self-assessment

SELF-ASSESSMENT

PAE

Self-assessment

Questions

Case 1

Case 2

An 18-month-old Caucasian boy presented with a 10-day

history of fever, poor appetite and lethargy. On examina-
A 15-year-old boy presented with a 48-hour history of severe
central abdominal pain and non-bilious vomiting. Over the

previous 4 months he had experienced similar short-lived

episodes. He had lost 3 kg in weight. On examination his

heart rate was 130/minute and he was diaphoretic but apyr-

exial; his abdomen was rigid with involuntary guarding in the

epigastric region. Investigations revealed the following:

Hb: 12.7 g/dL

WCC: 11.9 � 109/L

Platelets: 258 � 109/L

CRP: <10 mg/L

Urea: 5.5 mmol/L

Creatinine: 126 mmol/L

Na: 140 mmol/L

K: 4.0 mmol/L

Amylase: 918 U/L (0e100)

The patient was diagnosed with acute pancreatitis.

1 What is the most common underlying cause of pancre-

atitis in this age-group? Choose ONE answer.

A Alcohol binging

B Gallstones

C Blunt abdominal trauma

D Mumps

E Cystic fibrosis

The boy denied any history of trauma or alcohol and

subsequent investigations revealed total calcium of 4.59

mmol/L (2.12e2.46). The parathyroid hormone was 49.9

pmol/L (1.4e6.2)with normal phosphate and vitaminD level.

2 Which investigation would aid diagnosis of the under-

lying pathology? Choose ONE option.

A Chest X-ray

B Tumour markers (LDH, AFP, beta-HCG)

C Urine calcium:creatinine ratio

D TFTs, gut hormone profile, urinary catecholamines

E Ultrasound of the neck followed by 99mTc imaging

3 Which of the following takes priority in this patient’

management? Select ONE answer.

A IV Fluids

B IV frusemide

C IV pamidronate

D Proton pump inhibitor

E Surgical resection

Kristina Marshall MB BChir BA Cantab is a Paediatric ST1 at Peter-

borough City Hospital, Peterborough, UK. Conflicts of interest: none

declared.

Amitabh Gite DNB DCH MRCPCH is a Paediatric ST8 at Peterborough City

Hospital, Peterborough, UK. Conflicts of interest: none declared.

DIATRICS AND CHILD HEALTH 23:10 456

tion, he looked unwell and his tonsils were inflamed. A

small patch of redness and swelling was noted over the

right ankle and, on direct questioning, his mother reported

his reluctance to mobilize in the previous 24 hours.

1 Choose the most important first line investigations?

Choose FIVE options.

A FBC and blood film

B U þ E and LFTs

C CRP and ESR

D Urine dip and culture

E Blood culture

F ASOT

G Throat swab

H X-ray ankle

I MRI ankle under GA

Blood tests revealed a normal FBC, CRP 263 mg/L and

ESR 50 mm/hour. An X-ray of the ankle was normal.

2 What is the most likely diagnosis? Choose ONE option.

A Reactive arthritis

B Bacterial tonsillitis

C Septic arthritis

D Cellulitis

E Kawasaki disease

The boy was admitted and treated with 5 days of IV

ceftriaxone and flucloxacillin. An MRI of the foot suggested

osteomyelitis of the right calcaneum. Exploration under

anaesthesia returned scanty blood-stained aspirates from

the bone. No organisms were grown from these samples, or

from blood cultures on admission.

Despite a further 5 days of IV antibiotics, he continued to

spike temperatures and his mother reported a high-pitched

cry during nappy changes. On re-examination, the ankle

swelling had resolved. However, there was significant

distress on external rotation of both hips.

3 Which is the most likely diagnosis at this stage? Choose

ONE answer.

A Reactive arthritis

B Oligoarticular juvenile idiopathic arthritis

C Haematological malignancy

D Immunodeficiency

E Tuberculosis

Case 3

A 5-week-old boy presented with a 24-hour history of fever

and irritability to A&E. He was born at term born by normal

vaginal delivery and his mother had developed a fever

shortly after delivery. On examination, the baby was hy-

potonic and poorly responsive with mottled skin and cool

peripheries. His anterior fontanelle was full on palpation.

� 2013 Elsevier Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.paed.2013.07.005

SELF-ASSESSMENT

His heart rate was 200/minute, respiratory rate 86/minute

and capillary refill time was 4 seconds.

1 You are the A&E SHO. What first line management steps

will you take? Choose five options.

