INFECTIOUS DISEASE: PEARLS AND PITFALLS
From Pediatric Infections and Pulmonary Diseases, presented September 8-10, 2006, by Nemours
| INFECTIOUS DISEASES WALKING THROUGH YOUR OFFICE DOOR —Stephen C. Eppes, MD, Clinical Associate
Professor of Pediatrics, Jefferson Medical College, Philadelphia, PA, and Alfred I. duPont Hospital for Children, Wilmington,
DE
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| Case 1: 70-day-old previously healthy infant; 2-day history of diarrhea with small amount of blood, feeding less well, and
temperature recorded by parents (maximum 101°F); physical examination (PE) in office normal; stool culture performed;
child sent home on no antibiotics, with instructions for follow-up; next day, laboratory reports child’s stool
growing 4+ nonlactose fermenters; phone call to family finds child’s condition essentially unchanged; following day,
Salmonella species identified by laboratory; another phone call to family finds no change in child’s status
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 | Management: if not done before, take good history about potential exposures (does family have reptile? ask about food
preparation); recognize that young infants at risk for extraintestinal spread; start antibiotic; find out exact species and
susceptibility of pathogen from laboratory; monitor patient carefully; questions—should baby have been empirically
treated earlier? (possibly; especially if sufficient evidence to suspect bacterial pathogen); possible downsides to use of
antibiotics—unnecessary antibiotic exposure; prolonged carriage; risk for hemolytic uremic syndrome if pathogen Escherichia
coli 0157:H7 (unclear whether true downside)
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| Case 2: 16-yr-old girl admits to being sexually active; boyfriend admitted to being promiscuous; girl concerned and wants
test for exposure to HIV; simple blood test advised; however, patient afraid of needles and will leave office if blood test
performed; HIV blood test alternative—OraQuick ADVANCE Rapid HIV-1/2 Antibody Test; approved by Food and
Drug Administration (FDA) in 2004; uses saliva instead of blood; extremely sensitive and specific; positive results must
be confirmed with traditional blood test; currently performed in certified laboratories
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| Case 3: 4-yr-old child presents with lesions on face which have appeared 6 times in last year; medical history otherwise unremarkable;
no fever or systemic symptoms; child fully immunized; picks at lesions; lesions go through stages of papule,
blister, crusting, and scabbing (lasting ≈2 wk); differential diagnosis—impetigo; herpes simplex virus type 1 or
type 2 (HSV-1; HSV-2); herpes zoster; epidermolysis bullosa; linear IgA bullous dermatosis; diagnosis HSV-1 (confirm
by direct fluorescent antibody [DFA] test or viral culture)
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| Management: discuss with family (distinguish HSV-1 from HSV-2; discuss need for hygiene); question of whether to
follow with observation or treat; options for treatment—topical acyclovir (popular choice, but has little, if any, efficacy);
oral acyclovir (effective in treating recurrent herpes genitalis and herpes labialis); if ocular involvement, consult
ophthalmologist
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| Case 4: parents awakened at midnight by fluttering sounds in child’s room; father investigates, finds child sleeping peacefully;
when awakened, she seems fine; wind blowing, so he shuts open window; next morning, parents alarmed by
screaming of their daughter; father bursts into room and startled to see bat; shoos it out of window with broom; daughter
not sure whether she felt bat during night and does not appear to have any marks or scratches; management—
postexposure prophylaxis against rabies (exposure to bats one of most common ways people get rabies, even without obvious
bite or scratch; rabies almost 100% fatal)
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| Case 5: 16-mo-old child presents with 1-mo history of loose stools (2-3 per day) and flatulence, no fever; diet table food
and whole milk; had otitis media ≈2 mo ago, treated with amoxicillin; in day care 3 days/wk; family lives in suburbs;
no travel or unusual exposures; work-up done, including stool ova and parasite examination; 2 days later, laboratory
report shows cysts of Entamoeba coli, Dientamoeba fragilis, Blastocystis hominis, or Endolimax nana in stool (common
protozoal intestinal parasites but minimally pathogenic; E coli and E nana generally considered nonpathogenic;
main importance as markers for exposure to other pathogens; D fragilis and B hominis can cause low-grade symptoms)
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| Management: for E coli or E nana, no treatment required; for D fragilis or B hominis, options include metronidazole
(probably first-line agent); if patient does not respond to medical therapy, consider alternative diagnosis
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| Case 6: unimmunized infant diagnosed with pertussis; antibiotic treatment of infant and antibiotic prophylaxis for family
members required; no antibiotic allergies in family members; potentially useful antibiotics—American Academy of Pediatrics
(AAP) 2006 Redbook lists azithromycin, clarithromycin, and erythromycin as effective first-line choices for pertussis
treatment and prophylaxis (for infants <1 mo of age, azithromycin drug of choice); trimethoprim–sulfamethoxazole
recommended for patients intolerant of macrolides
