Pediatric emergency medicine trisk 2307 2307
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gastric aspirate) for acidfast culture; additional
cultures if
extrapulmonary TB is
suspected
Ancillary: tuberculin skin
test, interferon gamma
release assay (IGRA),
chest radiograph; check
for HIV
Yellow fever
Serology
Ancillary:
thrombocytopenia,
elevated PT, PTT,
hyperbilirubinemia,
prolonged elevation of
hepatic transaminases
diagnosis is made on Consultation with specialists in pediatric
the basis of (1)
given infrequency of diagnosis in chil
consistent clinical
States
and radiographic
findings, (2)
epidemiologic link
to a source case, (3)
immunologic
evidence of TB
(skin test, IGRA),
and exclusion of
other diagnoses
Serology
Supportive
Patients who received Avoid nonsteroidal anti-inflammatories
yellow fever vaccine
can have an elevated
IgM for several
years; cross-reaction
with other
flaviviruses can be
seen
CDC, Centers for Disease Control and Prevention; PCR, polymerase chain reaction; ELISA, enzyme-linked immunosorbent assay; CSF, cerebrospinal
fluid; EKG, electrocardiogram; TB, tuberculosis; HIV, human immunodeficiency virus; DIC, disseminated intravascular coagulation; G6PD, glucose-6phosphate dehydrogenase; WHO, World Health Organization.
In the next section, six major diseases or syndromes will be reviewed: malaria, tuberculosis, typhoid, dengue,
chikungunya, and diarrheal diseases. Other infections will then be organized based on the primary organ system
involved. HIV will be covered at the end of this chapter.
Malaria
CLINICAL PEARLS AND PITFALLS
Persons returning to their native countries (VFRs) are at particular risk for malaria, since many fail to
take the necessary precautions either to avoid insect exposure or to take prophylaxis.
Malaria should be considered in the differential diagnosis of any febrile child who has returned from a
malaria-endemic region in the preceding month; one negative blood smear should not lead the PEM
provider to rule out malaria.
Chloroquine resistance is widespread, and this drug should not be used as empiric therapy for the ill
child with suspected malaria.
Current Evidence
Malaria is the most important parasitic disease of man with prevalence estimated to be over 200 million with
almost 500,000 deaths each year, most of whom are children. The majority of morbidity and mortality is due to
Plasmodium falciparum. Malaria is endemic throughout tropical regions worldwide; in 2017, 90 countries were
malaria-endemic, and over 3 billion persons were at risk of malaria. The most common species worldwide are
Plasmodium vivax, prevalent on the Indian subcontinent and in Central America, and P. falciparum, prevalent in
Africa and in Papua New Guinea. High-risk regions include sub-Saharan Africa, Papua New Guinea, the Solomon
Islands, and Vanuatu.
Approximately 40% of the reported cases of malaria in the United States are from foreign travelers. Infections
with P. falciparum can progress rapidly, some fatally, and must be considered in the differential diagnosis in all
febrile children who have recently visited an endemic region. Approximately 90% of P. falciparum infections are
acquired in sub-Saharan Africa, and up to 90% of travelers who are infected begin to have symptoms within 1
month after their return. In contrast to P. falciparum infections, travelers infected with P. vivax and Plasmodium
