Neonatal

Condition Description Signs/symptoms Ddx

Transmission during
pegnancy/exposure to maternal fluids
during birth. Higher transmission rate if
mother acquires disease during
pregnancy
CMV
Preterm birth, IUGR, microcephaly, poor
feeding, lethargy, petechiae/purpura,
blueberry muffin spots, jaundice, HSM
Elevated liver enzymes, anemia,
thrombocytopenia
intracranial (esp periventricular) calcifications, CMV in urine within first 2 wks of life
seizures, chorioretinitis

Perinatal transmission; higher rates if First 4 wks:

mother has primary infection during 1) isolated mucocutaneous lesions,
pregnancy. Most are born to women keratoconjunctivitis
Viral cx, DFA testing of scrapings. CSF:
who have never experienced 2) encephalitis
HSV PCR
symptoms 3) disseminated disease involving mult
EEG
organs

Parvovirus Hydrops fetalis Maternal IgM, IgG levels

Mostly asymptomatic
LAD/HSM, FTT, DD, encephalopathy, bacterial
HIV infections, opportunistic infection, lyphoid HIV culture, PCR
interstitial pneumonitis

Congenital: anytime during pregnancy. Congenital: IUGR, "zigzag" scarring, limb

Acquired: mothers who develop atrophy, ocular abnormalities Acquired:
VZV lesions 5d before- 2d after delivery widespread cutaneous lesions, PNA,
hepatitis, death

Rubella Transmission at any time during Congenital rubella syndrome: cataracts, Maternal antibody titers during pregnancy
pregnancy sensorineural hearing loss, congenital cardiac After birth: elevated rubella IgM or
defects, DD IgG

Premature delivery, asymptomatic at birth

Skin lesions, anemia, thrombocytopenia,
jaundice, "snuffles", HSM, elevated liver
Transplacental transmission; any time enzymes, skeletal abn
Syphilis during pregnancy esp 1st/2nd (osteochondritis, periostitis),
trimesters

Toxoplasmosis
Dermatology
Condition Description Signs/symptoms Ddx
Viral infections
Prodrome: fever, anorexia, oral pain Crops of ulcers
on tongue/oral mucosa, Vesicular rash on
Hand-foot-mouth Coxsackie A hands/feet/buttocks/ thighs
- football shaped vesicles

Giannoti-Crosti Occurs 1-6 yrs, after URI hepatitis Asymptomatic erythematous papular eruption Order hep B serologies
Syndrome (papular B, EBV, varicella - symmetrically distributed on face, extensor
acrodermatitis) surfaces of arms, legs, buttocks
- spares trunk
 Primary infection with VZV incubation 10-21d Clinical diagnosis
fatal disseminated disease in prodrome: fever, malaise, anorexia, morbilliform - Tzanck smear
immunocompromised rash - DFA, viral culture, PCR
next day: pruritic rash on trunk, spreading
peripherally.
Varicella - red papules --> clear vesicles (dewdrop on rose
petal) --> crusts
- occurs in crops

Reactivation of VZV from dorsal Pain/pruritus

root ganglia Vesicular eruption in crops, confined to dermatome
Uncommon in children <10 - clears up in 7-14d
Herpes zoster Pain persists for wks-months (postherpetic
neuralgia)

Molluscum contagiosum Poxvirus Small, flesh colored, pearly, umbilicated,

Common in childhood, dome-shaped papules in moist areas
wrestlers, sauna bathers - axilla, buttocks, groin
- resolve in 1-2 yrs

HPV Verruca vulgaris: common wart Verruca plantaris:

Spread by skin-skin contact or plantar wart Verruca plana: flat wart
Verrucae fomites Condylomata accuminata: genital wart

Presumed viral exanthems

Viral URI prodrome sometimes
Rash begins as herald patch, 2-10cm oval salmon
plaque on trunk, neck, UE, or thigh --> smaller
Pityriasis Rosea lesions in christmas tree pattern over trunk and
UE.
- fades over 4-12 wks

Dermatology
Condition Description Signs/symptoms Ddx
Unilateral thoracic Exanthem on one side of trunk that spread
exanthem (asymmetric centripetally
periflexural exanthem of - variable: erythematous macules/papules with
childhood) Children 1-5 yrs Winter and surrounding halo, morbilliform, eczematous, Often confused with
spring scarlatiniform, reticulate contact dermatitis

Skin manifestations of bacterial infections

red macules --> bullous (fluid filled) eruptions on Can be mistaken for
erythematous base cigarette burns
Bullous impetigo S. aureus toxin S. aureus can be cultured from vesicle fluid

papules --> vesicles --> 5mm pustules --> rupture

--> honey colored crust over ulcerated base
Organism can be isolated from lesions
group A beta hemolytic strep, s.
Nonbullous impetigo
aureus
 abrupt onset erythema, skin tenderness, irritability,
fever --> flaccid bullae --> rupture --> beefy red,
weeping surface
- periorificial areas of face, flexural areas around
neck, axillae, inguinal creases
S. aureus
Staph scalded skin positive Nikolsky sign: separation of epidermis
Common in infancy, rare beyond
syndrome after light rubbing
5 yrs
Unruptured bullae contain sterile fluid

S. aureus Buttocks/lower legs of girls who shave Deep forms:

Infection of hair follicle shaft - furuncle (boil): areas of friction - scalp, buttocks,
Folliculitis Hot tubs: pseudomonas axillae
- carbuncles: collections of furuncles

Dermatology
Condition Description Signs/symptoms Ddx
Silvery scales, tends to be on extensor surfaces, Eczema: pruritic, flexural
symmetric, Auspitz sign creases
Koebner phenomenon: psoriasis appears at sites Scalp lesions may look
of physical/thermal/ mechanical trauma like seborrheic dermatitis
Nail pitting, onycholysis (detachment of nail plate), or tinea capitis
accumulation of subungual debris.
Group A strep: common exacerbation
Psoriasis Family history, HLA inheritance

Eruptions secondary to allergic reactions

Erythematous macules, papules, plaques, vesicles, Polycyclic urticaria: can
target lesions appear targetoid, but
- evolve over days lesions are not fixed and
- fixed, develop necrotic centers do not have necrotic
- dorsum of hands and feet, palms and soles, centers.
Acute, self limited hypersenitivity
extensor surfaces, may spread to trunk Edematous,
reaction
Erythema multiforme erythematous borders
- herpesvirus, adenovirus, EBV
with central clearing,
- recurrent EM: HSV 1
resolving in 12-24 hrs

10% mortality if untreated Prodrome 1-14d: fever, malaise, myalgias,

NSAIDs, penicillins, arthralgias, HA, emesis, diarrhea
sulfonamides, antiepileptic meds, Sudden onset fever, erythematous purpuritic
mycoplasma, immunizations macules with duscky centers, inflammatory bullae of
Stevens Johnson mucous membranes
syndrome - GI, resp, GU tract involvement if severe

Toxic epidermal Severe form of SJS involving Positive Nikolsky sign

necrolysis 30% of body 30% mortality if Elevated liver enzymes, renail failure, fluid and
untreated Upregulated expression electrolyte imbalance
of
Fas-ligand in epidermis

Pulmonology
Condition Definition Epidemiology Etiology Signs/symptoms Ddx
Obstructive lung diseases
 Upper airway: nostril to Choanal atresia: narrowing of
thoracic inlet nasal passages
- obstruction leads to Laryngomalacia: large, floppy
inspiratory obstruction arytenoid cartilage, MCC
- obstruction below congenital stridor Suspect
thoracic inlet leads to subglottic hemangioma in child
expieratory obstruction with persistent stridor and
cutaneous hemangioma
Older child: large adenoids and
Upper airway obstructive tonsils laryngotracheitis,
disease peritonsillar or retropharyngeal
abscess
Noisy inspiration, increased work of
breathing (nasal flaring, accessory
muscles), retractions (suprasternal)
Obstruction of subglottic space: high
pitched, monophonic stridor
Obstruction above glottis: more variable,
fluttering stridor
Flexible bronchoscopy often required to
evaluate anatomy and dynamics of upper
airway

Obstructive sleep apnea Pickwickian syndrome: Changes in upper airway tone Restless sleep with position changes, Polysomnography: measure respiratory
OSA associated with during sleep, anatomic irregular snoring, daytime somnolence, muscle activity, air flow, oxygenation, sleep
obesity obstruction poor stage, and heart
growth, enuresis rate

Prolonged respiratory infections, decr Methacholine challenge test CXR:

exerise tolerance, persistent hyperinflation, increased bronchial markings
day/nighttime coughing

1) Reversible airway 15-20% children in US Acute exacerbation: wheezing, subcostal Ddx:

obstruction 25% in blacks and retractions, nasal flaring, tracheal - intraluminal inflammation or failure to clear
2) inflammation hispanics tugging, prolonged expiratory phase secretions: bronchiolitis, GER with aspiration,
3) bronchial most common cause of resulting from obstruction cystic fibrosis, TE fistula, primary ciliary
hyperresponsivenes s hospitalization - absence of wheezing/decr breath dyskinesia
>50% present before sounds indicate severe airway - intraluminal mass effets: foreign body
age 6 obstruction aspiration, tracheal or brochial tumors or
Risk factors: genetic, - CXR: hyperinflation, focal atelectasis granulation tissue
atopy, cigarette exposure, Severity/Control: determined by - dynamic arway collapse:
urban impoverished areas, impairment and risk tracheobronchomalacia
rhinovirus/RSV URIs - Impairment: nighttime awakenings, - intrinsic narrowing of airway:
Asthma interference with normal activity, lung congenital/acquired stenosis
function - extrinsic compression: masses, LN
- Risk: exacerbations requiring oral - cough variant asthma: chronic cough
systemic corticosteroids triggered by exercise or noted primarily at night
during sleep. +/- wheezing. Improves with
corticosteroids

Nasal polyps in any pediatric pt should

prompt further testing for CF.

AR, chromosome 7 delta CFTR channel: cAMP activated
F508 deletion (single chloride channel on apical
nucleotide deletion) surface of epithelial cells in
Lifespan mid-late 30s respiratory tract, pancreas, sweat
and salivary glands, intestines,
and repro system.
Abnormally viscid secretions and
impairment of mucociliary
clearnace
Cystic Fibrosis
Frequent pneumonias: S aureus, H Elevated sweat chloride (>60mEq/L),
influenza, Pseudomonas aeruginosa pancreatic insufficiency, chronic pulmonary
(>90%), Burkholderia (associated with disease.
accelerated pulmonary deterioration and - lower airways: bronchiectasis, parenchymal
early death) loss, bleb on CXR
GI: pancreatic insufficiency, bowel Newborn screen
obstruction, rectal prolapse, diabetes,
diabetes, hepatic cirrhosis.
failure to thrive is most common
manifestation of untreated CF.
Meconium ileus is pathognomonic

Pulmonology
Condition Definition Epidemiology Etiology Signs/symptoms Ddx

bronchial obstruction, sinusitis, chronic

Light microscopy: abnormal ciliary beat
Primary ciliary Impaired mucociliary DNA11 and DNAH5 otitis media, recurrent respiratory
Ultrastructural changes in ciliary cells from
dyskinesia clearance mutations infections
nasal/bronchial scrapings
sxs same as asthma, CF
 Tracheal cartilage rings
that completely encircle
trachea and grow more
slowly than the rest of
trachea
"washing machine" inspiratory and
Congenital tracheal
expiratory noise, hypoxemia, failure to
stenosis
thrive

Widening of posterior
membranous portion fo
trachea with dynamic
collapse during exhalation

wheezing made worse by treatment

with bronchodilator
Esophageal atresia with TE
Tracheomalacia - bronchodilator makes the posterior
fistula is a common cause
tracheal membrane more flaccid and
more likely to collapse