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| Case 7: otherwise healthy child finds syringe on playground in lower middle class area of large city; child “plays nurse” with
your patient and punctures her with needle; puncture reportedly drew blood; within ≈2 hr, child brought to your office by
parent; has tiny puncture wound but PE otherwise normal
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| Questions: parent’s—is my child going to get HIV? physician’s—likely origins of discarded needle; size of needle
(large needle and hollow-bore needle more likely to transmit HIV than small needle); was there visible blood in syringe
(known risk factor for HIV transmission from needlestick)? depth of puncture wound (deep wound more likely to
transmit HIV than superficial scratch); immunization status of patient (make sure child immunized for tetanus and hepatitis
B)
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| Risks for transmission of: HIV—extremely low, <0.3% associated with health care worker injuries (no documented case in
United States of child getting HIV from playing with discarded needle); hepatitis B—hardiest of blood-borne viruses, but
risk still low; hepatitis C—risk also extremely low
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| Management: acute wound care; tetanus prophylaxis (if appropriate); hepatitis B series if not already done (if child has
had <2 doses of vaccine, consider giving hepatitis B immune globulin in addition to hepatitis B series); baseline HIV
testing controversial (however, if initial testing performed, child requires follow-up testing at ≈6 wk or 3 mo); postexposure
prophylaxis with antiretroviral drugs extremely controversial and not routinely recommended; counseling and
reassurance
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| Case 8: mother brings 11-yr-old son to office because of concern he might have fifth disease (erythema infectiosum);
mother 16 wk pregnant and obstetrician advised she might need to be isolated from son; on PE, child has classic skin
findings (“slapped cheeks”; papulopurpuric glove stocking [PPGS] presentation of parvovirus B19); diagnosis
erythema infectiosum
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| Questions: risks for child; risks of potential exposure for pregnant mother; do mother and son need to be isolated from
each other?
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| Facts: in most children, parvovirus B19 causes minor self-limited illness (more serious in immunocompromised patients
or those with blood disorders); ≈50% of people immune to virus by adulthood; by time rash develops, patient usually
not infectious; parvovirus B19 infection can cause congenital anemia (leading to fetal hydrops and death), but unusual
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| Treatment: mother and child do not need to be isolated from each other; low risk for fetal infection should be explained to
mother (and father); option of serologic testing for mother
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| Case 9: 3-yr-old boy who attends day care presents with otalgia and low-grade fever; examination shows bulging left tympanic
membrane without landmarks; history of rash with amoxicillin at ≈2 yr of age; mother reports allergy to cephalosporins
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| Treatment options: antibiotic choices—no antibiotics; high-dose amoxicillin; high-dose amoxicillin and potassium clavulanate;
cefdinir; intramuscular (IM) ceftriaxone; azithromycin; clindamycin plus trimethoprim-sulfamethoxazole; recommended
management—observation; azithromycin; cefdinir
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| WHEN TO PROMOTE OR DISCOURAGE OPTIONAL IMMUNIZATIONS —Henry M. Feder, Jr, MD, Professor of Pediatrics
and Family Medicine, University of Connecticut Health Center, Connecticut Children’s Medical Center, Farmington
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Meningococcal Vaccine
| Invasive meningococcal disease: 3000 cases/yr in United States; fatality rate 40% in patients who develop overwhelming
sepsis, ≤10% in those who develop meningitis; annual incidence 1.4 cases per 100,000 in general population, 6.4 per
100,000 in children <2 yr of age, 3.0 per 100,000 in patients 13 to 14 yr of age, 3.6 per 100,000 in those 17 to 18 yr of age
(ie, while incidence tends to decline with age, still double that of general population in those just about to enter high
school and college)
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| Antibiotic prophylaxis for close contacts recommended for: college students living under same roof; day care exposures;
medical exposures (only in extenuating circumstances, eg, mouth-to-mouth resuscitation; casual exposure to disease
in room associated with low risk for contagion); incubation period after exposure 1 to 10 days; options for
prophylaxis—ciprofloxacin (easiest regimen; 1 dose; worth considering in younger children); rifampin (4 doses); IM
ceftriaxone (1 dose)
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| Comments: case of University of Virginia student who drank from keg of beer and diagnosed following day with Neisseria
meningitides (concern over contagion led to prophylaxis being given to all other students who drank from keg); case of
airline passenger who died from meningitis (no documented case of getting disease from being on airplane with individual
who has N meningitides infection); room for judgment on when to give postexposure prophylaxis (but if patient
frightened or worried, prophylaxis with rifampin or ciprofloxacin good way to alleviate fears); meningococcal vaccine
