All the NICU Babies
Bugs &
Animals
It's all about Location
What should I do now?
Name that infection
100
The use of ointment in a newborn’s eye is useful for preventing what infection?
Answer: Gonorrhea Teaching points: Contrary to popular belief, the use of eye prophylaxis is only beneficial in preventing gonorrheal infection, NOT Chlamydia trachomatis infection
100
A 5 year old girl presents after a cat scratch with a 1 week history of a tender lymph node (the scratch was to her left hand) What is the name of the organism most likely responsible for her disease?
Answer: Bartonella henslae Teaching points: Treatment is supportive and the key is to NOT I&D the lymph node Azithromycin has been shown to reduce the time for lymph node swelling to resolve
100
A child from upstate New York presents with erythema migrans. What serology (if any) should you order on this patient?
Answer: None! (Trick Question) Teaching points: you were thinking lyme disease and to order lyme serology, but the reality is that with the presence of the pathognomonic rash of erythema migrans, you have already made the diagnosis clinically, serology is not indicated Commonly lyme serology is very inaccurate and not specific Also this is an early infection, the serology could easily be negative
100
You spend one hour to examine a child with fever and purpura. It is later determined that the child has meningococcemia. As a primary care physician examining a child with meningococcemia in close contact, should you receive prophylaxis?
Answer: No Teaching points: For health care workers, we should only receive prophylaxis for meningococcus if we have had “intimate oral contact” which is defined as intubating the patient or performing mouth-to-mouth resuscitation Otherwise we can live with the patient in the household, go to daycare with the patient, or sit directly next to them on an airplane for more than 8 hours, all without requiring prophylaxis
100
A child presents with a history of an itchy bottom. The mother reports that she saw some ‘rice’ in the stool yesterday. What is the most likely diagnosis?
Answer: Pinworms Teaching points: Pinworm is very common infection The worm is called Enterobius vermicularis Diagnose by ‘scotch tape test’ which allows you to see eggs under the microscope Occasionally you can see them in the perianal region – look like rice or spaghetti
200
A newborn presents with microcephaly, hydrocephalus, hepatosplenomegaly, maculopapular rash, chorioretinitis, and cerebral calcifications that are widespread. What is the diagnosis?
Answer: Congenital toxoplasmosis Teaching points: Problem with women who BECOME infected DURING the pregnancy Risk of congenital infection increases as the pregnancy progresses from 25% in first trimester to 65% in last trimester. Severity of disease is inverse to this, with those infants infected early in pregnancy more likely to be severely affected as this child was Cerebral calcifications that “CircuMVent” the ventricles are more likely to be from CMV
200
What is the most common organism to cause infection in a cat bite?
Answer: Pasturella Teaching points: Pasturella is the #1 cause of infection in a cat bite, followed by Staph aureus. Generally all cat bites are treated because cats have puncture like teeth Drug of choice is amoxicillin-clavulanate
200
A 13 year old from Missouri presents with: interstitial pneumonia, palate ulcers and splenomegaly. What is the most likely diagnosis?
Answer: Histoplasmosis is seen in Mississippi and Ohio River valleys Teaching points: Associated with bird and bat droppings KEY: Remember that histoplasmosis has a pneumonia with splenomegaly similar to C. psittaci infection, but histoplasmosis commonly has the palatal ulcers KEY: "histoplasMOsis" (Mississippi/Ohio)
200
A 2 year old presents with an enlarged, matted anterior cervical lymph nodes that combined measure about 3 x 6 cm. The nodes have been painless. A PPD is placed and it is 8 mm. The nodes have been persistent for 2 months despite various courses of antimicrobials including cephalexin and amoxicillin-clavulanate. What is the next best management at this time?
Answer: complete excision of the nodes Teaching points: This is lymphadenitis, most likely due to atypical mycobacteria either M. scrofulaceum or M. avium-intracellulare These are best treated by complete excision of the nodal complex Do not incise the node- it will cause a chronic draining lesion (Review: In a normal child, this PPD of 8 is negative)
200
A 17 year old girl presents with: low grade fever, cough, wheezing, and negative cold agglutinins. What is the most likely etiology for this patient’s PNA?
Answer: Chlamydophilia pneumoniae Teaching points: Chlamydophilia pneumoniae is a common cause of PNA in adolescents For the atypicals, probably only 2nd to Mycoplasma. Can be treated with macrolides including doxycycline, erythromycin, or axithromycin
300
An 8 day old infant presents with macules on the scalp that have become vesicular with a red base in the last few hours. They appear to be at the site of previous scalp electrode. The mother wonders if this is infected. Her maternal serologies were negative. What is the most likely diagnosis?
Answer: Neonatal HSV Teaching points: HSV that is isolated to the SEM region (Skin, Eye, Mucus membrane) are 40% of cases, 35% in CNS only, and 25% are disseminated. Commonly the mother has NO HISTORY of herpes infection!! Mention of scalp electrode increases the risk! These are commonly misdiagnosed as staphylococcal infection so BE CAREFUL!
300
A 13 year old girl who lives on a turkey farm, presents with: fever to 105 F, myalgias, rigors, pneumonia, and splenomegaly. What is the most likely etiology?
Answer: Chlamydophilia psittaci Teaching points: Think of this with PNA + splenomegaly Also think about Histoplasma but that is less likely to cause an indolent disease
300
A patient is from North Carolina and presents with: fever, headaches, arthralgias, maculopapular rash on extremities that has become more petechial, serum sodium is 128 and platelets are 110,000. What is the most likely diagnosis?
