Pediatrics By Lesson– Infectious Diseases+Immunology

A 3-year-old boy was admitted due to fever and cough over the last 2 days.
Radiological findings are presented in the following x-ray.



Which of the following is the most likely causative agent?

Which of the following is the most common serious bacterial infection in neonates presenting with fever?

A 1-year-old infant is admitted for urinary tract infection and treated accordingly. She had responded to treatment and improved after 48 hours. Renal ultrasound is normal.

Which of the following represents the recommended approach?

A 4-year-old boy presents with a week of purulent lesion under his left ear, which was followed by fever and the finding demonstrated in the attached picture.
Palpation reveals a tender and warm lesion.
Which of the following is the treatment of choice?

A 10-year-old boy is examined in the emergency room due to a short febrile seizure followed by a few episodes of bloody diarrhea. A week earlier his brother and sister suffered from diarrhea. Examination reveals a temperature of 39.5C, poor nutritional condition, and rectal prolapse.Stool smear is demonstrated in the attached picture.
Treatment with intravenous isotonic solution is initiated.

Which of the following is the recommended treatment at this point?

3-year-old boy presents with 2 days of fever and a day of left knee pain. Examination reveals reasonable general condition, a temperature of 39oC, and the finding in the attached picture. Laboratory results are presented in the table.

Which of the following is the recommended treatment?

The finding in the picture is revealed during a neonatal examination. The mother has encountered a febrile illness abroad during the first trimester.
The mother has not received routine immunization and had no prenatal follow up.

Which of the following findings is likely in this newborn, now or further in life?

An 8-year-old girl presents with a 12-day febrile disease, and shortness of breath over the last day. Examination is significant for inspiratory dyspnea, 92% saturation in room air, mild hepatosplenomegaly, and the finding in the attached picture. Laboratory findings include leukocytosis with atypical lymphocytes, a sterile pharyngeal culture, and the findings in the table attached.

Which of the following treatments may improve the girl’s condition now?

A 2-year-old boy presents with speech difficulties. His history is positive for multiple ear infections.
Examination now reveals bilateral turbid ear drums, and middle ear effusion.
The boy is well, calm, and afebrile.

Which of the following is the most appropriate next step?

A 9-months-old baby with atopic dermatitis develops the extensive rash demonstrated in the picture.

Which of the following is the most recommended treatment?

A 2-year-old female presents with a rash appearing 5 hours ago. History is positive for fever up to 39oC over the last 3 days. The mother reports the fever resolved today and then the rash appeared. Examination is positive for a maculopapular rash over the trunk which disappears when compressed

An 8-year-old boy presents with a limp over the last week, with no history of trauma. Over the last two days he has high systemic fever. Examination reveals a temperature of 38.5oC, refusal to bear weight on the right leg, and significant tenderness in external rotation of the right hip. Laboratory results include leukocytosis and elevated inflammatory markers, and ultrasound demonstrates a large quantity of turbid fluid in the right hip joint.

Which of the following is the most likely causative agent?

A 16-year-old girl presents to the clinic with 3 days of worsening throat pain, with no rhinorrhea or cough.

Examination reveals erythema of the pharynx with no exudate, and bilateral cervical lymphadenopathy.

Which of the following is the most appropriate next step?

A 5-year-old boy presents with fever and throat pain for the last 2 days. Examination is positive for enlarged, erythematous tonsils, with bilateral exudate. Which of the following will make a bacterial infection less probable?

A 6-year-old girl with a history of sickle cell anemia presents with fever.
Blood tests reveal significantly decreased hemoglobin and very low reticulocytes.
Which of the following is the most likely causative agent?

A 4-year-old girl presents with 4 days of fever, maculopapular rash, worsening malaise, and dyspnea which appeared on the day of admission. Examination reveals a temperature of 38.3°C, low blood pressure, heart rate of 160/minute, maculopapular rash which disappears with compression, bilateral cervical lymphadenopathy, erythema and hypertrophy of the pharynx with no exudate. Heart rate is fast and regular with gallop and a new murmur, good and equal breath sounds, and a soft abdomen with mild hepatosplenomegaly.

Which of the following is the most appropriate treatment?

A 30-month-old, healthy and vaccinated toddler, presents with high fever, torticollis, dysphagia and drooling. Other vital signs are normal.

