Pediatrics: Oral and Written Revalida > Percutaneous HbIg + vaccine (0.

6 mg/kg within 24 hours)

Hepatitis > Vaccination: Deep IM (deltoid or anterolateral part of thigh)
 Inflammation of the liver > Treatment: None
 Usually affect older children
Infectious Hepatitis C
 Viruses (TORCH) hypertropic viruses goes straight to the liver and  Incubation = 7- 9 weeks
causes Hepa A,B, C,D, E, F  Chronicity = 85% increased risk of liver failure/ cancer
 Bacterial – typhoid, TB, gram (-) E.coli Risk factors:
 Parasitic a. Blood pressure = most important
Non-Infectious b. Sexual
 Drugs (anti-TB drugs) c. Perinatal transmission
 Chemicals (anesthetics) d. Hemodialysis
Viral Hepatitis e. IV drug abusers
Physical Findings: No treatment or vaccine
 Jaundice 90%
 Hepatic tenderness 85%
 Hepatoma 70%
 Splenomegaly 20% Hepatitis D
 Spider angiomata +/-  Smallest
Treatment:  Delta agent, defective RNA virus
 Supportive  Replicates only when associated with Hepa B, exists as either
 Regular diet coinfection or superinfection
- If patient has abdominal pain & intolerance to  Incubation: 2-8 weeks
fat → decrease fat intake  Chronic Hepa D may lead to cirrhosis or even death
Hepa A and E are not known to cause chronic illness, whereas Hepa B, C, D  Management is generally supportive
can cause significant morbidity and mortality through chronic infections Hepatitis E
 Enterically transmitted, similar course to Hepa A
Hepatitis A  Non A and Non B
 Maybe aymptomatic, mild non-specific in children (anicteric  15-34 y/o
hepatitis)  HEV IgM/IgG
 Fecal-oral transmission  No treatment, no vaccination
 Incubation period = 4 weeks Hepatitis G
 0-4 weeks = body weakness, anorexia, fever  HGV RNA
 4th week = fecal shedding (very infectious shedding)  10-20% adult with HBV/HCV/HDV
 Serology = anti-HAV  BloodBorne
- IgM-presence means acute Hepa A  Organ transplantation
- Prognosis=complete recovery  Persistent viremia with normal ALT
1. Hygiene/Sanitation  No histologic insult
a. food handling
 It is not clear if HGV is a pathogen
b. hand washing
c. enteric presentation
Differential Diagnosis:
2. Vaccination
 The probable causes of hepatitis vary by age. In the newborn
a. post exposure prophylaxis within 2 weeks (among
period, infection remains an important cause of hyperbilirubinemia
households)
but metabolic and anatomic causes (biliary atresia, choledochal
- Ig
cyst) also must be considered.
- HAV vaccine
 In later infancy and childhood:
- hemolytic-uremic syndrome
Hepatitis B
- Reye and Reye-like syndrome
 One of the forerunners of hepatocellular carcinoma - Malaria, leptospirosis, brucellosis and with severe
 Transmission: infection
 Fecal –oral route  In older children , adolescents
 Percutaneous – blood borne - Gallstones
 Sexual - Chronic hemolytic process
 Vertical – mother to baby - Wilson’s disease, cystic fibrosis, systemic lupus
 HbeAg + Mom = 70-90% infant carrier erythematosus
 Incubation period: 45-160  Medications, including acetaminophen overdose, valproic acid,
 Hepa B course: Vertical Transmission various hepatotoxins such as long-acting mushroom toxins
Hepa B Virion
 (+) anti-Hbe= px not replicating anymore
 (+) HbeAg = very infectious
 IgM- recent (active)
 IgG = post
Prevention (no treatment)
 Prenatal screen for hepa B
 Blood donor screen
 Enteric precautions (stool disposal)
 Safe sex
 Nursery: wear gloves
 Rinse off amniotic fluid
 Immunization (most important)
 Plasma/ yeast derived

