Pediatrics
Certification Exam Review Online

Educational Objective:

Describe the epidemiology and clinical findings of encephalitis.

Key Point:

Encephalitis is defined as inflammation of the brain parenchyma - the grey and white matter (versus “just” the meninges in meningitis). Viruses are the most frequent cause of encephalitis.  

Explanation:

Infectious causes of encephalitis can be divided into 3 general categories:

1) Arboviruses spread by insects (eg, West Nile virus, equine encephalitis)

2) Zoonotic spread by non-insect vectors (eg, parasites, rabies virus)

3) Community-acquired viruses (eg, enterovirus, adenovirus, herpes simplex virus)

Symptoms of viral encephalitis range from flu-like symptoms to severe neurologic complications, including paralysis, dementia, and seizure. Lumbar puncture, brain imaging, and laboratory studies are commonly performed to help diagnose the infection. Treatment often depends on managing the associated inflammation, the increased intracranial pressure, or both.

Notable examples of encephalitis not caused by direct central nervous system infection include grey and white matter inflammation from acute disseminated encephalomyelitis (ADEM) and acute cerebellar events ataxia. ADEM is characterized by a brief but widespread attack of inflammation in the brain and spinal cord that damages myelin – the protective covering of nerve fibers. ADEM often follows viral or bacterial infections, or less often, vaccination for measles, mumps, or rubella.

References:

Central nervous system infections (Chapter 621). In: Kliegman RM, et al, eds. Nelson Textbook of Pediatrics. 21th ed., 2019.

Falchek SJ. Encephalitis in the pediatric population [Erratum in Pediatr Rev. 2012;33(8):383 and Pediatr Rev. 2012;33(6):275]. Pediatr Rev. 2012;33(3):122-133.

Osgood-Schlatter disease, or tibial tubercle apophysitis, is an overuse injury commonly seen in active adolescents after a recent growth spurt. The pain is caused by chronic traction on the secondary ossification center of the tibial tubercle. Classic symptoms include localized anterior knee pain made worse by kneeling and jumping but there is no pain at rest. Examination typically shows tenderness over the tibial tubercle and sometimes swelling and warmth in this area but the examination is otherwise entirely normal. Clinical diagnosis is usually possible.

Baker’s cysts usually cause pain and swelling posterior to the knee joint and pain is exacerbated by prolonged standing or hyperflexion of the knee.

Patellar tendinitis is also an overuse injury and typically the pain is worse after going up or down stairs or following prolonged sitting. The point of tenderness on examination is usually directly over the patellar tendon while the pain in Osgood-Schlatter disease is confined to the tendon insertion.

A fracture of the proximal fibula would cause pain and swelling over the fibula and the pain would be present even at rest.

References:

Hergenroeder AC. Approach to acute knee pain and injury in children and skeletally immature adolescents. Updated October 2017. Accessed November 18^th, 2017.

Sarkissian EJ, Lawrence TR. The Knee. Book Chapter in Nelson Textbook of Pediatrics, Chapter 677, 3268-3273.e2.

Multiple factors contribute to the incidence and persistence of asthma in children. In a landmark study of the epidemiology of respiratory symptoms in children, allergy played a major role in childhood asthma. The predominant risk factor for persistent asthma in childhood is a personal or family history of allergy. In large population studies, 40% to 80% of children who have asthma have at least 1 positive result on allergen skin testing.

Historically, major educational efforts have focused on limiting allergen exposure in the home by controlling the presence of house dust mites, cockroaches, mold, and indoor pets. Ironically, several recent studies suggest that exposure to indoor pets or living in a farming environment in the first year after birth may decrease allergen sensitization and asthma manifestations in later life.

Spirometry and peak flow meters cannot be accurately performed in a child 2 years of age.

References:

Guill MF. Asthma update: epidemiology and pathophysiology. Pediatr Rev. 2004;25(9):299-305.

Link HW. Pediatric asthma in a nutshell. Pediatr Rev. 2014;35(7):287-298.

Optic neuritis represents the same disease process as retrobulbar neuritis, but with visible changes in the optic disc, such as edema and hyperemia of the optic disk. Optic or retrobulbar neuritis usually presents in children, adolescents, or young adults with variable degrees of vision loss, and may be unilateral or bilateral. Papilledema (or, more precisely, papillitis) may be present, but the veins are not engorged and the acute loss of vision helps distinguish this disorder from papilledema due to intracranial hypertension. There may be pain on eye movement or globe palpation.

Primary optic or retrobulbar neuritis is usually self-limited. In children, the condition is usually associated with bacterial meningitis, viral encephalomyelitis, toxins (lead, prolonged high-dose vincristine, or chloramphenicol), disseminated sclerosis, multiple sclerosis, or one of the other demyelinating diseases of childhood.

Reference:

Olitsky SE, Hug D, Plummer LS, et al. Abnormalities of the Optic Nerve. Book Chapter in Nelson Textbook of Pediatrics, 20^th Edition. 2016.

Educational Objective:

Summarize the importance of the pneumococcal vaccine in a child with diabetes mellitus.

Key Point:

A child with T1DM or T2DM is at increased risk of mortality and morbidity from Streptococcus pneumoniae infection, so he or she should receive the pneumococcal vaccine.

Explanation:

People with T1DM or T2DM are susceptible to pneumococcal infection and are at increased risk for the morbidity and mortality of bacteremia caused by Streptococcus pneumoniae infection. According to the ACIP and the AAP, the pneumococcal vaccine is indicated in patients with diabetes to prevent morbidity and mortality associated with the disease. Patients with T1DM or T2DM can present with diabetic ketoacidosis as well as dehydration and significant acidosis if they become infected with S pneumoniae.

A pneumococcal polysaccharide vaccine should be administered to all persons with diabetes older than 2 years of age. A one-time revaccination is recommended for individuals 65 years of age or older if they were previously immunized when they were younger than 65 years of age and if the vaccine was administered more than 5 years ago.

References:

Kliegman R, et al. Diabetes mellitus (chapter 589). In: Kliegman R, et al, eds. Nelson Textbook of Pediatrics. 20th ed., 2016:2760-2790.

Levitsky LL, Misra M. Epidemiology, presentation, and diagnosis of type 1 diabetes mellitus in children and adolescents. Updated June 18, 2018. Accessed July 23, 2018.