Infectious Diseases

1
Common Cold - Coryza

oThe commonest viral infection in

childhood.

oIt causes inflammation of the mucous

membranes lining the nose and throat.

oClassical features include a clear or

mucopurulent discharge and nasal
blockage.
2
Common Cold - Coryza
Etiology
• Para influenza viruses, respiratory syncytial
viruses (RSV), influenza, and adenoviruses
cause common cold-like illnesses in infants and
children

• Rhino viruses (100 serotypes) are the major

causes in adults.

3
Common Cold…
Epidemiology
• it occurs world wide both in endemic and
epidemic forms-many people have one to
six colds per year.
• Greater incidence in the highlands.
• Incidence is high in children under 5
years

4
Symptoms
• Generally unwell
(malaise) with watery
eyes.
• Common Cold
• Pyrexia (Usually mild)

• Runny nose and

sneezing

• Sore throat and cough

• Lethargic, headache
and miserable. 5
 Pathology
• The commonest
• The symptoms usually pathogens are viruses
intensify over 24 – 48 of which there are over
hours unlike influenza 100 serotypes.
which worsens rapidly
over a few hours • Colds are self limiting
and antibiotics are of
no value as the
common cold is viral in
origin and secondary
bacterial infection is
uncommon.
6
Treatment.
• Frequent small
feeds.
• Keep the room
• Bed rest and tepid
warm especially at
sponging if pyrexial.
night

• Analgesics such as
Paracetamol for
pain and reduce
temperature.

• Copious fluids.
7
Complications.
• Infection spread
by droplet
The viral infection
infection
may spread to:
The sinuses ( sinusitis)
The middle ear (ottitis media)
The throat (Pharyngitis)

The lower respiratory

tract, causing:
• bronchitis,
• bronchiolitis or
• pneumonia. 8
 Prevention.
There are no practical
ways of avoiding the
common cold.

Children should be
kept off school for
a week.

9
Acute Pharyngitis/ Tonsillitis

• Infection of upper respiratory tract with

principal involvement of the throat.
Etiology
• Mostly viral as parts of URTI
• Group A B-hemolytic streptococcus is
the most common and the most
important bacterial agent after 2 years of
age.
10
Acute Pharyngitis..

 Clinical Manifestions
Viral pharyngitis
• Insidious onset
• Other signs of URTI
• Contact history with individuals with common cold
Streptococcal pharyngitis
• Common in those older than 2 yr of age and peak 4-7yr
• Headache, abdominal Pain, vomiting, high grade fever,
sore threat
• On physical examination: diffuse redness
• exudates, cervical tender lymphadenopathy.
11
Treatment:

• Benzathine penicillin

• Oral penicillin

• Analgesics - paracetamol

12
Complications

• Suppurative:
– Otitis media
– Local /abscess retropharyngeal( behind the
pharynx)
• Non suppurative:
– Acute glomerulonephritis
– Rheumatic fever.

N.B suppurative means formation of pus

13
Sinusitis

• Sinusitis is a common illness of childhood and

adolescence with significant acute and chronic
morbidity as well as the potential for serious
complications.
• There are 2 types of acute sinusitis: viral and
bacterial.
• The common cold produces a viral, self-limited
rhinosinusitis
• Approximately 0.5–2% of viral upper respiratory
tract infections in children and adolescents are
complicated by acute bacterial sinusitis.. 14
Sinusitis…

Etiology.
• The bacterial pathogens causing acute bacterial
sinusitis in children and adolescents include :
• Streptococcus pneumoniae (≈30%),
• Haemophilus influenzae (≈20%), and
• Moraxella catarrhalis (≈20%).
• Staphylococcus aureus, other streptococci, and
anaerobes are uncommon causes of acute
bacterial sinusitis in children

15
Sinusitis…
Epidemiology.
• Acute bacterial sinusitis can occur at any
age.
• Predisposing conditions include:
o viral upper respiratory tract infections
o allergic rhinitis, and
o cigarette smoke exposure.

