Pediatric Infectious Diseases

A 7-year-old boy is brought to the emergency department by his parents due to a high fever, severe headache, and recurrent vomiting for the past 24 hours. Over the last 2 hours, the parents noticed that he has become increasingly drowsy and is not moving his right arm normally. His temperature is 39.4°C (102.9°F), blood pressure is 110/70 mmHg, heart rate is 115/min, and respiratory rate is 22/min. Physical examination reveals marked nuchal rigidity and right-sided hemiparesis. Fundoscopic examination shows blurring of the optic disc margins bilaterally.

Arrange the following steps in the most appropriate chronological order for the acute management of this patient.

An 8-month-old male infant is evaluated in the pediatric clinic in late January for a 3-day history of nasal congestion, clear rhinorrhea, and a low-grade fever. Over the past 24 hours, he has developed a harsh cough and increased work of breathing. He has no significant past medical history and is fully vaccinated for his age. Vital signs show a temperature of 37.8°C (100.0°F), heart rate of 145/min, respiratory rate of 55/min, and oxygen saturation of 96% on room air. Physical examination reveals an alert, well-perfused infant with mild intercostal retractions, flared nostrils, and diffuse bilateral expiratory wheezes with prolonged expiration. There is no focal consolidation or crackles. Which of the following is the most appropriate next step in the management of this patient?

An $11$-month-old female infant arrives at the pediatric emergency department during late autumn accompanied by her parents. They report she has had a low-grade fever, severe nasal congestion, and a progressively worsening cough for the past four days. Over the last $12$ hours, she has been unusually lethargic and has completely refused all bottle feedings. Her medical history is notable for severe atopic dermatitis, and her biological father has severe persistent asthma. Vital signs include a temperature of $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$), heart rate of $165/\text{min}$, and respiratory rate of $72/\text{min}$. Oxygen saturation is $88\%$ on room air. Physical examination reveals an infant in significant respiratory distress, demonstrating nasal flaring, head bobbing, and marked subcostal retractions. Lung auscultation reveals widespread fine crackles and high-pitched expiratory wheezes bilaterally. Capillary refill time is $2$ seconds. The patient is immediately placed on high-flow supplemental oxygen, which improves her oxygen saturation to $95\%$. Which of the following is the most appropriate next step in the management of this patient?

A 4-year-old girl is brought to the emergency department with a 1-day history of fever and severe right knee pain. She refuses to bear weight on her right leg. Her temperature is 39.0°C (102.2°F), heart rate is 130/min, and blood pressure is 95/60 mm Hg. Physical examination reveals an erythematous, warm, and exquisitely tender right knee with a palpable effusion. Range of motion is severely restricted due to pain. Arrange the following steps in the most appropriate chronological sequence for the diagnosis and management of this patient's suspected septic arthritis.

A 10-month-old boy is brought to the clinic by his parents due to fever, irritability, and crying when laid down to sleep. The symptoms began 2 days ago following a mild viral upper respiratory tract infection. His temperature is 39.1°C (102.4°F), heart rate is 130/min, and respiratory rate is 28/min. Otoscopic examination reveals bulging, intensely erythematous tympanic membranes bilaterally with absent mobility on pneumatic otoscopy. He has no known medical conditions, takes no daily medications, and has no known drug allergies. He has not received any antibiotics since birth. Which of the following is the most appropriate next step in management?

A $3$-year-old girl is evaluated in the hospital on day $4$ of admission for acute mastoiditis. She initially presented to the emergency department with a $3$-day history of high fever, severe left ear pain, and outward displacement of the left auricle. On admission, she underwent tympanostomy tube placement and was empirically started on intravenous vancomycin and ceftriaxone. Cultures of the purulent middle ear fluid obtained during the procedure grew Streptococcus pneumoniae. Susceptibility testing reveals the organism has a penicillin minimum inhibitory concentration (MIC) of $0.06$ $\mu$ g/mL (highly susceptible). It is also susceptible to clindamycin, ceftriaxone, and levofloxacin. Currently, the patient has been afebrile for $48$ hours, the postauricular erythema has resolved, and she is tolerating a regular diet. The medical team plans to discharge her today to complete a $14$-day total course of antimicrobial therapy as an outpatient. Which of the following is the most appropriate oral pharmacotherapy to prescribe for discharge?

Match each pediatric clinical vignette with the most appropriate next step in management.

Match each pediatric respiratory or upper airway infectious clinical presentation with its most likely causative pathogen.

A 48-hour-old full-term male newborn is evaluated in the nursery prior to discharge due to the appearance of a new rash. He was born via an uncomplicated spontaneous vaginal delivery to a 26-year-old primigravid woman. The mother received regular prenatal care, and her screening tests for group B *Streptococcus*, hepatitis B, HIV, and syphilis were negative. She has no history of genital herpes. The infant has been breastfeeding well and has normal urine output and bowel movements. Vital signs show a temperature of 37.0°C (98.6°F), heart rate of 142/min, and respiratory rate of 42/min. Physical examination reveals an alert, vigorous infant. There are numerous blanching, erythematous macules and papules, many of which contain central 1- to 2-mm yellow-white pustules, widely distributed across the chest, back, and proximal extremities. The palms and soles are completely spared. The remainder of the examination is unremarkable. Which of the following is the most appropriate next step in management?

A 2-day-old male newborn is evaluated in the nursery for a newly developed skin rash. He was born at 39 weeks gestation via uncomplicated spontaneous vaginal delivery to a 28-year-old primigravid mother. Maternal prenatal laboratory testing, including group B Streptococcus screening, was negative. The infant has been breastfeeding well and stooling normally. Vital signs are temperature 36.8°C (98.2°F), heart rate 140/min, and respiratory rate 40/min. Physical examination reveals multiple erythematous macules and papules with small central pustules scattered across the trunk and proximal extremities. The palms and soles are spared. The infant is vigorous and in no apparent distress. Which of the following is the most appropriate next step in management?