Dynamic bronchial collapse on

Poor cartilage or poor
exhalation --> wheezing upon forced
Bronchomalacia elastic recoil in
exhalation, failure to respond to
surrounding tissues
bronchodilators or steroids

Cardiology
Condition Description Cardiac exam
Cyanotic Congenital Heart Disease: Ductal-independent lesions
Single arterial vessel arising from base of Systolic ejection murmur at left sternal border
heart - loud ejection click
- VSD is always present - single S2
- Nonspecific murmur at birth - widened pulse pressure; bounding pulses
- CHF develops in weeks CXR: cardiomegaly, incr pulm vascularity, R aortic arch (30%)
Truncus arteriosus - 22q11 microdeletion (DiGeorge): ECG: biventricular hypertrophy (70%)
tetralogy of Fallot, interrupted aortic arch,
VSD

Parallel systemic and pulm circuits Loud, single S2

D-transposition of
great arteries
- Most common form of cyanotic CHD in
first 24 h of life
- patent foramen ovale required to mix
circuits
- intact ventricular septum (60%), VSD
(30%), VSD + pulm stenosis (10%)
VSD +/- pulm stenosis: systolic murmur
CXR: mild cardiomegaly, incr pulm vascularity. "egg- shaped
silhouette"
- ant aorta superimposed on posterior pulm artery results in narrower
mediastium
ECG: R. ventricular hypertrophy

Pulmonary veins not connected to L. No obstruction: progressive CHF

atrium. - R. ventricular heave
- supracardiac (50%): drain into SVC or - wide and fixed split S2 with loud pulmonary
brachiocephalic vein component
- cardiac (20%): drain into coronary sinus - systolic ejection murmur at L. upper sternal border
or R. atrium - CXR: cardiomegaly, snowman contour
- infradiagphragmatic (20%): drain into - ECG: R. axis deviation, R. ventricular hypertrophy
Total anomalous portal or hepatic veins Obstruction: cyanosis, resp distress
pulmonary venous - mixed (10%) - Loud, single/narrowly split S2
connection Obstruction: vein enters at acute angle. - Tachypnea
pulm venous HTN and severe cyanosis - CXR: normal heart size, diffuse pulmonary edema
- ECG: R ventricular hypertrophy

Cyanotic Congenital Heart Disease: Ductal-dependent pulmonary blood flow

 Complete atresia of tricuspid valve.
hypoplasia of R. ventricle. VSD. PFO
- Normally related great arteries
(NRGA) - ductal independent
- Transposition of great arteries (TGA)
(30%) - ductal dependent systemic blood
flow
- VSD in 90% - allows blood to pass from
Tricuspid atresia L. ventricle to R. outflow chamber and
pulmonary arteries
- pulmonary blood flow depends on size
of VSD and degree of pulm stenosis
1) VSD 2) Pulm valve stenosis 3) R.
ventricular hypertrophy 4) overriding aorta
- R-->L shunt through VSD results in
cyanosis. Timing/severity depends on
degree of R. ventricular outflow
obstruction
22q11 microdeletion, most common CHD
Tetralogy of fallot presenting in childhood
Cardiology
Condition Description
Inferior displacement of tricuspid into
R. ventricle, small R. ventricle, enlarged R.
atrium, patent foramen ovale (80%)
- atrialization of R. ventricle
- severe tricuspid regurg --> majority of
pulm blood flow comes from PDA
- dilated R atrium results in tachycardia
- Wolff-Parkinson White syndrome
Ebstein anomaly - Maternal Lithium use
Cyanotic Congenital Heart Disease: Ductal-dependent systemic blood flow
Atresia/hypoplasia of mitral valve Aortic Neonates: severely decr systemic blood flow when PDA closes.
atresia or stenosis
PDA
PFO with L-->R shunt
Decr blood flow through left heart.
Systemic blood flow is completely PDA
dependent
Hypoplastic left heart
syndrome
Significant pulm stenosis: progressive cyanosis No pulm stenosis:
no symptoms
TGA: cyanosis, poor feeds
Holosystolic VSD murmur at L. lower sternal border Continuous
PDA murmur
CXR: normal heart size.
- TGA: cardiomegaly
ECG: Left-axis deviation, R. atrial enlargement, L. ventricular
hypertrophy
Tet spells: episodes of cyanosis, rapid/deep breathing, agitation
- incr in R. ventricular outflow tract resistance --> incr shunt across
VSD
- squatting increases venous return and systemic perfusion
R. ventricular heave
Loud systolic ejection murmur at L. upper sternal border
CXR: boot shaped heart
ECG: R. axis deviation, R. ventricular hypertrophy
Cardiac exam
Severe: Cyanosis and CHF
Mild: fatigue, exercise intolerance, palpitations, mild cyanosis w/
clubbing
Widely fixed split S2, gallop
Blowing holosystolic murmur (tricuspid regurg)
CXR: cardiomegaly with R. atrial enlargement and decr pulm
vascularity
ECG: R bundle branch block with R. atrial enlargement
- Wolff-Parkinson White: delta wave and short PR interval
Shock, tachycardia, tachypnea
Right ventricular heave Single S2
Continuous PDA murmur
CXR: pulmonary edema and cardiac enlargement
ECG: R. ventricular hypertrophy, poor R wave progression
 Extreme coarctation of aorta Type A:
interruption beyond L. subclavian
Type B: Betw L. subclavian and L.
common carotid (most common) Type C:
Interrupted aortic arch Same as hypoplastic left heart syndrome
Betw L. common carotid and
brachiocephalic

Acyanotic Congenital Heart Disease

Ostium secundum: midportion Ostium Paradoxical embolism
primum: lower septum SVT from atrial enlargement
Sinus venosus defect: Junction of R. Systolic ejection murmur in pulmonic area (pulmonary valve),
atrium and SVC/IVC middiastolic rumble in lower right sternal border (tricuspid valve)
L-->R shunt: R. atrial and R. ventricular Loud S1, fixed widely split S2
enlargement CXR: enlarged heart and main pulmonary artery ECG: R ventricular
Atrial septal defect
enlargement

Most common congential heart defect

Muscular: muscular portion of septum
Inlet: endocardial cushion defect, inlet
portion of septum below tricuspid
Conoseptal hypoplasia: RV outflow tract
below pulmonary valve Conoventricular:
membranous portion
Malalignment: infundibular septum
- anterior malalignment results in TOF Eisenmenger
Ventricular septal - posterior malalignment results in aortic Harsh systolic murmur at left sternal border
defect stenosis CXR: mild cardiomegaly, incr pulm vascularity,
ECG: L atrial, L ventricular, or biventricular hypertrophy

Cardiology
Condition Description
Down syndrome
Endocardial cushion defect --> ostium
primum ASD, inlet VSD with lack of
septation of mitral and tricuspid valves
Incomplete: CAVV leaflets attach directly
to muscular portion of ventricular septum.
- ASD only. Some mitral regurg
Common Complete: CAVV is not attached to
atrioventricular canal muscular ventricular septum
defect - ASD and large inlet VSD. L-->R shunting
at ASD and VSD.
Cardiac exam
Incomplete: Same as ASD.
- Blowing systolic murmur at L. lower sternal border and apex
(mitral regurg)
Complete: CHF
- blowing holosystolic murmur at L lower sternal boder
- Widely split, fixed S2
- CXR: cardiac enlargement, incr pulm vascularity
- ECG: superior axis (canal defect), enlargement of R and L atria

Premies Large, L-->R flow: CHF, FTT

Symptoms related to size of defect and - bounding pulses
direction of flow - continuous murmur after S1, peaks at S2, trails off during
diastole
Patent ductus - CXR: cardiomegaly, incr pulm vascularity
arteriosus - ECG: L or biventircular hypertrophy
Reversal of flow (R-->L): cyanosis
 Delayed/weak femoral pulses, upper extremity HTN
nonspecific ejection murmur at apex
bicuspid valve: apical ejection click
CXR: enlarged aortic knob, cardiomegaly
Coarctation of the ECG: R ventricular hypertrophy In neonate, L ventricular hypertrophy
Turner syndrome
aorta in older pt

Thickened, rigid, valvular tissue Increased Harsh systolic ejection murmur at right upper sternal murmur
pressure in L ventricle --> L ventricular Ejection click Thrill
hypertrophy, decr compliance CXR: cardiomegaly, pulmonary edema
ECG: L ventricular hypertrophy. ST depression, inverted T waves
Aortic stenosis (ischemia)

Dysplastic valve. Incr R. ventricular Most are asymptomatic

Pulmonic stenosis
afterload --> R ventricular hypertrophy
Critical stenosis: decr R ventricle
compliance --> incr R atrial pressure --
> opening of foramen ovale --> R to L
shunt
Severe: dyspnea on exertion, angina
Ejection click varies with inspiration
Harsh systolic ejection murmur on left upper sternal border
Severe: thrill, R ventricular heave
CXR: enlarged pulmonary artery segment

Infectious disease
Fever of unknown origin: Fever >14d, T>38.3C on mult occasions, uncertain etiology Ddx includes: infection, CT Bacteremia and sepsis:
disease, malignancy, other (IBD, kawasaki, drug) Occult bacteremia - appears in well-appearing child with no obvious source
s/s: conjunctivitis, LAD, joint tenderness, thrush, heart murmurs, organomegaly, etc Diagnostic eval: - highest in children 2-24 mo, T >39.0C, leukocytosis
- CBC + diff, electrolytes, BUN and creatinine, LFTs, alk phos, UA - MCC S. pneumo, resolves spontaneously
- Blood, urine, stool, CSF cultures Sepsis: bacteremia + systemic response, altered organ perfusion
- ESR, CRP - Neonates: GBS, enteric gram neg, listeria
- CXR, skin test for TB - Children <5: S. pneumo, N. meningitidis
- Children > 5: S. aureus
- Other: Salmonella, pseudomonas, viridans strep
- Evaluation: Blood, urine, CSF cultures, CXR if respiratory signs present

Condition Description Etiology Signs/symptoms Ddx Treatment

Inflammation of middle ear
Eustachian tube in children:
- angle of entry (horizontal)
- short length
- decr tone
Acute otitis media
Narrowing of eustachian Otitis media with effusion: fluid behind 1. High dose amoxicillin, topica
tube by edema in URI TM but no inflammation (no fever/ear pain) perforated
--> vaccuum draws - no abx 2. augmentin, PO second or 3rd
secretions from Myringitis: inflammation of eardrum cephalosporin, or IM ceftriaxone
nasopharynx to middle - no abx S. pneumo: 50% penicillin resis
ear Otitis externa (swimmer's ear): ear pain, H. influenza and M. catarrhalis:
MCC: but TMs looks normal, erythematous canal lactamase activity
Ear pain, fever, fussiness, URI sxs
- S. pneumo - topical abx drops Consider tympanostomy tube if
TMs bulging, opaque, aberrant light
- H. influenza moderate hearing loss, recurren
reflex, decr mobility
- Moraxella

HA, facial pain, sinus tenderness Similar abx as AOM but longer
Acute bacterial: 1) persistent treatment course (14-21d)
Same pathogens as respiratory sxs (10-14d) 2) severe sxs Viral URI, allergic rhinitis, nasal foreign Recurrent disease: sinus aspira
Sinusitis (high fever, purulent nasal discharge) body
AOM

High fever, very sore throat Vesicular Primary herpetic gingivostomatitis:lesions

