Pediatric Infectious Diseases

A 7-year-old boy is brought to the emergency department by his parents due to a 24-hour history of high fever, severe headache, and recurrent vomiting. He is fully immunized. On physical examination, his temperature is 39.5°C (103.1°F), blood pressure is 105/65 mm Hg, heart rate is 118/min, and respiratory rate is 22/min. He appears acutely ill and lethargic. Marked nuchal rigidity is present on flexion of the neck. Neurologic examination reveals an inability to abduct the right eye. The remainder of the examination is unremarkable. Intravenous access is rapidly established. Arrange the following next steps in the most appropriate sequential order for managing this patient.

For each of the following pediatric clinical vignettes describing a characteristic infectious exanthem or dermatologic manifestation, identify the most likely causative pathogen and the most appropriate next step in management.

Review the following clinical presentations of pediatric exanthems and pair each patient scenario with the most likely causative viral agent.

A 3-year-old boy is brought to the pediatric emergency department by his parents due to a 12-hour history of high fever, extreme lethargy, and a rapidly spreading rash. The patient was previously healthy and is fully immunized. Temperature is 39.9°C (103.8°F), blood pressure is 72/40 mm Hg, pulse is 175/min, and respirations are 38/min. Pulse oximetry shows 92% on room air. On examination, the child is lethargic and minimally responsive to pain. He has cold extremities with a capillary refill time of 5 seconds. A diffuse, non-blanching purpuric and petechial rash is present over the trunk and lower extremities. The airway is patent, but he has shallow breathing. Arrange the following critical management steps in the most appropriate sequential order of priority.

A 6-year-old girl is brought to the emergency department by her parents due to generalized tonic-clonic seizures that have been ongoing for 15 minutes. She recently returned from a 4-week trip visiting relatives in rural Uganda. Her parents report she has had a high fever, vomiting, and increasing lethargy over the last 3 days. She has not received any travel-related prophylaxis. On presentation, her temperature is $39.8^\circ\text{C}$ ($103.6^\circ\text{F}$), heart rate is $160/\text{min}$, and blood pressure is $85/50\text{ mmHg}$. She is unresponsive to verbal stimuli. Point-of-care blood glucose is $45\text{ mg/dL}$. Arrange the following acute management steps in the most appropriate sequential order.

A 14-month-old girl is evaluated during morning rounds on hospital day 3. She was initially admitted due to a high fever, irritability, and an inability to bear weight on her right leg. Her medical history is significant for acute lymphoblastic leukemia, and she is currently in the maintenance phase of chemotherapy with daily oral 6-mercaptopurine and weekly oral methotrexate. Upon initial evaluation, her temperature was $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$). Physical examination revealed an exquisitely tender, swollen, and erythematous right knee. Initial laboratory studies showed a leukocyte count of $4,500/\text{mm}^3$ with an absolute neutrophil count of $1,350/\text{mm}^3$. Arthrocentesis yielded visibly purulent synovial fluid, and she was promptly started on empiric intravenous vancomycin and cefepime.

Today, her temperature is $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$) and she is clinically improving with decreased knee swelling. Synovial fluid and blood cultures obtained on admission both grow Staphylococcus aureus. Susceptibility testing demonstrates resistance to penicillin and ampicillin, but susceptibility to oxacillin, cefazolin, clindamycin, and vancomycin.

During the evaluation, the parents express concern about a recent local measles outbreak. They note that their daughter missed her 12-month well-child visit due to her cancer treatments and ask if she can receive her measles, mumps, and rubella (MMR) and varicella vaccines before discharge.

Which of the following is the most appropriate management plan regarding her antimicrobial therapy and requested immunizations?

A 10-year-old girl is evaluated in the hospital on day 3 of her admission for acute hematogenous osteomyelitis of the left proximal tibia. Upon admission, her temperature was 39.2°C (102.6°F), blood pressure was 110/70 mm Hg, and heart rate was 118/min. She had severe left leg pain, localized swelling over the proximal tibia, and an inability to bear weight. Magnetic resonance imaging of the left lower extremity demonstrated marrow edema and a small subperiosteal abscess. She was empirically started on intravenous vancomycin and ceftriaxone. Today, she is clinically improved, her pain has decreased, and she has been afebrile for the past 24 hours. Blood cultures drawn on admission are now growing Staphylococcus aureus. Susceptibility testing shows the organism is resistant to penicillin, but susceptible to oxacillin, cefazolin, clindamycin, and vancomycin. Which of the following is the most appropriate next step in this patient's pharmacotherapy?

A $3$-year-old unimmunized boy is brought to the pediatric emergency department with a $6$-hour history of high fever, severe sore throat, and progressive difficulty breathing. On presentation, he is sitting on his mother's lap, leaning forward with his neck extended. He is drooling continuously and appears highly anxious. Inspiratory stridor and moderate suprasternal retractions are visible. His temperature is $39.5^{\circ}\text{C}$ ($103.1^{\circ}\text{F}$), heart rate is $145\text{/min}$, and respiratory rate is $38\text{/min}$. Arrange the following management steps in the most appropriate sequential order for this patient.

Match each neonatal clinical presentation (left) with the most likely causative pathogen and its appropriate diagnostic and management strategy (right).

