UNP-MEDICINE 2021 PEDIATRICS

BACTERIAL AND HELMINTHIC INFECTIONS

LECTURER: KARLA MAE ABAYA, MD, DPPS DECEMBER 9, 2019

HEAD NOTES
 TITLE/EMPHASIZED
 AUDIO
 NOTES/RECALLS/ADD-ONS  Syndrome resembling the rash of scarlet fever
 Superinfection of other non-infectious skin disease (eczema)
GRAM POSITIVE BACTERIAL INFECTIONS

A. STAPHYLOCOCCAL INFECTIONS
STAPHYLOCOCCUS
 Hardly aerobic gram positive bacteria that grow in pairs and
clusters
 Recovered in non-biologic environment weeks and months post-
contamination

STAPHYLOCOCCUS AUREUS
 Focal infections: Most common cause of pyogenic infections of
the skin and soft tissue 1. Drying of periphery
 Bacteremia: primary or secondary 2. Cigarette burn appearance
 Toxin Mediated diseases
o Toxic shock syndrome (TSS) Respiratory tract
o Staphylococcal Skin Scalded Syndrome (SSSS)  Pneumonia
o Food poisoning Staphylococcal scarlet fever (SSF) 1. Primary or Secondary
2. Usually a rapidly progressive necrotizing pneumonia
Etiology empyema, pneumatoceles or abscesses, pyopneumothorax
Virulence Factors and bronchopleural fistulas
 Loose polysaccharide capsule or slime layer
o Interferes with opsonophagocytosis Bones and Joints
 Teichoic acid  Most common cause of osteomyelitis and suppurative arthritis
o Mediates adhesion to mucosal cells  Fever, chills and other systemic symptoms
 Coagulase  Pain and tenderness over affected bone
o Causes plasma to clot  Limitation of movement if adjacent joint is involved
o Localizes infection
 Clumping factor STAPHYLOCOCCAL TOXIN MEDIATED DISEASES
o Interacts with fibrinogen to cause large clumps of STAPHYLOCOCCAL FOOD POISONING
organisms interfering with effective phagocytosis Etiology
 Protein A  Pre-formed enterotoxins of S. aureus
o Absorbs serum Ig preventing antibacterial antibodies Epidemiology
from acting as opsonins thus inhibiting phagocytosis  Transmission: ingestion of contaminated food left at room
 Pantonvalentinleukocidin (PVL) temperature
o Associated with invasive skin disease  Period of communicability: as long as carrier harbours the
o Combines with phospholipid of the phagocytic cell bacteria
membrane producing increased permeability, leakage  Incubation Period: 30 minutes to 7 hours after ingestion
of protein and eventual death of the neutrophil and Clinical manifestations
macrophage  Sudden severe vomiting and diarrhea with severe cramps,
without fever dehydration shock and death
Other enzymes:  Rarely persists more than 24 hours
 Catalase  Occasionally, symptoms may be mild
o Inactivates hydrogen peroxide promoting intracellular
survival STAPHYLOCOCCAL TOXIC SHOCK SYNDROME (TSS)
 Penicillinase or beta lactamase
o Inactivates penicillin at the molecular level Etiology
 Lipase  Toxic shock syndrome associated toxin (TSST-1) producing
o Associated with skin infection strains of S. aureus; enterotoxins B, C, F
Local tissue destruction by distinct hemolysin  women during menstrual period (Tampons, contraceptive
 Alpha toxin devices)
o Causes tissue necrosis, injures human leukocytes and  Non-menstrual: associated with cutaneous and subcutaneous
produce aggregation of platelets and spasm of lesions, childbirth or abortion, surgical wound infections, vaginal
smooth muscles infections, nasal packings
 Beta hemolysin
o Degrades sphingomyelin causing hemolysis of RBC Diagnostic Criteria of Staph TSS
 Delta hemolysin  Major criteria (all required)
o Disrupts membranes by a detergent-like action 1. Acute fever (T > 38.8◦C)
2. Hypotension
Clinical Manifestations o Orthostatic shock
Skin: most common cause of pyoderma o Below age-appropriate norms
 Impetigo contagiosa, ecthyma, bullous impetigo, folliculitis,
hydradenitis, furuncles, carbuncles
3. Rash
o Erythoderma with late desquamation *Massive loss of
 Abscesses and surgical wound infections
fluid from the intravascular space
TRANSCRIBER: OBRERO, OCAMPO, PALADO
LOOK IN THE MIRROR… THAT’S YOUR COMPETITION. MED 3-C | 1
 UNP-MEDICINE 2021 PEDIATRICS
 Minor criteria (any 3) B. GROUP A STREPTOCOCCUS (GAS)
1. Mucous membrane inflammation
STREPTOCOCCUS PYOGENES
2. Vomiting, diarrhea
3. Liver abnormalities Etiology
4. Renal abnormalities  Gram positive coccoid shaped in chains
5. Muscle abnormalities  Most common cause of bacterial pharyngitis
 2 potentially serious non-suppurative complications:
6. CNS abnormalities
o Rheumatic fever
7. Thrombocytopenia o Acute glomerulonephritis
 Exclusionary criteria  subdivided in > 100 serotypes based on M-protein antigen
8. Absence of another explanation  Nephritogenic: pharyngeal strains (M type 12) and skin strains
9. Negative blood cultures (M type 49, 55, 57, 60)

Treatment Pathogenesis
Specific  Virulence depends on the M protein:
o Resist phagocytosis in human blood
1. Parenteral beta lactamase resistant anti-staph antibiotic Nafcillin
o M (-) strains do not resist phagocytosis
or 1st generation Cephalosporin or Vancomycin in MRSA areas
 Chronic pharyngeal carriers contain little or no M protein:
2. Clindamycin in severe or unresponsive cases may terminate relatively avirulent
toxin production  Erythrogenic toxins known as streptococcal pyrogenic exotoxins
(A, B, C) responsible for the rash of scarlet fever
STAPHYLOCOCCAL SKIN SCALDED SYNDROME (SSSS,  Anti-streptolysin O: most commonly used antibody
RITTER’S DISEASE) determination

