PEDIATRIC ID QUIZ

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PEDIATRIC ID QUIZ 4
ENLARGE IMAGE

• CC/HPI A 5 year old female presents with
  history of fever for 5 days (Tm 104.2) and left
  cervical and submandibular swelling for 2 days.
  Her mother states that the child has had a sore
  throat for almost a week.
• Past medical history She was born
  prematurely at 32 wks of gestational age and had
  numerous episodes of otitis media during the
  first two years of life. She was also treated for
  cystitis when she was three years old.
• Family history Her 8 year old brother has
  had recurrent episodes of pharyngitis. His last
  episode was diagnosed 3 weeks ago for which he
  was treated with amoxicillin. No cultures or any
  other tests were performed at the time of his
  diagnosis.
• Immunizations up to date
• Social She lives with his parents and a
  small dog.

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ADDITIONAL INFORMATION
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WHICH AREAS WOULD YOU LIKE TO EXAMINE?
EARS
OROPHARYNX
EYES
HEART
NECK
LUNGS
ABDOMEN
NEUROLOGIC
SKIN
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ADDITIONAL INFORMATION
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NORMAL BILATERAL EAR EXAM
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NORMAL BILATERAL EYE EXAM
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(No Transcript)
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• LISTEN TO THIS PATIENTS HEART BY CLICKING ON THE
  SPEAKER BELOW

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• LISTEN TO THIS PATIENTS LUNGS BY CLICKING ON THE
  SPEAKER BELOW

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(No Transcript)
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NORMAL WITHOUT HEPATOMEGALY OR SPLENOMEGALY
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NORMAL
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WHICH LABORATORY STUDIESWOULD YOU LIKE ?
CBC
ANA
ESR
EKG
LUMBAR PUNCTURE
NECK CT-SCAN
THROAT CULTURE
B.henselae TITERS
MONOSPOT
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H/H 12/36 WBC 18,000/ul (63s,
20bands,17l) Plt 367,000/ul
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92 mm/hr
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NEGATIVE
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THIS TEST IS NOT INDICATED
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TEST HAS BEEN PERFORMED RESULTS ARE PENDING
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(No Transcript)
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WHICH IS THE BEST EMPIRIC THERAPEUTIC APPROACH?
PENICILLIN CLINDAMYCIN ABSCESS ID
CEFTRIAXONE ABSCESS ID
AZITHROMYCINGENTAMICIN ABSCESS ID
PENICILLIN CLINDAMYICIN
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PARAPHARYNGEAL ABSCESS
This patient has tonsillopharyngitis
associated to a left parapharyngeal abscess with
extension into the left submandibular space. Her
throat culture yielded S. pyogenes as well as
cultures of the abscess which was drained
surgically. Considering that the likely causes
for this process include S. pyogenes (Group A
B-hemolytic streptococcus), Staphylococcus aureus
and oral anaerobes empiric antibiotic treatment
should consist of intravenous penicillin and
clindamycin. Given the size of the abscess and
the compression of the airway, antibiotic
treatment alone without surgical drainage is not
the best option. Empiric treatment with
ceftriaxone would not be effective against
organisms such as S.aureus or oral anaerobes.
Treatment with azithromycin and gentamicin would
not provide effective coverage against S.aureus
or anaerobes. In addition, recent studies suggest
an increased level of resistance to macrolide
antibiotics such as azithromycin among strains of
S. pyogenes. Although penicillin alone is the
drug of choice for uncomplicated cases of
S.pyogenes tonsillopharyngitis, in severe
infections treatment with penicillin and
clindamycin is desirable. This combination is
ideal in situations in which a high inocula of
S.pyogenes associated with nonreplicative state
may decrease the efficacy of penicillin.
Clindamycin inhibits the synthesis of S.pyogenes
toxins at the ribosomal level. Suppurative
complications of S. pyogenes tonsillopharyngitis
include peritonsillar, parapharyngeal and
retropharyngeal abscesses. Non-suppurative
complications include rheumatic fever and
post-streptococcal glomerulonephritis.
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REFERENCES

• Bisno AL et al. Practice guidelines for the
  diagnosis and
• management of group A Streptococcal
  pharyngitis. CID 200235113-125 View reference
• Unkanont K et al. Head and neck space infections
  in infants and children. Otolaryngol Head Neck
  Surg 1995, 112 (3) 375-382 View reference
• Cottichia JM et al. Age, site and time specific
  differences in pediatric deep neck abscesses.
  Arch Otolaryngol, Head, Neck Surg 2004, 130
  201-207 View reference
• Martin JM, Green M, Barbadora KA, Wald ER.
  Erythromycin-resistant group A streptococci in
  schoolchildren in Pittsburgh. NEJM 2OO2 346
  1200-1206 View reference

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• Congratulations!! You have successfully
  completed this activity
• Check your e-mail frequently for Pediatric ID
  QUIZ
• If you have any questions about this or any
  other cases feel free to contact me by e-mail at
  bestrada_at_usouthal.edu or you may page me at
• 582-0072
• This activity has been supported by the
  Mitchell Clinical Scholars Program
• Benjamin Estrada MD
• Associate Professor of Pediatrics
• Division of Pediatric Infectious Diseases
• University of South Alabama