does not protect against N meningitides subtype B (accounts for at least 25% to 35% of cases of meningococcal infection
in United States); reason for recommending N meningitides vaccination for all students is “blip” in number of cases that
start in high school
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Hepatitis A Vaccine
| Hepatitis A: spread person to person; incubation period 4 wk; most contagious 1 to 2 wk before developing illness; previously
documented food- and water-borne outbreaks (case example of disease caused by green onions in restaurant salsa)
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| Efficacy of vaccination against person-to-person spread: county in California had high incidence of hepatitis A (25
cases per 100,000); hepatitis A vaccine offered to children 2 to 12 yr of age; incidence of disease subsequently dropped to
2 per 100,000; led to recommending vaccination for all children; vaccinating at 1 yr of age causes incidence of hepatitis
A to drop even lower; vaccine now recommended for all children ≥1 yr of age
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| Comments: hope is that by giving vaccination to all children ≥1 yr of age, incidence of hepatitis A eventually reduced to
virtually zero (eliminates concern associated with international travel; currently, 1 in 1000 chance of developing hepatitis
associated with taking 2-wk trip to developing country); case example of salad handler at McDonald’s infected with hepatitis
A; hepatitis A in children usually milder, asymptomatic disease; in adults, severity of disease increases with age
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Influenza Vaccine
| Influenza symptoms: abrupt onset of fever; muscle aches; headache (often located right behind eye); fever, dry cough;
sore throat; runny nose
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| Comments: clinical diagnosis of influenza, even during flu season, correct in 50% of cases (difficult to distinguish from
other respiratory illnesses); rapid flu tests improved and quite helpful
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| Influenza pandemics: influenza (1918-1919); Asian flu (1957); Hong Kong flu (1968); swine flu (1976)
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| Recommendations for influenza vaccination: 30 yr ago, vaccine recommended for people at high risk and >65 yr of age;
over time, expanded to high-risk people and patients >50 yr of age; then those >50 yr of age and children 6 to 24 mo of
age; then >50 yr of age and children 6 to 72 mo of age; some now recommending offering vaccine year round (not just
October through December); in 2006, expected 100 to 120 million doses of vaccine available; ultimately, speaker believes,
vaccine will be recommended for everybody
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| Influenza treatment: in many viral infections (including influenza), by time patient sick, too late for treatment to be helpful;
eg, in studies, zanamivir decreases symptoms of influenza from 6.5 days to 5.0 days; oseltamivir treatment reduces
symptoms from 4.5 days to 3.0 days; these drugs may be helpful when family member has already developed influenza
and another member starts to become ill; clinician knows flu present and knows to start medication early (when it can be
most effective); amantidine and rimantidine less expensive alternatives to zanamivir and oseltamivir; however, influenza
of 2005 resistant to these medications
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| Efficacy of vaccination against influenza: in study comparing vaccination and placebo, degree of fever, fatigue, and muscle
pain equal, and vaccination caused great amount of arm pain; however, patients who received vaccination had fewer respiratory
illnesses, fewer days missed from work, and fewer doctor visits
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| Bird flu: extremely dangerous disease in humans; since 2003, total of 239 documented cases of bird influenza; 58.6% fatal;
normal human influenza localized to lungs and respiratory tree and not very invasive; however, bird flu spreads throughout
body; most people who developed disease caught it from intimate living conditions with birds; cases of bird flu resistant
to oseltamivir
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Educational Objectives
| The goal of this program is to provide a better understanding of how to identify and treat some of the infectious diseases
that may present in the pediatrician’s office, and to review the indications for optional vaccines such as those against Neisseria
meningiditis, hepatitis A, and influenza. After hearing and assimilating this program, the clinician will be better able
to:
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| 1. Identify and effectively treat pediatric bacterial pathogens, including Salmonella, herpes simplex virus type 1 (HSV-
1), Entamoeba coli, and parvovirus 19.
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| 2. Recognize clinical manifestations of infectious diseases such as erythema infectiosum.
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| 3. Advise parents on the risks for transmission of disease (eg, HIV) and provide appropriate treatment for the child who
has had contact with a discarded needle.
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| 4. Cite the incidence of and risks for transmission of invasive meningococcal disease, as well as some of the current indications
for antibiotic prophylaxis after close contact.
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| 5. Discuss the indications for meningococcal, hepatitis A, and influenza vaccines.