Diagnosed during summer and
Herpangina
fall in young children
lesions progressing to ulcers are more widespread over gums, lips,
- soft palate, tonsils, pharynx mucosa
Enteroviruses: Hand foot mouth dz: also lesions on - HSV
palms and soles Self limited (5-7d)
coxsackievirus, etc

School aged children and
Streptococcal
adolescents, spread via oral
pharyngitis
secretions
Primary EBV infection in older
children and adolescents
Majority of people are infected
with EBV and seroconvert in
early childhood (usu
asymptomatic)
Infectious mono
Condition Description
Virus induced inflammation of
laryngotracheal tissues,
resulting in upper airway
obstruction
Most pronounced in young
children due to narrow caliber of
Croup Acute subglottic region. Peaks in late
laryngotracheo fall/winter
bronchitis
Acute viral lower respiratory
tract infection resulting in
inflammatory obstruction of the
peripheral airways
At least 50% of children are
infected before 1 yr of age,
recurrent infections are
common. 3% of infants in first 12
Bronchiolitis
mo of life are hospitalized for
bronchiolitis Chornic lung
disease, congenital heart
disease, immunodeficiencies are
risk
factors
URI and persistent cough in
Pertussis adults, life threatening disease
in neonates/infants
acute inflammatory process
Pneumonia
occuring in lungs
sore throat, f/HA/n/abd pain PE:
enlarged erythematous, exudative
tonsils, petechiae on soft palate
No rhinorrhea, hoarseness or
coughing
Scarlet fever: sandpaper rash with
fever and pharyngitis
- begins at neck/axillae/groin, spreads
Group A strep
to extremities, may desquamate
Severe exudative pharyngitis, fever,
EBV
profound fatigue
Etiology Signs/symptoms
Hoarse voice, barky/seal like cough,
inspiratory stridor which may progress
to respiratory distress
Prodrome: low grade fever and
rhinorrhea 12-24h prior to onset of
stridor
Paramyxovirus
(parainfluenza?), can
also result from
influenza or RSV
Infected neonates may develop life
RSV, also
threatening apnea
parainfluenza, influenza,
Initial fever, cough, rhinorrhea followed
human
by respiratory distress PE: wheezing,
metapneumovirus,
rhonchi, crackles, accessory muscle
adenovirus
use
Almost all are afebrile Catarrhal
phase: 7-10d incubation, 1-2 wks low-
grade fever, cough, coryza
Paroxysmal phase: spasms of
coughing followed by sudden
Bordetella pertussis inhalation ("whoop")
Convalescent phase: most sxs
resolve by cough persists 2-8wks
C. trachomatis: afebrile, conjunctivitis,
staccato cough M pneumo and C.
pneumo: f/HA/myalgia
M pneumo: macular/erythematous
rash, erythema multiforme
Viral: diffuse wheezing and crackles
Bacterial: focal crackles/decr
Young children: viruses percussion/egophony/bronchoph ony
MCC Young child: tachypnea out of
C. trachomatis at 2-3 mo proportion to fever
S. pneumo, etc
Viral pharyngitis, infectious mononucleosis
Definitive diagnosis requires throat culture
or antigen detection test for GAS
Rapid antigen detection: high specificity,
variable sensitivity (depends on quality of
swab). confirm negative test with throat
culture
CMV, toxoplasma gondii, HHV6,
adenovirus, HIV
Pancytopenia indicates malignancy
Leukocytosis or leukopenia, 50%
lymphocyte, at least 10% atypical
lymphocytes
Heterophile antibody: limited sensitivity in
pts <4 Thrombocytopenia, elevated
hepatic transaminase levels
Ddx
AP neck and chest radiographs
show steeple sign (<50%)
Ddx: epiglottitis, bacterial tracheitis,
foreign body aspiration, anaphylaxis,
angioneurotic edema
- Epiglottitis: life-threatening emergency,
thumbprint sign. Child drools and leans
forward with chin extended. Emergent
intubation or cricothyroidotomy. IV
ampicillin- sulbactam. Biggest risk factor is
failure to maintain Hib vaccination
status
Rapid assays from nasal secretions for
RSV, influenza A and B, etc CXR for ill or
hypoxic pts or recurrent wheezing
- lung hyperinflation, peribronchial
thickening (cuffing), incr interstitial
markings
Leukocytosis with lymphocyte
predominance
PCR or culture of organisms in
nasopharyngeal secretions
CXR usually normal, infiltrates may be
seen
If pleural effusion: drain, cell count, gram
stain, culture
If high fever in child: blood culture
rapid influenza test, DFA/PCR/tissue
culture for C. trachomatis
M pneumo: PCR or cold agglutinins
PO penicillin (10d)
Self limited, supportive care Ac
restrictions due to risk of spleni
rupture
Treatment
Cool night air/humidity for coug
stridor
Resolves in 4-7d
ER: give cool mist, racemic
epinephrine, PO/IV/IM
corticosteroids
Supportive, self limited
Pavalizumab (IM RSV monoclo
ab): passive prophylaxis. Give i
winter to at risk pts <2 yrs (hear
chronic lung disease of prematu
premies <35 wks)
Hospitalized to manage apnea,
cyanosis, hypoxia, and feeding
difficulties
Erythromycin or azithromycin o
catarrhal phase, decreases infe
prophylaxis in close contacts
High dose amoxicillin or amox/c
most bacterial pna.
Erythromycin/azithromycin/
clarithromycin for M pneumo or
pneumo.
Azithromycin/Erythromycin for C
trachomatis
Neonates: ampicillin and cefota
(or gentamicin)
Condition Description Etiology Signs/symptoms
Infection of leptomeninges and n/v, photophobia, irritability, lethargy,
CSF HA, stiff neck
Neonates: low birth weight, Viral prodrome: f/malaise, sore throat,
prolonged rupture of myalgias. Usually resolves in 2-4d
membranes, chorioamnionitis Bacterial: no prodrome. High fever
predispose to septicemia and - HTN, bradycardia, apneic, incr ICP
meningitis Lyme: low grade fever, HA, stiff neck,
MCC enterovirus photophobia over 1-2 wks
Bacterial: S. pneumo Kernig: knee extension --> flexion of
Meningitis and N. meningitidis hip with pain Brudzinski: passive
(neonates and children neck flexion
<3 are highest risk) --> involuntary leg flexion
Salmonella, Shigella, Excessive stooling --> dehydration,
E. Coli, Yersinia inadequate nutrition, electrolyte
enterocolitica, abnormalities
Campylobacter jejuni, Bacterial diarrhea: fever, abdominal
Vibrio cholera cramping, malaise, tenesmus,
Rotavirus: major cause vomiting is less common. Stools w/
of nonbacterial mucus, guiaic positive
gastroenteritis in infants Shigella: neurologic sxs Salmonella:
and toddlers extraintestinal disease (meningitis and
Giardiasis: MC intestinal osteomyelitis)
disease in US Shigella and E. Coli: hemolytic Electrolyte and renal function studies
Gastroenteritis
uremic syndrome Blood culture at time of initial evaluation
Yersinia: erythema nodosum,
pseudoappendicitis
Enterobius vermicularis
Pinworm Perianal, vulvar itching
Perinatally infected: asymptomatic
HAV and HEV: diarrhea
Scleral icterus or jaundice,
hepatomegaly, RUQ tenderness,
benign-appearing rash in early HBV
Carrier state associated with
Hepatitis
hepatocellular carcinoma
Congenital: hepatomegaly,
splenomegaly, mucocutaneous
lesions, jaundice, LAD, snuffles
(bloody, mucopurulent nasal
discharge)
Congenital or sexually acquired. Sexually acquired: primary chancre
Syphilis Commonly coinfection with other Treponema pallidum that heals in 3-6 wks, secondary
STD. dermatologic involvement (palm and
sole rash), tertiary gummas in skin,
bone heart, CNS
Condition Description Etiology Signs/symptoms
Genital HSV HSV 2 or 1
infection
Ddx Treatment
Encephalitis, drug intoxiation or s/e, Neonates: ampicillin for GBS a
anoxia/hypoxia, primary or metastatic CNS Listeria + cefotaxime Child:
malignancy, bacterial endocarditis with vancomycin + 3rd gen
septic embolism, intracrainial cephalosporin
hemorrhage/hematoma, malignant HTN, Abx usually 10-14d
demyelination disorders rifampin prophylaxis in close c
CSF analysis diagnostic: cell counts
+ diff, gram stain, glucose and protein
levels, culture
PCR for HSV and enteroviruses
Abx prolongs Salmonella shedd
increases risk of hemolytic urem
syndrome.
TMP SMX or azithromycin for s
erythromycin or azithromycin fo
jejuni
Adhesive tape mebendazole, pyrantel pamoat
stool O&P not recommended - few ova in albendazole
stool
Ddx: EBV, CMV, enterovirus, other viral
infections. Autoimmune heptatitis,
metabolic liver disease, biliary tract
disorders, drug ingestions
HAV: anti-HAB IgM antibody = infection
HCV antibody: present in acute and
chronic, 12 wk window period
HCV RNA: positive wtihin 1 wk HAV: immune globulin, adminis
- HCV RNA with negative antibody = acute within 14d of exposure
infection (window period)
- negative HCV RNA = recovery
VDRL and RPR: tests for antibodies to
lipoidal molecule rather than organism
itself.
- False positives in infectious mono,
connective tissue disease, endocarditis,
and TB
FTA-ABS and particle agglutination: fewer IM or IV penicillin G
false positives
Newborns: lumbar puncture to
identify neurosyphilis - pleocytosis and
elevated protein
12
Ddx Treatment
 Either cervical motion tenderness or NAAT tests for gonorrhea and chlamydia Rx for N. gonorrhea, C. trachom
uterine/adnexal tenderness - must also offer testing for syphilis, HIV, anaerobes
Additional criteria: oral T>101, and other STI C trachomatis and N. gonorrhea
elevated ESR or CRP, WBCs in - pregnancy test Single dose IV ceftiaxone + PO
vaginal secretions, mucopurulent Gyn ddx: mucupurulent cervicitis, ectopic doxycycline
C. trachomatis, N. discharge, lab evidence pregnancy, ruptured ovarian cyst, septic Anaerobes: metronidazole
Pelvic
gonorrheae abortion, endometriosis Nongyn ddx:
inflammatory Usually polymicrobial
- also anaerobes and appendicitis, pyelonephritis, IBD
Disease
enteric gram negs

Trichomonas: most asymptomatic, Trichomonas: PMNs and trichomonads on

malodorous, frothy gray discharge and wet prep
vaginal discomfort. Penile discharge Bacterial: vaginal pH > 4.5, clue cells
Bacterial: thin, white, foul- smelling Candida: yeast and pseudohyphae on wet
discharge with fishy odor when mixed prep with KOH
with KOH Trichomonas: PO metronidazol
Candida occurs in women with
Candida, Trichomonas, Candida: thick white vaginal discharge Bacterial: PO metronidazole Ca
Vulvovaginosis abx use, pregnancy, diabetes,
bacterial with vaginal itching and burning antifungal creams or single dos
immunosuppression, OCP use
PO fluconazole

N gonorrhea and C Urethral discharge, itching, dysuria, Diagnosis: mucoid or purulent urethral Gonococcal: 230mg IM ceftriax
trachomatis frequency. discharge, pos leuk esterase, WBCs on AND either 1 dose PO azithrom
- also mycoplasma first-void urine, gram neg intracellular OR 7d of PO doxycycline
genitalium and diplococci on gram stain - azithromycin preferred becaus
Urethritis
trichomonas vaginalis - test pts for other STDs covers mycoplasma
genitalium

