Pediatric emergency medicine trisk 2319 2319
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The diagnosis is made clinically and confirmed by culture. The laboratory should be notified that diphtheria is
suspected, as the organism has specific culture requirements (cysteine-tellurite blood agar or modified Tinsdale
agar). Treatment involves administration of IV equine antitoxin (after tests for sensitivity to horse serum are
performed, as allergic reactions can be seen in up to 20% of patients) and antibiotics. Antibiotic treatment with
erythromycin (oral or parenteral) or penicillin G IM or IV for 14 days will stop toxin production and prevent
dissemination. Cutaneous lesions should be thoroughly washed with soap and water and treated with antimicrobial
treatment as discussed above. Household contacts and providers, irrespective of their immunization status, should
receive nasopharyngeal cultures and be offered PEP with either oral erythromycin or intramuscular penicillin G.
Persons receiving PEP also should be offered a booster dose of a diphtheria-containing vaccine. Droplet
precautions are recommended for all patients and carriers with pharyngeal diphtheria until nasopharyngeal cultures
collected 24 hours after completing antimicrobial treatment are negative.
Hantavirus
Hantaviruses are members of the Bunyaviridae family and are spread by infected rodents. Two different syndromes
have been reported: hemorrhagic fever with renal syndrome (HFRS) and Hantavirus cardiopulmonary syndrome.
The clinical features of HFRS include fever, hemorrhage, hypotension, and renal failure. The clinical features of
Hantavirus cardiopulmonary syndrome consist of a 2- to 8-day prodrome, and a febrile phase associated with
diffuse interstitial edema with respiratory compromise developing within 72 hours. Patients may develop chills,
headaches, vomiting, myalgia, and diarrhea. Symptoms typically seen with upper respiratory tract infections are
notably absent, except for cough. Laboratory findings include a neutrophilic leukocytosis with bandemia,
thrombocytopenia, and increased hemoglobin. Renal manifestations include proteinuria and hematuria. The
diagnosis is serologic. Treatment is supportive. Mortality rates approaching 40% have been reported for
Hantavirus cardiopulmonary syndrome, whereas death from HFRS is rare. Standard precautions are recommended;
it has not been associated with healthcare transmission or person-to-person infection.
Lymphadenopathy
The differential diagnosis for lymphadenopathy in the returned traveler is broad, and should include both
pathogens endemic to the region of travel as well as infectious agents with a global distribution. Most returned
travelers with infectious adenopathy will have viral etiologies, similar to the epidemiology in children who have
not traveled. However, there are some systemic diseases for which the initial manifestations may be
lymphadenopathy or lymphadenitis. These are summarized below. Filarial diseases, which cause lymphedema, are
discussed separately later in the chapter.
Measles
Measles is caused by a paramyxovirus that is transmitted by droplet and airborne routes. It is one of the most
contagious infectious diseases. Approximately 1 million children per year develop measles globally, with an
estimated 120,000 deaths, primarily in children less than 5 years of age who live in tropical regions. In recent
years, more cases have been seen in industrialized countries due to un- or undervaccinated children. The
incubation period is 8 to 12 days. Transmission is directly from respiratory secretions and cases are infectious only
during the early stages of illness. Children present with fever, upper respiratory tract symptoms, nonpurulent
conjunctivitis, and an erythematous blanchable rash that begins on the head and moves in a cephalocaudal manner.
The presentation can mimic that of Kawasaki disease. Oral lesions (Koplik spots) are transient and not seen in all
children. Acute complications include pneumonitis and meningoencephalitis, and the dreaded delayed
complication is subacute sclerosing panencephalitis (SSPE), associated with irreversible neurocognitive decline
years–decades after the initial infection. The diagnosis is primarily clinical, with confirmatory serologies available.
Treatment is supportive. In developing nations, the use of vitamin A daily for 2 days has been associated with
reductions in morbidity and mortality. Any child with suspected measles should be placed in a negative-pressure
room and airborne precautions taken by providers for 4 days after the onset of rash. Exposed susceptible patients
should be placed on airborne precautions from day 5 after the first exposure until 3 weeks after the last exposure.
Mumps
Mumps is caused by a paramyxovirus transmitted by infected respiratory tract secretions. Humans are the only
known natural host. Mumps occurs worldwide (peaking in the winter), although there has been a significant
reduction in the number of cases in the United States since the introduction of the mumps vaccine in 1977. In
2018, over 2,200 cases were reported in the United States. Approximately 20% are asymptomatic. The incubation