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Discussed on This Program
Acyclovir (acycloguanosine) [Zovirax]
Amantadine HCl [Symmetrel]
Amoxicillin [Amoxil, Amoxil Pediatric Drops, Trimox, Trimox Pediatric Drops]
Amoxicillin and potassium clavulanate (co-amoxiclav) [Augmentin, Augmentin ES-600, Augmentin XR]
Azithromycin [Zithromax, Zmax]
Cefdinir [Omnicef]
Ceftriaxone sodium [Rocephin]
Ciprofloxacin [Ciloxan, Cipro, Cipro I.V., Cipro XR, Proquin XR]
Clarithromycin [Biaxin, Biaxin XL]
Erythromycin [Akne-Mycin, A/T/S, Emgel, Eryderm 2%, Erygel, Ery Pads, Ilotycin]
Hepatitis A vaccine, inactivated [Havrix, Vaqta]
Hepatitis A, inactivated and hepatitis B, recombinant vaccine [Twinrix]
Influenza virus vaccine [Fluarix, FluMist, Fluvirin, Fluzone]
Meningococcal polysaccharide vaccine [Menomune-A/C/Y/W-135, Menactra]
Metronidazole [Flagyl, Flagyl 375, Flagyl ER, Flagyl IV, Flagyl IV RTU, Metric 21, MetroCream, MetroGel, MetroGel-
Vaginal, MetroLotion, Noritate, Protostat]
Oseltamivir phosphate [Tamiflu]
Rifampin (rifampicin) [Rifadin, Rimactane]
Rimantadine HCl [Flumadine]
Trimethoprim-sulfamethoxazole (co-trimoxazole; TMP-SMZ) [Bactrim, Bactrim DS, Bactrim IV, Bactrim Pediatric,
Cotrim, Cotrim D.S., Cotrim Pediatric, Septra, Septra DS, Septra IV, Sulfatrim]
Zanamivir [Relenza]
Suggested Reading
Ambrose CS et al: Live attenuated influenza vaccine in children. Semin Pediatr Infect Dis 17:206, 2006; Andre FE: Universal
mass vaccination against hepatitis A. Curr Top Microbiol Immunol 304:95, 2006; Broder KR et al: Preventing tetanus,
diphtheria, and pertussi.among adolescents: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis
vaccines recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 55:1,
2006; Broliden K et al: Clinical aspects of parvovirus B19 infection. J Intern Med 260:285, 2006; Chiu CH et al: Salmonella
enterica serotype Choleraesuis infections in pediatric patients. Pediatrics 117: e1193-6, 2006; Delaney KP et al: Performance
of an oral fluid rapid HIV-1/2 test: experience from four CDC studies. AIDS 20:1655, 2006; Feder HM Jr:
Zanamivir to prevent influenza. N Engl J Med 344:528, 2001; Feder HM Jr et al: Bat bite? Lancet 350:1300, 1997; Feder
HM Jr, Hoss DM: Herpes zoster in otherwise healthy children. Pediatr Infect Dis J 23:451, 2004; Gardner P: Clinical
practice. Prevention of meningococcal disease. N Engl J Med 355:1466, 2006; Hoey J, Todkill AM: Bat rabies after undetected
exposure: implications for prophylaxis. CMAJ 157:55, 1997; Jefferson T: Influenza vaccination: policy versus evidence.
BMJ 333:912, 2006; Milstone AM et al: Alerting pregnant women to the risk of reptile-associated salmonellosis.
Obstet Gynecol 107:516, 2006; Munoz FM: Pertussis in infants, children, and adolescents: diagnosis, treatment, and prevention.
Semin Pediatr Infect Dis 17:14, 2006; Nolan T et al: Immunogenicity and safety of an inactivated hepatitis A vaccine
administered concomitantly with diphtheria-tetanus-acellular pertussis and haemophilus influenzae type B vaccines to
children less than 2 years of age. Pediatrics 118:e602, 2006; Pichichero ME: The new meningococcal conjugate vaccine.
A profile of its safety, efficacy, and indications for use. Postgrad Med 119:47, 2006; Prcic S et al: Erythema infectiosum in
children. A Clinical study. Med Pregl 59:5, 2006; Rupp R et al: Vaccination: an opportunity to enhance early adolescent
preventative services. J Adolesc Health 39:461, 2006; Temte JL: Breaking the chain: universal childhood hepatitis A virus
vaccination. Am Fam Physician 73:2127, 2006; Toney JF: Skin manifestations of herpesvirus infections. Curr Infect Dis
Rep 7:359, 2005; Willoughby RE Jr, Hammarin AL: Prophylaxis against rabies in children exposed to bats. Pediatr Infect
Dis J 24:1109, 2005; Wright PF: The use of inactivated influenza vaccine in children. Semin Pediatr Infect Dis 17:200,
2006; Wyndham M: Slapped cheek syndrome. Community Pract 79:48, 2006.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue, there is nothing
to report.
Drs. Eppes and Feder spoke at Pediatric Infections and Pulmonary Diseases, held September 8-10, 2006, in Rehoboth,
DE and presented by Nemours. The Audio-Digest Foundation thanks Drs. Eppes and Feder, and Nemours for their
cooperation in the production of this program.
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