16
Epidemiology…

• Children with immune deficiencies,

gastroesophageal reflux, anatomic defects (cleft
palate), nasal polyps, and nasal foreign bodies
(including nasogastric tubes) can develop
chronic sinus disease.
• Patients with nasotracheal intubation or
nasogastric tubes may have obstruction of the
sinus ostia and develop sinusitis with the
multiple-drug resistant organisms of the
intensive care unit (ICU)
17
Sinusitis…
Pathogenesis.
• Acute bacterial sinusitis typically follows a viral
upper respiratory tract infection.
• Initially, the viral infection produces a viral
rhinosinusitis
• MRI evaluation of the paranasal sinuses
demonstrates major abnormalities (mucosal
thickening, edema, inflammation) of the
paranasal sinuses in 68% of healthy children in
the normal course of the common cold.
18
Sinusitis…
• Nose blowing has been demonstrated to
generate sufficient force to propel nasal
secretions into the sinus cavities.
• Bacteria from the nasopharynx that enter the
sinuses are normally cleared readily, but during
viral rhinosinusitis inflammation and edema
may block sinus drainage and impair
mucociliary clearance of bacteria.
• The growth conditions are favorable and high
titers of bacteria are produced
19
Sinusitis…
Clinical manifestations.
• Children and adolescents with sinusitis may
present with nonspecific complaints, including
– nasal congestion,
– purulent nasal discharge (unilateral or bilateral),
– fever, and
– cough.
• Less common symptoms include bad breath
(halitosis), a decreased sense of smell, and
periorbital edema.
• Complaints of headache and facial pain are
20
rare in children.
Sinusitis…
• Additional symptoms include maxillary tooth
discomfort, pain or pressure exacerbated by
bending forward
• Physical examination may reveal erythema and
swelling of the nasal mucosa with purulent
nasal discharge.
• Sinus tenderness may be detectable in
adolescents and adults.

21
Sinusitis…
Diagnosis

• Mainly Clinical

• Culture – sinus aspirate culture

22
Sinusitis…
Treatment
• Initial therapy with amoxicillin (45 mg/kg/day) is
adequate for the majority of children with
uncomplicated acute bacterial sinusitis.
• Alternative treatments for the penicillin-allergic
patient include trimethoprim-sulfamethoxazole,
cefuroxime axetil, cefpodoxime, clarithromycin,
or azithromycin

23
Sinusitis…
• The use of decongestants, antihistamines,
mucolytics, and intranasal corticosteroids
has not been adequately studied in children
and is not recommended for the treatment of
acute uncomplicated bacterial sinusitis.
• Likewise, saline nasal washes or nasal sprays
may help to liquefy secretions and act as a
mild vasoconstrictor, but the effects have not
been systematically evaluated in children.

24
Sinusitis…
Complications.
• Because of the close proximity of the paranasal
sinuses to the brain and eyes, serious orbital
and/or intracranial complications can result
from acute bacterial sinusitis and progress
rapidly
• Intracranial complications can include epidural
abscess, meningitis, cavernous sinus
thrombosis, subdural empyema, and brain
abscess
25
Sinusitis…
Prevention
• Prevention is best accomplished by frequent
hand washing and avoiding persons with
colds.
• Because acute bacterial sinusitis can
complicate influenza infection, prevention of
influenza infection by yearly influenza vaccine
will prevent some cases of complicating
sinusitis.

26
Croup syndrome
• It is an acute upper airway obstruction
secondary inflammation of the larynx and
extrathoracic trachea.

• It is a generic term for heterogeneous

groups of diseases (both infectious and
non-infectious) causing upper air way
obstruction.

27
Croup syndrome…
• Presentation:
o Barking cough/brassy cough
o Stridor
o Respiratory distress
o Hoarseness of voice

28
Croup syndrome…

Encompasses
 infectious causes
• most common and most important
– acute laryngotracheobronchitis (viral croup)
– acute epiglotittis
– laryngeal diphtheria
– spasmodic croup
– bacterial tracheitis

29
Croup syndrome….
 non-infectious causes

• Laryngoedema

• hypocalcemia

30
 Acute Laryngotrachiobronchitis (viral croup)

 Etiology
• Parainfluenza viruses account 75% of
cases.
• Adenoviruses
• Respiratory synstial virus
• Rarely, Mycoplasma pneumoniae, and
• Measles virus

