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Pediatric Morning Report 4/9

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by

Ryan Heinrick

on 9 May 2014

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Transcript of Pediatric Morning Report 4/9

4 month old previously healthy baby girl presents with vomiting and diarrhea for two days.
History of Present Illness
Pediatric Morning Report 04/09/14
Constitutional:
Normal growth,
no fevers
.
ENT:
No changes in hearing or vision, no oral health issues
Resp:
No stridor, no wheezing, no history of pneumonia
CV:
No abnormal heart rates or rhythms, no history of fainting
GU:
No history of UTI or renal anomalies, normal urinary frequency
MSK:
No joint pains, no swelling, no deformity, no limitation of motion, no fractures
Neuro-Developmental:
Meeting developmental milestones,function
Derm:
No rashes, no breakdown, no sensitivities
Allergy/Immunology:
No sensitivities to foods or environment, no recurrent infections
Genetics:
GDS #1 normal. Unsure if GD2 #2 was obtained.
Heme/Lymph:
No anemias, no easy bruising or bleeding
Review of Systems
Started two days prior to presentation
Started after the NBNB emesis
Described as watery. No blood / mucous
4-5 episodes on day one
>20 episodes on day of admission
Diarrhea
Emesis
Growth Parameters
Vitals
Physical Exam
Physical Exam
Length: 64cm (50th %ile)
Weight: 6.87kg (50th %ile)
HC: 41cm (50th %ile)
Growth Parameters
Vital Signs
General
: Well-developed, well-nourished, non-toxic, Alert, NAD
HEENT
: AT/NC, Eyes, ears, TMs, nose normal.
Dry lips and tachy mucous membranes.
NECK
: Supple, full range of motion.
LYMPH
: No LAD
LUNGS
: CTABL, No W/R/R
CARDIOVASCULAR
:
Tachycardia.
Capillary Refill < 3 sec. No M/R/G
ABDOMEN
: Soft, NT, ND
GU
: Normal
SKIN
: No bruises, no rash
MUSCULOSKELETAL
: Normal limbs, digits, creases, and joints
NEUROLOGIC
: Alert and interactive baseline.
Physical Exam
J. Ryan Heinrick MD
4 month old girl with vomiting and diarrhea
Birth History
Past Medical History
Family History
Social History
Currently in Foster Care
Lives with Foster Father and Mother
16 year old child of foster parents live in house as well
Has been with foster family for 1 week
No pets
No smoking
Social History
Mother with jaundice and polysubstance abuse, found to be HIV positive during second trimester, started on ART:
- ritonavir
- lamuvidine
- zidovudine
- atazanavir

Father also HIV positive.
Family History
Born Full Term
Birth weight ~3500gm
Born via NSVD
AG: 8 / 9
Has never been hospitalized
Birth History / PMHx
Temp
: 37.2 ... 36.8
Pulse
: 162 ... 128
BP
: 149/125 ... 113/62
RR
: 28 ... 20
O2
: 97% ... 98% on Room Air
Audience Participation!
Differential?
Urinary Tract Infection
Sepsis
Meningitis
Bacterial enteritis (Camylobacter jejuni, E. coli, Salmonella, Shigella, Staphlococcus, Yersinia)
Viral enteritis (Rotavirus, Caliciviruses, adenoviruses, astroviruses)
HIV
Infectious
Pyloric Stenosis
Intussusception
Malrotation
Gastroparesis
Anatomic
Started two days prior to presentation
Non bilious, non bloody
3-4 episodes at first
Improved slightly
5-7 episodes on day of admission
Diet: Similac Advance Formula
Other Information
No recent travel
No new foods - just Similac Adv
Patient is in daycare

No Medications

Vaccines are up to date (but no Rota)
Carbohydrate metabolism disorders (Galactosemia, Glycogen Storage Diseases)
Mitochondrial diseases (Pearson Syndrome)
Lysosomal storage diseases (MPS I - Hurler Syndrome)
Amino acid disorders (Argininosuccinic acid lyase deficiency)
Organic acidemies (methylmalonic acidemia, propionic acidemia, isovaleric acidemia, and maple syrup urine disease)
Phenylketonuria
Urea cycle diseases (Ornithine transcarbamylase deficiency)
Metabolic
Milk Protein Induced Enteritis
Non Accidental Trauma
Overfeeding
Gastroesophageal Reflux Disease
Cystic Fibrosis
Antibiotic-associated
Ingestion
Drug Withdrawal
Other Causes
Workup
(Labs & Imaging)