Laboratory results reveal elevated inflammatory markers. Cervical CT is attached.

Which of the following is the most appropriate treatment?

An 18-months-old boy presents with fever for two days and left knee pain.Several other infants at his day care had oral lesions and fever two weeks ago.

On examination – appears well, temperature 38.2 oC, swelling and local warmth of the left knee, decreased range of motion. Labs are below:

Which of the following is the most appropriate treatment?

A 3-year-old girl presents with high fever and cough over the last 3 days. Examination reveals decreased breath sounds on the right, and rales over the right lung. Below is her X-ray. High dose amoxicillin was recommended.
On the third day the fever and cough persist, and there is back pain.

Which of the following is the next therapeutic step?

A 13-day-old newborn presents with a rectal temperature of 38.3ºC. She is feeding well, with no vomiting, and has normal bowel movements. Physical examination is normal.

Which of the following is the most recommended workup?

A 30-month-old boy presents with lesions on his hands and feet, with no fever.

The lesions started out as blisters, and then became purulent. Additional lesions appeared after a few days, and he now has some on his face as well.

Which of the following is the most common causative agent of his most likely disease?

15-year-old female is hospitalized due to a one-week history of fever. Initially, she experienced conjunctival erythema, chills, and myalgia. On physical examination, a maculopapular rash is noted. During hospitalization, her symptoms initially resolved but later the fever recurred, accompanied by jaundice and thrombocytopenia. Her history includes a trip to streams in northern areas about three weeks prior to admission. In the second week of hospitalization, a pathogen was identified in her urine
Which pathogen is most likely responsible for her illness?
 

11-years-old male, presents with a fever of up to 38.3°C and a dry cough lasting several days. Later, additional findings developed, as shown in the attached image. A recent blood count revealed new anemia.

Which of the following infections is the likely cause of the disease?

A 9-year-old girl is admitted due to headaches, rhinitis, cough, and fever of over 39°C for 10 days. On examination she is alert and vital, when tilting her head down headaches increase, on auscultation of the lungs there is an equal and good air intake.

What is the most recommended treatment for this patient?

A 15-day-old baby with a fever of 38.2°C. Normal obstetric course, heart rate and blood pressure are normal, no fever-related findings on physical examination. Laboratory test: leukocytes 6000 with normal differential, normal hemoglobin and platelets, normal complete chemistry panel.

Which of the following tests must be performed as part of proper case management?

A six-month-old female is hospitalized in the pediatric intensive care unit for septic shock, her weight is at the 1st percentile, and her head circumference is at the 20th percentile. In the past, repeated hospitalizations due to respiratory infections. On the second day of hospitalization, a result is received of the growth of gram-negative bacteria in blood culture and skin lesions appear as described in the image.

What is the most likely pathogen causing the baby’s illness?

A healthy and vaccinated 10-year-old boy arrives at the clinic due to diarrhea for about two weeks. The frequency of bowel movements – 3-4 times a day, liquid texture without blood or mucus, no fever, reports a mild lack of appetite, no abdominal pain. On examination: normal nutritional status, soft abdomen without hepatosplenomegaly. Microscopic examination of the feces demonstrated the following findings (see image).

What is the recommended treatment?

An 8-month-old female is hospitalized due to a urinary tract infection. At the age of 6 months, she was hospitalized due to pyelonephritis and was treated with antibiotics according to standard practice with a good response. After hospitalization, she underwent an ultrasound of the kidneys and urinary tract with no evidence of pathological findings.

What would be your recommendation for this baby at the end of the current treatment?

A 13-month-old male infant, healthy so far, not vaccinated, was examined in the clinic for fever and rash (image attached). In addition, cough, runny nose, and erythema of the conjunctiva. Later, similar symptoms were diagnosed among ten children of the kindergarten that the child attends. The child’s diagnosis was confirmed by a PCR test in saliva and urine. The baby was hospitalized for pneumonia.

What is the typical complication of his disease?

A normally healthy 7-year-old boy is examined at the clinic for fever and rash. Physical examination demonstrates the findings shown in the attached images. Except for the fever, the child feels well, and vital signs are normal.

What is the most recommended combination treatment in this case?

