Fever >101°F ≥8 d w/o clear etiology after H&P and basic lab eval; definitions vary

Most often uncommon presentation of a common disease (Pediatrics 1975;55:468)

Hx (fever pattern, assoc sx’s, ethnicity, ingestion, travel, animal and insect exposure, meds, FHx); complete exam (including accessible LNs, HSM, scalp and skin, MSK and GU); review meds

Labs: CMP, U/A, ESR and CRP, CBC w/ diff and periph smear, PPD, HIV, Bld and U cx

Additional testing (based on H&P, sx’s); Stool cx’s and O and P, viral serologies, ANA, Immunoglobulin levels (if h/o recurrent infections)

Imaging: CXR, abd CT (if ↑ inflammatory markers or other concern for IBD)

Generally avoid empiric Abx or corticosteroids until potential dx available

Empiric broad-spectrum antibiotics may decrease diagnostic yield

Mortality previously reported at <10%; less in more recent cohorts (Pediatrics 1975;55:468; Acta Paediatr 2006;95:463)

Inflammation of meninges, covering brain and spinal cord 2/2 infection

Peak incidence in 6–12 mo (infants = perinatal exposure and relatively immunocompromised); though 2/2 vaccinations bulk of disease shifted to adulthood

Incidence: 2500 cases in U.S. annually; S. pneumo 7.5/1.0/0.2 per 100,000 in >2 yr/2–4 yr/5–17 yr. (Pediatrics 2006;118:e979; JAMA 2001;285:1729)

Aseptic meningitis: Enterovirus (∼85%–95% of all viral meningitis), HSV, EBV, CMV, VZV, arbovirus (EEE, West Nile), influenza A/B, mycoplasma (Semin Neurol 2000;20:277)

Functional/anatomic asplenia, sickle cell disease, nephrotic syndrome, IgG deficiency → ↑ risk encapsulated organism infections (S. pneumo, Hib, N. meningitidis)

Late complement deficiency (C5–C8) → N. meningitidis

Anatomic defects/CSF leak → S. pneumo, S. epi, S. aur, Strep spp., Corynebact.

VP shunt for hydrocephalus → Staph. epidermis (coagulase-negative staph)

Galactosemia → E. coli; HIV → C. neoformans; Endemic area → Lyme

Bacterial meningitis tends to present acutely (<24 hr)

Infant (nonspecific): fever, irritable, lethargy, ↓feeding, abn tone, bulging fontanel, szr’s, vomiting, Δ body temperature; e/o sepsis (hypotension, respiratory distress, jaundice)

Older children: fever, headache, vomiting, neck stiffness, photophobia

Skin: widespread petechiae/purpuric rash (esp associated with meningococcemia)

Hx: Neck stiffness or pain, progressive petechial/purpuric rash, seizure, vaccine Hx; recent infxns (sinusitis, otitis media); exposure pts w/ meningitis; travel; h/o head trauma/craniotomy; VP shunt; immunodeficiency; Hx recent Abx use.

Neurologic exam; assess risk of ↑ ICP/herniation → follow neurologic exam during Rx

Meningeal signs: Nuchal rigidity; in >2 yo: Kernig (straighten flexed leg at knee → neck/back pain) and Brudzinski (passive neck elevation → hip flexion). Tripod sign: pt sitting w/ legs flexed and arms outstretched at the elbow

↑ ICP: Bulging fontanel in infants, ↑ head circum, papilledema in older, CN palsies

Labs: CBC w/ diff, blood culture × 2; chem. 10, LP (if suspect bacterial, do not delay)

Normal CSF findings

CSF GS (+)90% S. pneumo and 80% N. mening; Bcx (+)90% Hib and 80% S. pneumo

Repeat LP in 24–36 hr if: possible resistant organism (e.g., PCN-resist S. pneumo); s/p dexamethasone; poor Rx response; GNR (after 2–3 d of Rx)

Empiric Abx after LP: 3rd gen. cephalosporin (ceftriaxone, cefotaxime) + vancomycin (+ ampicillin if <3 mo for Listeria coverage)→ Δ when cx/sensitivities available

Hypovolemia, HypoNa (2/2 SIADH), hypoglycemia, acidosis, septicemia, seizures, DIC, metastatic infection, cerebral edema, ↑ ICP/herniation, stroke

Pneumococcal vaccine (PCV-7) → 33%–75% ↓ in invasive pneumococcal disease

MCV-4 conjugate vaccine (covers A, C, Y, W-135 strains (no B); ∼3–5 yr efficacy)

Hib vaccine → 75+% decrease in Hib meningitis rates

Close contact chemoprophy in N. meningitidis (rifampin, Cipro, CTX) and Hib (rifampin)

Infxn’s of eyelids, orbit, & surrounding structures. Separated by orbital septum

Periorbital cellulitis is a simple skin infxn and involves structures anterior to septum. Orbital cellulitis is posterior to septum; involves infxn of soft tissues w/i the orbit.

Periorbital infxn 2/2 direct inoculation of bacteria (trauma, insect bite) or via bacteremia.

Orbital infxn generally sinusitis complication w/ infxn extension, rarely 2/2 trauma.

Periorbital cellulitis does not spread and become orbital cellulitis (Pediatr Infect Dis J 2002;12:1157).

Essential to differentiate the 2 entities; can be challenging as symptoms overlap.

Periorbital cellulitis p/w erythema, induration, tenderness, and warmth of eyelid and periorbital tissue. No limitations or pain w/ eye mvmt. Systemic sx’s infrequently present.

