Pediatric Infectious Diseases

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.

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?

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

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 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 $4$-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 classic clinical presentation in a pediatric patient with its most likely causative pathogen.

A 15-month-old boy is evaluated in the pediatric clinic for a 3-day history of high fever, productive cough, and rapid breathing. His mother reports that he has been less active than usual but continues to drink fluids adequately. His medical history is unremarkable, though he missed his 12-month well-child visit because the family recently relocated. The mother expresses concern that he currently uses only about 5 distinct words, such as "mama," "dada," and "ball." She also asks if he can receive his missed vaccinations during today's visit.

Temperature is 39.1°C (102.4°F), heart rate is 148/min, and respiratory rate is 46/min. Blood pressure is 90/55 mm Hg, and oxygen saturation is 95% on room air.

Physical examination reveals an ill-appearing but consolable toddler. He walks independently around the examination room. Lung auscultation demonstrates localized crackles and decreased breath sounds over the right lower posterior lung field, with mild subcostal retractions. Cardiovascular examination is unremarkable.

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

A 7-year-old girl is brought to the emergency department by her parents due to severe headache, high fever, and progressive confusion over the past 8 hours. Her temperature is 39.6°C (103.3°F), blood pressure is 105/65 mmHg, heart rate is 138/min, and respiratory rate is 24/min. On examination, she is lethargic, spontaneously opens her eyes only to pain, and utters incomprehensible sounds. Pronounced nuchal rigidity is present. Fundoscopic examination reveals bilateral blurring of the optic disc margins. The patient has no history of immunodeficiency and is up to date on all vaccinations. Arrange the following management steps in the most appropriate chronological order for this patient's acute presentation.

Correlate the following clinical descriptions of pediatric dermatologic findings and associated symptoms with their respective etiologic agents.

An 8-month-old female infant is evaluated at an urgent care clinic in mid-February due to difficulty breathing and poor feeding for the past 24 hours. Her parents report that she developed clear rhinorrhea, a mild cough, and a low-grade fever three days ago. She was born at 39 weeks gestation without complications. When asked about her development, the parents note she sits without support and transfers objects from hand to hand, but she is not yet able to pull herself to a stand. Her temperature is 38.1°C (100.6°F), pulse is 155/min, and respiratory rate is 58/min. Oxygen saturation is 95% on room air. Physical examination reveals a fussy infant with prominent subcostal retractions and nasal flaring. Lung auscultation demonstrates diffuse expiratory wheezing and scattered coarse crackles bilaterally. Which of the following is the most appropriate next step in management?

A preschool-aged child is admitted to the pediatric ward due to restricted neck movement, high fevers, and a progressively enlarging left-sided neck mass. Admission imaging confirms a four-centimeter complex fluid collection with surrounding soft tissue inflammation, consistent with acute suppurative cervical lymphadenitis. The patient is empirically started on intravenous vancomycin and ceftriaxone. An ultrasound-guided aspiration is performed, yielding purulent material. The bacterial culture of the aspirate grows Staphylococcus aureus. The susceptibility report indicates the pathogen is susceptible to methicillin, oxacillin, and cefazolin, but resistant to penicillin. By the third day of hospitalization, the child has been afebrile for over forty-eight hours, the localized cervical swelling has markedly decreased, and oral intake has returned to baseline. The medical team is preparing the patient for discharge to complete a fourteen-day course of oral antibiotics at home. Which of the following is the most appropriate outpatient pharmacotherapy?

A 4-year-old boy, who recently immigrated from a country with a high tuberculosis prevalence, is brought to the pediatric clinic due to a 4-week history of low-grade fevers, night sweats, poor appetite, and a persistent, non-productive cough. He appears fatigued and malnourished. His vital signs show a temperature of 38.1°C (100.6°F), heart rate of 115/min, and respiratory rate of 26/min. The clinical facility is equipped with specialized infection control rooms. Arrange the following steps in the most appropriate sequential order for the evaluation and management of this patient.

A 14-day-old male infant is brought to the pediatric emergency department by his parents due to irritability, poor feeding, and a new rash that appeared 12 hours ago. He was born at 39 weeks gestation via spontaneous vaginal delivery. Membranes ruptured 18 hours prior to delivery, and a fetal scalp electrode was used during labor. The mother received standard prenatal care. His temperature is 38.3°C (100.9°F), heart rate is 168/min, and respiratory rate is 48/min. The infant appears lethargic but is arousable. Skin examination reveals a localized cluster of 2-mm fluid-filled vesicles on an erythematous base situated on the right temporal scalp. Lung auscultation reveals mild, scattered expiratory wheezing bilaterally. Which of the following is the most appropriate next step in management?