Pediatric Examination and Board Review (167 page)

(B) suitable for home therapy

(C) systemic allergic reactions occurring in 15% of recipients

(D) ability to deliver relatively large volumes of IG

(E) similar efficacy for prevention of serious infection primary immunodeficiency diseases compared with IGIV

18.
A 13-year-old adolescent female with no prior history of hepatitis B immunization accidentally sticks herself with an insulin syringe that belongs to her uncle who has diabetes but also is known to be an HBsAg-positive person. Appropriate management of the adolescent would include

(A) initiate hepatitis B vaccine series

(B) initiate hepatitis B vaccine series and HBIG 0.06 mL/kg

(C) administer HBIG 0.06 mL/kg

(D) administer IGIV 400 mg/kg and initiate hepatitis B vaccine series

(E) test for HBsAg and anti-HBs antibody

ANSWERS

1.
(A)
Immunocompromised children are candidates for varicella zoster immune globulin (VariZIG) or IGIV if there is no prior history of varicella.

2.
(E)
Past evidence of immunity is not helpful at this point. Immunocompromised patients with no history of varicella and low levels of antibody detected by sensitive antibody assays have developed varicella. Face-to-face contact indoors with a playmate for greater than 1 hour is considered an exposure that should warrant administration of VariZIG or IGIV.

3.
(C)
Susceptible individuals at high risk for developing severe varicella should receive VariZIG or IGIV within 96 hours of exposure.

4.
(D)
VariZIG or IGIV is not indicated if the mother has zoster. In this case the mother has had varicella in the past so the infant should have transplacentally acquired varicella zoster antibody. VariZIG or IGIV would be indicated for a newborn if the mother had developed varicella.

5.
(C)
VariZIG or IGIV would be indicated for the premature infant beyond a 28-week gestation if the mother lacks a reliable history of varicella or serologic evidence of protection. Premature infants (<28 weeks’ gestation or ≤1000 g birthweight) should receive VariZIG or IGIV regardless of maternal history of varicella. The term newborn infant whose mother developed varicella 5 or more days before delivery should have received transplacental antibody from the mother.

6.
(C)
Newborn infants whose mother had onset of varicella within 5 days before delivery or within 48 hours after delivery should receive VariZIG or IGIV. If the onset of the mother’s rash is within 5 days of delivery, the infant has been exposed to maternal viremia in the absence of transplacental varicella antibody. If onset of the mother’s rash is within 48 hours after delivery, the infant may be exposed to maternal viremia without the possible protective effect of transplacental antibody. If mother has onset of rash 3 or more days after delivery, the route of infection will be the respiratory route and not via the bloodstream. VariZIG, IGIV, or acyclovir are all not recommended for this exposure by the American Academy of Pediatrics.

7.
(C)
A 10-day course of tapering steroids would not be considered an immunosuppressive dose, and therefore VariZIG or IGIV is not indicated. Children who receive high doses of corticosteroids (≥2 mg/kg per day of prednisone or its equivalent) given daily or on alternate days for 14 days or more should not receive live-virus vaccines until corticosteroids have been stopped for at least 1 month.

8.
(B)
The cause of these minor reactions may be related to the formation of IgG aggregates during manufacture or storage. Most reactions will subside when the rate of infusion is decreased.

9.
(B)
Patients 65 years or older, patients receiving concomitant nephrotoxic agents, patients with diabetes mellitus, preexisting renal disease, hypovolemia, and sepsis are at increased risk for acute renal failure and renal insufficiency. Most reports of adverse renal events have involved IGIV preparations containing sucrose.

10.
(E)
IGIV is not recommended for routine use in preterm infants with birthweights 1500 g or less to prevent late-onset infection.

11.
(C)
Other indications for IGIV therapy in HIVinfected children include hypogammaglobulinemia (IgG level <400 mg/dL), 2 or more serious bacterial infections (bacteremia, pneumonia, meningitis) in a 1-year period, and failure to form antibodies to common antigens after immunization.

12.
(A)
Anaphylactic reactions are induced by anti-IgA and can occur in children with absence of circulating IgA but have IgG antibodies to IgA. In these situations with IgA deficiency and hypersensitivity reactions, IGIV with extremely low IgA content is available. Screening for IgA deficiency is not routinely recommended.

13.
(C)
Immune globulin can be given to prevent or modify measles in susceptible individuals, particularly children younger than 1 year of age, pregnant women, and immunocompromised children who are household contacts of a person with measles. The dose of 0.5 mL/kg is used for immunocompromised children (
Table 95-1
). Monovalent measles vaccine is seldom available.

14.
(C)
IG can be given to prevent or modify measles in a susceptible person within 6 days of exposure.

15.
(E)
The appropriate management is administration of IG alone. The child is too young for hepatitis A vaccine. Although most infected children in childcare settings are asymptomatic or have nonspecific symptoms, serologic testing is not recommended. Testing adds unnecessary cost and may delay administration of IG.

TABLE 95-1
Indications for the Use of Immune Globulin

Abbreviations: HAV, hepatitis A virus; IGIV, immune globulin intravenous.

16.
(C)
For immunoprophylaxis after exposure to hepatitis A for children younger than 12 months of age, IG should be administered within 2 weeks after exposure to HAV (
Table 95-1
).

17.
(C)
If IG is administered by the subcutaneous route, systemic allergic reactions occur in less than 1% of infusions and local tissue reactions are generally mild.

18.
(B)
In this clinical situation, the prophylaxis is driven primarily by the exposed adolescent not being immunized with hepatitis B vaccine and the source known to be HBsAg positive. If the adolescent was unimmunized and source is unknown or not tested, the recommendation is to initiate the hepatitis B vaccine series alone.

S
UGGESTED
R
EADING

Goldman DC: Passive immunization. In: Long SS, Pickering LK, Prober CG, eds.
Principles and Practices of Infectious Diseases.
3rd ed. Philadelphia, PA: Churchill Livingstone; 2008:41.

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.

CASE 96: A 2-YEAR-OLD AT DAY CARE WITH FEVER, ANOREXIA, AND NAUSEA

A 2-year-old boy is brought to your office with a 4-day history of fever followed by decreased appetite. His mother denies vomiting or diarrhea, but she thinks that he may be nauseated after eating or drinking. She also indicates that his stool pattern has changed. For the past 3 days he has only had 2 stools. The last stool was firm in consistency. The child has attended day care for the past 8 weeks. His immunizations, including PCV-13, a pneumococcal conjugate vaccine, have been documented to be up to date for age with the exception of hepatitis A and B.

On physical examination the child appears to be ill. The temperature is 101.8°F (38.8°C). The child’s weight is 0.1 kg less than when seen approximately 2 months ago for a physical examination before entering day care. There is no rash. The examination of the lungs and heart is normal. There is epigastric fullness and mild right upper quadrant pain upon examination of the abdomen.

SELECT THE ONE BEST ANSWER

1.
The diagnostic test most likely to be helpful in establishing the diagnosis in this child is

(A) serologic test for hepatitis A IgM antibody

(B) stool culture for
Salmonella
,
Shigella
,
Campylobacter

(C) enzyme immunoassay of stool for
Giardia
antigen

(D) serologic test for hepatitis E IgM antibody

(E) stool examination for ova and parasites

2.
Hepatitis A infection is identified in an employee of the day-care center. This is the second outbreak of hepatitis A in the center in the past year. The appropriate management of a 3-year-old child who also attends the day care is

(A) immune globulin 0.02 mL/kg IM

(B) immune globulin 0.06 mL/kg IM

(C) immune globulin 0.02 mL/kg IM and hepatitis A vaccine

(D) hepatitis A vaccine