Assessment

• Infectious diseases range from minor upper respiratory tract

infection to lethal sepsis.
• Occasionally, presumed noninfectious signs or symptoms are
due to an infectious disease. Many nonspecific disease
manifestations are presumed to be infectious.
 The foremost reason is the fear that an untreated minor
infection may progress to a life-threatening illness if antibiotic
treatment is not given.
• Many infections can be treated relatively easily with
antimicrobial agents; a good clinical response while receiving
antibiotic treatment is taken as evidence that it is not
necessary to pursue non-infectious diagnoses.
• Nonetheless, many illnesses are short-lived and would
resolve without antibiotics. The consequence is that many
individuals are treated unnecessarily with antimicrobial
agents.
This unnecessary treatment has resulted in the serious
problem of the development of antibiotic-resistant
bacteria.
 Appropriate diagnosis of infectious and noninfectious
diseases and providing specific treatment only as indicated
would help reduce the unnecessary use of antibiotics.
HISTORY
 A complete medical history is essential for assessment
of infectious risk.
• The principal symptom can suggest a primary
infectious disease or infection that is secondary to
another disease, such as immunodeficiency or cystic
fibrosis.
 The history may provide many potential clues for
diagnosis of infection.
Family history, especially of unexpected deaths of
male infants, may suggest familial immunodeficiency.
PHYSICAL EXAMINATION
 A complete physical examination is essential to identify
the signs of infection, which may be systemic, such as
fever, or focal, such as localized signs of inflammation,
including swelling, erythema, tenderness, and limitation
of function.
• Many infectious diseases have associated cutaneous
signs, which require firsthand examination of the patient
to characterize the lesions accurately.
 Accurate otolaryngologic examination is key to
diagnosing upper respiratory tract infections and otitis
media, the most common childhood infectious diseases in
the U.S.
COMMON MANIFESTATIONS
 Attention to the common manifestations of infectious diseases
usually leads to an appropriate diagnosis.
Infections often have signs and symptoms recognizable at
respiratory and gastrointestinal mucosal surfaces, where microbes
first interface with the host.
Viral infections of the respiratory tract rarely are limited to one
target site.
 Pharyngitis with coryza and conjunctivitis suggests a viral
(adenovirus) upper respiratory infection; if there is also cough, the
diagnosis may be viral bronchitis.
 If there are signs of respiratory distress and crackles, viral or
bacterial pneumonia is likely.
 Alternatively, if the only manifestation is severe conjunctivitis, the
diagnosis is more likely to be a bacterial conjunctivitis.
 The host immune response varies with age,
and neonates are at risk for different types of
infections and have different clinical
manifestations than school-age children or
adolescents.
 The clinical manifestations and consequences
of the inflammatory response may be more
deleterious than the injury directly attributed
to the pathogen.
Certain presentations of infections are medical emergencies.
 Severe gastroenteritis with extreme dehydration or sepsis with
hypotension can lead to multiorgan damage and requires immediate
fluid resuscitation and appropriate antibiotics.
 Infections of the airway, such as
o croup,
o epiglottitis,
o retropharyngeal abscess,
o peritonsillar abscess, or
o tonsillitis with obstruction from severe Epstein-Barr infection,
o can result in airway obstruction that may require emergent intubation
or rarely tracheostomy.
Fever, headache, vomiting, changes in sensorium, and signs of nuchal
rigidity suggest bacterial meningitis and necessitate emergent lumbar
puncture and examination of the CSF and a CT scan if indicated.
DIFFERENTIAL DIAGNOSIS
 Fever does not always represent infection; children with
overwhelming infection may be afebrile or hypothermic.
• Rheumatologic disease, inflammatory bowel disease,
Kawasaki disease, poisoning, and malignancy also may
present with fever.
• The varied manifestations of infectious diseases
frequently mimic rheumatoid arthritis, lupus
erythematosus, inflammatory bowel disease, leukemia,
and lymphoma.
Many manifestations of infectious diseases mimic
noninfectious diseases.
 Symptoms such as bone pain or lymphadenopathy that suggest
infection also are symptoms that could be due to leukemia,
lymphoma, juvenile rheumatoid arthritis, or Kawasaki disease.