AIDS: AIDS-defining illness Generalized LAD, hepatomegaly, Pregnant women: zidovudine (A

occurs or when CD4+ splenomegaly, failure to thrive, followed by treatment of infant f
lymphocyte count is less than a diarrhea, cadidiasis, parotitis, and 6 wks of life reduces vertical
defined number for age developmental delay transmission to 2%
>90% in utero or perinatal Risk Resp: lymphoid interstitial PNA, PCP ELISA and Western blot not useful in NRTI, NNRTIs, PIs
HIV and AIDS of transmission is 25% if PNA TMP-SMX prophylaxis against
children <18 months
untreated

Rocky Mountain Tick bite (wood tick, dog tick, Fever, HA, rash 7d after tick bite No reliable diagnostic test. Abs confirm Empiric rx - need to cover erlich
Spotted Fever lone star tick) - f/c/HA/n/v/myalgias diagnosis 10d after sxs and N. meningitidis
April-Sept - rash on 2nd-5th day, blanching Thrombocytopenia and hyponatremia doxycycline
erythematouc macular lesions that Ddx: erlichiosis, meningococcemia, add cefotaxime or ceftriaxone if
Rickettsia rickettsii prgress to petechiae or purpura atypical measles suspecting meningococcemia
- starts on wrists/ankles and
spreads inward

Erythema migrans (early localized
disease, 3-30d after bite), f, HA,
myalgias
Early (days--> wks): multiple erythema
Tick bite (deer ticks, black migrans lesions, cranial nerve palsy
legged ticks) meningitis
Lyme disease Borrelia burgdorferi Late (>6wks): arthritis, usually
- infected tick must feed for
>48h involving knee
Atypical rash may be confused with
erythema multiforme or erythema
marginatum
Ddx arthritis: juvenie idiopathic arthritis,
reactive arthritis, Reiter syndrome.
Ddx meningitis: aseptic meningitis
Clinical diagnosis, elevated IgM titer wks
after tick bite
Treatment prevents early
disseminated and late disease
Young children: amoxicillin or
cefuroxime
Children >8yrs: PO doxycycline

13
Heme
Condition Description Signs/symptoms Ddx
Microcytic anemias
Risk factors: extended exclusive breastfeeding Occurs as early as 3 mo in premie.
(>6 mo), low-iron formula, low-iron solids, Mild (6-8 g/dL): decr appetite, irritability, fatigue, decr exercise
excessive cow milk. tolerance. Skin/mucous membrane pallor, tachycardia, systolic
Occult blood loss: GI anomalies (meckel, ejection murmur along left sternal border
juvenile polyps) Severe (<3 g/dL): CHF, tachycardia, S3 gallop, cardiomegaly,
Overt loss: bloody stools or traumatic hepatomegaly, distended neck veins, rales
hemorrhage Glossitis, angular stomatitis, koilonychia in children with isolated Response to appropriate iron supplementation is
Iron deficiency anemia iron def anemia in developed nations best diagnostic test

Alpha thal: deletions
Beta thal: point mutations
Alpha and Beta
Imbalance between alpha and beta chains -->
thalassemia
excess of one type --> unstable monomers that anemia, organomegaly, growth failure during first year.
precipitate and damages membrane
Hb Barts: Gamma-globin tetramers. High affinity for oxygen -->
hypoxia, heart failure, HSM, edema, hydrops fetalis
HbH: beta globin tetramer. HbH disease: deletion of 3 out of 4
alpha genes.
- at birth: HbBarts predominates
- first few months: HbH predominates
- anemia, HSM, require intermittent transfusions
Alpha thal trait: deletion of 2 genes. Blacks and Mediterranean.
Often confused wtih Fe-def anemia
Beta thal: normal blood counts at birth (mostly fetal Hb), severe
Extramedullary hematopoiesis --> frontal bossing, maxillary
hypertrophy, overbite
Alpha thal major: HbBarts
HbH disease: 10-40% HbH, 60-90% HbA Alpha
thal trait: normal electrophoresis, similar to Fe
deficiency
Beta thal major: normal blood counts at birth.
- hypochromia, microcytosis, anisocytosis,
poikilocytosis
- elevated HbF
Beta thal minor: elevations of HbA2 and/or HbF

Inflammation --> incr hepatic production of
hepcidin --> internalization/degradation of
Anemia of ferroportin --> impaired release of iron from
macrophages and absorption of
inflammation
iron from gut
TIBC low, ferritin normal or incr
BM exam: Incr in storage iron, decr in iron-
containing erythroblasts
Mild anemia (8-10 g/dL) Usually normocytic initially

Nonmegaloblastic macrocytic anemias

Diamond-Blackfan Congenital pure red cell aplasia mutation in Presents in first year of life. Macrocytosis, reticulocytopenia elevated HbF
Anemia ribosomal protein S19 (RPS19) 25% have associated anomalies: short stature, web neck, cleft lip, Elevated RBC adenosine deaminase
shield chest, triphalangeal thumb

Macrocytosis Elevated HbF

10% develop leukemia
Hyperpigmentation, café au lait spots, microcephaly, Confirm diagnosis by demonstrating increased
AR or X linked, pancytopenia Defect in DNA chromosomal breakage with
Fanconi anemia microphthalmia, short stature, horseshoe/absent kidney, absent
repair exposure to diepoxybutane (DEB)
thumbs

Failure of hematoietic stem cells --> CBC: cytopenia, microcytosis

pancytopenia Diagnosis: peripheral pancytopenia +
Severe Aplastic - due to chemicals (benzene), drugs hypocellular bone marrow
(chloramphenicol, sulfonamides), infectious Anemia, thrombocytopenia, neutropenia
Anemia
agents (hepatitis), ionizing
radiation. Usually idiopathic.

Disorders of hemostasis
Antiplatelet autoantibodies --> destruction by CBC: normal, except thrombocytopenia
RES - large, young platelets
Immune - primary, or secondary to SLE or HIV Diagnosis based on history, physical, blood
Abrupt onset petechiae/bruising 1-4wks after febrile/viral illness count. Does not require BM exam, lab testing, or
thrombocytopenia
antibody detection

Unexplained post-op bleeding

Newborns: intracranial bleeding from delivery, bleeding after
circumcision (avoid circumcision)

Hemophilia A and B Hemophilia A: factor VIII Hemophilia B: factor IX

14
Onc
Condition Description Signs/symptoms Ddx Treatment
Leukemia
 Most common pediatric cancer (75%)
Most common is precursor B cell
(80%) good prognosis; T cell ALL
(19%), Mature B cell (Burkitt) (1%)
Poor prognosis: age >10 yrs or
<1 yr, WBC >50,000 at
diagnosis, failure to respond to
induction therapy, Philadelphia
chromosome
ALL
20% childhood leukemias
Best prognosis: M3 AML (APML) and
trisomy 21 pts with M7 AML
Worse prognosis: WBC
>100,000/mm3
Low risk: inv 16, t16;16, t8;21 High
AML risk: monosome 5 or 7, or no
remission
Lympoblastic (50%): pre-T or pre- B
Burkitt (35%) or large B cell
Anaplastic large cell (15%)
3rd most common malignancy in
childhood, 10% of childhood cancers.
Boys 3x as many as girls
Risk factors: congenital
immunodeficiency (Wiskott Aldrich,
Non-Hodgkin lymphoma SCID), acquired immunodeficiency,
Bloom syndrome, ataxia
telangiectasia
Onc
Condition Description
Increase incidence of immune
dysregulation
Association with EBV
Incr risk in ataxia teleangiectasia,
Wiskott-Aldrich, Bloom
Bimodal distribution
Subtypes:
- Nodular sclerosing (40-55%)
- Lymphocyte predominant (10- 15%)
- Mixed (30%)
- Lymphocyte depleted (5%)
Hodgkin lymphoma
Normochromic normocytic anemia, low retic
count, low WBC count variable
HSM and cervical LAD at diagnosis.
Extramedullary involvement in CNS, skin,
testicles (5%).
- HA emesis, papilledema, CN6 palsy
Fever, mediastinal mass (mostly T cell),
Chloroma: soft tissue tumor in spinal cord,
brain, skin
Leukemia cutis: Neonates, Blueberry
muffin spots
Gingival hypertrophy
T cell lymphoblastic lymphoma: mediastinal
mass
B cell lymphoblastic lymphoma: bone
involvement, isolated lymph nodes, skin
Burkitt: abdominal tumor w/ n/v,
intussusception, tonsils, bone marrow, CNS
Anaplastic large: slowly progressive
disease with fever
Signs/symptoms
Painless, rubbery, cervical LAD
(80%)
B symptoms: fever, night sweats, weight
loss
Enlargement of liver/spleen in advanced
disease
CBC: leukocytosis,
thrombocytopenia, anemia
CMP for tumor lysis
CXR for mediastinal mass BM
aspiration and biopsy with flow
cytometry
LP for CNS involvement CT
scan to assess extent ot
disease
Ddx
Ddx reactive/inflammatory
nodes: bacterial lymphadenitis,
infectious mono, TB, atypical
mycobacterial infection, cat
scratch, HIV, histo, toxo
1. CXR for mediastinal
involvement, airway
compromise
2. Pulmonary function test,
ECHO before anesthesia in pts
with mediastinal mass
3. Excisional lymph node
biopsy required for diagnosis:
Reed sternberg cells
Eosinophilia (15-30%)
CNS tumors
Induction therapy: 28d of
steroids, intrathecal MTX
Add daunomycin for high
Consolidation: intensifica
kill additional leukemic ce
fails
Interim maintenance: vinc
MTX
Radiation therapy for CN
disease, CNS prophylaxis
Chemotherapy more inten
Induction: anthracycline +
Low risk: chemo only Hig
transplant
Combination chemo Burk
resection
- tumor lysis: careful man
fludi intake, alkalinzation
electrolyte observation, a
- high risk of developing k
requiring dialysis from tum
Treatment
Multiagent chemo
Lymphocyte-predominanc
prognosis
 Childhood embryonal malignancy of
postganglionic sympathetic nervous
system. 8% of all childhood cancers
<15yrs, most common solid tumor
outside CNS.
- abdominal tumors (70%) from
sympathetic ganglia/adrenal medulla,
thoracic masses (20%) from
paraspinal ganglia, neck (5%)
involves cervical ganglion
Neuroblastoma
Onc
Condition Description
Most common renal tumor in children, Perlman syndrome: unusual facies, islet
chromosomal loci 11p13 and 11p15 cell hypertrophy, macroscomia,
Wilms tumor - most are unilateral
- most common renal tumor
- usually diagnosed in first 5 yrs
Undifferentiated sarcoma that arises
primarily in bone
- t(11;22) in 85% of pts
– adolescents
- flat and long bones: femur (20%),
pelvis (20%), fibula (12%), humurs
and tibia (12%)
- begins midshaft in long bones
Ewing sarcoma
Tumor of bone-producing
mesenchymal stem cells
- arises in medullary cavity or
periosteum
- usually at metaphysis of bones with
maximum growth velocity: distal
Osteosarcoma femur, proximal tibia, proximal
humerus
Abdominal tumors: hard smooth, nontender
abdominal masses palpated in flank,
displace kidney.
Neck: Horner syndrome, heterochromia of
iris on affected side
Epidural invasion --> back pain and cord
compression sxs
Metastatic sequelae:
- Hutchinson syndrome: cortical bone pain
causing limp
- Pepper syndrome: liver infiltrate causing
hepatomegaly
– Raccoon eyes: periorbital infiltratex
Paraneoplastic effects: watery diarrhea in
tumors secreting VIP, opsoclonus
myoclonus (chaotic eye movements,
myoclonic jerking, truncal ataxia)
Signs/symptoms
Associated anomalies: sporadic aniridia,
hemihypertrophy, cryptoorchidism,
hypospadias, other GU anomalies
Beckwith-Wiedemann: hemihypertrophy,
macroglossia, omphalocele, GU abn
WAGR: Wilms, aniridia, GU abn, mental
retardation
hamartomas
Other findings: hematuria, HTN, varicocele
Von willebrand's disease in 8%
Pain and localized swelling Systemic: fever, lesion with calcified
weight loss, fatigue
Pain and localized swelling Systemic
manifestations rare (vs Ewing)
20% have mets: lung most common Gait
disturbance, pathologic fractures
Ddx: adrenal hemorrhage, Prognosis: INSS staging,
hydronephrosis, polycystic tumor, MYCN gene ampli
kidney disease, splenomegaly, - Stage I, II, IVS have goo
renal cell ca, wilms tumor, Stage III, IV have poor pr
hepatoblastoma, leukemia, Surgery, chemo, radiation
lymphoma, retroperitoneal vincristine, cyclophospha
rhabdomyosarcoma doxorubicin, cisplatin
Confirm mass by CT of
chest/abd/pelvis
tumor cells on BM aspirate
+ elevated urinary
catecholamines
Tissue biopsy for histology,
DNA ploidy, and MYC- related
oncogene
Ddx Treatment
Ddx: hydronephrosis, PKD, Surgical removal of kidne
splenomegaly therapy can be used for m
Abd US, CT, or MRI Good prognosis: small siz
Staging done after no LN/metastases, no ca
exploratory laparotomy invasion
Bone tumors
Ddx: osteomyelitis, eosinophilic
granuloma (langerhans cell
histiocytosis), osteosarcoma,
neuroblastoma or
rhabdomyosarcoma metastasis
to bone
Radiographs: lytic bone
Chemo + radiation
- chemo: reduce size and
periosteal elevation (onion
(almost all pts have mets
skin) and/or soft tissue mass
Ddx: ewing sarcoma, benign
bone tumors, chronic
osteomyelitis
lytic bone lesion with
periosteal reaction (sunburst
appearance) Surgical removal of prima
MRI to assess extent, CT to Resistant to radiation th
detect pulm mets (calcified Chemo: cisplatin, doxorub
nodules), bone scan for mets