31
Acute Laryngotrachiobronchitis (viral croup) …

Clinical manifestations
 The degree of airway obstruction in
children is more severe due to :
• Small size of the airways
• Loosely attached mucous membrane
• Abundant mucous glands of the airways
• Frequent respiratory infections

32
Clinical manifestations.

• low grade fever

• intermittent stridor
• mild brassy cough are present during
early phase
• as the disease worsens patient will have
continuous stridor signs of severe
respiratory distress, decreased air entry
and lethargy.
33
Acute Laryngotrachiobronchitis
(viral croup) …
Diagnosis
• mainly clinical.
Indications for admission
• Stridor at rest
• Progressing stridor
• Respiratory distress
• Cyanosis

34
Acute Laryngotrachiobronchitis
(viral croup) …
 mild croup (no stridor at rest)
• outpatient treatment
– Advice care giver to increase fluid intake
– avoid manipulation of the throat
– come back when danger symptoms like
stridor at rest, respiratory distress appears.

35
Acute Laryngotrachiobronchitis
(viral croup) …
Stridor at rest
• Intranasal oxygen (nasal canulla)
• Corticosteroids
– Dexamethasone 0.5 mg/kg IM stat
• Racemic epinephrine
• Home-cold steam ( sooth throat & reduce
obstruction )
• Artificial airway if distress gets worse
(tracheostomy, nasotracheal intubation)
36
Epiglotitis

• Epiglotitis is an acute inflammatory

(infectious) processes involving the
epiglottis and surrounding structures.
Epidemiology
• Children between ages of 2 to 7 years are
affected
• Peak incidence at 3 ½ years
• Male to female ratio is 3:2
.
37
Epiglotitis…

Etiology
• H.influenzae type b causes almost all
cases of epiglotitis.
• Rarely S pneumoniae and, S pyogenes
can lead to epiglotitis

38
Epiglotitis…

Clinical manifestations
• Classically epiglotitis starts suddenly with
rapid progression to complete obstruction
• Patients are toxic with high grade fever, sore
throat , dysphagea
• Tachycardia
• Restlessness, drooling of saliva and stridor
• In older children hyper –extend their neck and
sit leaning forward and sit leaning forward
39
Epiglotitis…

• A brief period of air hunger with

restlessness may be followed by rapidly
increasing cyanosis and coma.
• Stridor is a late finding and suggests near-
complete airway obstruction
• Complete obstruction of the airway and
death can ensue unless adequate
treatment is provided

40
Epiglotitis…

Diagnosis
• Mainly clinical
• Blood culture and lateral neck x-ray help
for diagnosis but are time consuming and
add little to immediate management
• Laryngoscopy shows “cherry red” swollen
epiglottis if it is done with proper
preparation for respiratory support or
intubation
41
Management

Principles of management are:

• Admit all cases
• Routine tracheostomy/nasotracheal
intubation
• Oxygen
• Chloramphenicol 75-100mg/kg /dose IV
for 7 to 20 days

42
Bronchiolitis

• Acute bronchiolitis is a common disease of

the lower respiratory tract of infants,
• resulting from inflammatory obstruction of
the small airways.

43
Bronchiolitis...

Aetiology
• Acute bronchiolitis is a predominantly viral
illness.

• About 50% of the disease is due to respiratory

syncytial virus (RSV).

• Other causative organisms are parainfluenza

viruses, mycoplasma, some adenoviruses, and
occasionally other viruses.
44
Bronchiolitis...
Epidemiology
• Bronchiolitis occurs most commonly in :
– male infants
– between the ages of 3 to 6 months
– who have not been breastfed, and
– live in crowded conditions.
• The source of the viral infection is usually
a family member (older child or adult) with
a minor respiratory illness
45
Bronchiolitis...

Pathophysiology
• Acute bronchiolitis is characterized by
bronchiolar obstruction due to:
– oedema,
– accumulation of mucus and cellular debris, and
– Invasion of the smaller bronchial radicles by virus.
• The bronchiolar wall thickening affects air flow,
impairing the normal exchange of gases in the
lung, which will result in hypoxemia early in the
course of the disease
46
Bronchiolitis...

