Act as Pediatrician 👶

🔰Erythema Infectiosum (5th Disease)

▪︎Viral Infection Caused By DNA ParvoVirus B19

🔹Clinical Features & Dx

📍1. Start As Mild Fever/Headache/Malaise/Myalgia/Pharyngitis/Conjunctivitis 📍2. Then Rash After 7-10 Days :

▪︎Start As Slapped Check Rash With Circumoral Pallor (Like Lupus) ▪︎Then Rash On Trunk ▪︎Then Central Clearing Of Rash ➡️ Giving Appearance Of Lacy Reticulated Rash على شكل شبكة من الخطوط

📍3. Hematological Abnormalities (Aplastic Crisis)

🔹Complications

📍1. Transient Aplastic Crisis For 7-10 Days 📍2. Congenital Fetal Infection ➡️ Results in Severe Anemia/Heart Failure/Hydrop Fetalis & Fetal Death 📍3. Arthritis/Hepatitis/Myocarditis/Purpuric Gloves & Stocks Syndrome

🔹Mx (Supportive)

📍1. Blood Transfusion For Transient Aplastic Crisis 📍2. IVIG For Immunocompromised Patients

🔰Scarlet Fever الحمى القرمزية

▪︎Bacterial Infection Caused By GA Beta Hemolytic Streptococcus (GAS) ▪︎Primary Focus Of Infection ➡️ Pharyngitis/Skin Infections

🔹Clinical Features & Dx

📍1. Sudden Onset Of Fever & Sore Throat/Vomiting/Headache/Systemic Toxicity 📍2. Tonsils & Pharynx Swelling & Covered With Patches Of Exudates 📍3. Tongue Change Colour ➡️ White Strawberry (1st Two Days) Then Red Strawberry (At 5th Day) 📍4. Skin Rash (Scarlatiniform) At Same Time With The Fever :

▪︎Diffuse Red Punctate Feels Like SandPaper (Goose Skin Rash نقاط ناعمة) ▪︎Flushed Face & CircumOral Pallor (Like Lupus) ▪︎Blanch On Pressure ▪︎More Intense At Skin Folds (Axilla/Groin/Neck) ➡️ Here Don't Blanch ▪︎Residual Petechial Rash in The AnteCubital Fossa May Be Seen (Pastia’s sign) 📍5. Confirm Dx :

▪︎Typical Clinical Features ▪︎Neutrophilia ▪︎+Ve Throat Culture ▪︎ASO Titer >250

🔹Mx Of Scarlet Fever

📍1. Oral Penicillin V For 10 Days 📍2. Amoxicillin (50mg/Kg) For 10 Days 📍3. Single IM Benzathine Penicillin G 📍4. Erythromycin Or Azithromycin (For Penicillin Allergic Patients) 📍5. Clindamycin Or Rifampin ➡️ For Eradication Of Chronic Carrier State

🔹Complications

📍1. PostStrept Glomerulonephritis 📍2. Acute Rheumatic Fever 📍3. Strept Toxic Shock Syndrome 📍4. Reactive Arthritis 📍5. Chronic Carrier State

🔰ChickenPox

▪︎Primary Viral Infection Caused By Varicella Zoster (VZV) Member Of Herpes Family Transmitted By Droplets & Skin Contact

▪︎Gives Life Long Immunity & Latent Infection 🔹Clinical Features

📍1. Start As Fever With Malaise & Anorexia (Prodromal Stage) 📍2. After 24-48h Very Itchy Rash (Start On Scalp & Face & Trunk Then Descend To Limbs) :

▪︎About 200-500 Lesions ▪︎Rash Start As Erythematous Macules Then Papules Then Vesicles Then Crusts ▪︎Different Stages Of Rash Present At Same Time ▪︎Vesicles in Mouth Mucus Membrane May Ulcerate

📍3. Patient is Infective 2 Days Before Rash Onset Until Rash Crusted

🔹Complications Of ChickenPox 1. Permanent Scars If Lesions Scratched 2. Secondary Bacterial Infection (Staphylococci/GA Streptococcus) ➡️ Risk Of Toxic Shock Syndrome & Necrotizing Fasciitis 3. Encephalitis ➡️ Week After Onset Of Rash & Associated With Cerebellar Signs (Cerebellitis) 4. Purpura Fulminas ➡️ Large Area Of Skin & Subcutaneous Tissue Inflammation After VZV Infection 5. in Immunocompromised ➡️ Severe Vesicular & Hemorrhagic Eruption/Pneumonitis/DIC 6. Congenital Varicella Syndrome ➡️ Risk Of LBW/Mental Retardation & Congenital Anomalies 7. Rye's Syndrome If Aspirin Used 8. Shingles (Secondary Herpes Zoster) ➡️ ReActivation Of Latent VZV Causing Vesicular Eruption in Specific Dermatomes (Mostly At Thorax) & Risk Of Chronic Neuralgic Pain

🔹Mx Of ChickenPox

📍1. Acyclovir (20mg/Kg 4x Per Day For 5 Days) 📍2. Anti-Pruritics (Anti-Histamines/Calamine Lotion) 📍3. Anti-Pyretics (Paracetamol/Never Use Aspirin) 📍4. Antibiotics (If Secondary Bacterial Infection Developed) 📍5. Prevention & Prophylaxis :