Tumor of embryonic neural retina
Retinoblastoma Chromosome 13q14, BR1 locus
- 60% unilateral
Onc
Condition Description
Most common STS in children <10
- Associated familial syndromes:
neurofibromatosis, Li Fraumeni
- 2 subtypes: embryonal (53%),
Rhabdomyosarcoma
alveolar (21%)
- t(2;13) and t(1;13)
Non rhabdomyosarcoma Heterogenous
Malignant peripheral nerve sheath
tumors: associated with NF type I
- Malignant fibrous histiocytoma or
leiomyosarcoma
Immunology, Allergy, Rheum
Condition Description
1. X-linked: IL2RG gene - gamma chain Digeorge: congenital
T cell immunity: SCID of IL-2 receptors
2. DiGeorge
X linked agammaglobulinemia
(Bruton): no mature B cells. Life
threatening enterovirus infections
CVID: hypogammaglobulinemia, esp
IgG and IgA. Decr antibody formation to
vaccines. Incr lymphoma and
autoimmune dz
Selective IgA deficiency: IgA <5
Humoral immunity: mg/dl, bacterial infections of respiratory, Recurrent infections with encapsulated organisms
Antibody deficiency GI, and urinary tracts
syndromes
Wiskott-Aldrich: X linked, B and T cell
disorder. Host's abs do not respond to
carbohydrate antigens
Combined Hyper IgM: CD40L mutation. Failure of
immunodeficiency class switching.
Leukocoria (absent red reflex)
Trilateral rb: involvement of pineal or
parasellar sites
Signs/symptoms
Head and neck (35%), GU (22%),
extremeties (20%)
25% have distant mets, lung most common
site
Signs/symptoms
Viruses, mycobacteria infections, fungi, PCP X linked SCID:
presents in first 6 mo with
viral/bacterial infections, diarrhea, failure to thrive.
Lymphopenia, absent CD4 cells
heart disease, hypocalcemic
malformed ears/face
after 6 mos- otitis media, sinusitis, pneumonia
Incr susceptibility to virulent and opportunistic infections,
autoimmunity
Wiskott Aldrich: atopic dermatitis, thrombocytopenia.
Hyper IgM: recurrent sinopulm infections, PCP
DDx: congenital cataract, Enucleation, chemothera
medulloepithelioma, Toxocara therapies, radioplaques, e
canis endophthalmitis, radiation
persistent hyperplastic primary - treatment depends on R
vitreous, Coats disease classification
Ophthalmologic exam, MRI Child born to parent with
or unilateral rb with know
should be screened for rb
regular intervals until 4 or
Soft tissue sarcomas
17
Ddx Treatment
CT or MRI of site, chest CT
and bone scan for mets bone
marrow biopsy required
Surgery, radiation, chemo
- chemo helps reduce tum
CT or MRI of site, chest CT
and bone scan for mets
Surgery, radiation, chemo
Ddx
Immunology
Decreased absolute lymphocyte counts and
T cells.
Absent T cell function: in vitro mitogen
stimulation, intradermal delayed
tetany, hypersensitivity testing Absent antibody
function (measure after 6 mo)
DiGeorge: absent thymic shadow on CXR,
FISH
Diagnostic evaluation:
- IgG, IgA, IgM levels
- serum protein screen - albumin or
transferrin to r/o other etiologies
- antibody titers after immunization (tetanus
and diptheria = protein antigens;
pneumococci and H influenza = carb
antigens)
Transient hypogammaglobulinemia of
infancy: delayed acquisition of normal infant
immunoglobulin levels
- most develop normal levels by 2-5 yrs,
have intact responses to vaccination
 Insufficient number of PMNs
(neutropenia), cell dysfunction, or
migration defect
Chronic granulomatous disease: most
common. Failure to generate superoxide
Leukocyte adhesion deficiency:
defect in adhesion to endothelial cells,
most commonly CD18
Phagocytic immunity
Complement immunity
Impaired opsonization
Chronic relapsing/remitting reaction to
allergens (food/env) 10% of pediatric
population genetic predilection
Atopic dermatitis 50% develop allergic rhinitis
and/or asthma
Immunology, Allergy, Rheum
Condition Description
T1 hypersensitivty, IgE seasonal (hay
fever): limited to pollination months,
uncommon betfore 4-5 yrs
Risk factors: atopy, genetic, smoking
- heavy exposure to animal dander early
in life reduces risk
Allergic rhinitis
Urticaria and Hereditary angioedema: C1 esterase
angioedema deficiency
80% present in 1st year
Food allergies - peanuts, eggs, milk, soy, wheat, tree
nuts, fish
Gingivitis, skin infections, rectal inflammation, otitis media,
pneumonia, sepsis. S. aureus and gram neg infections.
- absense of inflammatory response --> no erythema, warmth,
or swelling
CGD: chronic/recurrent pyogenic infections by catalase pos
organisms, abscesses. Failure to thrive, diarrhea, persistent
candidiasis of motuh
LAD: WBC counts 5-10x normal, unable to form granulomas.
Severe gingivitis, intestinal fistuals, poor wound healing,
delayed separation fo umbilica cord
Bacterial infections, rheumatologic disease C5-C9 def:
Neisseria meningitidis infections C1-C4 def: SLE
Allergy
Pruritic, erythematous, weeping papulovesicular reaction -->
scaling, hypertrophy, lichenification
<2 yrs: extensor surfaces
>2 yrs: flexor surfaces, neck, wrists, ankles
Signs/symptoms
Nasal congestion, rhinorrhea, postnasal drainage, sneezing,
itching
Nasal mucosa appears boggy and bluish
1. allergic shiners: dark circles under eyes secondary to
venous congestions
2. allergic salute: horizontal crease across middle of nose
due to upward wiping motion with hand
Urticaria: raised edematous hives on skin/mucous
membranes resulting from vascular dilation and increased
permeability
- itch, blanch, resolve
Angioedema: lower dermis and subcutaneous areas, well
demarcated area, no pruritis/erythema/warmth
Isolated cutaneous rxns, GI sxs, respiratory sxs, life-
threatening anaphylaxis.
Rheumatology
Neutropenia ddx: infection (esp viruses),
medication administration (penicillin,
sulfonamides, anticonvulsants), malignancy
in BM, aplastic anemia
- severe: ANC <0.5x10^3
- chronic: >2-3 months
CGD: WBC betw 10,000-20,000,
leukoerythroblastic response
- nitroblue tetrazolium test,
dihydrorhodamine reduction (DHR)
LAD: flow cytometry analysis of CD18
DDx: contact dermatitis, psoriasis
Ddx
Ddx:
- Infectious rhinitis: more common in
infants/toddlers, mucopurulent
- Sinusitis: chronic rhinorrhea, postnasal drip
w/ facial tenderness, cough, and/or HA
- Nasal foreign body: unilateral, thick, foul
discharge
- Vasomotor rhinitis (idiopathic nonallergic):
exaggerated vascular respons to irritant
- Rhinitis medicamentosa: overuse of topical
decongestants
Elevated nasopharyngeal eosinophils,
serum radioallergosrobant (RAST) test,
direct skin testing
Ddx:
- Food intolerance: nonimmunologic
(caffeine-induced tachycardia, lactose
intolerance)
Double-blind placebo challenge - food
challenge: gold standard.
 Oligoarticular JIA: most common. Ddx: posinfectious arthritis (acute rheumatic
- girls 2-4yrs fever), systemic inflammatory conditions
- large joints (knee, ankle) (IBD, connective tissue diseases, HSP),
- joint contractures, muscle atrophy, increased extremity infections (septic arthritis, viral arthritis,
growth in affected limb Lyme disease), malignancy (leukemia,
- 75% have positive ANA test -- associated with chronic neuroblastoma, bone tumors)
nongranulomatous anterior uveitis - asymptomatic, detect Diagnosis:
on slit lamp - acute phase rxn
Polyarticular JIA - - ANA associated with anterior uveitis
- RF positive: resembles adult rheumatoid arhtritis - RF only in 5%
- RF neg: adolescents, large and small joints, better prognosis - Synovial fluid: WBC > 2000/mm3 with
Systemic JIA: autoinflammatory disorder mononuclear cells
- extraarticular, intermittent high fever, salmon colored rash,
HSM, LAD, pericarditis.
Chronic arthritis > 6 weeks in individuals - large and small joints
Juvenile Idiopathic <16 yrs synovitis: inflammation and - acute phase rxn: leukocytosis, thrombocytosis, anemia, incr
Arthritis hypertrophy of synovium ESR and CRP, incr ferritin.
- TNF alpha mediated Enthesitis-related arthritis: sacroiliac joints, occurs at
tendon insertions (achilles, plantar fascia, ASIS)
Psoriatic arthritis: nail pitting, onycholysis,
dactylitis due to flexor tendon tenosynovitis

Immunology, Allergy, Rheum

Condition Description Signs/symptoms Ddx
Anemia, leukopenia, thrombocytopenia,
elevated ESR, CRP normal
Positive coombs --> hemolytic anemia
Decr complemet levels
Painless oral ulcers, malar rash, discoird lupus, ANA, antiphospholipid abs, anti smith, anti-
Systemic lupus Abnormal cell death --> incr exposure to
photosensitivity. dsDNA, anti-RNP, anti- Ro, anti-La
erythematosus self nuclear components
Renal failure in Type IV LN (diffuse proliferative)