A High flow oxygen

B Intubate and ventilate

C CPAP

D Blood culture

E IV access

F Cranial ultrasound

G Suprapubic aspirate urine

H Bolus 20 ml/kg 0.9% saline

I IV mannitol

J IV cefotaxime and amoxicillin

K Weight measurement

L CT head

The initial investigations revealed a CRP of 25 mg/L and

neutropaenia (0.9 � 109/L). When the baby had been sta-

bilized, a lumbar puncture was performed:

White blood cells: 248/mL

Red blood cells: 6/mL

Polymorphs: 90%

Lymphocytes: 10%

Inspite of IV antibiotics, on day 6, the baby continued

to spike fevers, and remained irritable with a bulging

fontanelle. He developed left-sided focal seizures which

were controlled with a loading dose of phenobarbitone.

His CRP had risen to 136 mg/L. Blood cultures and

CSF cultures on admission had grown Group B beta-

haemolytic streptococcus sensitive to penicillin and

clarythromycin.

2 What is the most likely explanation for the baby’s sei-

zures? Select ONE answer.

A Hydrocephalus

B Subdural effusion/empyema

C Electrolyte or blood glucose abnormality

D Venous sinus thrombosis

3 An MRI head (Figure 1) was performed under general

anaesthesia. What does it show? Select ONE answer.

Figure 1 MRI head day 6 of admission.

PAEDIATRICS AND CHILD HEALTH 23:10 457

A Subdural effusion

B Infarction

C Subdural haemorrhage

D Cerebral oedema

E Meningeal inflammation

Case 4

A term neonate presented having developed grunting at 8

hours of age. He was born by normal vaginal delivery and

therewere no risk factors for perinatal sepsis. No resuscitation

was requiredat birth.Onexaminationhehada respiratory rate

of 62/minute, heart rate of 170/minute and oxygen saturation

of 97% in air. Thereweremild subcostal recessionswith equal

air entry bilaterally. The heart soundswere louder on the right

side of the chest and no murmur was heard.

The baby was admitted to SCBU, a chest X-ray (Figure 2)

and partial septic screen was performed:

C-reactive protein: 25 mg/L

Haemoglobin: 14.7 g/L

White cell count: 14.5 � 109/L

Platelets: 289 � 109/L

1 What is the most likely diagnosis?

A Left lower lobe consolidation

B Left-sided congenital diaphragmatic hernia

C Left-sided tension pneumothorax

D Congenital cystic adenomatous malformation

E Dextrocardia

2 In addition to commencing antibiotics, which of the

following management options would you consider

next? Choose ONE option.

A Echocardiogram

B CT thorax

C Needle thoracocentesis and chest drain insertion

D Nasogastric tube insertion on free drainage, paren-

teral nutrition

E Bronchoscopy

3 Match the following structures to the labels in Figure 3.

A Lingula

B Heart

Figure 2 Supine AP chest X-ray on day 1 of life.



Figure 3 CT thorax slice at level of T9.

SELF-ASSESSMENT

C Right lower lobe

D Left upper lobe

E Solid cystic portion

F Air-filled cystic portion

Answers

Case 1

1 C

2 E

3 A

Pancreatitis is rare in paediatrics. The common causes

of acute pancreatitis are blunt abdominal trauma and infec-

tion (mumps, coxsackie B) as our case had a 4 month history

these two etiologies were unlikely. Metabolic abnormalities

(hypertriglyceridemia, hypercalcaemia) and cystic fibrosis

were important differential diagnosis. Other causes of

hypercalcaemia are unlikely because hypercalcaemia in

malignancy is due to bone resorption resulting in a very low

PTH level. Familial hypocalciuric hypercalcaemia, is a rela-

tively benign condition and rarely causes symptoms or

complications. This patient had an elevated serum calcium

concentration which, coupled with a high PTH is suggestive

of hyperparathyroidism. A cystic lesion was detected on ul-

trasound of the neck and confirmed on 99mTc imaging.

Following excision, histology confirmed a diagnosis of

parathyroid adenoma. Ultrasound has a 90% detection rate

but 99mTc imaging may be required for small or mediastinal

adenomas. Pancreatitis retains a high morbidity and mor-

tality in the paediatric population. A rise in CRPmay indicate

formation of pancreatic pseudocyst which is a known

complication of pancreatitis. Adequate fluid hydration using

0.9% saline at an initial rate of 2e3 L/m2 with careful fluid

balance, renal function and electrolyte monitoring is the

mainstay of treatment for both pancreatitis and hyper-

calcaemia. There is limited evidence for the use of

loop diuretics in the treatment for hypercalcaemia. IV

bisphosphonates such as pamidronate have been used safely

in children. Definitive treatment is to remove the underlying

cause with parathyroidectomy.


Case 2

1 A, C, E, G, H

2 C

3 A

MRI spine and hips revealed septic arthritis of both hip joints

withmyositis andmultifocal abscesses in the rectusmuscles.