▪︎ChickenPox Vaccine At 12-18m Age (Also Given 3-5 Days After Exposure As Prophylaxis) ▪︎Anti-VZV IVIG (IM 1 Vial For Each 10Kg Of Body Weight) ➡️ Post Exposure Prophylaxis For Immunocompromised & Pregnants & Newborns

#Infection_present_with_Rash_fever@Clinicalpediatricround

🔴Infections Present With Rash & Fever

🔰Measles (Rubeola) الحصبة

▪︎Viral Infection Caused By RNA ParamyxoVirus ▪︎Highly Contagious ➡️ Infectivity Period 5 Days Before & 5 Days After Rash Onset ▪︎Gives Life Long Immunity

🔹Clinical Features & Dx

📍1. Catarrhal Stage (3 Days)

▪︎Start As High Fever/Cough (Dry & Irritant)/Coryza (MucoPurulent Rhinitis)/Conjunctivitis/Sore Throat ▪︎Then Koplik Spots (Gray White Dots On Buccal Mucosa Usually Seen in 3rd Day Of Fever & Last 12-24h) ▪︎Transverse Line Of Inflammation On Eyelid Margin (Stimson Line)

📍2. Exanthematous (Eruptive) Stage

▪︎High Fever ▪︎Macular Rash (Starts On The Head Behind Ears Then Descend Downward Over 24h) ▪︎Petechial Or Hemorrhagic Rash (Black Measles) ➡️ More in Children Received Killed Measles Vaccine Or Immunocompromised Patients ▪︎Generalised Lympahdenopathy (More in Cervical LN) ▪︎Abdominal Pain (Mesenteric LN Involvement)

📍3. Convalescent Stage ➡️ Rash Starts To Fade From The Head & Downward مثل ما بدة يروح

📍4. Confirm Dx :

▪︎Typical Clinical Features ▪︎Leukopenia ▪︎+Ve Serology (IgM Seen 1-2 Days After Rash & Persist 1-2m) ▪︎PCR (Not Always Available)

🔹Mx (Supportive)

📍1. High Dose Vitamin A (100-200k IU) For 2 Days 📍2. Hydration & Antipyretics 📍3. Antibiotics For Secondary Bacterial infections

🔹Prevention

📍1. MMR Vaccine 📍2. Post-Exposure Prophylaxis ➡️ Measles Vaccine Within 72h Or IVIG Within 6 Days

🔹Complications Of Measles

📍1. Otitis Media (Most Common)/Interstitial Pneumonia/Diarrhoea ➡️ More in Infants

📍2. Encephalitis (2-5 Days After Rash) 📍3. SubAcute Sclerosing PanEncephalitis (SSPE) ➡️ Progressive Behavioral & Intellectual Deterioration & Death 8-10 Years After Measles 📍4. Permanent Neurological Dysfunction (20-30%) 📍5. Risk Of Death (15%)

🔹Risk Of Death in Measles

📍1. Patients With Malignancy & Severe Malnutrition 📍2. Patients Develop Encephalitis Or Pneumonia Or SSPE 📍3. Age <5 Years

🔰Rubella (German Or 3 Day Measles) الحصبة الالمانية

▪︎Mild Viral Infection Caused By RNA Virus From TogaVirus Family ▪︎Gives Life Long Immunity ▪︎Infectivity Period 2 Days Before & 5-7 Days After Rash Onset

🔹Clinical Features & Dx

📍1. Characteristics LN Enlargement ➡️ PreAuricular/Posterior Cervical & Posterior Occipital 📍2. Rash Resemble Measles But Milder & Less Prominent 📍3. Low Grade Fever 📍4. Rose Spots On Soft Palate (Forchheimer Spots) 📍5. Confirm Dx : ▪︎Typical Clinical Features ▪︎Thrombocytopenia (Rare) ▪︎+Ve Serology (IgM Seen After 5 Days From Onset Of Symptoms Or 4x Elevated IgG)

🔹Mx ➡️ Supportive

🔹Complications

1. Congenital Rubella Syndrome ➡️ High Risk Of Fetal Infection During 1st Trimester (>90%) 2. Rubella Encephalitis 3. Arthritis (More in Adult Women) 4. Thrombocytopenia

🔹Prevention

📍1. MMR Vaccine 📍2. Avoid Pregnancy 28 days After Rubella Vaccine 📍3. Exposed Pregnant : ▪︎+Ve IgG ➡️ Have Immunity (No Risk To Fetus) ▪︎-Ve IgG & Remain Negative ➡️ No Infection (No Risk To Fetus But Mother Susceptible To Infection) ▪︎-Ve IgG Then Become Positive ➡️ Mother Infected (High Risk Of Fetal Infection) ➡️ Better Do Pregnancy Termination Or Give IVIg

🔰Roseola Infantum (Exanthem Subitum/6th Disease) الحمى الوردية

▪︎Mild Viral Infection Caused By DNA HHV 6-7 (Human Herpes Virus Mostly Type 6) ▪︎Usually Affects Infants At 5-15m Age ▪︎Develops Latent Infection (Like All Other Herpes Family) الفايروس يبقى خاتل بالجسم

🔹Clinical Features

📍1. Abrupt (Sudden) Onset Of High Grade Fever (39-40°C) Last 3-5 Days 📍2. Fever Disappears Then Rash Appear (Starts On Trunk Then Neck & Face & Lower Limbs) ➡️ Most Distinctive Feature 📍3. Child Appears Normal & Continue Usual Daily Activity

🔹Mx

1. Supportive 2. Ganciclovir Or Foscarnet ➡️ For Immunocompromised

🔹Complications

📍1. Febrile Seizure in Infants (Most Common & Important Complication) 📍2. Encephalitis/Hemophagocytosis Syndrome

🔆Toddler's diarrhea

(Chronic nonspecific diarrhea of childhood)

🔺Definition:

A common benign cause of chronic diarrhea in children aged 6 months–5 years. Characterized by frequent loose stools without growth failure or systemic illness.

