Académique Documents
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Culture Documents
• Typhoid Fever
• Miliary/Disseminated Tuberculosis
• Urinary Tract Infection
• Malaria
• Septicemia
• Hidden/”Cryptic” abscesses
Hidden Abscess
Differential diagnosis
DIAGNOSIS In favour
Abscess •Fever with no obvious focus of infection
(deep abscesses)
•Tender or fluctuant mass
•Local tenderness or pain
•Specific signs depend on site –
subphrenic, psoas,lung, renal
retroperitoneal
•Follows surgical operations or
manipulation/cumbilical catheterization
Urinary Tract
Infection
Differential Diagnosis
DIAGNOSIS In favour
Urinary tract •CVA or suprapubic tenderness
Infection •Crying on passing urine
•Passing urine more frequently
than usual
•Incontinence in previously
continent child
•White blood cells and/or
bacteria in urine on
microscopy
Signs and Symptoms of UTI in
Different Age Groups
AGE PRESENTATION
Neonate Hypothermia, hyperthermia,
and failure to thrive, vomiting,
infant diarrhea, sepsis, irritability,
lethargy, jaundice, malodorous
urine, crying on urination
DIAGNOSIS In favour
recognized illness
3. Enteric fever
– Typhoid fever (S.typhi)
– Paratyphoid fever (S.paratyphi)
4. Bacteremia without focality and
focal infections such as meningitis,
Symptoms of Typhoid Fever
• Fever - more than 5 days, stepladder
• Headache
• Nausea
• Vomiting
• Abdominal pain and distention
• Diarrhea or Constipation
• Cough,
• Chills
• Myalgia
Signs of Typhoid Fever
• Rose spots: 5-10% of cases
• Abdominal tenderness
• Hepatomegaly or splenomegaly
• Relative bradycardia
• Coated tongue
• Rales or rhonchi
• Epistaxis
• Meningismus
TYPHOID
FEVER
Medical Complications
• Lobar pneumonia - 2nd or 3rd week
• Venous thrombosis
• Hemolytic anemia
• Nephrosis/nephritis
• Meningitis- less than 1 %
• Neuropsychiatric sx e.g. psychosis
• Peripheral neuropathy
• Pharyngitis/parotitis/orchitis
• Myocarditis
Complications
• Secondary to Toxemia:
– Myocarditis
– Hepatic damage
– Bone marrow damage
– Encephalopathy
• Secondary to Local Gastrointestinal
lesions:
– 0.5 % of cases
– Intestinal hemorrhage
– Intestinal perforation
Diagnosis
1. Blood - anemia,leucopenia,
leucocytosis
2. Liver function tests- elevated bilirubin,
transaminase
3. Urinalysis- proteinuria, hematuria
4. Microbiologic studies:
Microbiologic Studies
• Blood culture: 75% positive during 1st
week in patients with no previous
antibiotic intake
• Urine: Positive during first 2 weeks
• Stool culture: 75% positive during 3rd-
4th week
• Bone marrow: positive in >90%, not
influenced by prior antibiotic intake
• Others: Rose spot aspirate or biopsy,
Duodenal String Culture
Approach to Management
First-Line Treatment
Chloramphenicol 3-4 g/d in adults and
50-75 mg/kg/d in children
Cotrimoxazole 320- 480 mg or 8 mg/kg/d
(Trimethoprim) in 2
divided doses
Amoxicillin 4-6 g/d TID in adults and
100 mg/kg/d in children
*Given for 14 days. Defervescence in 3-5
days
Miliary/
Disseminated
Tuberculosis
Differential Diagnosis
DIAGNOSIS In favour
Miliary Tuberculosis •Weight loss
•Anorexia, night sweats
•Systemic upset
•Enlarged liver and/or spleen
•Cough
•Tuberculin test positive or
negative
•Sterile pyuria
CHILDHOOD TB
• DIAGNOSIS
– Epidemiological
– Clinical grounds
– Cultures rarely available
– Tubercle bacilli few in number
– Sputum not obtained in < 6 years
– < 50% (+) in samples
TB in children
• Given
– Unlike adults, the diagnosis of TB in
children is difficult and often based on
epidemiological and/or clinical grounds
and cultures are rarely available
Classification
• TB Exposure (Class I)
• TB Infection (Class II)
• TB Disease (Class III)
• TB Inactive (Class IV)
RECOMMENDATION STATEMENT:
• In the evaluation of a child suspected of having
tuberculosis, a search for a history of exposure to an
adult &/or adolescent who has tuberculosis disease
should be done. (Grade A Level II)
• A negative history of exposure does not rule out
tuberculosis (Grade A Level II)
Evidence-Based CPG on the Diagnosis of
Childhood Tuberculosis
RECOMMENDATION STATEMENT:
The following clinical manifestations, when taken
together, are most suggestive of childhood tuberculosis
disease: history of recent weight loss or failure to
gain weight, cough &/or wheezing for > 2 weeks,
and prolonged unexplained fever (> 2 weeks).