An 11-year-old boy, healthy until now, arrived due to fever of up to 39°C, weakness, lack of appetite and sore throat. On examination he is alert, tonsils in pharynx are enlarged with redness and exudates, submandibular and cervical lymph nodes are enlarged, sensitive and mobile. On abdominal examination there is impression of mild enlargement of the liver and spleen. Atypical lymphocytes were observed in the blood smear.

What will you expect to see in the serology tests results?

A 17-year-old male patient returned two weeks ago from a trip to Africa. Now suffering from a fever of 39.8°C accompanied by headaches, muscle pains, and chills. On physical examination: prominent pallor, mild hepatosplenomegaly. Laboratory tests demonstrated anemia, thrombocytopenia, and metabolic acidosis. In repeated anamnesis: did not take the medication that was recommended to him before the trip at a travel clinic and even slept in an open area during the trip.

What test is recommended to advance the most likely diagnosis and treatment?

A 5-year-old presents with fever, nuchal pain, apathy, and repeated vomiting beginning on the day of admission. Examination reveals temperature of 39oC, heart rate of 50 bpm, blood pressure of 150/90 mmHg, room air saturation 97%, and compromised consciousness.

Which of the following is the most appropriate management in this case?

An 8-year-old immunized girl presents with axillar swelling (see photo), accompanied with malaise and anorexia. The mother reports there is a kitten at their home for the past month.

Which of the following is the most appropriate treatment?

A 14-year-old generally healthy girl presents with fever, rash, vomiting, diarrhea, and myalgia. Examination reveals an ill appearing girl, temperature is 38.8oC, blood pressure 90/50 mmHg, heart rate 130 bpm, normal saturation, disseminated rash, and strawberry tongue. Laboratory results:

Which of the following is the most appropriate treatment?

An 8-year-old healthy boy presents with fever and a limp. History reveals the family owns a goat farm. He has been treated with antibiotics for a few days with no improvement. Examination reveals a well appearing child, with right calf tenderness, with no erythema or local warmness. There is hepatosplenomegaly.

Which of the following will promote the boy’s diagnosis?

A 9-months old infant was born at a weight of 3000 gr, and now weighs 6000 gr. He has been admitted due to his second episode of pneumonia. Examination is positive for cervical lymphadenopathy and hepatosplenomegaly. Blood work is presented in the table 

Which of the following test will most likely promote the diagnosis?

A 2-year-old generally well boy, who has been treated in the past with inhalations, presents with acute stridor. Examination reveals stridor, as well as good and equal breath sounds.

Which of the following is not an appropriate treatment for his condition?

Which of the following pathogens is associated with congenital sensoneuronal hearing loss?

A 7-year-old girl presents with the ocular finding in the attached picture.

She has no fever, blurred vision, or swelling around the eye.

Denies entry of foreign body or use of creams / makeup

Which of the following is the most recommended initial treatment?

A 17-month-old unimmunized infant, who was born via vaginal delivery, presents with 2 days of rhinorrhea, non-purulent conjunctivitis, fever, cough, and the rash seen in the picture.

Otitis media was diagnosed in the emergency room.

Which of the following describes the required isolation in his condition?

A generally well and immunized 2-year-old boy presents with left cheek pain and fever (see attached picture).

Palpation reveals significant tenderness, with a clear demarcation line between the involved and the healthy skin.

Which of the following is the most likely causative agent?

A 14-year-old well and immunized girl presents with a fever of 40°C, malaise, abdominal pain, diarrhea, and later on throat pain. She is on her 2nd day of menstruation. Examination is positive for heart rate of 180 bpm, blood pressure of 70/40, mild conjunctival erythema, and a sun-burn like disseminated rash.

Laboratory tests reveal elevated liver enzymes and thrombocytopenia of 40,000.

Which of the following therapeutic agent combination is the most appropriate?

An 8-year-old, generally healthy boy, presents with right axillary swelling for 14 days, with no fever, weight loss, or night sweats. Examination reveals tender right axillary swelling with no significant erythema of the skin, and no rash or hepatosplenomegaly. The parents report adopting a kitten a few months back.

Which of the following is the most appropriate recommendation?

A 5-week-old baby, born following a normal pregnancy and delivery, had not had significant postnatal hyperbilirubinemia, and has not been treated with antibiotics or hospitalized. The baby presents with a fever of 38.5°C, and is generally well, with a normal physical examination.