🔺Causes / Risk factors

_Excessive intake of fruit juices (high fructose/sorbitol) -Low dietary fat intake -Increased intestinal motility -Normal immature gut function

🔺Features

- 3–10 loose stools/day - Often contains undigested food particles - Usually occurs during the day, may be absent at night - Normal growth and weight gain No blood, fever, or significant abdominal pain

🔺Managemen

- Reassurance - Reduce fruit juices/sorbitol - Increase dietary fat - Normal balanced diet

#pertussis@Clinicalpediatricround

🔴Pertussis (Whooping Cough) ▪︎Acute Bacterial Infection Of Respiratory Tract Caused By Bordetella Pertussis (Gram -Ve/Pleomorphic/Fastidious) ▪︎Mostly Affect Children At 1-10 Years Age ▪︎Highly Contagious & Droplets Transmission 🔹Clinical Features & Dx 📍1. Catarrhal Stage (1-2w) : ▪︎Most Infectious (Contagious) Stage ▪︎Start As Mild Nonspecific Low Grade Fever & Rhinorrhea 📍2. Paroxysmal Stage (2-4w) : ▪︎Paroxysms Of Cough (>5 Continuous Attacks) Followed By Whooping (Forcefull Inspiration Against Narrow Glottis) ▪︎Attacks More At Night ▪︎Triggered By Eating/Drinking/Exertion ▪︎During The Attacks There's Facial Redness/Eye Bulging/Tounge Protrusion/Distended Neck Veins ▪︎Vomiting After The End Of Whooping (PostTussive Emesis) 📍3. Convalescent Stage ➡️ Gradual Resolution Of Symptoms Over 1-2w 📍4. In Infants ➡️ Apnea Could Be 1st Sign (Dangerous) 📍5. In Adolescent & Adults ➡️ Severe Paroxysms Of Cough But No Whooping 📍6. Confirm Dx : ▪︎Hx Of Contact With Infected Person ▪︎Typical Clinical Features Present ▪︎Lymphocytosis On CBC ▪︎Lung Segmental Atelectasis & Perihilar Infiltration On Xray ▪︎NasoPharyngeal Swab For Direct Fluorescent AB Staning ▪︎NasoPharyngeal Swab For PCR Or Culture 🔹DDX 📍1. Spasmodic Cough Due To : ▪︎B.Parapertusis & B.Holmesii (Milder Symptoms) ▪︎Atypical Pneumonia (Mycoplasma/Chlamydia/Viral Interstitial) ▪︎AdenoVirus/RSV Infections ▪︎Bronchiolitis ▪︎Foreign Body Inhalation ▪︎Mediastinal Mass Compressing The Trachea 📍2. Bronchial Asthma & Pulmonary TB 🔹Complications 📍1. Secondary Infections : ▪︎Pneumonia (Most Common) ▪︎Otitis Media/Sinisitis ▪︎Latent TB Activation 📍2. Seizures & Encephalopathy (Due To Cerebral Hypoxia Or Haemorrhage Or Hypocalcemia & Carry Risk Of Permanent Disability) 📍3. Straining & High Elevation in Abdominal & Thoracic Pressure Results in : ▪︎Lung Atelectasis/Pneumothorax/PneumoMediastinum ▪︎Epistaxis ▪︎Retinal & SubConjunctival Hemorrhage ▪︎Hernia/Rectal Prolapse 📍4. Hypoxia/Apnea/Malnutrition & Death 🔹Mx Of Whooping Cough 📍1. Patient Isolation 📍2. Avoid Triggers Of Cough 📍3. Cough Sedatives 📍4. Continuous Feeding 📍5. Antibiotics : 🔻I. Macrolides : ▪︎Azithromycin (10mg/Kg/D) For 5D ▪︎Clarithromycin (15mg/Kg/D) For 7D ▪︎Erythromycin (50mg/Kg/D) For 10D 🔻II. Trimethoprim-Sulfa (Alternative) 📍6. Prevention : 🔻I. DTAP Vaccination (70-90% Efficacy) Given For : ▪︎Children At 2-4-6-15-18m Age With Booster At 4-6 Years ▪︎Booster Dose Given For Pregnant Women At 3rd Trimester With Each Pregnancy (Provides Antibody Protection To The Infant After Delivery) ▪︎DTAP (Higher Concentration) Booster Dose For Contacts <7 Years Age ▪︎Tdap (Lower Concentration) Booster Dose For Contacts 7-10 Years Age 🔻II. Antibiotics (Macrolides) For Contact

WHO 2026 | أحدث إرشادات السمنة لدى الأطفال والمراهقين 🥞

2026 7th of October

أحد أهم الأمور الي أوصت بيها منظمة الصحة العالمية هو

1️⃣ life style modification 🏃🏻‍♀️

Structured dietary interventions Physical activity and sedentary behaviour Sleep Behaviour-changing interventions Digital health interventions في النقاط أعلاه تبين ان هناك علاقة كبيرة جدا بين الحرمان من النوم و فرط السمنة حيث قلة النوم عند الاطفال إلى أقل من 4 ساعات هي عامل و مسبب حقيقي لفرط السمنة بنسبة 20%