 Acute mental status changes or focal neurologic impairment
could be due to infections, such as encephalitis, meningitis, or
brain abscess; manifestations of brain or spinal tumors;
inflammatory conditions, such as multiple sclerosis;
postinfectious sequelae, such as acute demyelinating
encephalomyelitis; or impairment owing to toxic ingestions or
inhalants.
• If the underlying cause is an infection, the presenting
manifestation may be CNS infection of bacterial, viral, fungal, or
parasitic origin.
• Certain infections are more common in specific geographic
areas;
• parasitic infections are more common in tropical climates.
• Diarrhea may be bacterial, viral, or parasitic in the tropics, but
in temperate climates parasitic causes of diarrhea other than
giardiasis are much less likely.
• Certain fungal infections are common in specific geographic
areas, such as coccidioidomycosis in the southwestern U.S.,
blastomycosis in the upper Midwest, and histoplasmosis in the
central part of the U.S., especially in the states bordering the
Mississippi and Ohio Rivers. In other areas, fungal pneumonias
are rare except in immunocompromised persons.
 Some infections are prone to recurrence,
especially if the treatment is suboptimal or for a
shorter duration than is recommended.
 Recurrent, severe, or unusual (opportunistic)
infections suggest the possibility of
immunodeficiency.
Many manifestations of mucosal allergy
(rhinitis, diarrhea) may mimic an infectious
disease.
DISTINGUISHING FEATURES
• Signs of inflammation, including fever, are routinely associated
with infection, but inflammation is not specific and may reflect
rheumatologic diseases, inflammatory bowel diseases, and
cancer.
• The absence of fever may suggest an allergic etiology, unless
secondary infection (sinusitis) occurs.
 Initial complaints of infection may be nonspecific, especially in
infants who present with fever, lethargy, irritability, excessive
sleeping, or poor feeding.
• Certain individual physical findings, such as unique rashes, may
be diagnostic.
• Because of the varied presentations of infectious diseases, it is
important to investigate thoroughly every objective finding
from the history and physical examination.
INITIAL DIAGNOSTIC EVALUATION
• The ability to diagnose specific infection accurately in pediatric
patients begins with an understanding of:
 the epidemiology and risk factors associated with each infectious
agent
 and the age-related susceptibility, which reflects the maturity of the
immune system.
Initial diagnostic evaluation requires
 accurately recognizing the site of the infection,
 recognizing all of the manifestations that are present,
 knowing all of the risk factors,
 recognizing exposure to potential infectious agents,
 and knowing the most likely organisms causing each infection
 and the usual host immune response to the infection.
• Obtaining a thorough history identifies most of these risk factors (see
Table 93-1).
 Antibiotics often are begun before a definitive diagnosis is
established, which complicates the ability to rely on
cultures for microbiologic diagnosis.
• Although persistent or progressive symptoms despite
antibiotic treatment may indicate the need to change the
regimen, they more frequently indicate the need to stop
all antibiotics to facilitate definitive diagnosis by obtaining
appropriate cultures.
 Antibiotics should not be given before obtaining
appropriate cultures, unless there is a life-threatening
situation (e.g., septic shock).
SCREENING TESTS
• Laboratory diagnosis of infection includes:
 examination of bacterial morphology using Gram stain,
 various culture techniques,
 molecular microbiologic methods such as polymerase chain
reaction (PCR),
 and assessment of the immune response with antibody titers or
skin testing (e.g., tuberculosis).
The acute phase response is the nonspecific metabolic and
inflammatory response to infection, trauma, autoimmune disease,
and some malignancies.
Acute phase reactants, such as erythrocyte sedimentation rate
(ESR) and C-reactive protein (CRP), are commonly elevated during
an infection, but are not specific for infection and do not identify
any specific infection. These tests are often useful to show response
to therapy (e.g., osteomyelitis).
 The complete blood count frequently is obtained to
identify evidence of bone marrow response to
infection.
The initial response to infection, especially in children,
is usually a leukocytosis, which is an increase in the
number of circulating leukocytes, with a neutrophilic
response to bacterial and viral infections.
• With most viral infections, the initial neutrophilic
response is transient and is followed quickly by the
characteristic mononuclear response.
 In general, bacterial infections are associated with
greater neutrophilia than are viral infections.