Etiology Clinical manifestations

 Epidermolytic toxin or Exfoliative exotoxins  Most common: acute tonsillitis and/or pharyngitis
 Focus of infection  Infants <6months:
o Impetiginous skin eruptions o Nasopharyngitis with low grade fever
o Conjunctivitis o Serous or seromucoid rhinitis with excoriated nares
o Gastroenteritis  Toddlers (1-3): display protracted atypical illness
o Pharyngitis o Low grade fever, irritability, anorexia, cervical adenitis
Children 3 y/o:
Clinical manifestations  Acute exudative tonsillopharyngitis
 Malaise, fever, and irritability with exquisite tenderness of skin o with enlarged cervical lymph nodes
macular rash on face, neck, axilla and groin rapid extension of o no signs of viral nasopharyngitis
brightly erythematous skin ill-defined flaccid bullae filled with
clear fluid
o Areas of epidermis may separate in response to
gentle stroking (Nikolsky sign)

GAS SCARLET FEVER

 Large sheaths of epidermis may peel away moist glistening
denuded areas, initially at flexures, later over much of body
surface dry quickly and heal by post inflammatory desquamation
heals rapidly and is complete in 10-14 days
 Caused by a pyrogenic exotoxin (erythrogenic toxin)
 URTI associated with a characteristic rash within 24-48 hours
after onset of symptoms
 Diffuse fine papular, erythematous rashes producing a bright
red discoloration of the skin which blanches on pressure
 Goose pimple appearance and feels rough (sandpaper like)
 Begins around neck trunk extremities
 More intense along the creases of the elbows, axilla and groin

TRANSCRIBER: OBRERO/OCAMPO/PALADO
LOOK IN THE MIRROR… THAT’S YOUR COMPETITION. MED 3-C | 2
 UNP-MEDICINE 2021 PEDIATRICS
GAS SCARLET FEVER  Arthritis
 After 3-4 days, rash begins to fade followed by desquamation o Earliest manifestation
first on the face progressing downwards o Migratory polyarthritis – 75%
o Similar to a sunburn o One or more large joints: knees, ankles, wrists,
 Sheet-like desquamation around the free margins of the elbows
fingernails, palms and soles o Joints become normal in 1-3 days without treatment
 Tongue is usually coated and papillae are swollen o Dramatic response to aspirin
 Subcutaneous nodules
o Rare;
o Firm nodules approximately 1 cm in diameter along
the extensor surfaces of tendons near bony
prominence - Aschoff nodules
o Positive correlation with significant rheumatic heart
disease
 Erythema marginatum
o Rare; <3% but characteristic rash of ARF
o Erythematous serpiginous macular lesions with pale
centers
o Not pruritic
o Trunk and extremities; not the face
o Accentuated by warming the skin
GAS ERYSIPELAS
 Rare, acute, involving the deeper layers of the skin and
underlying connective tissues
 Skin is swollen, red and very tender
 Superficial blebs may be present
 Most characteristic finding: sharply defined, slightly elevated
border
 Onset is abrupt: high fever, systemic infection
 Culture reveals the organ

 Chorea
o St Vitu’s dance = Sydenham’s chorea 10-15% of ARF
patients
o Isolated, subtle neurological behavioural disorders
o Emotional lability, incoordination, poor school
performance
o Uncontrollable movement, facial grimacing,
GAS RHEUMATIC FEVER (RF) exacerbated by stress and disappears with sleep
o Occasionally unilateral
Etiology o Latent period: months
 2/3 of patients with RF have a history of URTI several weeks Clinical maneuvers to elicit chorea
before  Milk maid’s grip: irregular contraction of the hand muscles while
 M types 1, 3, 5 , 6, 18, 24: most frequently isolated squeezing the examiner’s fingers
 Spooning and pronation of the hands when arms are extended
Epidemiology  Wormian darting movement of the tongue upon protrusion
 Most common acquired heart disease  Examine the handwriting to evaluate fine motor
 Sharp decline:
o Antibiotics
o Shift from rheumatogenic to non-rheumatogenic
strains
Pathogenesis
Theories
 Cytotoxicity
o GAS produces several enzymes that are cytotoxic for
mammalian cardiac cells (Streptolysin O) oImmune
mediated
o Antigenicity and immunologic cross reactions between
GAS components and mammalian tissues oShared
antigenic determinants
Jones Criteria: Major (CASEC)
 Carditis
o Most serious manifestation of ARF  Minor (2 clinical minor features)
o Tachycardia, murmur > CHF o Arthralgia: in the absence of polyarthritis
o Endocarditis (valvulitis) - universal finding in o Fever >39◦C in the early course of illness
Rheumatic carditis  2 laboratory features
o Most cases isolated: mitral valve disease o Elevated acute phase reactants: CRP, ESR
o Predisposed to infective endocarditis o Prolonged PR interval on ECG: first heart block

TRANSCRIBER: OBRERO/OCAMPO/PALADO
LOOK IN THE MIRROR… THAT’S YOUR COMPETITION. MED 3-C | 3
 UNP-MEDICINE 2021 PEDIATRICS
Prognosis
 Arthritis and chorea resolve spontaneously
 Long term sequelae limited to heart
 High risk of developing Infective endocarditis during episodes of
transient bacteremia (dental hygiene)
 The more severe the initial cardiac involvement, the greater the
risk for residual cardiac disease
 20% of patients with pure chorea not given secondary
prophylaxis develop RHD within 20 years oRequires long term
antibiotic prophylaxis

Prevention
 Primary
o Appropriate antibiotic treatment before the 9th day of
signs and symptoms of acute GAS pharyngitis
o Highly effective in preventing the attack of ARF
 Secondary
o Continual antibiotic prophylaxis with carditis
o Regimen of choice: Benzathine Pen G 1.2 million
units, IM every 4 weeks
 In high risk patients: every 3 weeks

