Nelson Pediatric Symptom-Based Diagnosis

1126 Pages·2017·135.06 MB·English

by  Robert M. Kliegman

Nelson
Pediatric
Symptom-Based
Diagnosis
Nelson
Pediatric
Symptom-Based
Diagnosis
Robert M. Kliegman, MD Heather Toth, MD
Professor and Chair Emeritus Associate Professor
Department of Pediatrics Program Director, Internal Medicine-Pediatrics
Medical College of Wisconsin Residency Program
Children’s Hospital of Wisconsin Hospitalist, Departments of Medicine and Pediatrics
Milwaukee, Wisconsin Medical College of Wisconsin
Milwaukee, Wisconsin
Patricia S. Lye, MD
Donald Basel, MD
Professor and Vice Chair of Education
Department of Pediatrics Associate Professor and Section Chief
Medical College of Wisconsin Division of Medical Genetics
Children’s Hospital of Wisconsin Medical College of Wisconsin
Milwaukee, Wisconsin Milwaukee, Wisconsin
Brett J. Bordini, MD
Assistant Professor of Pediatrics
Section of Hospital Medicine
Assistant Professor of Global Health
Medical College of Wisconsin
Milwaukee, Wisconsin
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
NELSON PEDIATRIC SYMPTOM-BASED DIAGNOSIS ISBN 978-0-323-39956-2
Copyright © 2018 by Elsevier, Inc. All rights reserved.
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Library of Congress Cataloging-in-Publication Data
Names: Kliegman, Robert, editor. | Lye, Patricia S., editor. | Bordini, Brett J.,
editor. | Toth, Heather, editor. | Basel, Donald, editor.
Title: Nelson pediatric symptom-based diagnosis / [edited by]
Robert M. Kliegman, Patricia S. Lye, Brett J. Bordini, Heather Toth,
Donald Basel.
Other titles: Pediatric symptom-based diagnosis
Description: Philadelphia, PA : Elsevier, [2018] | Includes bibliographical
references and index.
Identifiers: LCCN 2016050910 | ISBN 9780323399562 (hardcover :
alk. paper)
Subjects: | MESH: Signs and Symptoms | Pediatrics | Diagnosis, Differential
| Adolescent | Child | Infant
Classification: LCC RJ50 | NLM WB 143 | DDC 618.92/0075–dc23 LC
record available at https://lccn.loc.gov/2016050910
Executive Content Strategist: Kate Dimock
Senior Content Development Specialist: Jennifer Ehlers
Publishing Services Manager: Patricia Tannian
Senior Project Manager: Amanda Mincher
Design Direction: Brian Salisbury
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1
This book is dedicated to the Children’s Hospital of Wisconsin residents. Their enthusiasm, thirst for
knowledge, and desire to become outstanding pediatricians inspire us.
C O N T R I B U TO R S
Omar Ali, MD Deborah M. Costakos, MS, MD Bhaskar Gurram, MB BS, MD
Professor of Pediatric Endocrinology Associate Professor of Ophthalmology Assistant Professor of Pediatric
Department of Pediatrics Medical College of Wisconsin Gastroenterology
Medical College of Wisconsin Milwaukee, Wisconsin University of Texas Southwestern Medical
Milwaukee, Wisconsin Center
Emily M. Densmore, MD, MS Dallas, Texas
Louella B. Amos, MD Assistant Professor of Pediatrics
Assistant Professor Medical College of Wisconsin Kristen E. Holland, MD
Pediatrics, Division of Pulmonary and Sleep Milwaukee, Wisconsin Associate Professor of Dermatology
Medicine Medical College of Wisconsin
Medical College of Wisconsin John C. Densmore, MD Milwaukee, Wisconsin
Milwaukee, Wisconsin Associate Professor of Surgery
Medical College of Wisconsin Stephen R. Humphrey, MD
Donald Basel, MD Milwaukee, Wisconsin Assistant Professor of Dermatology
Associate Professor and Section Chief Children’s Hospital of Wisconsin
Division of Medical Genetics Patricia A. Donohoue, MD Medical College of Wisconsin
Medical College of Wisconsin Professor and Section Chief Milwaukee, Wisconsin
Milwaukee, Wisconsin Pediatric Endocrinology and Diabetes
Medical College of Wisconsin Alvina R. Kansra, MD
Brett J. Bordini, MD Milwaukee, Wisconsin Assistant Professor of Pediatrics
Assistant Professor of Pediatrics Medical College of Wisconsin
Section of Hospital Medicine Shayne D. Fehr, MD Wauwatosa, Wisconsin
Assistant Professor of Global Health Assistant Professor of Pediatric Orthopedics
