Pediatric Examination and Board Review (166 page)

Centers for Disease Control and Prevention. In: Atkinson W, Wolfe S, Hambursky J, McIntyre L, eds.
Epidemiology and Prevention of Vaccine-Preventable Diseases
. 11th ed. Washington, DC: Public Health Foundation; 2009.

Pickering LK, Baker CJ, Kimberlin DW, Long SS.
Red Book
2009 Report of the Committee on Infectious Diseases.
28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009.

Pickering LK, Orenstein WA. Active immunization. In: Long SS, Pickering LK, Prober CG, eds.
Principles and Practices of Infectious Diseases.
3rd ed. Philadelphia, PA: Churchill Livingstone: 2008:48.

CASE 95: A 4-YEAR-OLD IMMUNOCOMPROMISED GIRL WITH AN EXPOSURE TO VARICELLA

A 4-year-old girl, whom you have followed in your practice since birth, was recently diagnosed with acute lymphoblastic leukemia (ALL). You had considered the diagnosis after she developed persistent fever, fatigue, back pain, and pallor. She had completed induction chemotherapy and is now in remission. The child’s mother calls your office to inform you she had received a phone call from her daughter’s preschool teacher. Two days ago another child developed a rash and was sent home. That child’s mother called today to inform the teacher that the child was seen by their pediatrician and diagnosed with chickenpox. The teacher then called your patient’s mother to inform her of this.

The preschool class that your patient attends meets Monday through Friday for 4 hours per day. Your patient was present in the class for the 4-hour period on the day that the other child developed the rash. Both children were also present in class on the previous day.

SELECT THE ONE BEST ANSWER TO THE FOLLOWING QUESTIONS

1.
The first step in the management of varicella exposure in a child with leukemia is

(A) obtain a history of whether or not the child has had varicella

(B) administer the varicella vaccine to the child

(C) contact the pediatrician of the preschool classmate to verify the diagnosis of varicella

(D) draw blood for serologic testing on the child with leukemia

(E) determine whether the child is still receiving cancer chemotherapy

2.
The child with leukemia has no history of varicella. It is next important to determine if

(A) the child has developed any other skin lesions

(B) the child has had serologic test results to determine his immune status regarding varicella

(C) the child has laboratory evidence of immunity for varicella

(D) the child has received IGIV in the past 3 weeks

(E) the child and her classmate played together in the same classroom with face-to-face contact

3.
An immunocompromised child who is susceptible to varicella and at high risk for developing severe varicella should receive Varicella-Zoster Immune Globulin (VariZIG) or IGIV within what time period after exposure?

(A) 48 hours

(B) 72 hours

(C) 96 hours

(D) 120 hours

(E) 144 hours

4.
All of the following types of exposure to zoster (shingles) are an indication for VariZIG or IGIV administration to susceptible people at higher risk for developing severe varicella except

(A) residing in one household

(B) face-to-face indoor play

(C) intimate contact (touching or hugging) with a person who has zoster

(D) newborn infant: onset of zoster in the mother 5 days or less before delivery or within 48 hours after delivery

(E) hospitalization in the same 2- to 4-bed room with another child who develops varicella

5.
Candidates for VariZIG or IGIV provided an important exposure to varicella has occurred include

(A) a term newborn infant whose mother developed varicella 7 days before delivery of the infant

(B) a 21-year-old pregnant woman who has a history of varicella at age 5 years

(C) a hospitalized premature infant (<28 weeks’ gestation), regardless of maternal history of varicella or serologic varicella virus serostatus

(D) an 8-year-old girl with asymptomatic HIV infection with a history of varicella at age 2 years

(E) hospitalized premature infant (>28 weeks’ gestation) whose mother has a reliable history of varicella

6.
A healthy term infant is born to a mother who develops varicella 7 days after delivery. Which of the following is true regarding management of this exposure?