• A shift to the left is an increase in the numbers of
circulating immature cells of the neutrophil series,
including band forms, metamyelocytes, and myelocytes.
 A shift to the left indicates the rapid release of cells
from the bone marrow and characteristically is seen in
the early stages of infection and with bacterial
infections.
Transient lymphopenia at the beginning of illness and
lasting 24 to 48 hours has been described with many
viral infections.
 Atypical lymphocytes are mature T lymphocytes
with larger, eccentrically placed, and indented
nuclei that classically are seen with infectious
mononucleosis caused by Epstein-Barr virus (EBV).
 Other infections associated with atypical lymphocytosis
include:
 cytomegalovirus (CMV) infection,
 toxoplasmosis,
 viral hepatitis,
 rubella, roseola, mumps,
 and some drug reactions.
• Eosinophilia is characteristic of tissue-invasive
multicellular parasites, such as the migration of the
larval stages of the parasite through skin, connective
tissue, and viscera.
• High-grade eosinophilia (>30% eosinophils, or a total
eosinophil count >3000/μL) frequently occurs during
the muscle invasion phase of trichinellosis, the
pulmonary phases of ascariasis and hookworm
infection (eosinophilic pneumonia), and the hepatic
and CNS phases of visceral larva migrans.
• Other common screening tests include
urinalysis for urinary tract infections (UTIs),
transaminases for liver function, and lumbar
puncture for evaluation of the CSF if there is
concern for meningitis or encephalitis. A
grouping of various tests may help distinguish
viral versus bacterial infection, but definitive
diagnosis requires culture or PCR.
Cultures are the mainstay of diagnosis.
• Blood cultures are sensitive and specific for bacteremia
that may be primary or secondary to a focus (osteomyelitis,
gastroenteritis, urinary tract, endocarditis).
• Urine cultures confirm UTI, which may be occult in young
infants.
• CSF cultures should be obtained with any lumbar puncture.
• Other cultures are determined by the presence of fluid
collections or masses that are suspected to be infectious.
• Tissue culture techniques help identify viruses and
intracellular pathogens.
Rapid tests are useful for preliminary diagnosis and are
included in numerous bacterial, viral, fungal, and parasitic
antigen detection tests.
• Serologic tests, using enzyme-linked immunosorbent
assay (ELISA) or Western blotting, showing an IgM
response, high IgG, or seroconversion between acute
and convalescent sera can be used for diagnosis.
• Molecular detection methods, such as PCR for DNA or
RNA, offer the specificity of culture, high sensitivity, and
rapid results.
• When an unusual infection is suspected, the laboratory
must be notified before the sample is obtained.
DIAGNOSTIC IMAGING
• The choice of diagnostic imaging mode should be based
on the location of the findings.
• In the absence of localizing signs and an acute infection,
imaging of the entire body is rarely productive.
• There is often more than one suitable approach to
diagnostic imaging of suspected infections.
 Plain x-rays are useful for the middle and lower
respiratory tract, but they have been superseded by
cross-sectional imaging techniques.
 Ultrasonography is a noninvasive, nonirradiating
technique well suited to infants and children for solid
organs, such as the kidneys, liver, pancreas, and
spleen. It also is useful to identify soft tissue
abscesses with lymphadenitis and to diagnose
suppurative arthritis of the hip.
• CT (with contrast enhancement) and MRI (with
gadolinium enhancement) allow characterization of
lesions and precise anatomic localization and are the
modalities of choice for the brain.
• CT shows greater bone detail, and MRI shows greater tissue
detail.
• High-resolution CT is useful for complicated chest infections.
• Contrast studies (upper gastrointestinal series, barium enema)
are used to identify mucosal lesions of the gastrointestinal
tract, with CT or MRI for evaluation of appendicitis and intra-
abdominal masses.
• A voiding cystourethrogram (VCUG) is used to evaluate for
ureteral reflux, which is a predisposing factor for upper UTIs.
 MRI is especially useful for diagnosis of osteomyelitis, myositis,
and necrotizing fasciitis.
• Radionuclide scans, such as technetium-99m for osteomyelitis
and dimercaptosuccinic acid (DMSA) for acute pyelonephritis
or chronic renal scarring, are often informative.