Ddx: polymyositis (no skin findings, CD8

autoimmune disease involving
Dermatomyositis
skin/skeletal muscles
lymphocytes infiltrate muscle fascicles and
attack muscle fibers directly), less common
in children
elevated serum creatine phosphokinase
(released during muscle breakdown), other
Violaceous dermatitis of eyelids (heliotrope), hands, elbows, muscle enzymes. Elevated VWF.
knees, ankles. Definitive diagnosis: muscle biopsy -
Gottron papules: scaly erythematous papules on extensor perivascular inflammatory infiltrate,
surfaces of fingers, elbows, knees perifascicular atrophy

Henoch Schonlein IgA immune complexes in vessel walls Skin, joint, GI, kidney disease. Nonthrombocytopenic purpura Supportive, Spontaneous resolution within 4
purpura on lower extremities, buttocks. Scroal edema, extremity wks, sxs may persist for 12 wks
swelling
Fever with abrupt onset and termination
Familial Mediterranean Fever: MEFV gene, most common.
Peritonitis, erysipelas-like rash, oligoarthritis
TNF receptor-associated Period Fever Syndrome
(TRAPS): AD, fevers 7-21d, 2-3x/yr. Abd pain, severe muscle
aches with overlyting erythema, conjunctivitis, periorbital
edema, large joint arthritis
Periodic Fever, Apthous stomatitis, pharyngitis, adenitis
syndrome (PFAPA): 3 or more episodes of fever, tender
Periodic Fever cervical LAD, pharyngitis/apthous ulcers, normal WBC, CRP, WBC, CRP, ESR elevated during fever
Syndromes ESR attacks

Endocrine
Condition Description Signs/symptoms Ddx
Nephrology and Urology
Condition Description
Renal Dysplasia: Renal parenchymal tissue does not form correctly throughout, usually bilateral. incr risk of abnormal development elsewhere
- inability of kidney to concentrate urine
- impaired ability to resorb fluids --> frequency, incontinence, susceptibility to dehydration
- often does not present with HTN
- Renal US: kidneys appear hyperechoic
Failure of one or both kidneys to form
- Bilateral --> oligohydramnios -->
Potter sequence (clubbed feet, cranial
Renal agenesis
abnormalities)
Kidney consists of numerous
noncommunicating fluid filled cysts.
- Almost always unilateral
Most common renal cystic dz of
Multicystic dysplastic childhood, most common abdominal mass
kidney in newborn
Polycystic kidney ARPKD: dilated renal collecting tubules
disease --> small cysts
- dilated hepatic bile ducts
ADPKD: usually not detected until
adulthood
MCC of hydronephrosis in childhood
- Primary: intrinsic narrowing at junction of Older children: abd or flank pain, cyclic
renal pelvis and ureter or angulation of
ureter from a crossing renal vessl
Ureteropelvic junction - Secondary: scarring, angulation
secondary to ureteral dilation
obstruction
(stones)
Length of tunnel of ureter through
bladder submucosa is insufficient to
prevent retrograde flow of urine
- unilateral or bilateral
Vesicoureteral reflux
Obstructing leaflets within posterior
urethra --> partial-to- complete bladder
outlet obstruction
- urethral dilation, bladder neck
hypertrophy, bladder trabeculation
- males only
One of the most common causes of end- Distended bladder or renal mass
Posterior urethral valves stage renal disease in male child Older infants: weak/dribbling urinary
stream or unexplained daytime wetting
Incomplete development of distal urethra
--> malposition of urethral meatus along
ventral side of penis toward perineum
Hypospadias - chordee: associated curvature
of penis
Nephrology and Urology
Condition Description
Lack of posterior attachment to tunica
vaginalis --> mobile testis --
> bell-clapper deformity
Testicular torsion
Signs/symptoms
Palpable renal mass in infant ARPKD:
HTN, decline in renal function
ADPKD: HTN, hematuria
Newborns: palpable abdominal mass
vomiting, hematuria + mass
Frequent UTIs
Retrograde flow of infected urine -
-> pyelonephritis
Signs/symptoms
Acute onset unilateral scrotal pain, n/v
Swollen, erythematous scrotum Absent
cremasteric reflex
Ddx
Renal dysplastic and cystic diseases
Postnatal US: noncommunicating cysts
Renogram: lack of function
Increased echogenicity on US
Renal US
VCUG: voiding cystourethrogram detects
abnormalities at erteral insertion sites and
allows classification of grade of reflux
- high grade: large tortuous ureters, distortion
of renal pelvis and calyces
Prenatal US: hydronephrosis and bladder
distention
Renal US: distended bladder with thickened
walls and trabeculation. Bilateral
hydronephrosis.
VCUG: visualization of posterior urethral
valvesx
- dilated bladder, hypertrophied neck, dilated
posterior urethra with shield-shape
(spinnaker-sail)
Hypospadias + cryptorchidism prompts
ambiguous genitalia workup (genetic
karyotyping)
Ddx
Ddx:
- epididymitis (infectious or secondary to
epididymal appendix)
- appendix testes: "blue dot" sign + normal
cremasteric reflex
clinical diagnosis
Treatment
Most cases undergo spontaneous involution
Nephrectomy if kidney changes in size or
appearance, persistent HTN
ARPKD: dialysis
Surgical correction: minimally invasive
surgery or open pyeloplasty
Antibiotic prophylaxis for UTIs
- < 3yrs: amoxicillin
- older: bactrim or nitrofurantoin
Surgery: lengthen intravesicular segment of
tunnel (ureteral reimplantation)
Ablation of obstructing valve leaflets Abx
prophylaxis if VUR is present
Early surgical correction of reflux is
discouraged: bladder pathophys changes
over time, early surgery has high failure
rate
Circumcision is contraindicated- surgical
repair may require preputial tissue
Treatment
Surgical emergency
- surgery within 6 hrs
- remove necrotic testes, fix CL testis to
scrotal envelope
Testicular or epididymal appendix: torsion
resolves spontaneously Epididymitis: abx
 Hydroceles: fluid-filled sacs in scrotal
cavity consisting of remnants of
processus vaginalis
- communicate with peritoneal cavity
through patent processus, risk for
incarceration
Varicocele: dilation of testicular veins +
Hydroceles and
enlargement of pampiniform plexus
varicoceles
First year of life: girls = boys After first
UTI
year: girls have 10x incidence
Proteinuria, hypoalbuminemia,
hyperlipidemia, edema
- Primary: MCD (most common),
Nephrotic syndrome FSGS, MPGN, MN
- Secondary: Infections, systemic dz
(SLE, HSP, IgA), drugs (NSAIDs, heroin),
malignancies, genetic
Ophthalmology
Condition Description
4% of children Esotropia: inward
Exotropia: outward
Associated with cerebral palsy, down
Strabismus syndrome, hydrocephalus,
brain tumors
Reduced vision in otherwise normal
eye
- strabismic amblyopia: suppression of
retinal images in misaligned eye
Amblyopia - anisometropic amblyopia: unequal
refractive errors in two eyes
Leukocoria
Varicoceles: detectable in boys during
adlescence, more common on left,
nontender
- evident when pt is standing: veins
distend, "bag of worms"
Infants: fever may be only sign
- hematogenous seeding of kidney
Older children: same as in adults
- upper tract involvement: incr WBC,
ESR, CRP
Nonspecific illness a few weeks prior
Periorbital edema: first abnormality
noted
Dependent edema, weight gain
FSGS, secondary etiologies,
glomerulonephritis: gross hematuria,
HTN
Signs/symptoms
Amblyopia found in most pts with esotropia
Subnormal vision
White pupil/absence of red reflex
Hydroceles: repair communicating
hydroceles and hernias to prevent
incarcerated hernia
Varicoceles: surgical repair
- unrepaired varicoceles incr risk for
infertility
UTI
DDx: Pts with positive leukocyte esterase should
- Adenovirus: self-limited hemorrhagic cystitis be treated for presumed UTI until culture
that does not respond to abx results are available
- Posterior urethralgia: benign, self- limiting Cystitis: amoxicillin, ampicillin,
inflammation of posterior urethra in boys nitrofurantoin, or TMP-SMX
- Lower lobe PNA in febrile child: f/chills/flank Pyelonephritis: PO cephalosporin or IV
pain ampicillin + gentamicin
- Urolithiasis: dysuria, hematuria, flank pain
All children <24 months must undergo renal
US to r/o hydronephrosis or structural lesions.
VCUG if hydronephrosis or nonresponders to
abx. DMSA if suspected pyelonephrosis
Marked proteinuria: > 1000 mg/m2/day, spot Dietary salt restriction, oral steroid therapy
urinary protein:creatinine ratio > 2.0 - stronger immunosuppressants in
- results in hypoalbuminemia (<2.5 g/dL) nonresponders (cyclophosphamide,
Hyperlipidemia (lipases are lost in urine) calcineurin inhibitors)
Microscopic hematuria, mild hyponatremia IV albumin: induces temporary diuresis
(fluid overload), hypocalcemia (albumin loss),
incr creatinine (renal hypoperfusion)
MCD: effacement of foot processes FSGS:
mesangial hypertrophy, tubular atrophy
Diffuse MPGN: incr mesagnial cellularity,
glomerular BM thickening MN: diffuse
thickening of capillary walls
Ddx
Corneal light reflex, cover test
Retinoblastoma, cataracts (most
common), retinopathy of prematurity,
congenital glaucoma, ocular toxocariasis
Congenital Failure of distal membranous end of Chronic tearing in absence of
nasolacrimal duct nasolacrimal duct to open conjunctival injection
obstruction - Common cause of overflow tearing
(dacryostenosis) - 25% of neonates

Corneal abrasion: Painful, tearing,

Infectious Inflammation in conjunctiva Viral: photosensitivity. Examination under blue
H. influenza: same-sided otitis media
conjunctivitis adenovirus light with fluorescein reveals abrasion.
Treat with eye patching. Heals in 24h

Hordeolum: acute infection of glands Hordeolum: localized tender swelling, then

around eyelas follicle rupture
- S. aureus Chalazion: firm, nontender area
Chalazion: sterile lipogranulomatous
Styes
reaction within glands in tarsal plate

Bacterial infection of eyelids/skin Orbital cellulitis: severe pain with eye

anterior to orbital septum movement, proptosis, vision changes, decr
- breaks in skin: s. aureus, group A ocular mobility.
strep Confirm with CT.
Periorbital cellulitis - hematogenous: s. pneumo, h. Skin around eye is indurated, warm, tender Trauma, edema, allergies, tumor
influenza
- sinuses/resp: s. pneumo, h. influenza,
moraxella
 Treatment Complications

MCC of infectious sensorineural

hearing loss
within first 2 wks of life Supportive; ganciclovir
Developmental delay, MR, CP, dental
defects

Local disease: recurrent mucocutaneous

lesions Encephalitis: cataracts/bindness,
microcephaly, DD/learning disabilities
esting of scrapings. CSF:
Disseminated: severe neuro
IV acyclovir.
impairment, death

gG levels Intrauterine blood transfusions, supportive None

Prevention: zidovudine to mother during

pregnancy, zidovudine to infant for first 6
CR wks of life.

ody titers during pregnancy

vated rubella IgM or

Penicillin G Neurosyphilis, deafness

Ddx Treatment Complications

Supportive

Order hep B serologies Supportive

- takes up to 8 wks
Clinical diagnosis Supportive Progressive varicella:
Tzanck smear - Antipyretics, daily bathing meningoencephalitis,
DFA, viral culture, PCR Administer VZV vaccine within 72h of hepatitis, pneumonitis in
exposure immunocompromised
Acyclovir/valacyclovir/famciclovir not Reye syndrome if taking
indicated for children with uncomplicated aspirin
primary varicella

