatment of choice for Kawasaki disease is IVIG and aspirin. IVIG infusion is usually over 12 hours and will commonly result in rapid defervescence and clinical improvement.Treatment of Kawasaki disease is important as it will prevent long-term sequelae. A common side effect of IVIG is aseptic meningitis. Nearly a quarter of untreated children will develop coronary artery dilatation. This is most common cause of acquired heart disease in children younger than 5 years of age. The coronary artery dilatation can result in aneurysm formation and myocardial infarction.
You see a 31/2-year-old child in the emergency department who has had fever for the past week. The parents relate that their son has some swollen glands, fever, and now seems to be getting a rash on his arms. On examination, you find an uncomfortable appearing young boy whose vital signs are normal with the exception of a temperature of 104°F. You note t hat he has a red posterior oropharynx with dry, cracked lips. His TMs are normal. He has mild conjunctival injection bilaterally without any discharge. His chest is clear, and his heart sounds are normal. He does not have any hepatosplenomegaly. His has a lacy, confluent macular rash on his chest and upper arms, with mild peeling of the tips of his fingers.What is the most worrisome complication of this disease?
Answer(s): B
You see a 3-week-old infant in your office for an acute visit. She was born via spontaneous vaginal delivery following a term, uncomplicated prenatal course. The parents are concerned because they have seen some streaks of blood in her diaper over the past few days. The infant's stools have been soft and not difficult to pass. The parents relate that she is eating 2 oz every 2 hours of a cow's milk based formula.What is the carbohydrate source in most infant formula?
Most infant formulas are cow's milk based. The most common form of carbohydrate in these infant formulas is lactose. Soy formulas use corn syrup and/or sucrose as their source of carbohydrate. Casein is a form of protein. Human milk fortifier is a supplement added to breast milk for the premature infant and is a combination of protein and carbohydrate.GBS colitis is an uncommon disease in infants. Cow's milk protein intolerance is a common cause of blood-streaked stool in an infant on cow's milk based formulas. Lactose intolerance is very uncommon in an infant and usually causes chronic, nonbloody diarrhea. Pseudomembranous colitis would be a consideration in a child with diarrhea who recently had been on antibiotics.
You see a 3-week-old infant in your office for an acute visit. She was born via spontaneous vaginal delivery following a term, uncomplicated prenatal course. The parents are concerned because they have seen some streaks of blood in her diaper over the past few days. The infant's stools have been soft and not difficult to pass. The parents relate that she is eating 2 oz every 2 hours of a cow's milk based formula.What is the most likely cause of the blood in her stool?
Answer(s): C
Most infant formulas are cow's milk based. The most common form of carbohydrate in these infant formulas is lactose. Soy formulas use corn syrup and/or sucrose as their source of carbohydrate. Casein is a form of protein. Human milk fortifier is a supplement added to breast milk for the premature infant and is a combination of protein and carbohydrate.GBS colitis is an uncommon disease in infants. Cow's milk protein intolerance is a common cause of blood-streaked stool in an infant on cow's milk based formulas. Lactose intolerance is very uncommon in an infant and usually causes chronic, nonbloody diarrhea. Pseudomembranous colitis would be a consideration in a child with diarrhea who recently had been on antibiotics
In January, you see an 18-month-old boy in the middle of the night in the pediatric emergency department. The father relates that 1 hour ago his son started coughing. The father describes the cough as barking ("seal" like). The child has mild stridor at rest, but otherwise is not in respiratory distress. His RR is 45 breaths per minute. He has a temperature of 103.4°F .What is the most likely diagnosis?
This case is a common presentation for viral croup, with the symptoms of a seal-barking cough, stridor, tachypnea, and fever in the winter. Pneumonia must also be considered with tachypnea, cough, and fever, but it is less likely to cause stridor and may not have the seal-bark type of cough. Sinusitis may cause cough and fever, but would be more likely to have a purulent nasal discharge and less likely to have the typical croupy cough. Bronchiolitis due to RSV is a common cause of wintertime cough and fever. It is less likely to have stridor and more likely to have wheezing. Children with epiglottitis are typically found in the "tripod position" and may be drooling. It is, fortunately, becoming rare with the widespread use of the H. influenzae vaccine. Parainfluenza types 1 and 2 account for 6070% of all viral croup. HIB was a common cause of epiglottitis, but is now rare because of widespread vaccinations. Influenza B and RSV can cause croup, but not as commonly as parainfluenza types 1 and 2. S. pneumoniae would be the most common bacterial cause of pneumonia or sinusitis. (American Academy of Pediatrics, 2003, pp. 454455) The steeple sign is subglottic narrowing of the trachea seen on an AP view of the trachea or a CXR. The trachea is seen to narrow, almost to a point, like the steeple of a church. Swollen adenoids are difficult to identify in lateral neck x-rays. The presence of swollen adenoids is unrelated to the airway narrowing seen in croup. The thumb sign is a swollen epiglottis seen with epiglottitis. Alobar pulmonary infiltrate may be seen with a typical bacterial pneumonia.
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