Pediatric emergency medicine trisk 2270 2270
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HSV disease. The most severe disease typically occurs in children who never develop a vesicular rash, as the
diagnosis often is delayed in these children. As such, the absence of a rash should not lead the clinician to
eliminate HSV from the differential diagnosis.
Triage considerations: Febrile and hypothermic neonates should be evaluated promptly for HSV in addition to
bacterial infections. The clinician’s index of suspicion for HSV should be increased in the following
circumstances: vesicles; seizures or abnormal neurologic examination; CSF pleocytosis; or evidence of hepatic
dysfunction, including coagulopathy.
Clinical assessment: The diagnosis is confirmed by isolation of HSV via culture or polymerase chain reaction
(PCR). Surface cultures should be obtained from the conjunctivae, nose, mouth, and anus (even if there are no
obvious vesicles in these locations), in addition to cultures being obtained from vesicles. In the latter instance, the
swabs should be rubbed against the base of the vesicle, as opposed to aspirating fluid from the vesicle itself. HSV
PCR of the CSF is more sensitive (97% to 100%) than viral culture of the CSF, but the sensitivity is lower early in
the disease process. As such, a negative HSV CSF PCR does not rule out CNS involvement. If the index of
suspicion for HSV disease is high, it is reasonable to repeat PCR testing prior to stopping therapy. PCR (qualitative
or quantitative) can also be obtained from the blood; this is of particular utility in children who are coagulopathic
or have other clinical features which make LP difficult. HSV serologies are not useful in the acute setting. In
addition to routine laboratory evaluation and cultures, ALT, prothrombin time, and partial thromboplastin time
should be obtained. Obtaining a serum glucose is also useful, as hepatic dysfunction can result in an inability to
mobilize glycogen stores and result in hypoglycemia.
Management: Neonates with suspected HSV should receive parenteral acyclovir (20 mg/kg every 8 hours).
Children in whom ocular disease is present should be promptly evaluated by an ophthalmologist and receive
topical antiviral therapy, such as 1% trifluridine (one drop every 6 hours) to the affected eye(s), in addition to
parenteral acyclovir. Neonates, especially those with disseminated disease, are likely to require blood products and
fresh frozen plasma to treat coagulopathy. Many of the considerations noted in the section on bacterial meningitis
also are applicable for HSV meningoencephalitis. Standard and contact precautions (if vesicles are present) should
be used for children with suspected HSV disease.
Meningitis, Aseptic
Both infectious and noninfectious processes can produce aseptic meningitis ( Table 94.9 ). The most common
cause is viral meningitis. In Lyme-endemic regions, clinicians should also suspect Borrelia burgdorferi as a cause
of aseptic meningitis. The signs and symptoms of aseptic meningitis mimic those of acute bacterial meningitis, but
alterations in level of consciousness or focal neurologic deficits are rarer than in bacterial meningitis. Initial
laboratory evaluation should parallel that described for bacterial meningitis. Enteroviral PCR should be sent on the
initial CSF. Ill-appearing children or infants in the first 1 to 2 months of life should have HSV PCR on the CSF
and serum sent as well (see HSV meningoencephalitis section) and acyclovir (20 mg/kg every 8 hours for children
0 to 3 months; 15 mg/kg every 8 hours for children >3 months of age) should be initiated. Most patients need no
further tests, but in atypical situations, consideration should always be given to nonviral causes that may mandate
additional diagnostic steps or specific therapy. If tuberculosis is suspected based on family contacts, high CSF
protein, a low CSF glucose with lymphocytic predominance, or abnormal chest radiography, then a Mantoux
tuberculin skin test (TST), and an interferon gamma release assay should be obtained. In endemic areas, serologic
studies for Lyme disease and antibiotic therapy may be indicated based upon the exposure history and time of year.
A CT scan provides essential information about patients with symptoms or signs of parameningeal infection, HSV
encephalitis, or CNS tumors and hemorrhages. Immunosuppressed patients develop infections with a wide variety
of unusual bacteria, fungi, and parasites that can be identified in many cases with appropriate examination and
culture of the CSF (e.g., India ink and acid-fast stains, cryptococcal antigen testing, fungal and mycobacterial
cultures).