(Grade A Level II)
Evidence-Based CPG on the Diagnosis of
Childhood Tuberculosis
CONSENSUS ISSUES
In addition to the signs and symptoms
enumerated above, failure to respond to
appropriate medications and failure to
regain previous state of health 2 wks after
an infection are also suggestive of
tuberculosis disease.
In the presence of any 3 of the 5 signs
and symptoms, work up for TB disease is
recommended
Evidence based DRAFT on
TREATMENT FOR PULMONARY
Tuberculosis in children
CLINICAL QUESTION 4: What is the optimal drug regimen for
newly diagnosed pulmonary tuberculosis in children?
RECOMMENDATION STATEMENT:
1. For primary pulmonary tuberculosis, the optimal drug regimen is
a 6-month regimen consisting of 3 drugs (HRZ) for 2 months
followed by 2 drugs (HR) for 4 months. If primary drug
resistance is suspected, 4 drugs (HRZS or HRZE) should be
used during the intensive phase. (Grade A, Level 2c)
2. For children with extensive pulmonary disease, including those
with extensive parenchymal lesions, endobronchial tuberculosis,
upper lobe infiltrates, consolidation, cavitation, or extensive
pleural effusion; and for patients > 15 years old, the optimal drug
regimen is a 6-month regimen consisting of 4 drugs (HRZS or
HRZE) for 2 months followed by 2 drugs (HR) for 4 months.
(Grade A, Level 1)
Evidence based DRAFT on
TREATMENT FOR PULMONARY
Tuberculosis in children
CLINICAL QUESTION 4: What is the optimal drug regimen for
newly diagnosed pulmonary tuberculosis in children?
RECOMMENDATION STATEMENT:
3. Drugs may be administered by any of the following methods: (a)
daily during the intensive and continuation phase (b)
intermittent twice- or thrice- weekly during the intensive and
continuation phase; or (c) daily during the intensive phase of
treatment followed by intermittent twice- or thrice-weekly
administration during the continuation phase. (Grade A, Level
1)
4. Antituberculosis drugs given daily may be administered by
family-supervised or health-worker supervised directly observed
therapy (DOT) while drugs administered by intermittent therapy
must be given by health worker-supervised DOT. (Grade A,
Level 2c)
Basis for the Clinical
Impression
• Chronicity of the infection negates more acute
illnesses
• Clinical signs and symptoms fulfill the criteria
• Questionable history of exposure
• Cervical lymphadenopathies
• Hepatomegaly
• Involvement of multiple organ systems
• Non response to appropriate antibiotics
• Failure to regain health after a history of
infection
FINAL DISCLOSURE
• Partial autopsy (w/o head) showed multiple
areas of inflammation and ulcerations in both
small and large intestines. The entire right
ureter was obstructed with caseous material
with both kidneys showing areas of caseation
and inflammation. Likewise, the right adrenal
gland manifested areas of caseation necrosis. 3
granulomatous sites with some caseated foci
were seen in the right hepatic lobe. The lungs
were necrotic with inflammatory exudates and
the pleural cavities with some cheesy materials
and effusion
Thank
You