QUESTION: 353

An 8-year-old male presents to your office complaining of a 1-week history of painful knee and elbow joints. On examination, you find a painful, hot, and swollen knee. He also has multiple erythematous macules with pale centers on his trunk and extremities. The laboratory work you order reveals elevated antistreptococcal antibodies.

Which of the following information is required to make this diagnosis?

The child must currently have a fever.
The child must have arthritis.
The presence of a group A streptococcal (GAS) infection must be documented.
The child may have chorea alone.
Aspiration of fluid from the swollen knee is required to confirm the diagnosis.

Answer(s): D

Explanation:

ARF is clinically diagnosed by using the Jones criteria. The Jones criteria are separated into major and minor findings. The major criteria are arthritis (not simply arthralgia), carditis, Sydenham chorea, erythema marginatum, and subcutaneous nodules. The minor criteria include the presence of a fever, arthralgias, documentation of a GAS infection (either currently or in the past), or laboratory evidence of inflammation (increased ESR). Two major criteria, or one major and two minors, are required for the diagnosis of ARF. The only exception to this rule is that the presence of Sydenham chorea alone will make the diagnosis. While the documentation of a prior, or current, GAS infection is compelling, it is not a requirement for the diagnosis of ARF. Children with rheumatic fever are not considered contagious.

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QUESTION: 354

On a Monday morning you see a 12-year-old otherwise healthy boy in the emergency department. The parents brought the boy in because they noticed that he started to have an abnormal gait in the past few days. He seems to be shuffling his feet. The boy complains that his legs feel heavy and are tingling. He relates that his arms feel fine. His past history is significant for attention deficit/hyperactivity disorder (ADHD) for which he is taking methylphenidate. He denies trauma or taking any other medicines or drugs. On examination, he is afebrile with normal vital signs. His entire physical examination is normal with the exception of the examination of is lower extremities. He has 3/5 strength throughout both of his lower extremities with a normal muscle mass. His all joints have a full range of motion, without any pain or swelling. His reflexes are absent and he describes some paresthesias of his feet and ankles.

What is the most likely diagnosis?

methylphenidate toxicity
acute inflammatory demyelinating polyneuropathy (Guillain-Barré syndrome)
acute poliomyelitis
malingering (school avoidance)
polymyositis

Answer(s): B

Explanation:

Acute inflammatory demyelinating polyneuropathy, commonly called Guillain-Barré syndrome, is an ascending paralysis with a hallmark of absent reflexes. There may also be some nominal sensory deficits as well, but they are not as striking as the paresis. Methylphenidate toxicity usually results in seizures and tachycardia. In children with malingering, reflexes are usually present, as they are not under cognitive control. Reflexes are also present in children with polymyositis. Children with polymyositis will usually have fever and muscle pain with weakness, as well. With the use of the polio vaccines (OPV or IPV), poliomyelitis is no longer present in wild type in the United States. Guillain- Barré is usually a self-limited disease.
The most common complication is respiratory failure. The paresis usually advances for 4872 hours and then will slowly recede. The use of corticosteroids is not recommended. Plasmaphoresis is used in the following situations: progressive paresis, nonambulatory patients, or bulbar or respiratory involvement. As this child's disease has plateaued at the time of evaluation, plasmaphoresis would be of little benefit.

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QUESTION: 355

On a Monday morning you see a 12-year-old otherwise healthy boy in the emergency department. The parents brought the boy in because they noticed that he started to have an abnormal gait in the past few days. He seems to be shuffling his feet. The boy complains that his legs feel heavy and are tingling. He relates that his arms feel fine. His past history is significant for attention deficit/hyperactivity disorder (ADHD) for which he is taking methylphenidate. He denies trauma or taking any other medicines or drugs. On examination, he is afebrile with normal vital signs. His entire physical examination is normal with the exception of the examination of is lower extremities. He has 3/5 strength throughout both of his lower extremities with a normal muscle mass. His all joints have a full range of motion, without any pain or swelling. His reflexes are absent and he describes some paresthesias of his feet and ankles

Which of the following is the most appropriate initial management plan?

hospitalization and close observation for progression of his weakness
high-dose corticosteroids
gastric lavage and activated charcoal
outpatient family counseling
plasmaphoresis

Answer(s): A

Explanation:

Acute inflammatory demyelinating polyneuropathy, commonly called Guillain-Barré syndrome, is an ascending paralysis with a hallmark of absent reflexes. There may also be some nominal sensory deficits as well, but they are not as striking as the paresis. Methylphenidate toxicity usually results in seizures and tachycardia. In children with malingering, reflexes are usually present, as they are not under cognitive control. Reflexes are also present in children with polymyositis. Children with polymyositis will usually have fever and muscle pain with weakness, as well. With the use of the polio vaccines (OPV or IPV), poliomyelitis is no longer present in wild type in the United States. Guillain- Barré is usually a self-limited disease.
The most common complication is respiratory failure. The paresis usually advances for 4872 hours and then will slowly recede. The use of corticosteroids is not recommended. Plasmaphoresis is used in the following situations: progressive paresis, nonambulatory patients, or bulbar or respiratory involvement. As this child's disease has plateaued at the time of evaluation, plasmaphoresis would be of little benefit.

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QUESTION: 356

You are called to see a 12-hour-old male infant who was born to a 19-year-old G1 woman with no prenatal care. She presented to the emergency room completely dilated and crowning. The baby was born minutes later. On examination, the baby is febrile and tachypneic. A CXR confirms the presence of pneumonia.

What is the most likely infectious agent?

group B Streptococcus (GBS)
HSV
E. coli
respiratory syncytial virus (RSV)
Streptococcus pneumoniae

Answer(s): A

Explanation:

GBS is the most common cause of infection in the newborn infant, followed by E. coli and L. monocytogenes. GBS is the most common cause of pneumonia, septicemia, UTI, and meningitis. The risk of early-onset (within the first 7 days of life) GBS infection can be reduced with the antenatal administration of appropriate antimicrobials. The use of perinatal antimicrobials has no effect on the occurrence of late- onset (after 7 days of life) GBS disease.

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QUESTION: 353

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QUESTION: 354

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QUESTION: 355

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QUESTION: 356

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