C. DIPHTHERIA
Etiology and Epidemiology
 Corynebacterium diphtheria; strains may be toxigenic or non-
toxigenic
 Incidence  Laryngeal
o Age: highest during the 1st few years of life; males o Symptoms predominantly those of laryngeal
o Most common in lower socioeconomic groups with obstruction and a dry metallic cough
overcrowding o Toxemia: minimal, unless it is an extension of the
o Infection occurs in immunized, partially and faucial and pharyngeal type
unimmunized persons o Course: in mild cases, membrane is coughed out by
Clinical Manifestations the 6th or 10th day but may cause sudden death if
 Features common to most types of Diphtheria coughed out, membrane completely obstructs airway
o Low grade fever: not exceeding 38 deg C
o Gradual onset of manifestation over 1-2 days
o Toxemia (except in nasal type): malaise, weakness,
and pulse disproportionately rapid to the temperature
 Normally: Increase of 10 bpm for every
degree rise in temperature

 Nasal
o Discharge: serous serosanguinous mucopurulent
o Excoriating anterior nares and upper lip impetiginous
appearance, either unilateral/ bilateral
o Dirty white membrane on septum hidden by discharge

GRAM NEGATIVE BACTERIAL INFECTIONS

A. NEISSERIA MENINGITIDIS
 Gram-negative diplococcus
 Kidney-shaped pairs with flattened adjacent sides, encapsulated
 Common commensal of human nasopharynx
 Humans are the only natural reservoir

 Faucial and pharyngeal

o Onset: sore throat
o Membrane: thin, dirty white or gray or black, if
bleeding occurs: smooth and resembles spider web
extending from tonsil to soft and hard palate and
adherent to faucial tonsils, uvula or pharyngeal wall
o Bleeds when detached
o Appears within 24 hours after onset Virulence
o Cervical adenitis and periadenitis bullneck  Cell wall lined by lipid A containing lipooligosaccharides,
including endotoxins, which is covered by a polysaccharide
capsule
 Antigenic variation of the capsule has led to recognition of 13
serogroups
o A,B,C,Y,W135: disease in humans
TRANSCRIBER: OBRERO/OCAMPO/PALADO
LOOK IN THE MIRROR… THAT’S YOUR COMPETITION. MED 3-C | 4
 UNP-MEDICINE 2021 PEDIATRICS
o B,C: more common seen in Western regions of world o Recommended for children 2 y/o and older in high
o 2005: A and C (Meningococcal scare) risk groups
 2 vaccines – against A and C o Chemoprophylaxis
o Quadrivalent vaccine: A, C, Y and W strains o To eradicate nasopharyngeal carriage of N.
o No vaccine against B because it is not immunogenic Meningitidis
 Chemoprophylaxis
Pathogenesis o Rifampicin
 Organism colonizes nasopharynx  < 1 month 5 mg/kg q 12 hours x 2 days
 In some persons organism invades bloodstream and causes  > 1 month 10 mg/kg q 12 hours x 2 days
infection at distant site o Alternative drugs
 Antecedent URI may be a contributing factor  Ceftriaxone
 < 12 y/o 125 mg SD IM
 > 12 y/o 250 mg SD IM
 Ciprofloxacin 500 mg SD PO

B. HAEMOPHILUS INFLUENZAE

Etiology
 Gram negative, pleomorphic coccobacilli
 Six antigenic types (a-f) based on polysaccharide capsule
 The most virulent isolates belong to serotype B
 Nonencapsulated (nontypable)
 H. Influenza
 ACUTE MENINGOCOCCEMIA
Pathogenesis
 Abrupt onset of sore throat, fever, chills, myalgia, headache
Type B strain – resist intravascular clearance
rapid progression to septic shock
mechanisms more readily than do strains of other serotypes and
 Rash – initially morbilliform or urticarial rapidly progresses to
nonencapsulated organisms
petechiae, purpura and ecchymosis (purpura fulminans)
Type B PRB capsules
 DIC, shock, coma and death in fulminant cases (Waterhouse-
o PRP (polysaccharide polyribosylribitol phosphate) The most
Friderichsen Syndrome)
important known element of host defense is antibody directed
against the type B capsular polysaccharide PRP
o Non-invasive H. influenzae infections-enter middle ear or sinus
cavities by direct extension from the pharynx

 ACUTE EPIGLOTTITIS OR SUPRAGLOTTITIS

 Cellulitis of tissues comprising laryngeal inlet (epiglottis,
aryepiglottic folds, arytenoids cartilages)
 Usually seen in children 2-7 years of age
 Medical emergency- risk of sudden, unpredictable airway
obstruction
o Prepare for intubation
o Cherry epiglottis, child is sniffing position due to
upper airway obstruction
 Positive “thumb sign”
 Hypopharyngeal dilatation
 Obliteration of vallecula and aryepiglottic fold

ACUTE EPIGLOTTITIS OR SUPRAGLOTTITIS

 ACUTE MENINGITIS
 Most common clinical manifestation
 Headache, photophobia, lethargy, vomiting, nuchal rigidity and
other signs of meningeal irritation
 Seizures and focal neurologic signs occur less frequently than in
patients with meningitis caused by S. pneumoniae or H.
influenzae type B

Treatment
Specific
 Penicillin G 250,000-400,000 U/kg/day IV in 4-6 divided doses x
5- 7 days
 Alternative drugs:
o Cefotaxime 200 mg/kg/day
o Ceftriaxone 100 mg/kg/day oFor Penicillin allergy:
o Chloramphenicol 75-100 mg/kg/day q 6 hours

Prevention
 Active immunization – meningococcal polysaccharide/ conjugate
vaccine
o Quadrivalent ( A, C, Y, W-135)

TRANSCRIBER: OBRERO/OCAMPO/PALADO
LOOK IN THE MIRROR… THAT’S YOUR COMPETITION. MED 3-C | 5
 UNP-MEDICINE 2021 PEDIATRICS
 ACUTE PNEUMONIA
 True incidence in children is unknown
 Important cause in unvaccinated children 4 years or younger
 Signs and symptoms cannot be differentiated from those of
pneumonia caused by other microorganisms