Medical College of Wisconsin Medical College of Wisconsin Virginia Keane, MD
Milwaukee, Wisconsin Milwaukee, Wisconsin Mt. Washington Pediatric Hospital
Baltimore, Maryland
Amanda M. Brandow, DO, MS Susan Feigelman, MD
Associate Professor of Pediatrics Professor of Pediatrics Kirstin Kirschner, MD
Medical College of Wisconsin University of Maryland School of Medicine Child and Adolescent Psychiatrist
Milwaukee, Wisconsin Baltimore, Maryland Rainier Associates
Tacoma, Washington
Ryan Byrne, MD Veronica H. Flood, MD
Department of Psychiatry Associate Professor Julie M. Kolinski, MD
Division of Child and Adolescent Psychiatry Division of Pediatric Hematology/Oncology Assistant Professor
Medical University of South Carolina Department of Pediatrics Department of Pediatrics and Internal
Charleston, South Carolina Medical College of Wisconsin Medicine
Milwaukee, Wisconsin Medical College of Wisconsin
Yvonne E. Chiu, MD Milwaukee, Wisconsin
Associate Professor of Dermatology and Jessica Francis, MD
Pediatrics Department of Obstetrics and Gynecology Chamindra Konersman, MD
Medical College of Wisconsin Medical College of Wisconsin Affiliated Assistant Professor of Neurosciences
Milwaukee, Wisconsin Hospitals University of California, San Diego
Milwaukee, Wisconsin San Diego, California
Dominic Co, MD, PhD
Assistant Professor of Pediatrics Julia Fritz, MD John V. Kryger, MD
Medical College of Wisconsin Instructor in Pediatrics Chief of Pediatric Urology
Milwaukee, Wisconsin Pediatric Gastroenterology, Hepatology, and Children’s Hospital of Wisconsin
Nutrition Professor
Paula Cody, MD, MPH Medical College of Wisconsin Department of Urology
Assistant Professor of Pediatrics Milwaukee, Wisconsin Medical College of Wisconsin
University of Wisconsin School of Medicine Milwaukee, Wisconsin
and Public Health Sandra Gage, MD, PhD
Madison, Wisconsin Associate Professor of Pediatrics Jacquelyn C. Kuzminski, MD
Medical College of Wisconsin Pediatrician
Gary Cohen, MD, MS Milwaukee, Wisconsin Aurora Health Care
Associate Professor of Pediatrics Milwaukee, Wisconsin
Medical College of Wisconsin
Milwaukee, Wisconsin
vii
viii Contributors
Sara M. Lauck, MD Brittany Player, DO, MS Grzegorz W. Telega, MD
Assistant Professor of Pediatrics Assistant Professor of Pediatrics Associate Professor of Pediatrics
Medical College of Wisconsin Section of Hospital Medicine Medical College of Wisconsin
Milwaukee, Wisconsin Medical College of Wisconsin Milwaukee, Wisconsin
Milwaukee, Wisconsin
Patricia S. Lye, MD John G. Thometz, MD
Professor and Vice Chair of Education Angela L. Rabbitt, DO Medical Director, Orthopedic Surgery
Department of Pediatrics Associate Professor of Pediatrics Children’s Hospital of Wisconsin
Medical College of Wisconsin Medical College of Wisconsin Professor of Orthopaedic Surgery
Children’s Hospital of Wisconsin Milwaukee, Wisconsin Medical College of Wisconsin
Milwaukee, Wisconsin Milwaukee, Wisconsin
Amanda Rogers, MD
Seema Menon, MD Assistant Professor of Pediatrics Heather Toth, MD
Pediatric and Adolescent Gynecology Medical College of Wisconsin Associate Professor
Program Director, Children’s Hospital of Milwaukee, Wisconsin Program Director, Internal Medicine—
Wisconsin Pediatrics Residency Program
Associate Professor John R. Routes, MD Hospitalist, Departments of Medicine and
Obstetrics and Gynecology Professor of Pediatrics Pediatrics
Medical College of Wisconsin Medical College of Wisconsin Medical College of Wisconsin
Milwaukee, Wisconsin Milwaukee, Wisconsin Milwaukee, Wisconsin
Adrian Miranda, MD
J. Paul Scott, MD Scott K. Van Why, MD
Professor of Pediatrics
Professor Professor
Division of Pediatric Gastroenterology,
Division of Pediatric Hematology/Oncology Department of Pediatrics
Hepatology, and Nutrition
Department of Pediatrics Medical College of Wisconsin
Medical College of Wisconsin
Medical College of Wisconsin Milwaukee, Wisconsin
Milwaukee, Wisconsin
Milwaukee, Wisconsin
Sarah Vepraskas, MD
Priya Monrad, MD
Anjali Sharma, MD Assistant Professor of Pediatrics
