Pediatrics

Congenital infections often present with distinct clinical syndromes in the neonatal period. Identify the correct causative pathogen for each of the described neonatal clinical presentations.

A 12-month-old boy is brought to the pediatric clinic for a routine well-child visit. Two weeks ago, he experienced a mild upper respiratory tract infection characterized by clear rhinorrhea, a low-grade fever, and a mild cough. These symptoms have completely resolved. Today, he appears well, active, and playful. His temperature is 37.1°C (98.8°F), pulse is 110/min, and respirations are 24/min. Otoscopic examination of the right ear reveals an amber-colored, retracted tympanic membrane with decreased mobility on pneumatic otoscopy; there is no bulging or erythema. Lung auscultation reveals a few scattered expiratory wheezes that clear completely after the child coughs. The mother expresses concern that her son only says "mama" and "dada" and is not yet speaking in two-word phrases. She asks if he needs antibiotics to "clear up whatever is in his ear." Which of the following is the most appropriate next step in the management of this patient?

During morning rounds, the pediatric team evaluates a $13$-month-old male infant who was admitted $48$ hours ago for a febrile urinary tract infection. He has a past medical history of acute lymphoblastic leukemia and is currently receiving maintenance chemotherapy. Upon admission, he was started on empiric intravenous ceftriaxone. Today, he is afebrile and tolerating a regular diet. Urine cultures from admission have grown \textit{Escherichia coli} ($>100,000 \text{ CFU/mL}$) that is resistant to ampicillin but susceptible to cephalexin, ceftriaxone, and trimethoprim-sulfamethoxazole.

Additionally, since yesterday, the patient has developed copious rhinorrhea and a frequent cough. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), heart rate is $110/\text{min}$, and respiratory rate is $36/\text{min}$. Pulse oximetry shows $97\%$ on ambient air. Physical examination reveals clear nasal discharge and diffuse expiratory wheezing bilaterally without intercostal retractions. A viral multiplex polymerase chain reaction panel is positive for respiratory syncytial virus (RSV).

The infant's mother notes he missed his $12$-month wellness visit due to his oncology treatments and requests that all overdue immunizations be administered before he is discharged. She also expresses concern that he is delayed because he only cruises along furniture and cannot yet walk independently without support.

Which of the following is the most appropriate comprehensive management plan for this patient at discharge?

A previously healthy $9$-month-old female infant presents to an urgent care center with a five-day history of persistent high temperatures, a harsh barking-like cough, and a severely runny nose. Her parents note that she has been rubbing her excessively red, tearing eyes. The family recently moved from a rural region in a developing country, and the infant has not received any childhood immunizations. On triage, her temperature is $39.7^\circ\text{C}$ ($103.5^\circ\text{F}$), pulse is $158\text{/min}$, and respirations are $48\text{/min}$. Pulse oximetry is $96\%$ on room air. Examination of the oropharynx reveals tiny white lesions on the inner cheeks that resemble grains of salt on a red background. Additionally, a non-pruritic, erythematous, maculopapular exanthem is visible starting at the forehead and extending downward to the neck and upper shoulders. Auscultation of the chest demonstrates coarse breath sounds bilaterally without wheezing. Which of the following is the most appropriate next step in management?

A 4-year-old boy is brought to the emergency department by ambulance due to altered mental status and fever. The parents state that he complained of a severe headache and photophobia yesterday before becoming progressively lethargic. His immunizations are incomplete. On examination, the patient is obtunded and grimaces only to painful stimuli. Temperature is $39.6^\circ\text{C}$ ($103.3^\circ\text{F}$), pulse is $152/\text{min}$, blood pressure is $82/48\text{ mm Hg}$, and respirations are $26/\text{min}$. Physical examination reveals nuchal rigidity. The right pupil is $5\text{ mm}$ and sluggish, while the left pupil is $3\text{ mm}$ and briskly reactive. Papilledema is present on fundoscopy. Arrange the following next steps in management in the most appropriate chronological order.

A male neonate is born at $38$ weeks of gestation via induced vaginal delivery at a tertiary care center. Prenatal ultrasonography at $22$ weeks revealed a left-sided congenital diaphragmatic hernia. At birth, the infant has a scaphoid abdomen and a barrel-shaped chest. He exhibits significant respiratory distress with severe intercostal retractions and central cyanosis. The heart rate is $145$/min. Arrange the following management steps in the correct chronological sequence for this patient.