 Temperature rises in stepwise fashion- unremitting and high

within 1 week
 2nd week
Treatment  Sustained high fever
 Specific for Invasive Disease  More severe fatigue, anorexia, cough and abdominal
 Chloramphenicol 100 mg/kg/day in 4 divided doses symptoms Delirium, stupor
o Ampicillin 200-300 mg/kg/day in 6 divided doses +  Relative bradycardia
Chloramphenicol since about 1/3 of isolates produce B  Hepatomegaly, splenomegaly and distended abdomen with
lactamase and are Ampicillin-resistant diffuse tenderness very common (doughy abdomen)
o For resistant strains  Tongue brown and furred
 Cefotaxime  Rose spots – macular or maculopapular discrete,
 Ceftriaxone erythematous rash, slightly raised and blanch on pressure;
o Duration of therapy: 10-14 days appear on about 7th to 10th day
o Appear in crops on lower chest and abdomen
Prevention o Lasts for 2-3 days then leave a slight brownish
 Active immunization – HiB vaccine discoloration of skin on healing
 Complete:
o 15 months: 1 dose unconjugated vaccine
o 12-14 months: 2 doses
o 1 year: 3 doses
o 1 year 6 months: booster dose (4th dose)
 Universal immunization with HiB vaccine is recommended for all
infant

C. SALMONELLA
Isolation of Salmonella in: BUS
Etiology  Blood
 Motile, (peritrichous flagella), nonsporulating, nonencapsulated,  Highest: 1st week
gram negative bacilli  Lowest: During or after 4th week
 Possess somatic O and flagellar H antigens  Urine – first 2 weeks
 Clinical forms:  Stool – throughout
 Enteric fever or  Bone marrow aspirate: Throughout
Typhoid Fever  Single most sensitive method of diagnosis
 Nontyphoidal  Less influenced by prior antimicrobial therapy
Salmonellosis  Duodenal string capsule culture
 Bacteremia without a
focus Treatment
 Localized metastatic infections  Specific
 Acute Infection
ENTERIC FEVER OR TYPHOID FEVER  Chloramphenicol 50-100 mg/kg/day in 4 divided doses
 S. ser typhi (typhoid fever) PO x 14 days
 Other Salmonella strains (paratyphoid fever)  Alternative drugs
 S. ser Paratyphi A  Cotrimoxazole 8 mg/kg/day of TMP; 40 mg/kg/ day of SMX
 S. ser Paratyphi B (Schottmuelleri) in 2 divided doses x 14 days
 S. ser Paratyphi C (Hirschfeldii)  For suspected resistant strains
 Ceftriaxone 100 mg/kg/day OD IV or IM x 5-7 days
Pathogenesis  Ciprofloxacin 20-30 mg/kg/day in 2 divided doses PO or IV
 Inoculums size required to cause enteric fever: 105 to 109 x 7-10 days
organisms **TOC- Chloramphenicol
 Stomach acidity – important determinant of susceptibility to
Salmonella D. ESCHERICHIA COLI
 High acidity: more protected  Neonatal septicaemia with or without meningitis
 Bacteria invade through Peyer patches- Organisms are
transmitted to regional lymphnodes- Multiply within Etiology
mononuclear cells- monocytes carry organisms into mesenteric  E. coli strains with K1 capsular polysaccharide antigen
lymph nodes- organisms reach bloodstream through thoracic Account for 40% of cases of neonatal septicaemia and 80% of
duct- reticuloendothelial cells in liver, spleen and bone marrow- meningitis
Bacteremia Source:
 Early onset: maternal genital tract
TRANSCRIBER: OBRERO/OCAMPO/PALADO
LOOK IN THE MIRROR… THAT’S YOUR COMPETITION. MED 3-C | 6
 UNP-MEDICINE 2021 PEDIATRICS
 Nosocomial  Oral tetracycline (50 mg/kg/day divided QID PO for 3 days;
o Person to person among nursery personnel maximum 2 g/day)
o Nursery environmental sites  Doxycycline (5 mg/kg PO as a single dose, maximum 200
o Invasive procedures, mg/day)
eg. Umbilical Catheterization

 Urinary Tract Infections ANAEROBIC BACTERIAL INFECTIONS

 Most common pathogen of community acquired UTI in all age
groups A. CLOSTRIDIUM BOTULINUM
Which among the following is the clin manifestation of H.
influenzae? pneumonia… except: UTI Etiology
 Gram-positive, spore-forming, obligate anaerobe whose natural
 Diarrhea habitat worldwide is soil, dust, and marine sediments
 Enterotoxigenic E. coli (ETEC)  It is found in a wide variety of fresh and cooked agricultural
o Major cause of infantile diarrhea and traveller’s products
diarrhea  Botulism: acute, flaccid paralysis caused by the neurotoxin
 Enteropathogenic E. coli (EPEC) produced by Clostridium botulinum
o Severe and protracted diarrhea in neonates and
young infants Pathogenesis
 Enteroinvasive E. coli (EIEC)  Botulinum toxin is carried by the bloodstream to the to
o Can cause dysentery- bloody mucoid diarrhea, fever, peripheral cholinergic synapses, where it binds irreversibly,
crampy abdominal pain and tenesmus blocking acetylcholine release and causing impaired
neuromuscular and autonomic transmission
 Shiga Toxin producing E. coli (STEC)
 Hemolytic uremic syndrome Clinical manifestations
 Strains of serotype O157:H7  Symmetric descending, flaccid paralysis beginning with the
 Cardinal Features cranial nerve musculature
o Animal contaminated food  Multiple bulbar palsies
 Unpasteurized fruit juice  Generalized weakness and hypotonia
 Undercooked hamburger  Fatigability with repetitive muscle activity is the hallmark of
o HUS after diarrhea botulism
o HUS: acute renal failure, microangiopathic  Toxin acts only on motor nerves: paresthesias are not seen
anemia, thrombocytopenia  Sensorium remains clear
 Enteroadherent E. coli (EAEC)
 One of etiologic agents in AIDS-associated chronic diarrhea INFANT BOTULISM
 1st indication of illness is a decreased
Treatment  frequency or even absence of defecation
 Correction of fluid and electrolyte losses  Inability to feed, lethargy, weak cry, diminished spontaneous
 Antimicrobial therapy movement
o For neonatal infections  Dysphagia: secretions drooling from the mouth
o EPEC: Neomycin 50-100 mg/kg/day  Gag, suck, and corneal reflexes diminish as the paralysis
o ETEC: self limiting advances
o EIEC: no controlled clinical trials  Oculomotor palsies
o Hemorrhagic colitis due to STEC: role of antimicrobial  Loss of head control is typically a prominent sign Respiratory
therapy uncertain arrest
 For C. botulinum anong food ang bawal sa bata less than 1 year
E. VIBRIO CHOLERAE old? honey