Labs
148
4.1
122
13
19
96
0.6
9.8
Alb 4.4, AST 56, ALT 37
ALP 207, TBili 0.2
9.9
14
41.1
530
39N, 45L, 16M
Cultures and More!
What studies would you like...
AND WHY?
Blood Culture
: NGTD (No growth to date)
Urine Culture:
No Growth (Final)
Stool:
Final culture still pending
Rare (1+) WBC (Polys)
Many (4+) Mixed GI flora
Shiga toxin negative
Campylobacter Ag negative
Cryptosporidium Ag negative
No ova or parasites
Discussion
HIV?
HIV RNA PCR:
Pending
Background
Need for Early Diagnosis
Maternal HIV Status Unknown?
HIV Infected Mother
Diagnostic Tests
HIV
DNA
PCR Testing
HIV
RNA
PCR Testing
Exclusion of HIV Infection
Natural History
Other Testing
Prevention of Maternal-Fetal HIV transmission medication dosing
Incidence worldwide is 2.5 million cases/yr in 2011
12% of infections (330K cases) occurred in children < 15yo
CDC estimates that the number of infants born with HIV each year in the US dropped from 1650 in 1991 to fewer than 200 in the 2000s.
Vertical transmission can occur at any time during gestation and delivery, and through breast milk in the postpartum period
Most transmissions (50 to 80 percent) are believed to occur during the time period near or during delivery
overall rate of perinatal HIV transmission is approximately doubled in populations where breastfeeding is the norm compared with areas where breastfeeding is uncommon among HIV-infected women
High morbidity and mortality if undiagnosed or ART is delayed
Prophylaxis for PJP is recommended in infants infected with HIV.
Serologic testing should be performed
The results of serologic testing, whether of the mother or infant, reflect the HIV status of the mother, not the infant, since it is maternal antibodies to HIV that will be detected
If serologic testing for HIV is positive, testing of the infant should proceed...
If mother received ART and infant is low risk, testing should be performed at 14 to 21 days, one to two months, and four to six months of age.
Serologic tests routinely used in Adults and Children > 18 months
Maternal HIV antibiotics persist for months
One study of 271 children born to HIV infected mothers showed the mean age of loss of maternal antibody was 10.3 months
One child had Ab over 18 months
If mother received ART, HIV viral load may be undetectable even in an infected infant
Qualitative test
Detects HIV proviral DNA within peripheral blood mononuclear cells
Should be positive in patients infected with HIV even while they are being treated with ART
Will not detect very recent infection
Sensitivity: 55% at birth, >90% by DOL 28, 100% at 4-5 months
Specificity: 99.8% at birth, 100% by DOL 28+
Quantitative or qualitative
May better detect HIV infection at birth
Sensitivity and specificity at least as good as DNA testing
May be falsely negative if mother is on ART
Therefore, DNA PCR remains the preferred virologic method for establishing the diagnosis of HIV infection in infants and children younger than the age of 18 months
HIV-1 peripheral blood culture
(expensive, long time to grow in culture, about 4 weeks)
HIV-1 p24 antigen
(poor sensitivity in children < 6 months old)
These tests are not recommended
Definitive exclusion of HIV infection in non-breastfed infants is based on two or more negative virologic tests (one obtained at ≥1 month of age and one at ≥4 months of age)
OR
two negative antibody tests from separate specimens obtained at ≥6 months of age.
Some experts recommend a follow up antibody test at 12 to 18 months of age to document clearance of maternal antibody and confirm the child’s HIV-negative status
CD4+ cells depleted, and children get opportunistic infections
Serious OI: pneumonia, bacteremia, herpes zoster, disseminated MAC, invasive candidal infections
Two basic patterns:
Rapid (20%):
Rapid progression of disease where children reach severe clinical/immunologic stages within first year of life
Slow (80%):
1st year of life shows mild symptoms (LAD, organomegaly, dermatitis, URI, AOM), then progression with clinical detioration by age 5 or 6
6-week course of zidovudine is recommended for all HIV-exposed neonates
zidovudine in combination with nevirapine in certain situations (HIV+ mothers with no antepartum ART, mothers resistant to ART)
Given within 6-12 hours after delivery and continue for the first 6 weeks of life
4 mg/kg/dose every 12 hours for term neonates
lower dosing for pre-term infants
Treatment Dosing
Natural History
CD4+ cells depleted, and children get opportunistic infections
Serious OI: pneumonia, bacteremia, herpes zoster, disseminated MAC, invasive candidal infections
Two basic patterns:
Rapid (20%):
Rapid progression of disease where children reach severe clinical/immunologic stages within first year of life
Slow (80%):
1st year of life shows mild symptoms (LAD, organomegaly, dermatitis, URI, AOM), then progression with clinical detioration by age 5 or 6
2 Nucleoside analog reverse-transcriptase inhibitors (NRTIs):
Zidovudine
AND
(Lamivudine or Emtricitabine)

PLUS

Lopinavir/ritonavir
(protease inhibitor)
http://aidsinfo.nih.gov/contentfiles/lvguidelines/pedarv_tablesonly.pdf
Patient Update
VSS, afebrile, pt was very fussy at beginning of this shift, MD paged to room for assessment. Pt was crying unknown reason, MD order colace to both ears and ear lavage done as order. Tylenol was also order and given, pt was able to relax after tylenol. Foster parents were visiting with pt until 2300. Pt needed stool replacement once. IV bolus order and given. Formula was change to soy, pt tolerating well, no N/V, 2 small loose stools, didn't need replacement. Good urine output. Will keep monitoring.
Questions?
Positive Western Blot Test for HIV at age 4 months old
Full transcript