2️⃣ Pharmacological treatment💊

﴾ treatment with approved medicines may be considered when a supervised, multimodal lifestyle programme has not achieved the desired results ﴿

فقرة تحتها الف خط الغالبية السكانية تبلش مباشرة ب الأدوية رغم ان منظمة الصحة توصي بالاعطاء حسب الحاجة و لحالات محددة فقط راح اذكر ب اختصار بعض من هذه النقاط

- Medication is not the automatic first step. - Lifestyle treatment should be structured and supervised, not merely general advice to lose weight. - The decision must consider age, eligibility, contraindications, potential adverse effects, local approval, and the adolescent's clinical circumstances. - Medication should be integrated with ongoing nutritional, physical activity, and behavioural support.

و غيرها الكثير و كل هذا دا اشوف hazard باستخدام الأدوية عادي و اذا عنده renal impairment المهم يضعف 😶

3️⃣ Bariatric surgery✂️

It's considered for adolescents with severe obesity under strict conditions, It is not routine treatment for all adolescents with obesity. بالوصول إلى الجراحة التجميلية لعلاج السمنة هي بحد ذاتها اخر خيار كون المريض راح يمشي وفق protocol صارم جدا يتعلق بالغذاء و الأودية و الجانب النفسي و غالبية المرضى صعب الالتزام للمدى البعيد ﴿ في العراق على سبيل المثال الكثير من الحالات تنتهي بالوفاة كون المريض راح يعاني من مشاكل كثيرة تتمثل على مستوى electrolyte disturbing و undernutrition لذلك هذا الخيار جدا صعب و يحتاج إلى team متكامل لاتخاذ القرار ﴾

< لذلك السمنة ليست مجرد زيادة في الوزن، ولا يمكن اختزالها في الطعام وحده؛ بل هي اختلال معقّد تتداخل فيه الوظائف الحيوية والعوامل الهرمونية والنفسية والسلوكية والبيئية >

Prevention is better than treatment

Topic of tonight is #IDA@Clinicalpediatricround

🔴Iron Deficiency Anemia (IDA) ▪︎Anaemia is When HB Level Below The Normal Range 📍1. In Children : •Neonate: Hb <14 g/dl •1–12 months: Hb <10 g/dl •1–12 years: Hb <11 g/dl 📍2. In Adults : ▪︎in Male <13g/dl (14-18g/dl) ▪︎in Female <12g/dl (12-16g/dl) ▪︎IDA is The Most Common Cause Of Anemia Worldwide & Specially in Pediatrics At Age <5 Years & Pre-MenoPausal Women (Due To Menstruation) ▪︎Peak At Late Infancy & Early Childhood & Adolescents ▪︎Daily Iron Requirements in Pediatrics 8-15 mg/Day ▪︎Iron Absorbed From The Proximal Small Bowel Then Bound To Transferrin To Stored As Ferritin in Liver 🔹Causes Of Iron Deficiency 🔺A. Low (Deficient) Iron Intake in : 1. Prolonged Breast Feeding Without Iron Supplementation (Breast Milk Iron Enough Only For 1st 6m Of Life) 2. Unfrotified Cow's Milk (More Iron But Bad Absorption) 3. Diet Low in Iron After Weaning (Vegetables) 🔺B. Decrease Iron Absorption in : 1. Malabsorption Syndrome (Celiac/IBD/Bowel Resection/Prolonged Diarrhoea/Bowel Infections) 2. Drugs & Diet ➡️ Antacids/Tea/Phytate/Phosphate 3. Achlorhydria/Atrophic Gastritis 🔺C. Increase Body Demands in : 1. Low Birth Weight/Prematurity/Twins 2. Cyanotic Congenital Heart Disease (Polycythemia) 3. Rapid Growth in Infants & Early Childhood 4. Pregnancy 🔺D. Iron Loss Due To Bleeding in : 1. Perinatal Bleeding ➡️ From Placenta Or Umbilicus 2. GIT Bleeding ➡️ From Cow's Milk Allergy/Gastric Ulcers/Intestinal Parasites/Gastritis/Meckle's Diverticulum/Esophageal Varices/Polyps 3. Menstrual Bleeding At Puberty 4. Recurrent Epistaxis & Hematuria 🔹Clinical Features Of IDA 1. Asymptomatic in Mild Anemia 2. Conjunctival & Hands Pallor 3. Anorexia/Irritability/Tachycardia 4. Koilonychia (Spoon Shape Nails) & Atrophic Glossitis With Angular Stomatitis & Pica (ice Or Dust Ingestion) 5. Decrease Attention & Learning 6. Cardiomegaly & HF in Severe Cases (High Output Heart Failure) 🔹Dx Of IDA 🔺1. CBC & Blood Picture ➡️ MicroCytic Hypochromic Anaemia ▪︎Low HB & RBCS Count (Anemia) ▪︎Low MCH & MCHC (Hypochromia) ▪︎Low MCV (<70) (MicroCytic) ▪︎Increase RDW (>14.5%) ▪︎Large Central Pallor With Different shape & Sizes RBCs (Poikilocytosis & Anisocytosis) 🔺2. Iron Study ▪︎Decrease ➡️ Serum Iron <30µg/dl & Transferrin Saturation <16% ▪︎Increase TIBC 🔺3. Other Indicators ▪︎Decrease Serum Ferritin (<15ng/dl) ➡️ Specific & Sensitive But Increase By Inflammation ▪︎Decrease Reticulocytes-HB Conten (<27.5Pg) ➡️ 1st Parameter Corrected After Iron Therapy 🔹DDX Of IDA 1. Beta Thalassemia Trait ➡️ Normal RDW & Iron Study/Increase HbA2 & HbF 2. Alpha Thalassemia Trait ➡️ Dx By Exclusion 3. Lead Poisoning ➡️ Increase Blood & Urinary Level Of Coproporphyrin/RBCs Stippling (نقاط صغيرة داخل خلايا الدم) 4. Chronic Infection & Inflammation (Anemia Of Chronic Diseases) ➡️ Increase Serum Ferritin/Decrease Iron & TIBC/Normocytic Normochromic Anemia 5. Sideroblastic Anemia ▪︎Iron Present But Can't Be Attached To HB Due To Genetic Disorder in Enzymes ▪︎Produce Ringed RBCs (Sideroblasts)/Increase Serum Iron & Ferritin & Transferrin Saturation & BM Iron/Normal TIBC 6. Copper Deficiency 🔹Mx Of IDA 🔺1. Oral Iron ➡️ Ferrous Sulphate For 3m Minimum ▪︎3-6mg/Kg/Day in Infants ▪︎65-130mg in Older Children 🔺2. Parentral Iron (IV Dextran & Sucrose/IM Sorbitol) in : ▪︎Severe Deficiency & Heart Failure ▪︎Chronic Ongoing Bleeding (Rapid Iron Loss) ▪︎Intolerance Or Non-adherence To Oral Iron ▪︎Severe Bowel Disease & Malabsorption (IBD/Celiac/Atrophic Gastritis/Gastric & Bowel Resection) ▪︎Anemia With Renal Dialysis (Receiving ErythroPoietin) ▪︎Anemia With Inflammation 🔺3. Blood Transfusion Indications : ▪︎Severe Anemia (HB 7-8g/dl) ▪︎Sick Child With Infection & Anemia ▪︎Heart Failure & Anemia 🔺4. Diet Correction ➡️ ▪︎Iron Prophylaxis For Breast Fed Infants (2mg/kg/Day At 4-6m Age) ▪︎Avoid Cow's Milk in 1st Year Age ▪︎iron Rich Food (Meat/Fish/Chicken/Vitamin C)