Which of the following will support low risk of a serious bacterial infection?

An 11-year-old generally healthy boy presents to the emergency room due to a fever of 39°C, malaise, anorexia, and throat pain. Upon examination he seems weak, but alert, the tonsils are enlarged, erythematous, and have a purulent discharge, he has submandibular and cervical enlarged and tender lymph nodes, diffuse abdominal tenderness and mild hepatosplenomegaly.

Laboratory results are significant for atypical lymphocytes.

Which of the following do you expect on serologic testing?

A 17-year-old boy, who is having unprotected sex, presents with itching in the urethral meatus.

Examination reveals irritation of the meatal area and purulent discharge.

Which of the following pathogens is the most likely causative agent for his condition?

A 3-year-old female, normally healthy, was discharged about 10 days ago from hospitalization due to pneumonia, treated with intravenous penicillin, referred due to edema and erythema of the hand in the infusion area, accompanied by fever up to 38.7°C, evidence of enlarged lymph nodes and joint pain. What is the best treatment in this case?

A 10-month-old was hospitalized due to a fever and dermatitis. The disease started with rhinorrhea, conjunctivitis, and high fever. The dermatitis is shown in the image.

Which of the following is a common complication of his probable illness?

A 7-year-old male arrives for investigation for right-sided neck swelling that appeared about a week before his presentation. On examination, a rigid lesion in the anterior triangle of the neck, sensitive to touch, without erythema, and mild localized warmth. The child reports redness in the eyes and the appearance of a fever about a week before the appearance of the swelling. In the physical examination, the following finding presented in the image was observed.

Which of the following supports the likely diagnosis?

Which of the following pathogens is associated with congenital sensorineural hearing loss (congenital SNHL)?

A 3-day-old male, after a home birth, undergoing an infectious investigation due to an increase in temperature up to 38.4°C, accompanied by apnea. It should be noted that water broke about 18 hours before the birth, and during the birth, the mother’s temperature was measured at 38°C. Which of the following bacteria is the most likely to have caused the baby’s illness?

A 16-year-old male arrives at the pediatric emergency room unconscious; on initial examination, he responds to pain, a temperature of 38.4°C, and tachycardia. In physical examination, the appearance of individual lesions on the back does not disappear when pressed. Cerebrospinal fluid culture demonstrated gram-negative diplococci growth. For whom of the following prophylactic treatment is recommended?

All of the following patients are recommended antibiotic treatment in the diagnosis of Nontyphoidal Salmonella gastroenteritis except for:

Which of the following is a manifestation/result of congenital CMV infection?

A healthy 6-year-old male, vaccinated according to his age, arrives to the clinic with a fever and a sore throat. It is known that his uncle has PFAPA (Periodic Fever Aphthous Pharyngitis Adenopathy). Upon physical examination, a finding was observed, as shown in the picture.

What will the management of the case include?

Female, 5 years of age, examined due to fever and a runny nose. Due to the persistence of the fever, a blood count was performed which demonstrated mild anemia with reticulocytopenia. Later, a rash appeared as shown in the attached image.

Which of the following constitutes part of the symptoms for her likely condition?

An 11-month-old male is hospitalized in the pediatric intensive care unit due to a fever,
 swollen fontanelle, and vomiting; later, he develops  a rash that is shown in the attached photo.
Gram-negative diplococci were observed on the direct cerebrospinal fluid smear.

Which isolation is recommended on the first day of treatment?

On examination of a baby in the Newborn Nursery Ward, the finding observed in the attached image was observed.

Later, the newborn was diagnosed with a Congenital infection.

What is the likely cause of his condition?

Female, 8 years of age, healthy up until now. Arrived to the clinic due to swelling in the right armpit over the past two weeks. Upon examination, tenderness upon palpation, swelling with slight redness, no impression of a skin infection. There are 3 cats at home, she often plays with them. 2 small papules were observed in the forearm area.

What is the recommended treatment for her probable condition?