A $48$-hour-old term male newborn is evaluated in the nursery for a new skin eruption. The infant was delivered via uncomplicated spontaneous vaginal delivery at $39$ weeks gestation to a $28$-year-old primigravida. Maternal prenatal laboratory studies were unremarkable, and maternal Group B Streptococcus screening was negative. The newborn has been breastfeeding vigorously and has had normal bowel and bladder output. Vital signs show a temperature of $37.0$ °C ($98.6$ °F), a heart rate of $135$/min, and a respiratory rate of $42$/min. Physical examination reveals a well-appearing, alert infant. His skin exhibits a scattered rash on the chest, abdomen, and proximal extremities consisting of $1$- to $3$-cm erythematous macules, many of which contain a central $1$- to $2$-mm yellow-white pustule. The palms, soles, and mucous membranes are entirely clear. Which of the following is the most appropriate next step in management?

A $3$-year-old boy is brought to the pediatrician's office during the winter with a $4$-day history of high fever, worsening cough, and rapid breathing. The mother reports that he has been less active than usual but continues to drink fluids well. He has no significant past medical history and is up to date on all immunizations. His temperature is $39.2^{\circ}\text{C}$ ($102.6^{\circ}\text{F}$), pulse is $135\text{/min}$, respirations are $42\text{/min}$, and blood pressure is $94/60\text{ mm Hg}$. Oxygen saturation is $96\%$ on room air. He is alert and interactive. Physical examination reveals focal crackles and decreased breath sounds over the left lower lung field. There are no retractions, diffuse wheezing, or stridor. Which of the following is the most appropriate next step in management?

Emergency medical services bring a somnolent 4-year-old girl to the resuscitation bay due to progressive respiratory distress and a high fever lasting 48 hours. Her parents report a severe, harsh cough leading up to her rapid clinical deterioration. She is barely arousable upon arrival. Vital signs reveal a temperature of 39.6°C (103.3°F), a heart rate of 175/min, a respiratory rate of 45/min, and a blood pressure of 70/40 mm Hg. Pulse oximetry shows an oxygen saturation of 88% on ambient air. Physical examination demonstrates cold extremities, mottled skin, and a prolonged capillary refill time of 5 seconds. Lung auscultation reveals dense crackles over the right lower lung field. Arrange the following initial management steps in the most appropriate sequential order according to pediatric resuscitation and sepsis guidelines.

Pediatric head and neck infections and localized lymphadenopathy have distinct clinical presentations that guide specific management. Match each clinical vignette (left) describing a pediatric patient to the most appropriate management strategy (right).

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

An 8-year-old boy is evaluated in the hospital on hospital day 4. He was originally admitted for acute, severe right thigh pain, limp, and high fever. Magnetic resonance imaging (MRI) of the right lower extremity at admission demonstrated marrow edema and a subperiosteal fluid collection in the distal femur. He was diagnosed with acute hematogenous osteomyelitis and empirically started on intravenous vancomycin and ceftriaxone. Over the last 48 hours, his temperature has normalized, and his thigh pain has significantly decreased.

Blood cultures drawn prior to the administration of antibiotics have grown *Staphylococcus aureus*. The susceptibility report is as follows:

The patient has no known drug allergies. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

A 10-week-old boy is brought to the emergency department in mid-January by his parents due to a 3-day history of nasal congestion and a worsening cough. Over the past 12 hours, he has been feeding poorly and breathing rapidly. The family recently immigrated to the United States, and the infant has not received any immunizations. His temperature is 37.9°C (100.2°F), heart rate is 156/min, respiratory rate is 68/min, and oxygen saturation is 89% on room air. On physical examination, the infant appears mildly lethargic and is using accessory respiratory muscles. Copious clear rhinorrhea is present. Lung auscultation reveals diffuse polyphonic wheezing and crackles bilaterally. Skin examination shows multiple scattered erythematous papules and pustules on his cheeks, which the parents state have been present since he was 3 weeks old. Which of the following is the most appropriate next step in the management of this patient?

A 5-year-old boy recently immigrated to the United States and has an unknown immunization history. He is brought to the emergency department by his parents due to the sudden onset of high fever, severe sore throat, and difficulty breathing over the past 4 hours. The patient appears highly anxious, toxic, and is sitting leaning forward with his neck extended. He is drooling profusely and has a muffled voice, but no cough is noted. Vital signs reveal a temperature of 39.8°C (103.6°F), heart rate of 145/min, respiratory rate of 42/min, and oxygen saturation of 91% on room air. Marked inspiratory stridor and suprasternal retractions are present. Arrange the following management steps in the most appropriate and safest sequence for this patient.

Match each pediatric clinical vignette describing a severe infection with the most likely causative pathogen based on the specific diagnostic or microbiological clues provided.

A $2$-year-old girl is evaluated in the emergency department at 11:00 PM for a worsening cough and noisy breathing. Two days ago, she developed a mild fever, nasal congestion, and clear rhinorrhea. This evening, her cough became harsh and sounds similar to a barking seal. Her temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), heart rate is $130/\text{min}$, respiratory rate is $40/\text{min}$, and oxygen saturation is $96\%$ on room air. The patient is sitting in her mother's lap and appears anxious. There is noticeable inspiratory stridor even when the child is resting quietly. Chest auscultation reveals transmitted upper airway sounds but no lower airway wheezing or crackles. Which of the following is the most appropriate next step in management?

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.