Antivirals for immunocompromised, pts >12

yrs, children with chronic disease, and those
who have received systemic steroids

Curretage, cryotherapy, cantharidin, PO

cimetidine, imiquimod cream

Topical salicylic acid, liquid nitrogen,

imiquimod cream, PO cimetidine, PO zinc
sulfate, injected immunotherapies (candida
antigen),
squaric acid dibutylester

hems
Self limited
Antihistamines, topical steroids for pruritis
sunlight

Ddx Treatment Complications

Self limited - 6-8 wks Antihistamines, topical
steroids for pruritis
Often confused with
ontact dermatitis

rial infections
Can be mistaken for
igarette burns

Limited: Muciprocin ointment Numerous:

cephalexin (1st gen)
- covers staph and strep
Suspect MRSA: clindamycin or TMP- SMX
Remove honey colored crusts with warm
compress
 Mild-moderate: PO antistaphylococcal
medication Severe: treat like 2nd degree
burn

antiseptic cleansers, topical muciprocin

Ddx Treatment Complications

Eczema: pruritic, flexural
reases
Scalp lesions may look
ke seborrheic dermatitis
r tinea capitis
Keep skin well hydrated Topical steroids
Vit D, UVB light Psoriatic arthritis
Severe: MTX, immunosuppressants

gic reactions
Polycyclic urticaria: can
ppear targetoid, but
esions are not fixed and
o not have necrotic
enters.
Edematous,
PO antihistamines, moist compresses,
rythematous borders
oatmeal baths
with central clearing,
esolving in 12-24 hrs

Hospitalization, fluid and electrolyte support,

moist compresses, oatmeal baths
Oral mucosal: mouthwashes with lidocain,
diphenhydramine, Maalox
Ophthalmology consult

Fluid therapy, treat like a burn

IVIG: may affect binding/effect of Fas ligand

Treatment Complications High Yield facts

es

copy often required to
and dynamics of upper
hy: measure respiratory
r flow, oxygenation, sleep
allenge test CXR:
eased bronchial markings
mmation or failure to clear
hiolitis, GER with aspiration,
fistula, primary ciliary
s effets: foreign body
al or brochial tumors or
ollapse:
alacia
g of airway:
d stenosis
ssion: masses, LN
sthma: chronic cough
ise or noted primarily at night
wheezing. Improves with
loride (>60mEq/L),
iency, chronic pulmonary
onchiectasis, parenchymal
R Pancreatic enzyme replacement, high calorie
abnormal ciliary beat
hanges in ciliary cells from
rapings
Tracheostomy
Remove tonsils/adenoids, CPAP
Remove inciting agents from patient's
environment, maintence anti- inflammatory
medication
Acute exacerbation: inhaled bronchodilator
Persistent asthma: Inhaled corticosteroids
- symptom control, avoidance of
exacerbations
Also b2 agonists, leukotriene receptor
antagonists
Theophylline: add on therapy in pts who do
not respond to conventional therapy, severe
exacerbation.
Omalizumab: monoclonal ab vs IgE, use in
pts >12 yrs with severe allergic asthma
Corticosteroids PO or IV
Maintain effective airway clearance,
bronchodilators, abx, regular inhaled
tobramycin for pts with Pseudomonas,
azithromycin, inhaled hypertonic saline
high protein diets. Maintain height/weight
>25th percentile.
Treatment
Same as pulmonary CF treatment, except do
Bronchiectasis in 2nd or 3rd decade
not need pseudomonas treatment.
BL choanal atresia: presents
with life threatening respiratory
distress in delivery room.
Oxygenation improves when
infant is crying.
severe OSA --> CHF, death Pickwickian
syndrome: chronic hypoventilation results in
pulmonary
hypertension and CHF
Control vs severity: severity =
degree of impairment prior to
treatment, control = monitoring
impairment and risk of future
exacerbations
- assessing/maintaining control
is more important than
assessing severity
hemoptysis occurs in pts with severe
bronchiectasis. Frequent coughin and
inlfammation --> erosion of walls of bronchial
arteries --> sputum streaked with blood.
Blood loss >500mL in 24h requires arterial
embolization
spontaneous pneumothorax: place chest
tube. 50% recurrence unless pleurodesis is
performed
chronic pulmonary HTN: results from
progressive airway obstruction/hypoxia in
advanced disease.
Complications High Yield facts
Pts do not have propensity to
Pseudomonas infection
 Treatment
s
Surgery:
- close VSD
- separate pulmonary arteries from truncal
vessel
- place conduit between R. ventricle and
pulmonary arteries

PGE1
Balloon atrial septostomy (Rashkind
procedure)
- enlarge PFO, incr atrial level mixing
Arterial switch procedure

Surgery

od flow
 NRGA, pulm stenosis:
- PGE1
- Blalock-Taussig shunt (neonate):
connect subclavian and pulmonary artery
- Cavopulmonary anastomosis (infancy):
connect SVC to pulmonary artery
- Fontan (2-5 yrs): connect IVC and
hepatic vein to pulmonary circulation
TGA:
- PGE1
- severe arch obstruction: reconstruct
aortic arch

Tet spells: squatting, vagal maneuvers

(knee-chest position), O2, morphine
sulfate
- volume expansion, vasoconstrictors to
increase systemic vascular resistance
- beta blockers to decr infundibular spasm
- sodium bicarb to reduce acidosis and
decr pulmonary vascular resistance

Treatment

PGE1
Avoid surgery
Heart transplant if severe

od flow
PGE1
No corrective surgery available - only
palliative
First week:
- connect pulm artery and aorta
- atrial septectomy
- connect R. ventricle to pulm artery
(modified blalock-taussig)
3-6 months:
- cavopulmonary anastamosis (hemi
Fontan)
2-5 years:
- modified Fontan
PGE1
Connect interrupted aortic segments

Surgery
- may not be necessary
- patch closure

Treatment

CHF: ace inhibis and diuretics

Repair large VSDs within 6 months to
decrease risk of pulmonary artery HTN
and pulmonary vascular obstructive
disease

Indomethacin
- risk of renal insufficiency
Usually closes by itself in first month of life
in FT infant
 PGE1
Surgery: anastomosis or patch aortoplastic
Interventional: balloon angioplastic
Restenosis common

PGE1
balloon valvuloplasty

well-appearing child with no obvious source of infection

>39.0C, leukocytosis
ontaneously
response, altered organ perfusion
neg, listeria
eningitidis

nas, viridans strep

cultures, CXR if respiratory signs present

Treatment Complications High Yield facts

1. High dose amoxicillin, topical abx if
perforated
2. augmentin, PO second or 3rd gen
cephalosporin, or IM ceftriaxone
S. pneumo: 50% penicillin resistant.
H. influenza and M. catarrhalis: beta-
lactamase activity
Consider tympanostomy tube if
moderate hearing loss, recurrent AOM
Hearing loss, otitis media externa
Meningitis (MC intracranial)
Atopic constitution increases risk for
recurrent OM
Mastoiditis: severe, but uncommon
- high fever, tenderness of mastoid
bone
Decr mobility of TM is
most specific sign

Similar abx as AOM but longer Complications uncommon

treatment course (14-21d) - bony erosion, orbital cellulitis,
Recurrent disease: sinus aspiration intracranial extension

Self limited (5-7d)

 Suppurative: peritonsillar Do not treat pharyngitis
abscess, retropharyngeal abscess with abx empirically bc
Nonsuppurative: rheumatic fever, most causes are viral -
poststreptococcal glomerulonephritis make therapeutic
Rheumatic fever: 3wk following decisions based on
pharyngitis. Penicillin prophylaxis to throat culture or rapid
prevent recurrent ARF antigen detection results
Poststrep glomerulonephritis: occurs
PO penicillin (10d)
following either pharyngitis or skin
infection
- penicillin therapy and

Rare but serious: upper airway Pts infected with EBV

Self limited, supportive care Activity
restrictions due to risk of splenic
rupture
obstruction (rx: corticosteroids), who receive amoxicillin
splenic rupture, meningoencephalitis (for misdiagnosed
Immunocompromised at risk for bacterial infection) may
disseminated disease and have maculopapular
lymphoproliferative disorders rash

Treatment Complications High Yield facts

Cool night air/humidity for cough and
stridor
Resolves in 4-7d
ER: give cool mist, racemic
epinephrine, PO/IV/IM
corticosteroids

Supportive, self limited

Pavalizumab (IM RSV monoclonal
ab): passive prophylaxis. Give in
winter to at risk pts <2 yrs (heart dz,
chronic lung disease of prematurity,
premies <35 wks)

More airway hyperresponsiveness

later in life

Hospitalized to manage apnea,

cyanosis, hypoxia, and feeding
difficulties
Erythromycin or azithromycin only in
catarrhal phase, decreases infectivity,
prophylaxis in close contacts

High dose amoxicillin or amox/clav for Pleural effusion --> compromise

most bacterial pna.
Erythromycin/azithromycin/
clarithromycin for M pneumo or C
pneumo.
Azithromycin/Erythromycin for C.
trachomatis
Neonates: ampicillin and cefotaxime
(or gentamicin)
respiratory effort. Chest tube
- most large pleural effusions are
caused by s. aureus pneumonia
Lung abscesses due to anaerobic
infections
Cold agglutinin titers are
elevated in M. pneumo,
many viral and some
bacterial pneumonias
Treatment
Neonates: ampicillin for GBS and
Listeria + cefotaxime Child:
vancomycin + 3rd gen
cephalosporin
Abx usually 10-14d
rifampin prophylaxis in close contacts
Abx prolongs Salmonella shedding,
increases risk of hemolytic uremic
syndrome.
TMP SMX or azithromycin for shigella,
erythromycin or azithromycin for C.
jejuni
mebendazole, pyrantel pamoate, or
albendazole
HAV: immune globulin, administer
within 14d of exposure
IM or IV penicillin G
Treatment
Complications High Yield facts
Dp not attempt LP in a
child with focal
neurologic deficits
and/or increased ICP
until an expanding mass
lesion is excluded by CT
or MRI
10-20% develop persistent
neurologic deficit: hearing loss,
developmental delay, motor
incoordination, seizures,
hydrocephalus
reinfections are common
handwashing is best prevention
HAV: fulminant hepatitis rare but
mortality up to 50% HBV: chronic
infection
HDV: HDV and HBV
simultaneously infection puts pt at
greater risk for more severe chronic
hepatitis B and higher mortality rate.
HDV superinfection on top of
exisiting HBV results in acute
exacerbation and acclerated course
result.
HCV: 50% develo[ chronic hepatitis
Untreated infants may develop
anemia, thrombocytopenia, and
radiography abnormalities of long
bones
Complications High Yield facts
 Rx for N. gonorrhea, C. trachomatis,
anaerobes
C trachomatis and N. gonorrhea:
Single dose IV ceftiaxone + PO
doxycycline
Anaerobes: metronidazole
Decreased fertility, ectopic
pregnancy, dyspareunia, chronic
pelvic pain, adhesions
N. gonorrhea: arthritis
C. trachomatis: Reiter
syndrome
Both: Fitz-Hugh-Curtis
syndrome (perihepatitis)

Trichomonas: PO metronidazole
Bacterial: PO metronidazole Candida:
antifungal creams or single dose of
PO fluconazole

Gonococcal: 230mg IM ceftriaxone

AND either 1 dose PO azithromycin
OR 7d of PO doxycycline
- azithromycin preferred because it
covers mycoplasma
genitalium

Pregnant women: zidovudine (AZT),

followed by treatment of infant for first
6 wks of life reduces vertical
transmission to 2%
NRTI, NNRTIs, PIs
TMP-SMX prophylaxis against PCP