Etiology
 Vibrio cholerae is a slightly curved, gramnegative, aerobic
bacillus (1.5–3.0 × 0.5 µm) with a polar flagellum
Pathogenesis
 A large inoculum of bacteria (≥∼108 viable units) is required to
cause clinical disease in part because the organisms are killed
by normal gastric acidity
 Upper small intestine, V. Cholerae O1 and O139 produce an
enterotoxin that promotes the secretion of fluid and electrolytes
 Loss of electrolyte-rich isotonic fluid leads to blood volume
depletion with resulting low blood pressure and shock.
 Loss of bicarbonate and potassium
Clinical manifestations
 Acute onset of copious watery diarrhea and vomiting without
abdominal cramps or fever
 Stools are colorless with small flecks of mucus (“rice-water”)
and are sometimes described as having a fishy odor
 Severe dehydration*, metabolic acidosis, and hypokalemia can
occur in 4–12 hr.
Treatment
 Fluids and electrolytes
 Drugs of choice
TRANSCRIBER: OBRERO/OCAMPO/PALADO
LOOK IN THE MIRROR… THAT’S YOUR COMPETITION.
Treatment
 Infant botulism: Human botulism immuneglobulin (BIG-IV):
single intravenous infusion of 50 mg/kg
 Food, wound, or inhalational botulism: 1 vial of equine
botulinum antitoxin
 Antibiotic therapy is not part of the treatment of uncomplicated
infant or food-borne botulism
 Antibiotics are reserved for the treatment of secondary
infections Trimethoprim-sulfamethoxazole is preferred
B. CLOSTRIDIUM TETANI
Etiology
 Historically called lockjaw, is an acute, spastic paralytic illness
caused by the neurotoxin (tetanospasmin).
 Motile, gram-positive, spore-forming obligate anaerobe
 Drumstick or tennis racket- lalabas sa exam
 Not tissue-invasive
 Causes illness through the effects of a single toxin
 Tetanospasmin is the 2nd most poisonous substance
Pathogenesis
 Tetanus toxin binds at the neuromuscular junction
 and enters the motor nerve
 Exits the motor neuron in the spinal cord
 Enters spinal inhibitory interneurons, where it
MED 3-C | 7
 UNP-MEDICINE 2021 PEDIATRICS
 prevents release of the neurotransmitters glycine γaminobutyric  Pregnancy
acid (gaba)  Severe diarrhea
 Blocks the normal inhibition of antagonistic muscles on which  Severe malnutrition
voluntary coordinated movement depends  Severe abdominal distention
 Muscles sustain maximal contraction and cannot relax  Very high fever
o Patients would purge a lot
Clinical manifestations o Worms would undergo erratic migration
 Trismus (masseter muscle spasm, or lockjaw)
 Risus sardonicus results from intractable spasms of facial and A. ASCARIASIS
buccal muscles  Ascaris lumbricoides
 Opisthotonos  Most prevalent form of parasitism in the Philippines
 Boardlike rigidity  Large intestinal roundworm
 Patient unfortunately remains conscious  Largest nematode of the human intestines
 Seizures: sudden, severe tonic contractions of the  Poor sanitation
 muscles  Human feces fertilizer
 The smallest disturbance by sight, sound, or touch may trigger  Hand to mouth habit
a tetanic spasm
 Dysuria and urinary retention result from bladder sphincter
spasm; forced defecation may occur
 Neonatal tetanus (tetanus neonatorum)
 3–12 days of birth as progressive difficulty in feeding
(sucking and swallowing), associated hunger, and crying
 Paralysis or diminished movement, stiffness and rigidity to
the touch, and spasms, with or without opisthotonos, are
characteristic
 Umbilical stump
 Cephalic tetanus: involves the bulbar musculature (wounds
or foreign bodies in the head, nostrils, or face)
o Associated with chronic otitis media
o Characterized by retracted eyelids, deviated gaze,
trismus, risus sardonicus, and spastic paralysis of the
tongue and pharyngeal musculature

Treatment  Eggs are passed through excreta embryonated eggs are

 Human tetanus immunoglobulin (Tig) (500 u) ingested and then pass through venous plexi of mesenteric
 Human intravenous immunoglobulin (IVIg) veins and access the pulmonary circulation
 Equine- or bovine-derived tetanus antitoxin (tat) is 50,000– o Loeffler’s syndrome - pulmonary manifestation of a
100,000 u worm infection similar to bronchitis and pneumonia and
 Antibiotic of choice: penicillin g (100,000 u/kg/ day divided appear on XRay as hilar densities
every 4–6 hours IV for 10–14 days)  Regurgitated and swallowed back into intestines
 Metronidazole (500 mg every 8 hours IV for adults)  Diarrhea, abdominal pain, abdominal distention
 Erythromycin and tetracycline (for persons >8 years of age)  Access into biliary tree and pancreatic manifestations oHeavy
worm burdens oTreatment: Surgery
 Peritoneal manifestations oPenetrate intestinal wall – peritonitis
HELMINTH INFECTIONS
Incidence Diagnosis
 Philippines - Parasite rate o67% of all school age children have soil  Stool specimen – diagnostic test of choice
transmitted helminthiasis (STH)  Barium swallow/ enema
 Department of Health and DepEd  Spaghetti strands
 7 out of 10 of elementary school children  Dot sign
 Woldwide: 165, 000 die every year  Tramway sign/ railroad sign
 Majority: 1 – 5 year age group  String sign
 Food handlers
 University belt: 60% infection rate Treatment
 UP Dietary service: 40%  DOC: Albendazole
 Cebu CHO: 28%  Alternative:
 Mebendazole
Integrated Helminth Control Program  Pyrantel pamoate (Combantrin)
 AO no. 2010 - 0023; 2006-0028  Nitazoxanide
 Recommends deworming for all children aged 12 months to o Lesser side effects
adolescence, pregnant and special groups. o Similar cure rates for single dose Albendazole
 Albendazole o Effects are intraluminal
 12 - 24 months: 200 mg single dose every 6 months  For biliary/intestinal obstruction oPiperazine citrate- causes
 >/= 24 months: 400mg single dose every 6 months neuromuscular paralysis of the parasite and rapid expulsion of
 Can be used among pregnant patients but with caution worms
 Mebendazole
 >/= 12 months: 500 mg single dose every 6 months Nice to know
 Chewable tablets  About 1 billion humans are affected by Ascaris
o Not given to kids <36 months  Most are in pre - school or early school age
o Usual preparations of Albendazole and Mebendazole  Adult worm lifespan 12 - 18 months
 Females lay eggs at 8 - 10 weeks old
Integrated Helminth Control Program  Egg production: 200,000 eggs/day (Rmax 26M)
 *Deworming must not be done in certain special conditions  Ascaris eggs remain viable at 5-10⁰ C for as long as 2 years
 Contraindications of deworming
TRANSCRIBER: OBRERO/OCAMPO/PALADO
LOOK IN THE MIRROR… THAT’S YOUR COMPETITION. MED 3-C | 8
 UNP-MEDICINE 2021 PEDIATRICS
B. HOOKWORM INFECTIONS
 Necator americanus
 Ancylostoma duodenale
 Less common zoonotic species
o ceylanicum
o caninum
o braziliense
 Most common human hookworm
o N. Americanus