Assistant Professor
Pediatrician Department of Pediatrics
Department of Child and Adolescent
Children’s Medical Group Section of Hospital Medicine
Neurology
Milwaukee, Wisconsin Medical College of Wisconsin
Medical College of Wisconsin
Milwaukee, Wisconsin
Milwaukee, Wisconsin
Mark Simms, MD, MPH
Professor of Pediatrics James W. Verbsky, MD, PhD
James Nocton, MD
Medical College of Wisconsin Associate Professor of Pediatrics
Professor of Pediatrics
Medical Director Medical College of Wisconsin
Medical College of Wisconsin
Child Development Center Milwaukee, Wisconsin
Milwaukee, Wisconsin
Children’s Hospital of Wisconsin
Milwaukee, Wisconsin Bernadette Vitola, MD, MPH
Joshua Noe, MD
Assistant Professor of Pediatrics
Associate Professor of Gastoenterology,
Paula J. Soung, MD Pediatric Gastroenterology, Hepatology, and
Hepatology, and Nutrition
Assistant Professor of Pediatrics Nutrition
Department of Pediatrics
Section of Hospital Medicine Medical College of Wisconsin
Medical College of Wisconsin
Medical College of Wisconsin Milwaukee, Wisconsin
Milwaukee, Wisconsin
Milwaukee, Wisconsin
Richard J. Noel, MD, PhD Michael Weisgerber, MD, MS
Associate Professor and Division Chief Raji Sreedharan, MD Associate Professor
Pediatric Gastroenterology, Hepatology, and Associate Professor Department of Pediatrics
Nutrition Pediatrics/Nephrology Section of Hospital Medicine
Department of Pediatrics Medical College of Wisconsin Program Director, Pediatric Residency
Duke University Medical Center Wauwatosa, Wisconsin Program
Durham, North Carolina Program Director, Pediatric-Anesthesia
Robert R. Tanz, MD Combined Program
Cynthia G. Pan, MD Professor of Pediatrics Medical College of Wisconsin
Professor Northwestern University Feinberg School of Milwaukee, Wisconsin
Department of Pediatrics Medicine
Medical College of Wisconsin Attending Physician Peter M. Wolfgram, MD
Milwaukee, Wisconsin Division of Academic General Pediatrics Assistant Professor of Pediatrics
Ann and Robert H. Lurie Children’s Medical College of Wisconsin
Andrew N. Pelech, MD Hospital Milwaukee, Wisconsin
Professor of Pediatrics Chicago, Illinois
University of California, Davis
Sacramento, California
P R E FAC E
This book is intended to help the reader begin with a specific chief help provide a quick visual guide to the differential diagnosis of the
complaint that may be seen in many different disease entities. It is various diseases under discussion. The diagnostic approach includes
arranged in chapters that cover specific symptoms mirroring clinical standard laboratory and radiologic testing, as well as advanced imaging
practice. Patients do not usually present with a chief complaint of studies and genetic-based analysis.
cystic fibrosis; rather, they may present with a cough, respiratory dis- We appreciate the hard work of our contributing authors. Writing
tress, or chronic diarrhea. a chapter in this type of format is quite different from writing in the
With a user-friendly, well-tabulated, illustrated approach, this text format of a disease-based book. In addition, we thank Kate Dimock
will help the reader differentiate between the many disease states and Jennifer Ehlers of Elsevier, whose patience and expertise contrib-
causing a common symptom. The inclusion of many original tables uted to the publication of this book. We are all also greatly appreciative
and figures should help the reader identify distinguishing features of of Carolyn Redman at the Medical College of Wisconsin Department
diseases and work through a diagnostic approach to the symptom. of Pediatrics, whose editorial assistance and organization have made
Modified and borrowed artwork and tables from other outstanding this new edition a reality. Finally, we are ever grateful for the under-
current sources have been added as well. The combination of all of standing and patience of Diane Basel, Jessica Bordini, Ryan Festerling,
these illustrations and tables with diagnostic clues within the text will Sharon Kliegman, and Dale Lye in supporting this work.