A 12-day-old female neonate is evaluated in the neonatal intensive care unit for sudden-onset lethargy and temperature instability. She was born at 28 weeks of gestation via spontaneous vaginal delivery secondary to preterm premature rupture of membranes. Her birth weight was 1,050 g, and Apgar scores were 5 and 7 at 1 and 5 minutes, respectively. Over the past week, she had been tolerating incrementally advanced nasogastric feeds with premature infant formula. Current vital signs show a temperature of $35.4^\circ\text{C}$ ($95.7^\circ\text{F}$), heart rate of 175/min, and respiratory rate of 68/min with occasional apneic pauses. Physical examination reveals an ill-appearing neonate with a tensely distended abdomen and prominent abdominal wall erythema. Bowel sounds are absent. A recent diaper change revealed a grossly bloody stool.

Laboratory studies are as follows:

Which of the following is the most appropriate next step in the management of this patient?

An anxious mother brings her 11-month-old daughter to an outpatient clinic in mid-January, reporting that the infant has been struggling to breathe for the past 12 hours. The illness began three days ago with a runny nose and a low-grade fever. The mother notes that the child is now making a continuous whistling sound when she breathes out. The infant was born at term and her immunizations are up to date. The mother also mentions a secondary concern: she is worried her daughter is developmentally delayed because she can only cruise along furniture and is not yet walking independently without support. Vital signs include a temperature of $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), a pulse of $145/\text{min}$, respirations of $58/\text{min}$, and an oxygen saturation of $94\%$ on room air. Physical examination reveals an alert infant with clear nasal discharge. Chest auscultation reveals prolonged expiration with diffuse polyphonic wheezes and mild subcostal retractions. A rapid antigen detection test from a nasopharyngeal swab is positive for respiratory syncytial virus (RSV). Which of the following is the most appropriate next step in the management of this patient?

An $18$-day-old male infant is brought to the pediatric emergency department due to a $24$-hour history of fever, irritability, and poor feeding. The infant was born full-term at $39$ weeks gestation via an uncomplicated spontaneous vaginal delivery and was discharged home on the second day of life.

Vital signs show a temperature of $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), a heart rate of $185/\text{min}$, and a respiratory rate of $58/\text{min}$. Physical examination reveals a lethargic infant who cries inconsolably when handled. The anterior fontanelle is full and tense. The infant's skin exhibits numerous $1$- to $2$-$\text{mm}$ pearly white papules across the nasal bridge and cheeks without surrounding erythema. Auscultation of the lungs is clear, and capillary refill is $3$ seconds.

Which of the following is the most appropriate next step in management?

Match each pediatric patient's clinical presentation with the most appropriate empiric or targeted first-line pharmacological therapy.

At 2 hours of life, a male newborn is assessed in the nursery because he has developed rapid breathing. His delivery occurred at 38 weeks and 6 days of gestation via a scheduled cesarean section due to a maternal history of previous cesarean deliveries. The pregnancy was unremarkable, and the mother had a negative group B streptococcus swab at 36 weeks. There was no rupture of membranes prior to the surgical delivery. One- and five-minute Apgar scores were 8 and 9, respectively. Current vital signs demonstrate a temperature of 36.8°C (98.2°F), a heart rate of 152/min, and a respiratory rate of 78/min. Pulse oximetry indicates an oxygen saturation of 96% on room air. The physical examination highlights an alert newborn displaying mild intercostal retractions, nasal flaring, and scattered crackles upon pulmonary auscultation. Additionally, the skin exam reveals multiple erythematous macules containing 1-to-2 mm central pustules distributed across the trunk. A chest radiograph reveals bilateral hyperinflation, prominent perihilar streaking, and visible fluid within the right horizontal fissure. Which of the following is the most appropriate next step in the management of this patient?

Match the following atypical and classic clinical descriptions of pediatric viral exanthems with their most likely causative pathogen.

A 4-week-old male infant is brought to the emergency department in January due to a 2-day history of nasal congestion, cough, and fast breathing. His 3-year-old sister recently recovered from a mild upper respiratory tract infection. The infant was born at term via an uncomplicated vaginal delivery. Vital signs show a temperature of $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), heart rate of $165/\text{min}$, respiratory rate of $68/\text{min}$, and oxygen saturation of $89\%$ on room air. He appears moderately distressed but is consolable. Physical examination reveals prominent subcostal retractions, nasal flaring, and diffuse bilateral expiratory wheezes. Skin examination shows multiple small, erythematous papules and pustules confined strictly to the cheeks and forehead, with no grouped vesicles. The remainder of the examination is unremarkable. Which of the following is the most appropriate next step in management?