Hepatitis B Post-Exposure Prophylaxis

- perinatal
> HbIg + vaccine within 24 hours (give Ab 1st
before Ag
Pneumonia  Radiographic appearance alone not diagnostic other clinical
 is an inflammation of the parenchyma of the lungs features must be considered
 caused by: microorganisms (most cases)  The peripheral WBC count useful in differentiating viral from
 noninfectious causes include: bacterial pneumonia:
- aspiration of food or gastric acid, foreign bodies, > Viral: WBC normal or elevated but not 20,000/mm3 with a
hydrocarbons, & lipoid substances lymphocyte predominance
- hypersensitivity reactions >Bacterial: elevated WBC count 15,000-40,000/mm3 and
- drug or radiation induced pneumonitis predominance of granulocyte
 classified on an anatomic basis: lobar or lobular, alveolar, or  Definitive diagnosis: isolation of a virus from respiratory tract
interstitial process secretions
 Specific risk factors:  Growth of a respiratory virus in tissue culture usually takes 5-10
 Lung disease-asthma/ cystic fibrosis days
 Anatomic problems – tracheoesophageal fistula  Reliable reagents for the rapid detection of RSV, parainfluenzae,
 GERD w/ aspiration influenzae, and adenoviruses are available
 Neurologic disorders that interfere with protection of the airway  Serologic techniques
or compromise clearing of the airway  can be used to diagnose a recent respiratory viral infection
 Diseases that alter the immune system – immunodeficiency  laborious, slow, and not generally clinically useful, as the infection
diseases or hemoglobinopathies usually is resolved by the time it is confirmed serologically.
 Most common cause: respiratory syncytial virus (RSV)  Serology useful as epidemiologic tool to define the incidence and
> especially children <3 y/o prevalence of the various respiratory viral pathogens
 Other causes: parainfluenza, influenza, and adenoviruses Treatment:
Pathophysiology:  Amoxicillin – mildly ill children who do not require
 The lower respiratory tract is normally kept sterile by physiologic hospitalization
defense mechanisms, including the mucociliary escalator, the  High doses of amoxicillin (80-90 mg/kg/24hr) in communities
properties of normal secretions such as secretory IgA and clearing with high % of penicillin-resistant pneumococci
of the airway by coughing.  Therapeutic alternatives:
 Immunologic defense mechanisms of the lung that limit invasion  cefuroxime axetil or amoxicillin/clavulanate
by pathogenic organisms include macrophages that are present in  azithromycin (school-aged children with suggestive M.
alveoli and bronchioles, secretory IgA, and other immnoglobulins. pneumoniae infection)
 Viral pneumonia results from spread of infection along the
airways, accompanied by direct injury of the respiratory epithelium  Hospitalized children:
resulting in airway obstruction from swelling, abnormal secretions,  Bacterial: Parenteral cefuroxime (75-150mg/kg/24hr)
and cellular debris.  Staphylococcal pneumonia: include vancomycin/clindamycin
 Bacteria typically enter the lung when airborne droplets are
inhaled, but they can also reach the lung through the bloodstream  If viral pneumonia: withhold antibiotic therapy
when there is an infection in another part of the body. Many  Reserved for patients who are mildly ill
bacteria live in parts of the upper respiratory tract, such as the  (+) clinical evidence of viral infection
nose, mouth and sinuses, and can easily be inhaled into the alveoli.  (-) respiratory distress
Once inside the alveoli, bacteria may invade the spaces between
cells and between alveoli through connecting pores. This invasion Complications
triggers the immune system to send neutrophils, which are a type  Result of direct spread of bacterial infection within the thoracic
of defensive white blood cell, to the lungs. The neutrophils engulf cavity
and kill the offending organisms, and they also release cytokines,  pleural effusion
causing a general activation of the immune system. This leads to  emphysema
the fever, chills, and fatigue common in bacterial and fungal  pericarditis
pneumonia. The neutrophils, bacteria, and fluid from surrounding  bacteremia & hematologic spread
blood vessels fill the alveoli and interrupt normal oxygen
 rare complications: meningitis, suppurative arthritis, osteomyelitis
transportation.
 Bacteria often travel from an infected lung into the bloodstream,
causing serious or even fatal illness such as septic shock, with low
blood pressure and damage to multiple parts of the body including
the brain, kidneys, and heart. Bacteria can also travel to the area
between the lungs and the chest wall (the pleural cavity) causing a
complication called an empyema.
Clinical Manifestations
 Viral & bacterial pneumonia: preceded by several days of
respiratory symptoms-rhinitis and cough
 Often other family members are ill
 Viral pneumonia: (+) fever but temperatures are generally lower
than in bacterial pneumonia
 Most consistent clinical manifestation of pneumonia: Tachypnea
 Increased work of breathing accompanied by:
 intercostals, subcostal, & suprasternal retractions
 nasal flaring
 use of accessory muscles
 Severe infection may be accompanied by: cyanosis & respiratory
fatigue especially in infants .
 Auscultation: crackles & wheezing, often difficult to localize
source in very young children with hyperresonant chest
 Difficult to clinically differentiate viral pneumonia from disease by
Mycoplasma and other bacterial pathogens
Diagnosis:
 Chest radiograph confirmatory may also indicate complication
such as pleural effusion/ emphysema
 Viral pneumonia: hyperinflation with bilateral interstitial
infiltrates & peribronchial cuffing
 Pneumococcal pneumonia: confluent lobar consolidation
Dengue Fever  From 2nd-6th days of fever, nausea & vomiting are apt to occur, &
– a benign syndrome caused by several arthropod-borne viruses generalized lymphadenopathy, cutaneous hyperesthesia or
– characterized by biphasic fever, myalgia or arthralgia, rash, hyperalgesia, taste aberrations, & anorexia.
leucopenia, & lymphadenopathy  About 1-2 days after defervescence → a generalized, morbilliform,
Dengue hemorrhagic fever maculopapular rash appears (spares the palms & soles). It