Orbital cellulitis w/ same superficial inflamm, but w/ vision Δ’s, pain w/ and limitation of eye mvmt, chemosis (edema of bulbar conjunctiva) or proptosis. (Pediatr Rev 2004;25:312)

Noninfectious causes of periorbital swelling:

Infections that can be mistaken for preseptal cellulitis

No imaging needed with periorbital cellulitis.

CT of orbits/sinuses for orbital cellulitis, esp if persistence or worsening sx’s on appt Rx.

For periorbital cellulitis, Rx PO if >1 yo and full vac w/o systemic sx’s to cover Gram+’s, (cephalexin, dicloxacillin, clinda). Good outpt f/u. Duration of Rx: 7–10 d.

For orbital cellulitis, Rx w/ IV Abx against potential pathogens.

AAP guidelines require Hx acute onset of signs/sx’s, presence middle ear effusion on exam, and signs/sx’s of middle ear inflammation for diagnosis.

Accounts for ∼20% of pedi clinic visits and for most outpt Abx prescriptions.

50% of pediatric patients will have 1st episode of AOM before 6 mo, 90% by 2 yr.

Risk factors: atopic dz, low socioeconomic status, immune def, craniofacial abn (cleft palate), genetic syndr (Downs), day care, siblings, smoke exposure, pacifier use, bottle feeding, 1st AOM before 6 mo.

Middle ear connected to nasopharynx by Eustachian tubes, drain middle ear secretions and protect middle ear from nasopharyngeal secretions.

Eustachian tube obstruction and drainage impairment more common in children; more horizontal, less stiff and surrounded by lymphoid follicles (inflamed w/ URI)

Distinguished from simple otitis media w/ effusion (OME); fluid in middle ear space but no acute inflamm (otalgia or erythema of the TM).

Otitis externa (swimmer’s ear) bacterial infxn involving inflamm and skin breakdown of external ear canal. (Pediatr Rev 2007;28:77)

Rapid onset signs and sx’s; otalgia, otorrhea, and/or fever; may be irritability in infant.

Middle ear effusion (MEE) via otoscopy; w/ bulging tympanic membrane (TM), ↓ mobility TM, TM air fluid level, or otorrhea. Can be benign finding w/ URI.

For MEE to indicate AOM, need middle ear inflamm (erythema of TM or otalgia).

Generally none. Definitive dx via tympanocentesis (rarely). (Pediatr Rev 2004;25:187)

Pain; Rx w/ Tylenol/ibuprofen and/or topical agents in pts >5 yo (Auralgan).

Observe w/o Abx (Abx at 1st visit ↓ course 1 d in 5%–14% vs Abx adverse rxn in 5%–10%):

Antibiotics: In all pts <6 mo; pts 6 mo–2 yo w/ certain dx or w/ uncertain dx and severe illness; or failure to improve after 24–72 hr obs w/o Abx.

Choice of Abx:

TM perforation is most common complication, seen in 5% of patients

MEE (otitis media w/ effusion) persists following AOM normally, if it persists it can increase the risk for language delay due to partial hearing loss.

Mastoiditis rare but is most common serious complication of AOM; p/w fever, mastoid tenderness, displacement of the ear anteriorly.

Other much less common complications include bacteremia, meningitis, and abscess.

Enlarged, inflamed, lymph node(s); also see Oncology section for more details

Hx: Duration, laterality, location, exposures (TB, kittens, uncooked meat), dental probs, vaccination Hx, B symptoms (F/C/S, weight loss), recent illness, travel

Noninfectious causes: Neoplasms, Kawasaki, PFAPA Periodic Fever, Apthous stomatitis, Pharyngitis, Adenitis, CTD’s, Kikuchi dz, branchial cleft cyst, cystic hygroma

Unilateral (acute) → if mod sx’s, FNA for Cx. If severe → US/CT, I&D, Bcx

Bilateral (acute) → usually no w/u necessary as likely viral

Unilateral/bilateral (subacute/chronic) → consider CBC/diff, ESR, PPD, serologies for EBV/CMV/Bartonella/Tularemia, HIV, excisional biopsy

Unilateral (acute) → Abx cover for Staph, GAS, +/- oral flora; if mild sx’s → cephalexin, clinda, amox/clav, TMP-SMX (if CA-MRSA prevalence high). If mod/severe sx’s, consider IV cefazolin, nafcillin, ampicillin/sulbactam, clindamycin, or vancomycin.

Most common vector born dz in U.S., ↑ trend; peak incidence in summer

Endemic areas include Northeast and Great Lakes regions, usually in rural, wooded areas (for local prevalences: American Lyme disease foundation: http://www.aldf.com/usmap.shtml)

Most prevalent in children 2–15 yo (Pediatrics 1998;102:905)

Spirochete Borrelia burgdorferi spread by tick (Ixodes scapularis) on deer and mice.

Coinfection w/ Babesia, and other rickettsial species not uncommon (up to 10%), may contribute to prolonged sx’s despite Rx for Lyme.

Infection usually requires tick attachment >36 hr

Clinical dx during early stages (erythema migrans), Ab against B. burgdorferi not detectable w/i first few weeks after infection.

In early disseminated or late dz, dx based on clinical findings and serologic tests.

Note: Rx’d individuals early in course of infection might not develop Ab’s.

PCR and culture not recommended.

Prophylaxis: RCT (>12 yo) w/ efficacy doxycycline 200 mg × 1 w/i 72 hr of tick bite (must have seen and removed tick) to prevent Lyme dz (N Engl J Med 2001;345:79)

Recommended treatment of Lyme disease in children (Lyme Disease. Red Book 2006:428)