Clinical manifestations
• Most affected infants have:
• History of exposure to older children or adults
with a minor respiratory disease within the week
preceding the onset of illness.
• The first symptoms are that of a mild upper
respiratory tract infection, with serous nasal
discharge and sneezing, lasting for several
days.

47
Clinical manifestations...

• These maybe accompanied by decreased

appetite and fever.
• Then there will be a gradual development
of respiratory distress characterized by
wheezy cough, dyspnoea and
irritability.
• Infants may have difficulty of sucking

48
Clinical manifestations...
• On examination there will be :
o Tachypnea
o hyper-expanded chest
o severe respiratory distress,
o a prolonged expiratory phase and
o wheezing, which is usually audible

49
Bronchiolitis...
Radiography
• Chest X-ray shows hyper-inflation of the lungs
and an increased anteroposterior diameter on
lateral view.
Diagnoses
• Mainly clinical
Differential diagnosis
• asthma
• bacterial bronchopneumonia
• heart failure 50
Treatment
 Supportive:
• The child should be placed in an atmosphere of
cool and humidified oxygen to relieve
hypoxemia, reduce insensible water loss from
tachypnea, and also relieve the dyspnoea,
cyanoses, anxiety and restlessness.
• Oral intake must often be supplemented or
replaced by parenteral fluids.
• Antibiotics should be given if there are secondary
bacterial infections like bacterial pneumonia.
51
Pneumonia

Definition
• Inflammation of the parenchymal structure
of the lung,

• such as the alveoli and the bronchioles

52
Pneumonia...

Etiology
• It is caused by bacteria, viral agents, and
non-infectious agents.
• The most common causes are bacterial
agents especially streptococcus
pneumonia, followed Haemophilus
Influenza.

53
Pneumonia...
Epidemiology

• Pneumonia is responsible for the 70-80%

deaths that occur due to Acute Respiratory
Infections (ARI) worldwide.

• In Ethiopia pneumonia is the cause of one

third of infant mortality and one fifth of under
5 mortality
54
Pneumonia

 Pneumonia is more severe in developing countries

due to the high prevalence of risk factors such as:
• Malnutrition, including Vitamin A and D
deficiencies
• Overcrowding and indoor-air pollution
• Intercurrent infections such as measles,
whooping cough, malaria and diarrhea and
• Immune-deficient states
 Severe forms of pneumonia are commonly
encountered in children between the age of 6
months and 3 years. 55
Pneumonia...

Pathogenesis
• The normal lung is sterile. Most of the agents are inhaled
in to the lung in the air breathed or aspirated in to
periphery of the lung from the upper air ways
• S. pneumoniae attaches to the respiratory epithelium
inhibits ciliary action, and leads to cellular destruction
and an inflammatory response in the sub mucosa.
• As the infection progresses, sloughed cellular debris,
inflammatory cells, and mucus cause airway obstruction,
with spread of infection occurring along the bronchial tree
similar to that of viral pneumonia.

56
Pneumonia

 Clinical manifestations
• In infants, initial manifestations may be mild with upper
respiratory tract infection like:
– Cough
– Sudden onset of fever
• S/S of respiratory distress such as :-
– rapid and difficult breathing (Tachypnea and dyspnea)
– nasal flaring
– intercostal retraction
– chest indrawing
– cyanosis in severe forms. 57
Pneumonia...

Other possible findings are

• Crepitation
• diminished breath sounds
• bronchial breathing and
• dullness on percussion

58
Pneumonia..

• A child with fast breathing but with out

chest indrawing is classified as having
Pneumonia.

• A child with fast breathing and chest

indrawing or any danger signs such as
lethargy, unconsciousness or convulsion is
classified as having Severe Pneumonia.

59
 Cut off for fast breathing

Age Breathes per minute

<2 months ≥60

2 months -12 months ≥50

12 months -5 years ≥40

60
Pneumonia..

• The child who is exactly 12 months old

has fast breathing if you count 40 breaths
per minute or more.