HOOKWORM INFECTIONS

Clinical Manifestations
 Prominent intestinal symptoms
 Dysentery oChronic colitis
 Rectal prolapse
 Appendicitis

Treatment
 Mebendazole
 Safe and effective in part because it is poorly absorbed in
the GIT
 Reduces egg output by 90-99%
 Cure rates of 70-90%
 Alternative
 Albendazole
o In heavy infections, longer dose
o The heavy dose may have to be administered for
3 days
 Nitazoxanide

Prevention
 Infective stage: filariform larva  WASH
 Penetrate skin (usually foot): ground itch or dew itch- gain  Don’t use human poo as fertilizer
access to circulation- pulmonary circulation-swallowed into the
intestines- multiply in the intestines- intestinal manifestations Nice to know
(anemia, IDA, edema)  Estimated 800M infected individuals worldwide
 Suck approximately 0.005ml of blood/worm/day
Treatment  Adult female produces up to 20, 000 eggs/day
 DOC: Benzimidazoles (Mebendazole/Albendazole preferred)  Transmission can also occur indirectly through flies or other
 Pyrantel insects
 N. americanus usually refractory to single treatment
 Mebendazole reported 10% cure rate ONLY D. ENTEROBIASIS
 Replacement therapy with oral iron  Oxyuriasis
 Usually not necessary  Enterobius vermicularis
 As soon as you get rid of Hookworms, anemia gets  Human pinworm, seat worm
resolved  Most common helminth infection in the United States
o Transcends socioeconomic status
Nice to know  Co-infection: Dientamoeba fragilis
 Hookworm infection affects an estimated 576 million individuals
worldwide
 Each adult A. duodenale hookworm causes loss of an estimated 0.2
ml of blood/day
 Lays 25-30, 000 ova/worm/day
 Chronic hookworm disease- Chlorosis
Greenish, unique kind of pallor

C. TRICHURIASIS
 Trichuris trichiura
 Human whipworm Clinical Manifestations
 Prevalence of T.trichuria infection can be as  Nocturnal pruritis
 high as 95% - Very common, discrete and almost unmistakeable
 Where protein-energy malnutrition and anemia are symptom for Enterobius vermivularis
common  Aberrant migration
o Appendicitis
o Salpingitis
o PID
TRANSCRIBER: OBRERO/OCAMPO/PALADO
LOOK IN THE MIRROR… THAT’S YOUR COMPETITION. MED 3-C | 9
 UNP-MEDICINE 2021 PEDIATRICS
o Peritonitis o Hyperinfection syndrome
o Hepatitis
*Capable of autoinfection Diagnosis
 Look for larvae
Diagnosis o Stool, duodenal fluid (enteric string test/Enterotest)
 Finding adult pinworms in the perianal region  IgG ELISA
 Rarely seen in fecal smears
 Detection of ova via scotch tape method Treatment
o Tape placed on the perianal area of patient  DOC: Ivermectin
o Before the patient bathes or washes o 3 consecutive days; 10 days and repeated course in
Treatment hyperinfection
 Morning bathing removes a large portion of eggs  Alternative:
 Simultaneous treatment of entire household is necessary o Thiabendazole
 Repeat treatment after 2 weeks Nice to know
- Kills viable eggs in the environment  Only adult female worms inhabit the small intestine
 Mebendazole (Parthenogenesis)
o Cure rates: 90-100%  Strongyloides infection can be potentially lethal in the
“hyperinfection” syndrome
Nice to know  Infections as long as 30+ years
 Gravid females migrate at night to the perianal and perineal
regions where they deposit up to 15, 000 eggs F. CAPILLARIASIS
 Egg viability: 20 days  Capillaria philippinensis
 More common in whites than blacks  1964, Northwestern Luzon
o Pudoc and Tagudin, Ilocos sur
E. STRONGYLOIDIASIS o Bangar, La Union
 Strongyloides stercoralis – Threadworm  Ingestion of uncooked or partially cooked fish
 Complex life cycle  Autoinfection
 Autoinfection in malnourished/immunocompromised  Most stages found in the human intestines
o Hyperinfection o Larvae, oviparous and larviparous females
 Communicability: indefinite
o As long as larvae is positive in the stool Life Cycle
 Birds: definitive host
 Man: accidental host
 Intestinal manifestations:
o Diarrhea and malabsorption
o Dehydration
o Acidosis
o Shock
o Cardiac failure
o +/- intercurrent infections and undernutrition and anemia

Diagnosis
 Classic: Ova in stools
 Decreased levels of serum proteins, potassium, sodium and
calcium
 Elevated IgE