A male, 7 weeks old, presents with a fever of 38.3°C. Normal gestation and delivery. Upon examination, he appears to be in good general condition, with no notable findings in the physical examination. All the following findings support a high risk for a serious bacterial infection in the baby except for:

A male, 4 years of age, recently completed a treatment course with Moxypen for secretory otitis media. About one day after completing the antibiotic treatment, he began to suffer from a sub-febrile temperature, headache, and fatigue. In the past day, there has been a significant worsening of the headache, with vomiting and a focal seizure. Computerized Tomography (CT) of the brain demonstrates the following finding:

Which of the following pathogens is most common in the context of the most probable diagnosis of the child?

A two and a half-year-old boy has been complaining of back pain for a week. His parents note that he refrains from walking, refuses to sit down, no fever. Physical examination – increased back muscle tone (paraspinal spasm) and limitation in spinal mobility. The collected blood tests are presented in the table. No anormal findings were seen in a spine X-ray.

Which of the following tests is the most diagnostic and sensitive to promote the diagnosis?

A 13-year-old generally well girl is referred to the emergency room for workup of malaise, recurrent episodes of fever, weight loss, arthralgia, and abdominal pain. History reveals exposure to non-pasteurized milk products.
Which of the following is the most likely clinical finding?

A two-year-old toddler was referred to the ER due to stridor. Has had rhinitis and fever for the past 3 days. Attached is a neck X-ray with the finding marked (with an arrow).

Which of the following pathogens is common for his likely diagnosis?

A 10-year-old boy was hospitalized due to fever with several diarrhea episodes, the diarrhea is with blood. PCR contains evidence for Salmonella enterica (nontyphoidal). The baby is in good general condition, eats well, no signs of dehydration.
What is correct regarding the management of this case?

A full-term newborn with a birth weight of 1900 grams and a head circumference below the 3rd percentile is under investigation. A brain ultrasound reveals periventricular calcifications. His diagnosis was performed via a PCR of a pathogen in the urine.

What is the most common complication for his likely diagnosis?

A 6-year-old male, healthy and vaccinated, presents to the clinic with a fever and sore throat. On physical examination, the following was found, as shown in the image.

What is the recommended management of the case?

Male, 6 years of age, woke up at the night with stridor that worsens with crying. Upon examination – inspiratory stridor. No respiratory distress. Normal vital signs. Upon auscultation of the lungs – no abnormal findings.

What is the next recommended step in the treatment process?

A 2-month-old male, healthy until now, has been suffering from a cough and breathing difficulties for the past 3 days.

Upon examination: tachypnea and intercostal retractions. Upon auscultation of the lungs – bilateral diffuse crackles.

What is the most recommended reasonable treatment in this case?

An 18-month-old baby girl arrives at the pediatric ER due to a fever for 3 days accompanied by restlessness. Physical examination demonstrates the findings shown in the attached images.

Which of the following steps must be included in case management?

A 7-year-old boy arrives for evaluation due to complaints of a persistent cough. His medical history is positive for several cases of pneumonia and repeated episodes of excretory ear infections. As part of the investigation of chronic cough, a chest X-ray demonstrates the observed finding (see X-ray).

What additional finding would most likely support the diagnosis?

A 13-year-old boy is hospitalized due to prolonged fever, weakness, and myalgia. The physical examination reveals a new murmur on auscultation to the heart and an enlarged spleen is palpated. Later, lesions appeared as seen in the attached images. Blood cultures positive.

What is the common pathogen that causes this condition?

A 7-year-old male, partially vaccinated, was brought to the ER due to dysphagia, afebrile, odynophagia, and dysphonia. On examination, significant bilateral neck swelling and the findings are presented in the image (below) in the mouth and pharynx.

Which of the following vaccines could have prevented this disease?

A child presents to the emergency room with a barking cough beginning acutely
in the middle of the night. Breath sounds and oxygen saturation are normal.
Upper airway X-ray is attached. His condition is relieved by a budesonide inhalation.

Which of the following is the most likely pathogen causing his condition?

Which of the following is an absolute contraindication for physical activity?

A 5-year-old generally healthy boy presents with fever, rhinorrhea, cough, and myalgia over the last 2 days. Examination reveals reactive lymphadenopathy without any other abnormalities.

Blood work is presented in the table.

Which of the following is the most appropriate diagnostic step?

