Pediatric Examination and Board Review (179 page)

19.
(A)
In children, the most common presentation of invasive pulmonary aspergillosis occurs in the setting of fever and neutropenia without any initial respiratory tract symptoms, and there is a failure to respond to broad-spectrum antibacterial therapy. Bacterial pathogens, especially
S pneumoniae
and
H influenzae
, most commonly are the etiologic agents of pneumonia in patients with common variable immunodeficiency.

S
UGGESTED
R
EADING

Aggarwal M, Rein J. Acute human immunodeficiency virus syndrome in an adolescent.
Pediatrics.
2003:112: e323.

Goldman AS. Back to basics: host responses to infection.
Pediatr Rev.
2000;21:342-349.

Shetty AK, Maldanado YA. Epidemiology and prevention of HIV infection in children and adolescents. In: Long SS, Pickering LK, Prober CG, eds.
Principles and Practices of Infectious Diseases.
3rd ed. Philadelphia, PA: Churchill Livingstone; 2008:641.

CASE 102: A 2-WEEK-OLD WITH FEVER, RASH, AND A SEIZURE

A 3000-g infant was born at 40 weeks’ gestation to a 24-year-old G1P1 white woman by normal spontaneous vaginal delivery. The infant was discharged in 2 days, and mother was breast-feeding the infant without difficulty. An office visit in the first week of life revealed that the infant was afebrile, breast-feeding well, and back to birthweight.

At 2 weeks of age the mother noticed that the infant was not breast-feeding as well. This continued for 24 hours when the mother measured the infant’s temperature at 101.1°F (38.4°C). The mother called you, and you advised her to bring the infant directly to the pediatric emergency department.

On physical examination at the emergency department, the infant is found to be sleepy but arousable. The temperature is 100.7°F (38.2°C). The infant has two papulovesicular lesions on the right arm. The oropharynx and eye examination are normal. Examination of the lungs and heart also are normal. There are no focal neurologic deficits.

SELECT THE ONE BEST ANSWER

1.
The most accurate statement regarding neonatal HSV with disease localized to the skin, eyes, and mouth (SEM) is

(A) if untreated, 20% of neonates progress to disseminated or CNS disease

(B) most neonates infected with HSV in the perinatal period are born to women who are completely asymptomatic for genital HSV infection during pregnancy and at delivery

(C) women who have recurrent HSV genital infection cannot transmit the virus by an ascending infection from the genital tract

(D) treatment of a neonate with an SEM presentation includes acyclovir at a dose of 10 mg/kg every 8 hours IV for 10 days

(E) the recommended duration of treatment for HSV SEM disease is the same as for CNS disease

2.
The risk of HSV infection in a neonate varies based on the type of HSV infection in the mother. The risk of neonatal infection in primary versus recurrent HSV infection in the mother is

(A) 50% versus 8%

(B) 50% versus 10%

(C) 25% versus 2%

(D) 25% versus 20%

(E) 25% versus 10%

3.
You suspect congenital CMV infection in a term newborn infant with bilateral sensorineural hearing loss. Vertical transmission of CMV to an infant occurs by all except one of the following methods

(A) transplacental passage of blood-borne virus

(B) at delivery by exposure to virus in the maternal genital tract after maternal primary infection

(C) at delivery by exposure to virus in the maternal genital tract after reactivation of infection during pregnancy

(D) by ingestion of breast milk in the postnatal period

(E) asymptomatic oral shedding of CMV in postnatal period

4.
In healthy children and adolescents, infectious mononucleosis is a self-limited disease. However, some children can develop serious complications from EBV. The most likely disorder associated with complicated EBV infection is

(A) primary immunodeficiency involving T lymphocytes

(B) primary immunodeficiency involving B lymphocytes

(C) primary immunodeficiency involving phagocytes

(D) primary immunodeficiency involving complement

(E) secondary immunodeficiency involving B lymphocytes

5.
A 5-year-old boy with ALL develops fever of 102.2°F (39°C) and a vesicular rash involving the face, trunk, extremities, palms, and soles. Some of the vesicular lesions are deep-seated with surrounding erythema. You suspect hemorrhagic varicella, which is confirmed by DFA staining of the skin lesions. The most common life-threatening complication of varicella in immunocompromised children is

(A) encephalitis

(B) hepatitis

(C) pneumonia

(D) necrotizing fasciitis

(E) secondary bacterial infection with group A streptococcus

6.
An 8-month-old male infant who recently came to the United States with his family from Mexico presents to your office with a 4-day history of fever associated cough, coryza, and conjunctivitis. On the third day of illness, a maculopapular rash began along the hairline and spread to involve the face, neck, trunk, and extremities. You strongly suspect the diagnosis of measles. The complication that causes the most morbidity in young children with this disease is

(A) encephalitis

(B) hemorrhagic shock

(C) pneumonia

(D) myocarditis

(E) hepatitis

7.
An 8-year-old girl develops fever of 102°F (38.8°C), bilateral swelling of the parotid glands, and headache. You suspect mumps. The most likely complication of mumps is

(A) pancreatitis

(B) meningitis

(C) sensorineural hearing loss

(D) myocarditis

(E) glomerulonephritis

8.
A 17-year-old adolescent female in her junior year of high school develops a low-grade fever of 101°F (38.3°C), a maculopapular rash that first appears on the face, and suboccipital/postauricular lymphadenopathy. You suspect rubella and confirm the diagnosis by serology. Serologic surveys of young adults indicating the percentage that are susceptible to rubella are

(A) 3%

(B) 5%

(C) 10%

(D) 15%

(E) 25%

9.
A 4-year-old boy with sickle cell disease (homozygous hemoglobin SS disease) develops mild fever of 100.5°F (38°C) associated with fatigue for 2 days. On physical examination he is noted to have pallor. Laboratory results reveal a WBC count of 6800/mm
³
, hemoglobin 5.4 g/dL; the reticulocyte count is 0.7%; and the platelet count is 150,000/mm
³
. The most likely etiology of the severe anemia in this child is

(A) parvovirus B19

(B) human herpes virus type VI

(C) human herpes virus type VIII

(D) coxsackie virus A16

(E) adenovirus

10.
A 13-month-old infant boy has mild nasal congestion and eyelid edema associated with erythema of the palpebral conjunctiva for 1 day. He then develops fever of 104°F (30°C) associated on the same day with a 5- to 10-minute generalized tonic-clonic seizure. The child’s parents bring him to the emergency department. After an observation period, the temperature decreased to 101°F (38.3°C) and he is alert and consolable. The most likely etiology of the seizure is

(A) adenovirus

(B) RSV

(C) influenza A

(D)
Shigella sonnei
(E) HHV-6

11.
A 15-month-old boy is evaluated for recurrent bacterial infections (one episode of culture-proven pneumonia caused by
S pneumoniae
and one episode of septic arthritis caused by
S aureus
). On physical examination the infant is afebrile; the weight is at the 5th percentile for age, and he has hepatosplenomegaly and generalized lymphadenopathy. The most likely etiology to explain these findings is

(A) Epstein-Barr virus

(B) HIV

(C) CMV

(D)
Histoplasma capsulatum
infection

(E) adenovirus

12.
Enteroviruses often cause a nonspecific febrile illness in young children but can also cause exanthems. All of the following exanthems have been reported to be caused by the nonpolio enteroviruses except

(A) papular-purpuric rash in a glove-and-stocking distribution

(B) papulovesicular rash

(C) papular urticaria

(D) petechial rash

(E) maculopapular rash