 The nematode parthenogenesis and releases eggs Treatment

containing mature larvae into the intestinal lumen.  Mebendazole
 Rhabditiform larvae immediately emerge from the ova and o 200 mg BID daily for 20 days
are passed in feces, where they can be visualized by stool  Correct dehydration, shock and/ or acidosis
examination.  Maintain adequate nutrition
 Rhabditiform larvae either differentiate into free-living
adult male and female worms or metamorphose into the
infectious filariform larvae. BLOOD AND TISSUE NEMATODES
o Sexual reproduction occurs only in the free-living stage
o Humans are usually infected through skin contact with soil
A. FILARIASIS
contaminated with infectious larvae
 Wuchereria bancrofti
 Larvae penetrate the skin, enter the venous circulation and then
o Africa, Asia and Latin America
pass to the lungs, break into alveolar spaces, and migrate up
o Accounts for 90% of lymphatic filariasis
the bronchial tree.
 Brugia malayi
 They are then swallowed and pass through the stomach, and
o South Pacific and Southeast Asia
adult female worms develop in the small intestine
 Brugia timori
o Egg deposition begins about 28 days after initial infection
o Restricted to several islands of Indonesia
Clinical Manifestations
 Skin invasion
o Larva currens
 Pulmonary
 Parasitism by adult worm
o Cochin-China diarrhea
o Steatorrhea
▪ Protein losing enteropathy
▪ Weight loss
TRANSCRIBER: OBRERO/OCAMPO/PALADO
LOOK IN THE MIRROR… THAT’S YOUR COMPETITION. MED 3-C | 10
 UNP-MEDICINE 2021 PEDIATRICS
▪ Hypertension
▪ Death
▪ Especially with high microfilarial levels
▪ Dose of DEC should be increased gradually

B. ONCHOCERCIASIS
 Onchocerca volvulus
 River blindness
 Primarily in West Africa
o Also Central and East Africa
 The world’s 2nd leading infectious cause of blindness
o 1st: Ophthalmia neonatorum associated with Chlamydia

Clinical Manifestations
 Most infections: asymptomatic
 Adults have a certain predilection to lymphatics
 Acute stage
 Lymphangitis and lymphadenitis
 Chills
 Fever
 Myalgia  Vector: Simulium black fly
 Few days to several weeks o Lodge into subcutaneous tissues
 Repeat attacks of lymphangitis ▪ Particular predilection for iliac crest, bony prominence
 Gradual thickening of skin of scapula, sacrum
 Elephantiasis  Viviparous
 Hydrocoele (affects only >30 years, repeat infections)  Offsprings enter the eye (aqueous or vitreous humor), die
 Epididymitis  produce retinal detachment, chorioretinits, corneal abrasions
 Orchitis (Wuchereria > Brugia)  Blindness or loss of the eye
 Chyluria  Pannus formation
- Obstruction in lymph nodes and leakage of chyle o Iris clumping up
 Tropical Pulmonary Eosinophilia Syndrome o Beginning cataract
 Nocturnal paroxysms of cough
 Diffuse military lesions or increased bronchovascular Diagnosis
markings  Biopsy
 Microfilariae in the lungs and lymphatics but NOT in the o Adult worms on nodules
blood  Saline immersion of snips of skin
 Extremely high titer of filarial antibody o Scapulae, iliac crest, buttocks, calves
 Elevated ESR  Slit lamp
 Hypereosinophilia and IgE
Treatment
Diagnosis  DOC: Ivermectin
 Demonstration of microfilaria in fresh blood film o Clears microfilariae transiently (several months)
o Obtained between 8pm and 2-4 am or concentration with o Repeated at 3-6 months intervals if there are continuing
formalin (difficult to obtain) symptoms or evidence of eye infection
o No effect on the adult worm

C. LOAIASIS
 Loa Loa
 Eye worm
 Calabar swellings/Fugitive swellings
 Biopsy
o Non-erythematous areas of subcutaneous edema 10-20 cm
o Adult and microfilarial worms in tissue biopsy specimens
in diameter typically found around joints such as the wrist
 Ultrasonography
or knee or elbows
o Adult worms in lymphatic vessels
o Produced by the migration of adults or microfilaria in the
 Serology
system
o Detection of parasite antigen in serum

Treatment
 Diethylcarbamazine citrate (DEC)
o Tapered dosing x 14 days
o Increased microfilaremia = toxicity
- Will not cure elephantiasis
- Increase inflammatory reaction
- Mazzotti Reaction
▪ Urticaria
▪ Pruritus
▪ Fever
▪ Generalized body pain
TRANSCRIBER: OBRERO/OCAMPO/PALADO
LOOK IN THE MIRROR… THAT’S YOUR COMPETITION. MED 3-C | 11
 UNP-MEDICINE 2021 PEDIATRICS
 Vector: Chrysops fly
 Adults lodge into subcutaneous tissue but may enter the eye

Diagnosis
 Clinical
 Microfilaria may be detected in blood smears
o Collected between 10 am and 2 pm

Treatment
 Diethylcarbamazine
o For eradication of microfilaremia
o Does not kill adult worms
 Adult worms should be surgically excised when possible
 Alternative
o Albendazole: 3 week course
o Ivermectin: single dose
F. TOXOCARIASIS
 Supportive
 Toxocara species
o Antihistamine or Corticosteroids
o Dogs: Toxocara canis
o Cats: Toxocara catis
D. ANGIOSTRONGYLOIDIASIS
 Visceral and Ocular Larva Migrans
 Angiostrongylus cantonensis
o Rat lungworm
o But is usually found in the brain
o Most common cause of human eosinophilic meningitis
 Angiostrongylus costaricensis (Parastrongylus)
o Abdominal or intestinal angiostrongyliasis
o From Costa Rica