ix
SECTION 1  Respiratory Disorders
1
Sore Throat
Robert R. Tanz
Most causes of sore throat are nonbacterial and neither require nor are is rarely reason to test outpatients and infrequent benefit to testing inpa-
alleviated by antibiotic therapy (Tables 1.1, 1.2, and 1.3). Accurate tients except to confirm and treat influenza.
diagnosis is essential: Acute streptococcal pharyngitis warrants diag- Adenoviruses can cause upper and lower respiratory tract disease,
nosis and therapy to ensure prevention of serious suppurative and ranging from ordinary colds to severe pneumonia and multisystem
nonsuppurative complications. Life-threatening infectious complica- disease, including hepatitis, myocarditis, and myositis. The incubation
tions of oropharyngeal infections, whether streptococcal or nonstrep- period of adenovirus infection is 2-4 days. Upper respiratory tract
tococcal, may manifest with mouth pain, pharyngitis, parapharyngeal infection typically produces fever, erythema of the pharynx, and fol-
space infectious extension, and/or airway obstruction (Tables 1.4 and licular hyperplasia of the tonsils, together with exudate. Enlargement
1.5). In many cases, the history and/or physical exam can help direct of the cervical lymph nodes occurs frequently. When conjunctivitis
diagnosis and treatment, but the enormous number of potential causes occurs in association with adenoviral pharyngitis, the resulting syn-
is too large to address all of them. drome is called pharyngoconjunctival fever. Pharyngitis may last as
long as 7 days and does not respond to antibiotics. There are many
adenovirus serotypes; adenovirus infections may therefore develop in
VIRAL PHARYNGITIS children more than once. Laboratory studies may reveal a leukocytosis
and an elevated erythrocyte sedimentation rate. Adenovirus outbreaks
Most episodes of pharyngitis are caused by viruses (see Tables 1.2 and have been associated with swimming pools and contamination in
1.3). It is difficult to clinically distinguish between viral and bacterial health care workers.
pharyngitis with a very high degree of precision, but certain clues may The enteroviruses (coxsackievirus and echovirus) can cause sore
help the physician. Accompanying symptoms of conjunctivitis, rhini- throat, especially in the summer. High fever is common, and the throat
tis, cough, discrete ulcerations, croup, or laryngitis are common with is erythematous but usually not bright red; tonsillar exudate and cervi-
viral infection but rare in bacterial pharyngitis. cal adenopathy are unusual. Symptoms resolve within a few days.
Many viral agents can produce pharyngitis (see Tables 1.2 and 1.3). Enteroviruses can also cause meningitis, myocarditis, rash, and two
Some cause distinct clinical syndromes that are readily diagnosed specific syndromes that involve the oropharynx.
without laboratory testing (Table 1.6; see also Tables 1.1 and 1.4). In Herpangina is characterized by distinctive discrete, painful, gray-
pharyngitis caused by parainfluenza and influenza viruses, rhinovi- white papulovesicular lesions distributed over the posterior orophar-
ruses, coronaviruses, and respiratory syncytial virus (RSV), the symp- ynx (see Table 1.6). The vesicles are 1-2 mm in diameter and are
toms of coryza and cough often overshadow sore throat, which is initially surrounded by a halo of erythema before they ulcerate. Fever
generally mild. Influenza virus may cause high fever, cough, headache, may reach 39.5°C. The illness is due to enteroviruses and generally lasts
malaise, myalgia, and cervical adenopathy in addition to pharyngitis. less than 7 days, but severe pain may impair fluid intake and occasion-
In young children, croup or bronchiolitis may develop. When influenza ally necessitates medical support.
is suspected on clinical and epidemiologic grounds or confirmed by Hand-foot-mouth disease is caused by coxsackievirus A16. Painful
testing (polymerase chain reaction [PCR] is most accurate), specific vesicles that ulcerate can occur throughout the oropharynx. Vesicles
antiviral therapy is available for treatment of patients and prophylaxis also develop on the palms, soles, and, less often, on the trunk or
of family members. RSV is associated with bronchiolitis, pneumonia, extremities. Fever is present in most cases, but many children do not
and croup in young children. RSV infection in older children is usually appear seriously ill. This disease lasts less than 7 days.