Topic of tonight is #Pleural_effusion_Empyema@Clinicalpediatricround.

🔴Pleural Effusion ▪︎Fluid Accumulation Inside The Pleural Space (Between Visceral & Partial Pleura) 🔹Common Causes Of Pleural Effusion 1. Pneumonia 2. TB Infection 3. Heart Failure (HF) 4. Pulmonary Infarction 5. Malignancy 6. Subphrenic Abscess 7. Pancreatitis 🔹Types Of Pleural Fluid 📍1. Transudate (Protein <25g/L) ▪︎Clear Fluid Low in Protein & Cells ▪︎Due To Increase Hydrostatic Pressure (HF) Or Decrease Oncotic Pressure (Liver & Kidney Diseases/Malnutrition/HypoAlbuminaemia) 📍2. Exudate (Protein >35g/L) ▪︎Yellow Or Cloudy Fluid High in Protein & Cells ▪︎Due To Increase Microvascular Capillary Permeability By Infection Or Inflammations (Pneumonia/TB/Malignancy/Abscess/Lupus/Rheumatoid Arthritis/Uremia/Asbestos) 📍3. Chyle ➡️ Milky Fluid High in Lipids Due To Obstruction Of Lymphatic Drainage 📍4. Bloody ➡️ Due To Malignancy/Pulmonary Infarction/Traumatic Needle Tip 🔹Clinical Features Of Pleural Effusion 📍1. Small Amount (<300 ml) ➡️ Asymptomatic 📍2. Symptomatic Pleural Effusion (>500 ml) : ▪︎Pleuritic Chest Pain & Dyspnea ▪︎Pleural Rub ▪︎Stony Dullness Over The Effusion ▪︎Decrease Breath Sounds ▪︎Asymmetric Chest Expansion 🔹Dx Of Pleural Effusion 📍1. Chest Xray (Detection After 200ml Fluid Accumulation) : ▪︎Meniscus Sign ▪︎Obliteration Costophrenic Angle 📍2. US (Very Sensitive & Can Detect Small Amounts Of Fluid As 20 ml) ➡️ HypoEchoic Or Anechoic Lower Margin Of Pleural Space 🔹Mx Of Pleural Effusion 📍1. Therapeutic Aspiration (Remove 400-500 ml Fluids) 📍2. Tube Thoracotomy Indications : ▪︎Heart Or Pulmonary Diseases ▪︎Recurrent Effusion ▪︎High Viscosity Fluid ▪︎Urgent Drainage Of Infected Fluid 🔰Empyema ▪︎Pus Accumulation in Pleural Space Contain Large Amounts Of Neutrophils ▪︎Due To Infection in Neighbouring Structures (Bacterial Pneumonia/TB/Haemothorax Infection/Esophageal Rupture/SubPhrenic Abscess Rupture) 🔹Complications Of Empyema 📍1. BronchoPleural Fistula & PyoPneumothorax (Abscess Rupture into Bronchus) 📍2. Subcutaneous Abscess (Empyema Necessitans 📍3. Abscess Rupture Into Chest Wall 📍4. Pleural Effusion 🔹Clinical Features Of Empyema 📍1. Severe Pleuritic Chest Pain 📍2. High Remitting Or Persistent Pyrexia 📍3. Dyspnea With Cough & Sputum 📍4. Rigor/Sweating/Weight Loss 📍5. Increase WBCS & CRP 🔹Dx Of Empyema 📍1. Chest Xray ➡️ D-Shape Shadow/Air Fluid Level 📍2. Fluid Aspiration ➡️ Thick Turbid Fluid/Glucose <60 mg/PH <7/LDH >1000 IU 🔹Mx Of Empyema 📍1. Wide Bore InterCostal Tube Insertion 📍2. Antibiotics For 2-4w (IV Co-Amoxiclav/Cefuroxime/Metronidazole) 📍3. Surgical Removal (If Pus Is Thick & Loculated)