61
Pneumonia...

Diagnosis
• Mainly reached on the basis of clinical
feature

• Chest X-ray may be helpful in patients

who fail to respond to treatment to check
for complications such as pleural effusion,
pneumatocele, atelectasis, or abscess
formation. 62
Pneumonia...

Treatment
• Children with severe pneumonia should be
admitted for in patient care
• Supportive: include
• administration of Oxygen nasally and
• hydration to replace insensible water loss
• Vitamin A

63
Pneumonia...
Antibiotics
• Children with Pneumonia are treated at out patient level
with:
– Cotrimoxazole or Amoxicillin orally for 5 days
– Advice parents to come back if there is worsening.
• Children with severe Pneumonia are given:
– Intravenous antibiotics
• Crystalline penicillin as a first line drug
– Assess response after 48 to 72hrs.; if no improvement
or worsening add Chloramphenicol

64
Pertussis

Definition:
• Pertussis is an acute respiratory
infection caused by Bordetella pertussis

• Pertussis is better terminology than

whopping cough since not all children
specially infants whoop.

65
Pertussis…

Epidemiology
• Pertussis occurs as sporadic and epidemic
cases.
• Most patients are under six years old, but any
age including neonatal age groups are
susceptible since there is no transplacental
protection.
• Overcrowding favors the spread because
transmission is via droplet infection.
• The highest infectivity is in the early stage of the
disease and the attack rate is close to 100%. 66
Pertussis…

Etiology
• B. pertussis and B parapertussis are
gram-positive rods which grow well on
Bordet Gengon agar (glycerin-potato-
blood) media.
• Adenoviruses, influenza and interviewers
can cause pertussis like diseases

67
Pertussis…
Pathogenesis
• Transmission is through aerosol droplet at
close range.
• Bacteria attach to ciliated epithelium of
respiratory tract resulting is congestion,
excessive mucous production and infiltration
with lymphocytes.
• The lumen of the air ways especially
bronchioles narrow producing atelectasis and
emphysema.
• B pertussis produces many toxins. Pertussis
toxin (PT) plays central roles in the
68
pathogenesis.
Pertussis…

Clinical Manifestations
• The clinical manifestations are divided into three
stages each lasting about two weeks;
catarrhal, paroxysmal and convalescent.
a. Catarrhal stage
• After incubation period of 3 – 12 days
• non distinctive symptoms of low grade fever,
nasal discharge, sneezing and lacrimation
are seen.
• This stage usually simulates simple upper
69
respiratory infections.
Clinical Manifestations…
b. Paroxysmal stage
• Progressively increasing repetitive series of
forceful cough in a single expiration
• Whoop (inspiratory whoop against closed glottis)
between paroxysms.
• -Child looks healthy b/n paroxysms
• - Cyanosis and sub conjunctival haemorrhage due
to violent cough
• Children above the age of 2 years have massive
inspiratory effort.
• The cough is followed by vomiting (post tussive
vomiting) and profuse sweating (post tussive
70
exhaustion).
Clinical Manifestations…

• The intense cough and its associated included

pressure may result in hernia, rectal prolapse,
orbital edema, ulceration of frenulum of the
tongue and epistaxis which are helpful in the
diagnosis.
• Immunized children and adults have no distinct
stages.
c. Convalescent stage
• Severity and frequency of paroxysms decrease
but cough and whoop may persist for months.
71
Pertussis….
Diagnosis:
• URTI at beginning ,then paroxysmal cough ( Typical
inspiratory whoop)
• History and physical examination at phase two
ensure the diagnosis
• Marked lymphocytoisis.
Treatment
• Erythromycin: 30-40mg/ke PO QID for 10dys to
treat the infection in phase one but to decrease
transmission in phase two.
• Antibiotics for super infection like pneumonia b/c of
72
bacterial invasion due to damage to cilia.
Pertussis….
Supportive Rx
• Proper feeding of the child, high fluid intake
• Encourage breast feeding immediately after
an attack of each paroxysm
• Proper ventilation-continuous well humidified
oxygen administration
• Reassurance of the mother (care giver)