A $14$-day-old male infant is brought to the pediatric emergency department by his parents due to a fever noted at home. The parents report that he has been feeding slightly less than usual over the past $24$ hours but is producing a normal number of wet diapers. He was born at $38$ weeks gestation via uncomplicated spontaneous vaginal delivery. Maternal group B *Streptococcus* screening was negative. The mother reports no history of genital ulcers, although she does have a history of occasional oral cold sores. On physical examination, the infant is awake and alert. Vital signs show a temperature of $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), heart rate of $160/\text{min}$, and respiratory rate of $42/\text{min}$. Skin examination reveals a cluster of $4$ small, erythematous vesicles on the right shoulder. The anterior fontanelle is flat, and the neurological examination is nonfocal. Laboratory studies show a peripheral leukocyte count of $12,500/\mu\text{L}$. Urinalysis is unremarkable. Which of the following is the most appropriate next step in management?

An unimmunized 4-year-old male child arrives at the pediatric triage with sudden-onset high fever, a muffled voice, and severe drooling. He is sitting upright, leaning forward with his neck extended, and exhibits notable inspiratory stridor. The clinical presentation is highly suspicious for acute epiglottitis. Arrange the following management steps in the most appropriate sequential order, from first to last.

An 8-week-old boy is brought to the pediatric clinic by his mother due to a 3-week history of severe nasal congestion and a skin rash. The mother reports that the infant has a thick, blood-tinged nasal discharge that frequently interferes with his ability to feed. A few days ago, a red, peeling rash appeared on the infant's extremities, distinctly involving the palms and soles. The infant was born at home in a rural setting, and the mother did not receive any formal prenatal care. On physical examination, the infant's temperature is 37.5°C (99.5°F), pulse is 145/min, and respirations are 38/min. The infant appears mildly fussy but easily consolable. Generalized lymphadenopathy and firm hepatosplenomegaly are palpable. The lungs are clear to auscultation bilaterally. Which of the following is the most appropriate next step in the management of this patient?

Match each pediatric infectious disease exposure scenario with the most appropriate post-exposure management or prophylaxis strategy.

A $12$-day-old female neonate is brought to the emergency department due to a $1$-day history of fever, lethargy, and poor feeding. Physical examination reveals a cluster of intact and ruptured erythematous vesicles on the scalp at the site of a prior fetal scalp monitor. The neonate has a temperature of $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), a heart rate of $190/\text{min}$, a respiratory rate of $65/\text{min}$, and a blood pressure of $50/30\text{ mm Hg}$. The extremities are cool and mottled, with a capillary refill time of $5$ seconds. Based on the clinical presentation, arrange the following management steps in the most appropriate chronological sequence.

A $5$-year-old boy is brought to the emergency department due to a $24$-hour history of high fever and refusal to walk. His temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), heart rate is $118/\text{min}$, respiratory rate is $22/\text{min}$, and blood pressure is $105/65\text{ mm Hg}$. Physical examination reveals that the right hip is held in flexion, abduction, and external rotation. Any passive movement of the right hip elicits severe pain and crying. The patient is hemodynamically stable and appears well-perfused. Arrange the following steps in the most appropriate chronological sequence for the evaluation and management of this patient's condition.

A $6$-month-old boy is brought to the pediatric clinic by his parents due to a worsening cough. For the past week, he had a mild runny nose and low-grade fever. Over the last $48$ hours, the cough has become severe, occurring in intense spasms. The parents note that he occasionally vomits immediately after these coughing spells and his face turns red during the episodes. He has only received his first set of immunizations at $2$ months of age due to parental hesitancy. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $90/55\text{ mmHg}$, pulse is $135/\text{min}$, and respirations are $42/\text{min}$. Pulse oximetry shows $98\%$ on room air. The patient appears comfortable and playful in the examination room. Cardiopulmonary examination reveals clear lungs bilaterally without crackles or wheezes. Laboratory testing shows a leukocyte count of $24,000/\text{mm}^3$ with $78\%$ lymphocytes. Which of the following is the most appropriate next step in management?

Parents bring their $3$-year-old daughter to an urgent care center in late autumn after she developed a sudden high fever and a persistent, productive cough over the past $48$ hours. The parents report that she has been significantly less active and is breathing more rapidly than usual since waking up this morning. Her past medical history is unremarkable, and she has received all standard childhood immunizations except for her seasonal vaccines this year. Her temperature is $39.5^\circ\text{C}$ ($103.1^\circ\text{F}$), pulse is $135/\text{min}$, and respiratory rate is $44/\text{min}$. Pulse oximetry is $96\%$ on room air. Physical examination reveals an ill-appearing, fatigued child. Lung auscultation demonstrates focal fine crackles and decreased breath sounds localized to the right lower lung field. No wheezing, rhonchi, or stridor is appreciated. Which of the following is the most appropriate next step in management?

During a busy winter shift in early February, parents bring their $7$-month-old son to the pediatric clinic. They report a $3$-day history of nasal congestion, mild cough, and a low-grade fever. This morning, the infant developed rapid breathing and increased respiratory effort. He was born at term and has no significant past medical history. Vital signs show a temperature of $37.7^\circ\text{C}$ ($99.9^\circ\text{F}$), a heart rate of $145/\text{min}$, a respiratory rate of $58/\text{min}$, and an oxygen saturation of $95\%$ on room air. The physical examination is notable for copious clear rhinorrhea, mild subcostal retractions, and diffuse expiratory wheezing heard in all lung fields. What is the most appropriate next step in the management of this patient?

Match each classic pediatric exanthem clinical presentation with the most likely causative viral pathogen.