Topic of the day is #Bronchiectasis@Clinicalpediatricround

🔴Bronchiectasis

▪︎Abnormal Permanent Dilatation Of Respiratory Bronchi As Result Of Chronic inflammatory Process Leading To Chronic Respiratory Infections (Chronic Productive Cough) & Lung Damage

▪︎Risk Of Progression into Respiratory Failure (Bad Prognosis)

🔹Causes Of Bronchiectasis

📍1. Congenital :

▪︎Cystic Fibrosis & Ciliary Dysfunction Syndrome ▪︎Primary Hypogammaglobulinaemia ▪︎Kartagener Syndrome/Young Syndrome/Yellow Nail Syndrome

📍2. Acquired :

▪︎TB Infection (Most Common) ▪︎Severe Infection in Childhood (Whooping Cough/Measles) ▪︎Foreign Body Ingestion ▪︎Suppurativa Pneumonia Infection ▪︎Allergic Aspergillosis ▪︎Bronchial Tumors

🔹Clinical Features Of Bronchiectasis

📍1. Chronic Daily Productive Cough 📍2. Pleuritic Chest Pain 📍3. Haemoptysis 📍4. Halitosis (Bad Mouth Odour) 📍5. Weight Loss & Anorexia 📍6. Exertional Dyspnea 📍7. Finger Clubbing (Not Always) 📍8. Auscultation : ▪︎Coarse Crackles & Wheeze ▪︎Local Diminished Breath Sounds (Lobe Collapse)

🔹Dx Of Bronchiectasis

📍1. Chest Xray (50% Sensitivity To See Signs Indicate Thickened Airways & Dilatation) :

▪︎Ring Shadow Sign ▪︎Tramlines Sign ▪︎Gloved Fingers Sign ▪︎Consolidation

📍2. CT (97% Sensitivity) :

▪︎1cm Airway Dilatation ▪︎Bronchial Wall Thickening ▪︎Airways Larger Than Accompanying Vessels (Signet Ring Sign)

🔹Mx Of Bronchiectasis

📍1. Regular Physiotherapy (To Assist Sputum Drainage) 📍2. Antibiotics : ▪︎Co-Amoxiclav/Macrolides (Clarithromycin)/Tetracyclines (Most Commonly Used) ▪︎Ciprofloxacin/Piperacillin-Tazobactam/Ceftazidime (For Psuedomonas Infection For 14 Days) 📍3. Bronchial Artery Embolization (For Severe Haemoptysis) 📍4. Surgical Excision Of Bronchiectatic Area 📍5. Lung Transplantation

🔹Mx Of Asthma

🔶A. Acute Attacks (Status Asthmaticus)

📍1. High Flow Oxygen 📍2. SABA + Antimuscarinics (Salbutamol 2.5mg + Ipratropium 0.5mg) Nebulized Every 20Min (3x) 📍3. Systemic Steroids (Continue For 3-7 Days) : ▪︎Oral Prednisolone (1-2mg/Kg) ▪︎IV Methylprednisolone (1mg/Kg) ▪︎IV Hydrocortisone (5-10mg/Kg) 📍4. Adrenaline (0.01mg/Kg SC Or IV) Every 20Min 📍5. Mg Sulphate (IV 25-75mg/Kg Over 30min) 📍6. Aminophyline (IV Loading 5-10mg/Kg Then Maintenance 1mg/Kg/h) 📍7. Mechanical Ventilation If No Response To All Measure 📍8. Antibiotics If Bacterial infection Suspected

🔶B. Long Term Controllers

📍1. Mild Intermittent & Prophylaxis Against Asthma Attacks ➡️ SABA (Salbutamol [Ventolin] Or Terbutaline)

*Induce Bronchial Relaxation in 5-10 Min That Last 4-6h

📍2. Mild Persistent (One Drug) ➡️ [Low Dose ICS (Budesonide)] Or [Leukotriene inhibitors (Montelukast)] 📍3. Moderate Persistent (Two Drugs) ➡️ [Low Dose ICS] + [Leukotriene Inhibitors Or LABA (Formoterol) Or Theophyline] ▪︎No Response ➡️ Moderate Dose ICS ▪︎No Response ➡️ [Moderate Dose ICS] + [Leukotriene Inhibitors Or LABA Or Theophylines] 📍4. Severe Persistent ➡️ [High Dose ICS] + [Leukotriene Inhibitors Or LABA Or Theophylines]