A 3-day-old female neonate is brought to the emergency department due to three episodes of bilious vomiting over the past four hours. The infant was born at 39 weeks of gestation via uncomplicated vaginal delivery and was discharged home yesterday. On physical examination, she appears lethargic, her abdomen is mildly distended, and her heart rate is 175/min. Arrange the following steps in the most appropriate sequential order for the evaluation and management of this patient's suspected condition.

A 15-year-old adolescent female presents to the clinic complaining of a severe, lingering cough. Her illness began three weeks ago with nasal congestion, low-grade fever, and malaise. These initial symptoms subsided after a week, but she subsequently developed a spasmodic cough. She reports discrete episodes of rapid, forceful coughing that sometimes conclude with a deep, high-pitched inspiratory sound and subsequent emesis. She recently immigrated and has an unknown immunization history. Vital signs include a temperature of 36.9°C (98.4°F), heart rate of 88/min, and respiratory rate of 16/min. Lung auscultation is clear bilaterally. A complete blood count reveals a leukocyte count of 28,000/mm³ with 78% lymphocytes. Which of the following is the single best next step in management?

A $5$-year-old girl with short bowel syndrome and reliance on home total parenteral nutrition (TPN) via a central venous catheter presents to the emergency department with a sudden onset of high fever and chills that began during her TPN infusion. Her temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), heart rate is $145/\text{min}$, respiratory rate is $26/\text{min}$, and blood pressure is $90/55\text{ mmHg}$. Physical examination reveals mild erythema at the catheter exit site without fluctuance or purulent discharge. The patient appears flushed but is alert. The physician suspects a central line-associated bloodstream infection (CLABSI).

Arrange the following steps in the most appropriate chronological order for the diagnosis and management of this patient's condition.

A 24-hour-old male newborn is evaluated in the nursery for respiratory distress. He was born at 39 weeks of gestation via spontaneous vaginal delivery to a 24-year-old primigravida. The mother had ruptured membranes 22 hours prior to delivery. Her group B *Streptococcus* (GBS) status is unknown due to a lack of prenatal care. The infant weighed 3.2 kg (7 lb 1 oz) at birth. Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. Current vital signs include a temperature of 38.4°C (101.1°F), heart rate of 175/min, and respiratory rate of 72/min. Physical examination reveals nasal flaring, mild subcostal retractions, and expiratory grunting. The skin examination demonstrates multiple scattered erythematous macules containing central 1- to 2-mm yellow-white pustules over the infant's chest, abdomen, and back. The palms and soles are spared. Microscopic evaluation of a Wright-stained smear from one of the pustules reveals numerous eosinophils. Which of the following is the most appropriate next step in the management of this patient?

A $4$-year-old unimmunized boy is brought to the emergency department by his parents due to a sudden onset of high fever, severe sore throat, and difficulty breathing. He is sitting on his mother's lap, leaning forward with his neck hyperextended, and is drooling continuously. He appears anxious and has a muffled voice. His temperature is $39.4^\circ\text{C}$ ($103^\circ\text{F}$), heart rate is $140/\text{min}$, respiratory rate is $40/\text{min}$, and oxygen saturation is $94\%$ on room air. He has audible inspiratory stridor. Arrange the following steps in the optimal sequence for the acute management of this patient, from most immediate to least immediate.

A 2-month-old male infant is brought to the clinic for a routine well-child examination. The patient was recently diagnosed with severe combined immunodeficiency (SCID) following an abnormal newborn screen and confirmatory flow cytometry. His mother reports that over the past two days, he has developed nasal congestion, a mild cough, and noisy breathing. She also expresses concern about a rash on his face that appeared at 3 weeks of age and has persisted. He is afebrile and feeding well. Vital signs show a heart rate of 130/min, respiratory rate of 42/min, and oxygen saturation of 97% on room air. Physical examination reveals small, scattered erythematous papules and pustules without comedones, limited strictly to his cheeks and forehead. Lung auscultation demonstrates mild, diffuse bilateral expiratory wheezes without subcostal retractions. The mother inquires about the plan for today's routine 2-month immunizations. Which of the following is the most appropriate management plan for this patient?

Match each clinical presentation of a neonate with respiratory compromise to the most likely corresponding diagnosis.