73
Pediatrics Tuberculosis

• Tuberculosis (TB) is a chronic infectious

disease with diverse clinical
manifestations
• caused in most cases by Mycobacterium
tuberculosis; occasionally it can also be
caused by Mycobacterium bovis and
Mycobacterium africanum

74
Pathogenesis…

 Primary infection occurs on first exposure to

tubercle bacilli.
• Infection begins with the multiplication of the bacilli
in the lungs (Ghon focus)
• Lymphatics drain the bacilli to the hilar lymph
nodes.
• The Ghon focus and related hilar
lymphadenopathy form the primary complex.
• The immune response (delayed hypersensitivity
reaction) develops about 4-6 weeks after the primary
infection
75
Pathogenesis…
• What happens next is determined by the size
of the infecting dose of bacilli and the strength
of the immune response.
• Mostly, the immune response stops the
multiplication of bacilli.
• However, a few dormant bacilli may persist.
• In a few cases the immune response is not
strong enough to prevent multiplication of
bacilli and disease occurs within a few
months.
76
Tuberculosis
• In children, the disease TB is usually primary
TB.
• The age at which the child is infected
determines the pattern of primary disease.
• Up to puberty, blood-borne spread is
common, resulting in disseminated (miliary
and extra pulmonary) disease; whereas,
• after puberty pulmonary spread is more
common.

77
Tuberculosis…
Post-primary TB
• occurs after a latent period of months or years
after the primary infection.
• It may occur either by reactivation or by re
infection.
• Reactivation occurs mainly in response to a
trigger, such as weakening of the immune
system by HIV infection.
• Post-primary TB usually affects the lungs but
can involve any part of the body.
78
Tuberculosis…
 The characteristic features of post-primary TB
are:
• extensive lung destruction with cavitations,
• positive sputum smear, and
• upper lobe involvement

79
Clinical Manifestations

 Primary Pulmonary disease (1o PTB )

• This includes the lung parenchymal focus and
regional lymph nodes.
• The hall mark of 1o PTB is the relatively large size
of the regional lymphadenitis compared with the
relatively small size of the initial lung focus.
 Infants are more likely to manifest with signs and
symptoms such as:
– Cough
– mild dyspnea
– failure to gain weight
80
Pulmonary TB

• Pulmonary TB is rare in childhood but may

occur in adolescence.
• Patients may experience:
– Fever
– Anorexia
– Malaise
– weight loss
– night sweats
– productive cough
– hemoptysis and chest pain than those with 1o PTB.
81
Pulmonary TB…

Diagnosis
• History and physical examination
• Microscopic examination of sputum or
gastric aspirate ( AFB)
• Radiological examination
• Culture of organism
• Histo-pathological(biopsy) examination
• Tuberculin test (ppd)
82
 Criteria for the diagnosis of tuberculosis in children

A. Probable tuberculosis:
If at least 2 of the following are found
• Contact history with tuberculosis patient
• positive symptom complexes
• positive PPD tests
• suggestive chest x-ray findings
• response to anti-TB therapy (retrospective
diagnosis)
83
Criteria for the diagnosis…

B. Confirmed tuberculosis
• Detection by microscopy or culture of
tubercle bacilli from secretions or tissues

• positive cytohistologic evidences

84
Pulmonary TB…

Case definition
a. Case definition by site and result of sputum
smear for PTB
• Smear positive case: at least 2 sputum
smears positive for AFBs or 1 sputum smear
positive and CXR abnormalities consistent with
TB
• Smear negative case: at least 2 (preferably 3)
sputum smears negative for AFBs and Chest
X-ray consistent with TB.
85
Case definition…
b. Case definition by previous treatment
• New case (N): a patient who has never taken
treatment for TB or has been on anti TB treatment
for less than one month
• Relapse case (R): A patient who has been declared
cured or treatment completed of any form of TB in
the past, but who reports back to the health service
and is found to be AFB smear positive or culture
positive
• Treatment failure(F): a patient who, while still on
treatment remain smear positive or come again
sputum smear-positive 5 months or more after
starting treatment 86
Case definition…