E. DRACUNCULIASIS
 Guinea worm disease
 Medina worm
 Dracunculus medinensis
 Now nearing extinction
 Usually in Ethiopia, Gambia, Nepal
 Humans: accidental hosts
o Become infected by ingesting infective eggs in
contaminated soil or infected paratenic hosts
 Larvae can cause severe local reactions that are the basis of
Toxocariasis
o Inflammatory capsule
o Eosinophilia
o Space occupying problems
 Immunocompromised dogs/cats:
o Can be transmitted transmammary or transplacental to
puppies, stool, major source of environmental egg
contamination
 Vector: Copepods
o Contain larvae
 Humans become infected by drinking unfiltered water
containing copepods which are infected with the larvae of D.
medinensis
 penetrate host stomach and intestinal wall
 After maturation into adults and copulation, the male worms die
and the females migrate in the subcutaneous tissues towards
the skin surface
 Approximately 1 year after infection, the female worm induces a
blister on the skin, generally on the distal lower extremity,
which ruptures
 When the lesion comes into contact with water, the female
worm emerges and releases larvae

Diagnosis
 Clinical Diagnosis
 Identification of larvae from discharge fluid  EIA for Toxocara antibodies
o (+) in 78% of VLM and 45% of Ocular Toxocariasis
Treatment  Liver biopsy
 Physical removal of worm o Generally not indicated
 Supportive
o Metronidazole Treatment
▪ Decreases local inflammation  Therapy not required for most cases
▪ Facilitates removal o If mild symptoms
o Topical corticosteroids ▪ Subside over period of weeks to months
o Topical antibiotics ▪ Disagreement on the use of antihelminthics

TRANSCRIBER: OBRERO/OCAMPO/PALADO
LOOK IN THE MIRROR… THAT’S YOUR COMPETITION. MED 3-C | 12
 UNP-MEDICINE 2021 PEDIATRICS
 Dying larva may cause more tissue damage than the SAMPLE TEST QUESTIONS
encapsulated dormant parasite 1. The most prevalent human helminthiasis and produces and
o Albendazole estimated 1 billion cases worldwide. Ascariasis
o Alternative: Mebendazole 2. This is the only GI helminth that actually multiplies in the GI
 For ocular Toxocariasis tract (the others produce eggs and pass with feces).
o Extended duration of treatment Hookworms
3. Official scientific name for the human threadworm.
G. TRICHINOSIS Strongyloides stercoralis
 Acquired by ingesting meat containing cysts (encysted larvae) 4. A previously healthy 4 y/o living in Irisan presents with a 1
of Trichinella week history of fever, cough and shortness of breath. Her
o After exposure to gastric acid and pepsin, the larvae are temperature is 37. 5⁰ C, PR: 80, rr: 30 and BP: 95/60. Chest film
released from the cysts and invade the small bowel reveals bilateral pulmonary infiltrates. The CBC is normal except
mucosa for eosinophilia. Which of the following is the most likely cause
o develop into adult worms of illness?
 Larvae migrate to striated muscles where they encyst a. Trichuris trichiura
o Trichinella pseudospiralis: does not encyst b. Ascaris
o Encystment completed in 4-5 weeks c. Enterobius
d. Mycobacterium TB
e. Streptococcus pneumoniae
5. A 3 – year old girl who was previously healthy presents with a 1
week history of intense nocturnal perianal itching after residing
in a different household. The cousins also had the same
symptoms. Bruxism was observed during sleep. There are no
other findings. PE is normal. The curative therapy is:
a. Bacitracin ointment in the perianal area
b. Diphenhydramine orally as needed for itching
c. Single oral dose Mebendazole repeated in 2
weeks
d. Permethrin and sulphur soap
e. Ketoconazole
6. An 8 – year old boy from Makati received a liver transplant 6
months ago abroad and is on corticosteroids and Azathioprine.
He presents in the ER with a 2 day history of cough and
wheezing. Hemoptysis was observed within the previous 12
Clinical Manifestations hours. A stool specimen is most likely to reveal?
 Intestinal symptoms a. Salmonella enteritidis
o Diarrhea b. Histoplasma capsulatum
o Borborygmi c. Ancylostoma braziliense
o Dehydration d. Pneumocystis carinii
 Classic symptoms- will ensue once they are hatched e. Strongyloides stercoralis
o Facial and periorbital edema 7. which of the following parasites is not transmitted by flies?
o Fever a. Schistosoma mansoni
o Weakness b. Loa loa - chrysops
o Malaise c. Onchocerca volvulus - silirium
o Myalgia d. Trichuris trichiura
▪ Usually in the part where encysted larvae are 8. Most common cause of human eosinophilic meningitis
o Eosinophilia a. Angiostrongylyus cantonensis
 Mortality b. Angiostrongylus costaricensis
o Myocarditis, Encephalitis, Pneumonia c. Loa loa
d. Onchocerca volvulus
Diagnosis 9. Which is the best time to extract blood to isolate maximum
 (+) serology or muscle biopsy + >/= 1 classical symptom microfilarial level of Brugia and/or Wuchereria?
o 1 case = outbreak a. 10 pm to 2 am
b. 6 am before defecation or bathing - enterobius
Treatment c. Midday
 Mebendazole TID PO x 10 days d. 10 am to 2 pm - loa loa
 Alternative 10. Which illness is considered the most serious tapeworm infection
o Albendazole BID PO for 8-14 days in the world? Echinococcosis
 No consensus for treatment of muscle stage trichinosis 11. What is PAIRing?
o Corticosteroids and Mebendazole - Guided Percutaneous Aspiration, Instillation
▪ Efficacy is anecdotal and hypertonic saline or other scolicidal agent
o Thiabendazole and Mebendazole and Reaspiration
12. An adolescent patient presents with stupor after a new onset
Prevention seizure. CNS imaging shows a distinct, contrast enhancing
 Cooking (>55⁰C) or freezing (<-15⁰C for >3 weeks) frontoparietal lesion. Careful CSF examination shows an
 Meat inspection eosinophilic pleocytosis. History from parents reveal a past
history of hemoptysis and recent dietary history of ingesting
food flavored with raw crab juice while on a vacation to the
Visayas.
-END- a. Chlonorchis sinensis
b. Angiostrongylyus cantonensis
c. Paragonimus westermani
d. Schistosoma japonicum

TRANSCRIBER: OBRERO/OCAMPO/PALADO
LOOK IN THE MIRROR… THAT’S YOUR COMPETITION. MED 3-C | 13