A 5-months-old generally well infant who is fed with milk substitutes, has two smoking parents, and a paternal history of asthma. He presents to the emergency room with two days of fever, cough and rhinorrhea, with difficulty in feeding. His oxygen saturation is 91% in room air, he is dyspneic and breathes 40 breaths per minute, and auscultation reveals

slight rales over both lungs.

Which of the following treatments, in addition to supplementary oxygen, is most appropriate for this patient?

A child is diagnosed with atopic dermatitis. He is referred for examination due to the rash in the photos.

Which of the following is the most appropriate treatment?

A 7-months-old infant presents with high fever, watery diarrhea, some containing mucus and some blood, and decreased appetite. He is generally well on examination. Stool culture reveals salmonella.

Which of the following is the most appropriate treatment?

 A 2-year-old generally well boy, who has been treated in the past with inhalations, presents with acute stridor.
Examination reveals stridor, as well as good and equal breath sounds.

Which of the following is not an appropriate treatment for his condition?

A 1-year-old boy with recurrent pneumonia due to Streptococcus Pneumonia infection. Underlying atopic dermatitis, significant hemorrhage following circumcision and also several dermal infections. The collected blood tests are described in the table below:

What is the most reasonable recommended treatment in this case?

An 18-month-old boy, history of several otitis events, diarrhea due to Cryptosporidium infection and skin warts (verruca vulgaris). Investigation found a normal number of B cells, normal number of T cells, and a normal lymphocyte reaction to mitogen, but a low number of B CD27 cells.
Which of the following tests will most likely promote his diagnosis?

A 1-year-old boy that for the past two months has had recurring events of high-grade fever accompanied by abdominal pains, vomiting and diarrhea. The episodes last about 5 days. The parents are healthy, born in Finland. The child has come in now with another episode. Physical examination: lymph nodes enlargement and also the findings described in the photos (please refer to the finding in the first photo even though the leg does not belong to a 1-year-old boy).

What is the most likely diagnosis?

A 5-year-old girl arrives for evaluation due to an enlarged cervical lymph node she has had for the past 7 months. A neck US demonstrates no signs of malignancy; there have been recurrent incidents of enlarged lymph nodes in the past, and she is known to suffer from anemia that does not respond to treatment with iron. On physical examinations over the years, there is evidence of an enlarged liver and spleen.

Blood tests are as described in the table:

Which of the following complications is likely to occur in her condition?

Which of the following patients is suspected of being immunodeficient?

An 8-year-old with known epilepsy for about 2 months. Presents with an itching rash and fever of 38°C.

He has been treated for seizures with lamotrigine (lamictal) over the last 4 weeks, with a good response. Examination reveals the rash seen in the picture, erythema in the pharynx, and enlarged cervical lymph nodes.

Laboratory tests are positive for elevated liver enzymes and eosinophilia of 700.

Which of the following steps is correct in managing this patient?

A 4-year-old boy is evaluated for repeat dyspnea episodes, abdominal pain, vomiting, and diarrhea. He has swelling and non-pitting edema around his ankles. There is no erythema, rash, or systemic fever. These episodes last for 2-3 days and spontaneously resolve.

Which of the following is the most appropriate treatment?

A 16-year-old male was referred due to suspected immunodeficiency after two episodes of Neisseria meningitidis meningitis, with no additional infections. Development, physical examination, and immunoglobulin levels are normal.

Which of the following tests will promote diagnosis?

A 2-year-old male was referred for workup of failure to thrive and recurrent respiratory infections. Complete blood count including differential are normal. All types of immunoglobulins are low, there are low immunoglobulins in response to vaccination, and CD19 levels are <1% of lymphocyte count. Sweat test is normal.

Which of the following is typical in the toddler’s most likely diagnosis?

A 3-year-old male is under follow-up due to ataxic gait, two prior pneumonias, and abnormal eye findings (image attached).

Which test should be avoided during further evaluation?

A 16-year-old girl presents with facial swelling and shortness of breath which appeared the same morning, and had become worse over the last hours. Her history is positive for a few events of facial swelling that resolved spontaneously. Examination reveals findings in the attached pictures, heart rate of 125/min, respiratory rate of 25 breaths/min, blood pressure 110/75, saturation of 96% in room air, and non-pitting edema of the face, tongue, oral mucosa, and larynx.

Which of the following is the most likely finding in her blood work?