A small volume (5ml) of blood-stained puswas aspirated but

exhibited no bacterial growth. Acid fast staining and myco-

bacterial cultures were negative. Intra-operative and histo-

logical findings reported limited joint destruction with no

evidence of caseation. His inflammatory markers returned to

normal andhe remained apyrexial after 2weeks of treatment.

The toddler was treatedwith a total of 6 weeks IV ceftriaxone

and clindamycin. Septic arthritis affecting multiple joints

occurs in 10% of paediatric cases and should prompt inves-

tigation for an unusual organism or immune deficiency. The

presence of sterile cultures cannot rule out infection, espe-

cially when samples are obtained after commencing antibi-

otics. Although JIA may be considered in this case due to

multiple joint involvement, the acute onset, absence of

systemic features, presence of infective changes on the MRI

scan and evidence of pus in the joints and good response to

treatment with antibiotics; makes the diagnosis of JIA less

likely. Management of septic arthritis involves timely aspi-

ration of the affected joint and institution of appropriate an-

tibiotics. Duration and choice of therapy will depend on the

age of the child, organisms identified and response to treat-

ment but up to 6e8 weeks of intravenous treatment may be

required.

Case 3

1 A, D, E, H, J

2 B

3 A

The baby was transferred to a neurosurgical unit where he

underwent subdural aspiration. Subsequently he made a

good recovery without the need for a V-P shunt. Late onset

Group B streptococcal (GBS) infection typically presents

between 7 and 90 days of life. Where prophylactic antibi-

otics have been shown to reduce the incidence and improve

outcomes in early onset neonatal sepsis, the benefit has not

been seen in late onset GBS sepsis. Given the range of po-

tential pathogens, IV cefotaxime and Amoxicillin should

provide adequate cover for community acquired infection

and has been shown to give greater CNS penetrance than

penicillin alone. A minimum of 2 weeks treatment for GBS

meningitis and 3 weeks for gram-negative organisms is

recommended.

Complications of bacterial meningitis are common in

infants under 6 months of age and include infarction, brain

abscess, subdural effusion or empyema, sinus thrombosis

and hydrocephalus. All babies should be monitored with

serial head circumference and cranial ultrasound imaging.

The presence of focal seizures should prompt suspicion of a

space-occupying lesion. MRI, where available, is the most

useful imaging modality. It is capable of differentiating

sterile effusions and empyema.



SELF-ASSESSMENT

5e10% of neonates with meningitis are likely to develop

brain abscesses. Mortality is significantly increased by their

presence but preterm babies can develop asymptomatic

frontal abscesses with surprisingly good neurological

outcome. Identification of a focal brain abscess should

prompt discussion with a neurosurgical unit for consider-

ation of surgical drainage.

Case 4

1 D

2 B

3 a-E, b-F, c-B, d-A, e-C, f-D.

This baby was treated with 5 days of IV antibiotics for

suspected sepsis. The chest X-ray findings, however, were

suggestive of a congenital cystic adenomatous malforma-

tion which was confirmed on CT thorax. Congenital cystic

adenomatous malformation comprises 25% of the paren-

chymal lung malformations. The majority are diagnosed

antenatally. Some lesions rapidly expand in utero leading to

pulmonary hypoplasia, foetal hydrops and foetal demise;

whereas others present later in life. Babies with an ante-

natal diagnosis require serial ultrasound monitoring for the

development of hydrops. Babies with significant medias-

tinal shift may require artificial ventilation and percuta-

neous drainage of fluid- or air-filled cysts prior to surgical

resection. The treatment of asymptomatic babies remains


controversial but the overall consensus is for elective sur-

gical resection between 1 month and 2 years of age to avoid

late complications, such as infection, bronchiectasis and

malignancy.

Further reading

1 Blaser S, Jay V, Becker L, Ford-Jones EL. Neonatal brain

infection. In: Rutherford MA, eds. MRI of the neonatal

brain. eBook, accessed 29 May 2013, http://www.mri-

neonatalbrain.com/ch04-10.php.

2 Heath P, Okike O. Neonatal bacterial meningitis: an

update. Paediatr Child Health 2010; 20: 526e30.

3 Johnson N, Tublin M, Ogilvie J. Parathyroid imaging:

technique and role in the preoperative evaluation of

primary hyperthyroidism. Am J Roentgenol 2007; 188:

1706e15.

4 Laberge J, Puligandla P. Congenital malformations of

lungs and airways. In: Landau L, Taussig L, Le Sou€ef PN

et al. eds. Pediatric respiratory medicine. Mosby, 2008;

907e41.

5 Petty RE Southwood T, Manners P et al. ILAR classifi-

cation of juvenile idiopathic arthritis. J Rheumatol 2004;

31: 390e92.

6 Srinath A, Lowe M. Pediatric pancreatitis. Pediatr Rev

2013; 34: 79e90.



self-assessment

Documents