• Return after default(D): a patient who has and

previously been recorded as defaulted from
treatment (Completed at least one month or
treatment and interrupted for at least 2 months)
and returns to health service with smear positive
sputum
• Transfer in (T): a patient is registered for
treatment in one district (Woreda) and is
transferred to another
87
Case definition…
• Chronic case(C): a patient who remains
smear-positive after completing a supervised
re-treatment regimen

• Others(O): a patient who does not easily fit

in to one of the above case definition, e.g.
Smear negative PTB who returns after
deafult

88
Pulmonary TB…

Phases of chemotherapy
• The treatment for tuberculosis has two phases:
1. Intensive (initial) phase: this phase
consists of three or more drugs for the first 8
weeks.
• This has the advantage of making the patient
non-infectious by rapidly reducing the load of
bacilli in the sputum and minimizing the danger
of development of drug resistance.

89
Phases of chemotherapy…

2. Continuation phase: immediately follows

the intensive phase and is important to
ensure that the patient is permanently
cured and does not relapse after
completion of treatment.
• This phase at least two drugs to be
taken for 6 months.

90
Pulmonary TB…
Drugs used for the chemotherapy of TB:
• Streptomycin (S)
• Ethambutol (E)
• Isoniazid (H)
• Rifampicin (R)
• Pyrazinamide (Z)

91
Pulmonary TB…
Treatment category
• Category I – Short course chemotherapy
for smear- positive PTB and seriously ill
smear-negative PTB and EPTB cases
• The treatment regimen for this category is:
• 2S (RHZ)/6 (EH
• 2S(RHZ)/4(RH)

92
Treatment category….

This regimen is prescribed to:

• New smear-positive PTB patients
• New smear-negative PTB patients, who are
seriously ill
• New EPTB patients, who are seriously ill
• Returns after default from DOTs, who have smear-
negative PTB (case definition = “other”)
• All children bellow 6 years of age
• Note: Ethambutol is contraindicated in children
bellow 6 years of age.
93
Treatment category…

Category II – Re-treatment regimen

The regimen for this category is:
• SE(RHZ) for 2 months, then E(RHZ) for
1month, and then E(RH) three times a
week for 5 months

94
Treatment category

• This treatment regimen is prescribed for:

• Smear-positive relapses
• Smear-positive treatment failures
• Smear-positive return after defaults
• Smear-negative PTB patients who became smear-
positive after 2 months of treatment (case definition=
other)
• Return after default from re-treatment should be given
the re-treatment regimen once again, but only once
• Relapses after re-treatment should also be given the re-
treatment regimen only once
95
Treatment category…

Category III – short course chemotherapy for

smear-negative PTB, EPTB and TB in children
• The treatment regimen for this category is:
• (RHZ) for 2 months and then (EH) for 6 months
This regimen is prescribed to:
• New adult patients with smear-negative PTB
• New adult patients with EPTB
• Children between 7 and 14 years old with any
type of TB, who are NOT seriously ill
96
Bacterial Meningitis
• Bacterial meningitis is one of the most potentially
serious infections occurring in infants and older
children.
• This infection is associated with a high rate of
acute complications and risk of long-term
morbidity.
• The incidence of bacterial meningitis is
sufficiently high in febrile infants that it should be
included in the differential diagnosis of those
with altered mental status and other evidence of
neurologic dysfunction.
97
Bacterial meningitis

Etiology
• Group B streptococci
• H. influenza type b
• Streptococci pneumonia
• Neisseria meningitides

98
Meningitis…
Epidemiology.
• A major risk factor for meningitis is the lack of
immunity to specific pathogens associated with
young age.
• Additional risks include recent colonization with
pathogenic bacteria, close contact (household,
daycare centers, college dormitories, military
barracks) with individuals having invasive
disease caused by N. meningitidis and H.
influenzae type b, crowding, poverty, black or
Native American race, and male gender. 99
Epidemiology…

• The mode of transmission is probably

person-to-person contact through
respiratory tract secretions or droplets.
• The risk of meningitis is increased among
infants and young children with occult
bacteremia
• the odds ratio is greater for
meningococcus (85 times) and H.
influenzae type b (12 times) relative to that
for pneumococcus. 100
Pathophysiology

• Bacterial meningitis is the result of bacteremia

from the URTI.