▪︎No Response (4 Drugs) ➡️ [High Dose ICS] + [Leukotriene Inhibitors Or LABA Or Theophylines] + [Oral Steroids] + [Omalizmab]

🔴Asthma

▪︎Chronic Obstructive Inflammatory Disorder Of Airways (Airway HyperResponsiveness) ▪︎In Adults More in Females While In Children More in Males

🔹Risk Factors For Asthma

📍1. +Ve Family Hx Of Asthma Or Atopy 📍2. Severe Respiratory Infections During Childhood (Pneumonia/Bronchiolitis) 📍3. Early Breast Milk Weaning 📍4. Male Gender & Low Birth Weight 📍5. Smoking Exposure 📍6. Eosinophilia & Wheezing Episodes

🔹Types Of Asthma

🔸A. Childhood Asthma

📍1. Allergic Asthma (Atopic/Extrinsic) : ▪︎Most Common Type Of Asthma ▪︎Childhood Onset ▪︎IgE Mediated Type I Hypersensitivity ▪︎Personal & Family Hx Of Allergic Diseases (Atopy) ▪︎Good Response To Tx 📍2. Transient NonAtopic Asthma ➡️ Recurrent Episodes Of Wheeze In Children After Viral Infections That Resolved Without Persistent

🔸B. Cough Variant Asthma ➡️ The Only Predominant Symptoms is Dry Cough

🔸C. Aspirin Induced Asthma

▪︎Mostly In A Middle Age Female With Asthma & Rhinosinusitis & Nasal Polyps ▪︎Symptoms Occur After Alcohol Or Foods Or Any Compound Containing Salicylate (Aspirin)

🔸D. Exercise Induced Asthma ➡️ Symptoms Triggered Only By Physical Activity

🔸E. Non Allergic Asthma

▪︎Onset At Adulthood ▪︎Due To Lung SubMucosal Irritation ▪︎Poor Response To Tx

🔹Clinical Features Of Asthmatic Attacks

📍1. Recurrent Episodes Of Diffuse Bilateral Expiratory Wheeze With SOB & Chest Tightness & Cough 📍2. Diurnal Variation in Symptoms (Worst At Early Morning & Night) 📍3. Sleep Disturbances By Symptoms 📍4. Chest Hyperinflation & HyperResonant With Prolonged Expiration 📍5. Hx Of Other Atopy & +Ve Family Hx 📍6. Symptoms Respond To Bronchodilators

🔹Precipitants Of Asthmatic Attacks

📍1. Exercise in Cold Weather 📍2. Airborne Allergens & Pollutants 📍3. Viral URTI 📍4. Drugs (BB/Aspirin/OCP/Prostaglandin/Cholinegric Agents) 📍5. GERD/RhinoSinusitis

🔹Confirm Dx (If Age >5 Years)

🔶A. Spirometer

📍1. FEV1/FVC <0.7 (<70%) ➡️ Obstructive Picture 📍2. FEV1 >12% Increase After Bronchodilators (Good Response To Bronchodilators Specific For Asthma) 📍3. FEV1 >15% Decrease After 6min Of Exercise

🔶B. Diurnal Variation in PEF >20% On More Than 3 days For 2 Weeks

🔶C. Increase IgE & Eosinophills

🔹Classification Of Asthma Severity

📍1. Mild Intermittent : ▪︎Day Symptoms ➡️ ≤2/Week ▪︎Night Symptoms ➡️ ≤2/Month 📍2. Mild Persistent : ▪︎Day Symptoms ➡️ >2/Week ▪︎Night Symptoms ➡️ >2/Month 📍3. Moderate Persistent : ▪︎Day Symptoms ➡️ Every Day (Daily) ▪︎Night Symptoms ➡️ >1/Week 📍4. Severe Persistent : ▪︎Day Symptoms ➡️ Every Day (Daily) ▪︎Night Symptoms ➡️ Frequent (7x)/Week 📍5. Acute Severe Attack : ▪︎PEF 33-50% ▪︎Tachycardia & Tachypnea ▪︎Can't Complete Sentence in One Breath 📍6. Life Threatening Attack : ▪︎PEF <33% ▪︎SPO² <92% (<8KPa) ▪︎Normal Or Increase PaCo² ▪︎Silent Chest ▪︎Cyanosis/Bradycardia/Hypotension/Delirium & Coma 📍7. Near Fatal Attack ➡️ Increase PaCo² That Requiring Mechanical Ventilation

Topic of the day is #Asthma@Clinicalpediatricround

🔹DDX ➡️ Allergic Hypersensitivity Pneumonitis/Asthma/Pulmonary Edema/Vasculitis & Lupus

🔹Complications ➡️

1. ParaPneumonic Pleural Effusion 2. Lung Abscess (Empyema & Pneumatocele) 3. Bronchiectasis & Bronchiolitis Obliterans 4. Unilateral Hyperlucent Lung (Swyer James Syndrome) 5. Respiratory Failure/HF 6. Paralytic Ileus ➡️ Vomiting & Abdominal Distension in Infants 7. Sepsis (Meningitis/Pericarditis)

🔹Mx

🔶A. Oxygen (40-60%)

🔶B. IV Fluids Restriction (Give ⅔ Of Maintenance) ➡️ To Avoid Risk Of SIADH (Syndrome Of Inappropriate ADH Secretion)