- is a severe, often fatal, febrile disease caused by dengue viruses disappears in 1-5 days; desquamation may occur
- characterized by capillary permeability, abnormalities of  Rarely there is edema of the palms & soles
hemostasis, & in severe cases, a protein losing shock syndrome  About this time, second rash appears, the body temperature may
(Dengue shock syndrome). become slightly elevated & demonstrate the characteristic
Etiology: BIPHASIC temperature pattern.
 Aedes aegypti – a daytime biting mosquito is the principal vector; Dengue Fever
breeds in clean water, rainwater collected in container - Acute febrile illness with no identifiable focus of infection of 2-7 days
Dengue hemorrhagic Fever duration with 2 or more of the following.
- endemic in tropical areas of America and asia.  Headache
- Can occur during the primary dengue infections, mostly infants  Retroorbital pain
whose mothers are immune to dengue.
 Myalgia
- Second dengue infections are mild in majority of instances
 Arthralgia
Replication and Transmission of Dengue Virus
1. Virus transmitted to human in mosquito  Rash
Saliva  Hemorrhagic manifestation (petechiae + tourniquet test)
2. Virus replicates in target organs  Lecopenia
3. Virus infects white blood cells and
lymphatic tissues Dengue Hemorrhagic Fever
4. Virus released and circulates in blood The following must all be present:
5. Second mosquito ingests virus with blood  Fever, or hx of acute fever, lasting 2-7 days
6. Virus replicates in mosquito midgut  Hemorrhagic manifestation include:
and other organs, infects salivary glands - positive tourniquet test
7. Virus replicates in salivary glands - petecchiae, eccyhmoses or purpuric rashes
Hypothesis on pathogenesis of DHF: - bleeding like epistaxis, gum bleeding, hematemesis,
 Persons who have experienced a dengue infection develop serum melena
antibodies that can neutralize the dengue virus of that same  Thrombocytopenia (< 100,000 cells per mm3 or less) or 1-2
(homologous) serotype platelets/oil immersion field
 In a subsequent infection, the pre-existing heterologous antibodies  Evidence of plasma leakage due to increased vascular permeability
form complexes with the new infecting virus serotype, but do not manifested by at any or more of the following:
neutralize the new virus  Hematocrit > 40% or a raise of > 20% in hematocrit for age & sex
 Antibody-dependent enhancement is the process in which certain  A drop in > 20 % hematocrit following volume replacement
strains of dengue virus, complexed with non-neutralizing treatment as compared to baseline
antibodies, can enter a greater proportion of cells of the  Signs of plasma leakage & hypoproteinemia
mononuclear lineage, thus increasing virus production.
 Infected monocytes release vasoactive mediators, resulting in Dengue Shock Syndrome
increased vascular permeability and hemorrhagic manifestations All of the above criteria for DHF must be present, plus evidence of circulatory
that characterize DHF and DSS failure manifested by:
Pathogenesis:  Rapid and weak pulse
 Acute illness and viremia 3-7 days  Narrow pulse pressure (< 20 mmHg) or manifested by:
 Recovery or progression to leakage phase  Hypotension for age (< 80mmHg systolic pressure for < 5 years of
 Dengue virus enters and replicates within monocytes, mast cells, age and < 90mmHg systolic pressure for > or = 5 years of age) and
fibroblasts  Cold, clammy skin and restlessness
 Innate and adaptive immune response Grading Severity of DHF:
 Cytokine release: TNF-a, IL-2, IL-6, IL-8 Grade 1
 Compliment activation Fever and nonspecific constitutional symptoms
 Antibody dependent enhancement (ADE) thought to contribute to Positive tourniquet test is only hemorrhagic
severe infections manifestation
 T-cell activation: CD4 and CD8 cells cytokine production Grade 2
Capillary Leak Syndrome: manifestations + spontaneous bleeding (skin or
• Transient increased capillary permeability due to endothelial cell other hemorrhages
dysfunction Grade 3:
• Widening of tight junctions Signs of circulatory failure (rapid/weak pulse,
• Cytokine release and complement activation narrow pulse pressure, hypotension,
Leukopenia, Thrombocytopenia and Hemorrhagic diathesis: cold/clammy skin)
• Direct viral bone marrow suppression Grade 4
• Platelet destruction in DHF Profound shock (undetectable pulse and BP)
• Molecular mimicry between viral protein and coagulation factors  The only difference between DF and DHF grade I is the presence
Clinical Manifestations: of thrombocytopenia and hemoconcentration
 Incubation period: 1-7 days Criteria and indication for admission:
 Variable & are influenced by age of the px Danger Signs:
 In Infants & young children: Fever of 1-5 days, pharyngeal - spontaneous bleeding
inflammation, rhinitis, & mild cough. - persistent abdominal pain
 Infected older children & adults: sudden onset of fever, w/ - persistent vomiting
temperature rapidly increasing to 39.4-41.1 C. accompanied by - changes in mental status
frontal or retro-orbital pain. Occasionally severe back pain - restlessness
precedes the fever (back-break fever). - weak and rapid pulse
 A transient, macular, generalized rash that blanches under pressure - cold, clammy skin
– seen during the 1st 24-48 hr of fever. - circumoral cyanosis
 Pulse rate- slow relative to degree of fever - difficulty of breathing
 Myalgia & arthralgia –occur soon after onset & increase in - seizures
severity. - hypotension or narrowing of pulse pressure (<20 mmHg)
- platelet count < 100,000 cells per mm3
- hemoconcentration
- prolonged bleeding time (> 5 minutes by Ivy method)
Laboratory criteria for confirmation of DF are:
 Serological Confirmation:
 Demonstration of a fourfold or greater change in IgG antibody
titers to one or more dengue virus antigens in paired serum
samples
 Anti-Dengue IgM Elisa positive
 Sample for serological confirmation
1. 3-5 sample, (refrigerated & sterile) obtained during acute and
convalescent phase
2. complete clinical information
 Virological Confirmation
- Isolation of the Dengue virus from serum or autopsy samples
- Demonstration of the dengue virus antigen in all serotypes by
immunoflourescence or immunoperoxidase test
-Demonstration of dengue virus genome by RT-PCR using dengue
consensus and serotypes specific primers