Answer: Rocky Mountain Spotted Fever Teaching points: This is the classic scenario RMSF is due to Rickettsi rickettsia Tick borne disease found in mid-atlantic states
300
What time frame determines which newborns should be given VariZIG (varicella immune globulin) if their mothers develop chicken pox in the perinatal period?
Answer: Newborns whose mothers had varicella < 5 days before to 48 hours after delivery should receive varicella immune globulin! These infants are at high risk for severe varicella infection!
300
A Caucasian boy presents with hypopigmented scaly lesions on his chest and back that worsen when he plays football in the hot sun. What is the diagnosis?
Answer: Tinea versicolor Teaching points: Tinea versicolor is due to Malassezia infection Organism is commonly seen in adolescents, especially if there is exposure to heat and moisture (ex. Football practice) or if occlusive clothing is being worn Doing a skin scraping will show classic ‘spaghetti and meatballs’ organisms Treat with topical itraconazole
400
A NICU infant is found to have an IV catheter infection with candida albicans. How should this be managed?
Answer: Remove the catheter and start systemic antifungals Teaching points: Key point: fungal line infections, the catheter MUST be removed and you should NOT try to ‘treat through’ and ‘clear’ the infection without removing the catheter Antifungals vary by institution, but fluconazole or an echinocandin are acceptable
400
A 9 year old boy presents with history of travel to Rocky Mountains for a camping trip this summer. He has watery, smelly diarrhea for the last week and multiple episodes of daily flatulence. His mother says that he has been burping a lot and it smells like sulfur. What is the most likely diagnosis?
Answer: Giardias Teaching points: Giardia is the most common disease-causing parasite in the US Acute symptoms are watery smelly diarrhea and flatulence “sulfuric burping’ is very common Diagnosis made by checking stool for Giardia specific antigen
400
A 14 year old boy from Hawaii presents with the following: history of swimming in fresh water lagoon, fever, myalgias, headache, jaundice. His labs reveal elevated bilirubin which is disproportionate compared to ALT/AST and creatinine of 1.9. What is the most likely diagnosis?
Answer: Leptospirosis Teaching points: A spirochetal disease transferred by contact with contaminated water or infected animals Rat and dog urine are the most common vectors Hawaii has the most cases in the US This is a disease that is biphasic with an initial systemic febrile illness with eventual (7 days later) hepatic and renal insufficiency that develops Diagnose with urine studies after 4-7 days of illness
400
A girl presents with chicken pox. When are chicken pox contagious?
Answer: From 1-2 days BEFORE the rash until ALL the lesions are crusted over Teaching points: Children may return to daycare only when all lesions have crusted over Those exposed in the hospital should be on isolation from days 10-21 after exposure
400
A 17 year old presents with: pneumonia, diarrhea, and CNS symptoms (headache/delirium/confusion) What is the most likely etiology of this triad?
Answer: Legionella pneumophilia Teaching points: Classic triad (PNA, diarrhea, CNS symptoms) Commonly associated with outbreaks related to contaminated water towers or air-conditioning water units in buildings, hotels, cruise ships, and hospitals
500
A neonate presents with fever and a blood culture growth citerobacter. What is the next test you should consider ordering?
Answer: CT or MRI of the head. Teaching points: You should be very concerned about a brain abscess and should order a CT or MRI of the head Citerobacter bacteremia has a high incidence of brain abscesses
500
A 17 year old works at a pet store spending most of his days cleaning the fish tanks. He has skin ulcerations on his right arm for several weeks that are unresponsive to cephalexin. Additionally he was treated with doxycycline for MRSA without improvement. What is the most likely etiology for his persistent skin ulcerations?
Answer: Mycobacterium marinum Teaching points: Mycobacterium marinum is the ‘fish tank bacillus’ It causes nonhealing skin ulceration in people working around fish tanks Often lesions are along lymphatic channels Treatment is with ethambutol + rifampin or clarithromycin + rifampin
500
A 5 year old boy from rural Arkansas presents with: fever to 102 F, swollen lymph node in right groin area. What is the most likely diagnosis?
Answer: Tularemia Teaching points: On the boards, if you see a child from Arkansas (or Missouri or Oklahoma area) and they have swollen lymph node with fever, go for tularemia Caused by Francisella tularensis Rat exposure Treat with gentamycin or doxycycline if they are not that ill (but increased risk of relapse)
500
A 2 month old presents with no fever, staccato cough, and CXR evidence of PNA. What is the most likely cause of this infant's PNA?
Answer: Chlamydia trachomatis Teaching points: Chlamydia trachomatis is responsible for neonatal PNA in the 1st 4 months of life The newborn is infected at birth due to transit through the infected birth canal Classically, the cough is described as a persistent staccato cough WITHOUT fever
500
A child has a persistent tooth abscess that has been ignored for several weeks. Now he presents with drainage on the outside skin lateral to the infected molar. Stains of the drainage show a yellow ‘sulfur’ granules. What is the most likely diagnosis?
Answer: Actinomyces Teaching points: Actinomyces is a microaerophilic/ facultative anaerobic organism that causes an infection in which staining yellow “sulfur” granules that are actually organisms Most commonly associated with dental infections Can also cause PID in adolescents
M
e
n
u