(A) the absolute CD4 count and percentage of CD4 cells are high enough to prevent infection

(B) natural killer cell cytotoxicity prevents neonatal infection

(C) the infant is not believed to be high at risk of complicated viremia when varicella zoster is acquired by the respiratory tract

(D) acyclovir should be administered to prevent clinical varicella from occurring in the newborn

(E) varicella vaccine or IGIV is recommended for the young infant

7.
VariZIG or IGIV is indicated in all of the following situations in which clinically important exposure to varicella occurs except

(A) a premature female infant of 25 weeks’ gestation whose mother had a history of varicella during childhood

(B) a 12-month-old girl with acquired immunodeficiency virus (AIDS) and significant immunodeficiency

(C) a 15-year-old boy with asthma who completed 10 days of a tapering course of steroids

(D) a 10-month-old male infant receiving immunosuppressive therapy after renal transplant

(E) a pregnant woman susceptible to varicella

8.
The incidence of minor adverse events associated with the administration of IGIV such as fever, headache, myalgias, chills, and vomiting is primarily related to

(A) the concentration of administered IGIV

(B) the rate of infusion of IGIV

(C) the lot of IGIV administered

(D) the age of the patient receiving IGIV

(E) the number of doses of IGIV administered

9.
An example of an infrequent serious reaction of IGIV therapy includes

(A) aplastic anemia

(B) acute renal failure

(C) HIV transmission

(D) Guillain-Barré syndrome

(E) acute hepatitis

10.
IGIV is recommended for use in all of the following disorders except

(A) a 2-year-old boy with Kawasaki disease

(B) a 3-year-old girl with severe combined immunodeficiency disorder

(C) a 10-year-old boy with common variable immunodeficiency and hypogammaglobulinemia

(D) postexposure varicella prophylaxis where VariZIG is not available

(E) an 800 g premature infant

11.
IGIV is recommended for an HIV-infected child in the following circumstance

(A) one episode of bacteremic pneumococcal pneumonia in the previous 12 months

(B) serum IgG level of 725 mg/dL or less (7.25 g/L)

(C) chronic parvovirus B19 infection

(D) chronic diarrhea caused by cryptosporidium

(E) cryptococcal meningitis

12.
The risk of anaphylaxis is highest with IGIV administration in children with which type of deficiency?

(A) IgA

(B) IgD

(C) IgE

(D) properdin

(E) adenosine deaminase (ADA)

13.
A 10-month-old healthy male infant traveling with his family to Africa was exposed 4 days ago to his 4-year-old native African cousin who was ill at the time with fever, cough, coryza, and conjunctivitis. The 4-year-old cousin was diagnosed with measles as have a number of children in the city where the family is visiting. The mother of the 10-month-old child makes an overseas phone call to your office asking your advice. Appropriate management of the 10-month-old includes

(A) MMR vaccine administration

(B) measurement of serum measles IgG antibody

(C) immune globulin 0.25 mL/kg by the intramuscular (IM) route

(D) immune globulin 0.25 mL/kg by the IV route

(E) monovalent measles vaccine administration

14.
IG can be given to prevent or modify measles in a susceptible person within how many days of exposure?

(A) 1

(B) 4

(C) 6

(D) 10

(E) 14

15.
A 9-month-old child attending day care comes to your office. The child is healthy, but his mother is concerned because another child of 2
¹
/
₂
years who attends the same day-care center was diagnosed with hepatitis A infection about 1 week ago. Appropriate management of the 9-month-old child includes

(A) administer hepatitis A vaccine to the child

(B) administer IG at dose of 0.02 mL/kg IM plus hepatitis A vaccine IM at a different site

(C) measure hepatitis A virus IgM to check for evidence of asymptomatic current infection

(D) measure hepatitis A virus IgG to check for evidence of past infection and immunity

(E) administer IG at dose of 0.02 mL/kg IM

16.
IG for IM administration should be given within what time period after exposure to have more than 85% efficacy in preventing symptomatic hepatitis A infection?

(A) 3 days

(B) 7 days

(C) 14 days

(D) 21 days

(E) 28 days

17.
A major limitation of IG for replacement therapy in antibody deficiency disorders is the need for deep IM injections. An alternative is slow subcutaneous administration of IG. Characteristics of this method of administration include all of following except

(A) less expensive than IGIV