Empiric rx - need to cover erlichiosis

and N. meningitidis
doxycycline
add cefotaxime or ceftriaxone if
suspecting meningococcemia

Treatment prevents early

disseminated and late disease
Young children: amoxicillin or
cefuroxime
Children >8yrs: PO doxycycline

Treatment Complications

Iron supplement: reticulocyte count incr within

3d, Hb concentration normalizes within a month.
Continue therapy for 2-3 mo to replenish stores
and prevent future occurrence.

iate iron supplementation is

Barts Thalassemia major: RBC transfusion to
% HbH, 60-90% HbA Alpha eliminate anemia, suppress extramedullary
trophoresis, similar to Fe erythropoiesis, decr iron overload
- goal is to maintain Hb >10g/dl
mal blood counts at birth. - Splenectomy with incr transfusion
cytosis, anisocytosis, requirement
Thalassemia intermedia (alpha or beta): folic
acid supplements for pts not on transfusion Beta thal major: Iron overload due to
ations of HbA2 and/or HbF therapy hyperabsorption of dietary iron or
transfusional iron loading
- cardiomyopathy, CHF
- cardiac disease is main cause of death

ormal or incr
rage iron, decr in iron-
sts
nitially Treat underlying inflammation

ocytopenia elevated HbF PO corticosteroids BM transplant

sine deaminase

ed HbF RBC transfusions

ia Hematologic improvement with androgen
demonstrating increased therapy
ge with SC transplant
butane (DEB) - decrease doses of radiation/chemo bc they
damage DNA

rocytosis BM transplant
al pancytopenia + Immunosuppression if no donor can be found
marrow

thrombocytopenia Usually self limited Corticosteroids, IVIG, anti-D

lets immunoglobulin can temporarily increase
history, physical, blood platelet count
ire BM exam, lab testing, or

Factor therapy to prevent joint damage from
recurrent hemarthrosis (hemophilic
arthropathy)
DDAVP: releases factor VIII from endothelial
cells
Aminocaproic acid: inhibits fibrinolysis
Older pts: received blood products with HIV
--> AIDS is MCC death
Formation of inhibitors: neutralizing IgG abs
vs factor VIII or IX

Treatment Complications
Induction therapy: 28d of vincristine,
steroids, intrathecal MTX, asparaginase.
Add daunomycin for high risk pts.
Consolidation: intensification of therapy to
kill additional leukemic cells if induction
fails
Interim maintenance: vincristine, 6- MP,
MTX
Radiation therapy for CNS and testicular
disease, CNS prophylaxis.
Chemotherapy more intense than ALL
Induction: anthracycline + arabinoside
Low risk: chemo only High risk: BM
transplant
Combination chemo Burkitt: surgical
resection
- tumor lysis: careful management with incr
fludi intake, alkalinzation of urine,
electrolyte observation, allopurinol
- high risk of developing kidney failure
requiring dialysis from tumor lysis
Treatment
Multiagent chemo
Lymphocyte-predominance has best
prognosis
Neutropenia (ANC < 500/mm3) predisposes to
serious bacterial and fungal infections.
High risk of tumor lysis syndrome:
hyperuricemia, hyperphosphatemia,
hyperkalemia
- especially in T cell ALL or Burkitt lymphoma
- greatest risk in first 3d of chemo
- maintain Hb <10mg/dL
Hyperleukocytosis (WBC>200,000): can
cause vascular stasis --> mental status
changes, HA blurry vision, dizziness, sz,
dyspnea
Mediastinal mass --> SVC syndrome:
distended neck veins, swelling of
face/neck/upper limbs, cyanosis, conjunctival
injection
Hyperleukocytosis (5-22%): dyspnea,
hypoxemia, etc
- treat earlier than ALL bc AML cells are larger
and stickier than lymphocytes in ALL.
- maintain Hb < 10 mg/dL
Mediastinal mass: SVC syndrome Burkitt:
tumor lysis syndrome - even before chemo is
started.
Complications
Secondary malignant neoplasms (breast,
thyroid, sarcomas), cardiac toxicity
(anthracyclines), pulm (bleomycin),
hypothyroidism (XRT)
Prognosis: INSS staging, DNA index of
tumor, MYCN gene amplification
- Stage I, II, IVS have good prognosis.
Stage III, IV have poor prognosis
Surgery, chemo, radiation, etc. Chemo:
vincristine, cyclophosphamide,
doxorubicin, cisplatin

Treatment Complications

Surgical removal of kidney Radiation

Invasion of renal capsule, extension through
therapy can be used for metastatic sites
adjacent vessels (IVC), regional nodes, lung,
Good prognosis: small size, younger age,
liver
no LN/metastases, no capsular/vascular
Lung most common site of metastasis
invasion

Chemo + radiation
- chemo: reduce size and treat mets
(almost all pts have mets)

Surgical removal of primary tumor

Resistant to radiation therapy (vs ewing)
Chemo: cisplatin, doxorubicin, MTX
 Enucleation, chemotherapy, local
therapies, radioplaques, external beam
radiation
- treatment depends on Reese- Ellsworth
classification
Child born to parent with BL retinoblastoma
or unilateral rb with known genetic mutation
should be screened for rb at birth and at
regular intervals until 4 or 5 yrs

Treatment Complications

Surgery, radiation, chemo

- chemo helps reduce tumor size and mets

Surgery, radiation, chemo

Treatment Complications

e lymphocyte counts and

on: in vitro mitogen

rmal delayed
ting Absent antibody Immunoglobulin replacement, aggressive
after 6 mo) Vaccine associated diarrhea with
identification and treatment of infections
hymic shadow on CXR, live/attenuated rotavirus vaccine
BM transplant

on:
ls
een - albumin or
her etiologies
er immunization (tetanus
ein antigens;
H influenza = carb

mmaglobulinemia of
cquisition of normal infant IVIG
els
mal levels by 2-5 yrs,
ses to vaccination
 infection (esp viruses), Acute neutropenia: no treatment
tration (penicillin, Chronic neutropenia/infections: recombinant
onvulsants), malignancy human gametocyte colony stim factor (rhG-
mia CSF)
x10^3 CGD: prophylactic TMP-SMX. BM
nths transplant
0,000-20,000, LAD: BM transplant.
response
lium test,
eduction (DHR)
try analysis of CD18

Termination of itch-scratch-itch cycle:

lotions, topical corticosteroids,
pimecrolimus cream (inhibits T cell
atitis, psoriasis activation), topical tacrolimus Bacterial superinfection

Treatment Complications
Allergen avoidance
more common in H1 blocker: PO or intranasal Intranasal
ucopurulent cromolyn: preventive Nasal topical steriods
rhinorrhea, postnasal drip PO leukotriene receptor antagonists
s, cough, and/or HA Topical/inhaled sympathomimetics -
y: unilateral, thick, foul pseudoephrine

(idiopathic nonallergic):
lar respons to irritant
entosa: overuse of topical
Recurrent sinusitis, otitis media with effusion
yngeal eosinophils,
srobant (RAST) test,

Subcutaneous epinephrine: emergency

Also IV diphenhydramine and steroids
PO antihistamines, sympathomimetics, PO
steriods C1 esterase replacement for
hereditary angioedema

Avoid offending food

nonimmunologic - Cow milk, egg, soy, and wheat allergies
achycardia, lactose can be outgrown
- peanut, nut, and fish allergies usually
ebo challenge - food persist
andard.
arthritis (acute rheumatic
ammatory conditions
sue diseases, HSP),
thritis, viral arthritis,
lignancy (leukemia,
ne tumors)

with anterior uveitis

C > 2000/mm3 with

Single large joint: intra-articular

corticosteroid injection Bony erosions, deformities, growth
Multiple joints: methotrexate disturbances
- TNF-alpha, IL-L, IL-6, T-cell costimulation

Treatment Complications
a, thrombocytopenia,
P normal
> hemolytic anemia
vels Aovid sun
pid abs, anti smith, anti- hydroxychloroquine for preventing disease
anti- Ro, anti-La flares
NSAIDs, corticosteroids

no skin findings, CD8 Corticosteroid therapy, IVIG, cyclosporine

te muscle fascicles and hydroxychloroquine: treats cutaneous
s directly), less common manifestations

eatine phosphokinase
uscle breakdown), other
Elevated VWF.
: muscle biopsy - Spontaneous perforation of bowel is leading
matory infiltrate, cause of death
hy

neous resolution within 4

st for 12 wks

levated during fever

dx Treatment Complications
ment Complications High Yield facts

cases undergo spontaneous involution

ectomy if kidney changes in size or
arance, persistent HTN

KD: dialysis

cal correction: minimally invasive

ry or open pyeloplasty

iotic prophylaxis for UTIs

rs: amoxicillin
r: bactrim or nitrofurantoin
ry: lengthen intravesicular segment of
l (ureteral reimplantation)

on of obstructing valve leaflets Abx

ylaxis if VUR is present
surgical correction of reflux is
uraged: bladder pathophys changes
ime, early surgery has high failure
Chronic kidney
disease - requires
long term follow up

mcision is contraindicated- surgical

may require preputial tissue

ment Complications High Yield facts

cal emergency
ery within 6 hrs
ove necrotic testes, fix CL testis to
al envelope
ular or epididymal appendix: torsion
es spontaneously Epididymitis: abx
 celes: repair communicating
celes and hernias to prevent
erated hernia
oceles: surgical repair
paired varicoceles incr risk for
ity

th positive leukocyte esterase should

ated for presumed UTI until culture
s are available
is: amoxicillin, ampicillin,
urantoin, or TMP-SMX
nephritis: PO cephalosporin or IV
illin + gentamicin

Pyelonephritis:
Bagged specimens are
perinephric abscess,
inadequate for UTI
renal scarring, renal
evaluation
failure

y salt restriction, oral steroid therapy Spontaneous

nger immunosuppressants in bacterial peritonitis -
sponders (cyclophosphamide, incr risk of
eurin inhibitors) encapsulated
umin: induces temporary diuresis organisms due to
loss of proteins
involved in
phagocytosis of
capsule
Thromboembolic
events, persistent
hyperlipidemia, steroid
toxicities

Treatment Complications

Amblyopia, reduced
stereopsis
Corrective lenses, occlusion, atropine
reflex, cover test
penalization, surgery

Correct refractive errors Occlusion of Permanent vision

better eye loss, diminished
Treatment is unsuccessful beyond 8 yrs stereopsis

ma, cataracts (most Enucleation, chemo, radiation, cryo Amblyopia ROP:

tinopathy of prematurity, Cataract surgery Retinal detachment,
aucoma, ocular toxocariasis ROP: laser ablation of retina or cryo scarring
reduces progression to retinal
detachment/scarring

asion: Painful, tearing,
vity. Examination under blue
orescein reveals abrasion.
ye patching. Heals in 24h
ulitis: severe pain with eye
proptosis, vision changes, decr Breaks in skin: penicillin or 1st gen
ty.
CT.
ema, allergies, tumor
96% resolve spontaneously in 1 yr
Probing of nasolacrimal duct system at
12-15 mo.
Antibiotic drops: polymyxin- bacitracin,
erythromycin
- abx limit infectivity and decrease duration
by 2 days
- Neisseria: IV ceftriaxone
- H. influenza: amoxicillin-clavulanic acid
- HSV1: do not give steroid- containing
abx. Risk of more severe disease and
visual impairment
Hordeolum: warm compresses, abx
Chalazion: excision may be required
IV abx
cephalosporin
Cefuroxime
3rd gen ceph: prevent extension to
meninges