🔶C. Empirical AB For 10-14 Days

📍1. Mild Case (At Home)

▪︎Amoxicillin (80-90mg/Kg/Day) ➡️ 1st Line ▪︎Alternative To 1st Line ➡️ Cefuroxime/Amoxiclav ▪︎Macrolides (Azithromycin) ➡️ For Atypical Pneumonia in School Age Children ▪︎Fluoroquinolones (Levofloxacin/Moxi/Gemi) ➡️ in Adolescents

📍2. Moderate-Severe (At Hospital) ➡️ IV Cefotaxime Or Ceftriaxone + Vancomycin Or Clindamycin

🔶D. Change To Specific AB According To Culture

▪︎Streptococcus/H.influenza ➡️ Amoxicillin ▪︎Staph.Aureus ➡️ Vancomycin/Clindamycin/Oxacillin ▪︎Klebsella ➡️ Aminoglycosides ▪︎Afebrile/Atypical/Viral ➡️ Macrolides (Erythromycin/Azithromycin)

🔶E. Oral Zinc (10-20mg/Day)

🔶F. Prevention ➡️ PCV-13 & Influenza Vaccine

🔹Causes Of No Improvement On AB (Slowly Resolving Pneumonia)

1. Complications Developed (Empyema) 2. Bronchial Obstruction (FB/Mucous Plug) 3. Bacterial Resistance To AB 4. Coexisting Diseases Causes Recurrent Pneumonia ▪︎Immunodeficiency/Cystic Fibrosis/Sickle Cell ▪︎Aspiration/GERD/Fistula ▪︎Bronchiectasis/Congenital Heart Disease (ASD/VSD/PDA) .....

Most Common Bacterial Cause Of Pneumonia ➡️ Streptococcus Pneumonia

1st Line Antibiotics For Bacterial Pneumonia ➡️ Amoxicillin/Ampicillin

🔴Pneumonia in Pediatrics

▪︎Acute Lower RT Infection Affects Lung Parenchyma & Alveolar Spaces & Bronchioles

▪︎Characterized By Lung Consolidation On Chest xray ▪︎Most Common Bacterial Cause ➡️ Streptococcal Pneumonia

🔹Risk Factors For Pneumonia

1. Lung Diseases (Asthma/Cystic Fibrosis) & Immunodeficiency 2. TracheoEsophageal Fistula & GERD & Neurological Disease (Risk Of Aspiration) 3. Foreign Body & Hydrocarbons Aspiration شارب نفط 4. Hospital Admission (ICU) 5. Fall & Winter Seasons

🔹Organisms Causing Pneumonia

📍1. In Neonates (3w-4Years) ➡️

▪︎Streptococcus (Pneumococcal) ▪︎Viral (RSV in Infants/ParaInfluenza & Influenza & AdenoVirus & Human MetaPneumo Virus in Children <5 Years)

📍2. Before School Age (<5 Years) ➡️ Staph.Aureus (Most Dangerous)

📍3. During School Age (>5 Years) ➡️ Atypical Pneumonia (Mycoplasma/Chlamydia)

📍4. At Any Age ➡️ Streptococcus (Pneumococcus)/H.influenza

📍5. Afebrile Pneumonia (No Fever) ➡️ Chlamydia Trachomatis/Mycoplasma Hominis/Ureaplasma Urealyticum/CMV

📍6. in Immunocompromised ➡️ Gram -Ve Enteric Bacteria/Mycobacteria/Asperigillosis/CMV/Pneumocystis Jirovecii

📍7. In Patients With Cystic Fibrosis ➡️ Staph.Aureus (Infants)/Psedomonas & Burkholderia (Older Age)

🔹Clinical Features & Dx

📍1. Prodromal Symptoms Of Rhinitis & Cough

📍2. Then Bad General Condition (Toxemia) & Decrease Feeding

📍3. Cough

▪︎Productive ➡️ Bacterial ▪︎Dry ➡️ Viral/Atypical

📍4. Dyspnea (Nasal Flaring/Muscle Retraction/Grunting)/Tachypnea

📍5. Cyanosis & Lethargy (in Severe Cases)

📍6. Fever

▪︎High Grade ➡️ Bacterial ▪︎Low Grade ➡️ Viral/Atypical ▪︎No Fever ➡️ Afebrile Pneumonia

📍7. Crackles & Wheeze

▪︎Localized ➡️ Typical Pneumonia (Streptococcus) ▪︎Diffuse ➡️ Viral/Atypical/Staph.Aureus

📍8. Chest Dullness To Percussion/Bronchial Breathing/Decrease Breath Sounds

📍9. Lung Infiltration On Chest Xray

▪︎One Or More Lobes ➡️ Lobar Bacterial Pneumonia ▪︎Scattered Bilateral Patchy Infiltration ➡️ Bronchopneumonia ▪︎Diffuse Bilateral Interstitial Infiltration With Hyperinflation ➡️ Viral/Atypical ▪︎Cavity/Air Fluid Level/Effusion/Collapse/Fibrosis/Pneumatocele ➡️ Staph.Aureus Pneumonia

📍10. Conjunctivitis in Chlamydia Pneumonia

📍11. CBC

▪︎Lymphocytosis ➡️ Viral ▪︎Neutrophilia & High ESR & CRP ➡️ Bacterial ▪︎Eosinophilia ➡️ Chlamydia Trachomatis

Topic of Tonight is #Pneumonia

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