• Invasion by direct extension may occur from

purulent infections of the paranasal sinuses,
mastoids.

• Bacteria may also gain entry to the CNS via

penetration wounds, LP or neurosurgical
procedures.
101
 Pathophysiology…
• Once the causative organism enters the
bloodstream, it crosses the BBB and causes an
inflammatory reaction in the meninges.
• Inflammation of the subarachnoid space and pia
mater occurs.
• A purulent exudate is released, and spread to
other areas of the brain by the cerebrospinal fluid
(CSF).
• If it is left untreated, the CFS becomes thick and
blocks the normal circulation of the CFS.

102
 Pathophysiology…

• Since there is little room for expansion within the

cranial vault, the inflammation may cause
increased intracranial pressure.

• Long-term effects of the illness causes a

decreased cerebral blood flow because of
increased ICP or toxins.

• If the infection invades the brain tissue itself, the

disease is then classified as encephalitis.
103
Clinical features

• Headache and fever

• lethargy, unresponsiveness, and coma
• Stiff neck (rigidity)
• Positive kerning sign: When the patient is
lying with the thigh flexed on the abdomen,
the leg cannot be completely extended
• Positive Brudzink’s sign: When the
patient’s neck is flexed, flexion of the knees
and hips is produced
104
105
Positive Brudzinski’s sign: When the patient’s neck
is flexed, flexion of the knees and hips is produced.

when passive flexion of the lower extremity of one

side is made, a similar movement is seen in the
opposite extremity.

106
Clinical features…
• Photophobia
• Increased ICP results from cerebral
edema characterized by
– headache,
– vomiting and
– depressed level of consciousness
• The diagnosis is confirmed by
examination of the CSF by performing
Lumbar puncture (LP)
107
Lumbar puncture (LP)

• LP is carried out by inserting a needle into

the lumbar subarachnoid space through
the third and fourth or fourth and fifth
lumbar inter space
• to withdraw CSF for diagnostic and
therapeutic purposes.

108
Lumbar puncture…

Contraindications for doing LP

• Increased intracranial pressure
• Infection on the lumbar space
• Severely ill infant if the lumbar puncture
will further compromise the respiratory
status.

109
Examination of the CSF
• CSF should be clear and colorless

• Pink blood-tinged or grossly bloody CSF

may indicate a cerebral contusion,
laceration, or subarachnoid hemorrhage.

• Sometimes with a difficult lumbar puncture

the CSF initially is bloody because of local
trauma but then becomes clearer.
110
Examination of the CSF…

CSF findings suggestive of meningitis

• WBC > 30/mm3

• CSF protein > 200 mg/dl.
• CSF glucose < 50% of blood glucose.

111
Treatment

• Ampicillin and chloramphenicol are

effective for initial treatment of bacterial
meningitis in infants and children

112
Treatment …
• H.influenzae type b: chloramphenicol
100mg/kg/d for 7-10days
• S.pneumoniae: aqueous penicillin G
300,000IU/kg/d for 10-14days
• N. meningitides: aqueous penicillin G
300,000IU/kg/d for 5-7days

113
Treatment …

• The use of intravenous dexamethasone

0.15mg/kg/dose every 6hours for two days
• is indicated for children greater than 6 weeks of
age

114
Treatment …

Supportive care
• Vital sign monitoring neurologic assessment
frequently
• IV fluid administration should be restricted to
one half to two thirds of maintenance until it can
be established that increased ICP is not present.
• Shock must be treated aggressively to prevent
brain and other organ system dysfunction .

115
Treatment …

Increases ICP should be treated with

• Endotracheal intubation and hyperventilation

• IV furosemide and mannitol osmotherapy

may reduce ICP

• Immediate therapy for seizures includes IV

diazepam

116
Complications

• Seizures
• Increased ICP
• Cranial nerve palsies
• Brain abscess
• Stroke
• Herniation of the brain

117
Prevention

• Chemoprophylaxis is recommended for all close

contacts with rifampin 10mg/kg Q 12hr for N.
meningitides

• Prevention of MOs from invading CNS

118
119