Differential Diagnosis

Viral: Influenza, HIV, Hepatitis A, Yellow Fever, Hantavirus, Measles,

Rubella, Coxsackie and other enteroviruses, parvovirus B19,
Chikungunya virus, EBV
Bacterial: Typhoid, Scarlet fever, Meningococcemia
Parasitic: Malaria, Leptospirosis, Rickettsial disease, Leishmaniasis,
Chagas disease
Fungal: Cryptococcus, Blastomycosis, Histoplasmosis
Non-Infectious: Malignancy, rheumatic, vasculitis, drug fever, other
miscellaneous

Mosquito Borne Illnesses

 Protozoa: Malaria
 Roundworm: Filariasis, dirofilariasis
 Alphaviruses: Chikungunya fever, Mayaro fever, Ross River fever,
Eastern, Western, and Venezuelan equine encephalitis
 Flaviviruses: West Nile fever, Zika fever, St. Louis encephalitis,
Japanese encephalitis, Yellow Fever
 Bunyaviruses: LaCrosse encephalitis, Oropouche virus, Bwamba
fever, California encephalitis

Treatment:

Treatment of uncomplicated dengue fever is supportive. Bedrest is

advised during the febrile period. Antipyretics should be used to keep
body temperature less than 40 C (104 F). Analgesics or mild sedation
may be required to control pain. Aspirin is contraindicated and should
not be used because of its effects on hemostasis. Fluid and electrolyte
replacement is required for deficits caused by sweating, fasting,
thirsting, vomiting, and diarrhea.