indistinguishable from a simple upper respiratory tract infection. Primary infection caused by herpes simplex virus (HSV) usually
Pharyngitis is not a prominent finding of RSV infection in any age produces high fever with acute gingivostomatitis, involving vesicles
group. Parainfluenza viruses are associated with croup and bronchiol- (which become ulcers) throughout the anterior portion of the mouth,
itis; minor sore throat and signs of pharyngitis are common at the including the lips. There is sparing of the posterior pharynx in herpes
outset but rapidly resolve. Infections caused by parainfluenza, influ- gingivostomatitis; the infection usually occurs in young children.
enza, and RSV are often seen in seasonal (winter) epidemics. Many High fever is common, pain is intense, and intake of oral fluids is
agents can be identified using multiplex or targeted PCR testing, but there often impaired, which may lead to dehydration. In addition, HSV may
1
CHAPTER 1  Sore Throat 1.e1
(See Nelson Textbook of Pediatrics, p. 2019)
2 SECTION 1  Respiratory Disorders
TABLE 1.1 Etiology of Sore Throat TABLE 1.2 Infectious Etiology
of Pharyngitis
Infection
Bacterial (see Tables 1.2, 1.3) Definite Causes
Viral (see Tables 1.2, 1.3) Streptococcus pyogenes (Group A streptococci)
Fungal (see Table 1.3) Corynebacterium diphtheriae
Neutropenic mucositis (invasive anaerobic mouth flora) Arcanobacterium haemolyticum
Tonsillitis Neisseria gonorrhoeae
Epiglottitis Epstein-Barr virus
Uvulitis Parainfluenza viruses (types 1–4)
Peritonsillar abscess (quinsy) Influenza viruses
Retropharyngeal abscess (prevertebral space) Rhinoviruses
Ludwig angina (submandibular space) Coronavirus
Lateral pharyngeal space cellulitis-abscess Adenovirus (types 3, 4, 7, 14, 21, others)
Buccal space cellulitis Respiratory syncytial virus
Suppurative thyroiditis Herpes simplex virus (types 1, 2)
Lemierre syndrome (septic jugular thrombophlebitis)
Vincent angina (mixed anaerobic bacteria–gingivitis–pharyngitis) Probable or Occasional Causes
Group C streptococci
Irritation Group G streptococci
Cigarette smoking Chlamydia pneumoniae
Inhaled irritants Chlamydia trachomatis
Reflux esophagitis Mycoplasma pneumoniae
Chemical toxins (caustic agents)
Paraquat ingestion
Smog
Dry hot air
Hot foods, liquids
TABLE 1.3 Additional Potential Pathogens
Other Associated with Sore Throat
Tumor, including Kaposi sarcoma, leukemia
Bacteria
Granulomatosis with polyangiitis (formerly Wegener granulomatosis)
Fusobacterium necrophorum (Lemierre syndrome)
Sarcoidosis
Neisseria meningitidis
Glossopharyngeal neuralgia
Yersinia enterocolitica
Foreign body
Tularemia (oropharyngeal)
Stylohyoid syndrome
Yersinia pestis
Behçet disease
Bacillus anthracis
Kawasaki syndrome
Chlamydia psittaci
Posterior pharyngeal trauma—pseudodiverticulum
Secondary syphilis
Pneumomediastinum with air dissection
Mycobacterium tuberculosis
Hematoma
Lyme disease
Systemic lupus erythematosus
Corynebacterium ulcerans
Bullous pemphigoid
Leptospira species
Syndrome of periodic fever, aphthous stomatitis, pharyngitis, cervical
Mycoplasma hominis
adenitis (PFAPA)
Virus
Coxsackievirus A, B
Cytomegalovirus
manifest as pharyngitis in adolescents. Approximately 35% of new-
Viral hemorrhagic fevers
onset HSV-positive adolescent patients have herpetic lesions; most
Human immunodeficiency virus (HIV) (primary infection)
teenage patients with HSV pharyngitis cannot be distinguished from
Human herpesvirus 6
patients with other causes of pharyngitis. The classic syndrome of
Measles
herpetic gingivostomatitis in infants and toddlers lasts up to 2 weeks;
Varicella
data on the course of more benign HSV pharyngitis are lacking. The
Rubella
differential diagnosis of vesicular-ulcerating oral lesions is noted in
Table 1.6.
Fungus
A common cause of a local and large lesion of unknown etiology
Candida species
is aphthous stomatitis (Fig. 1.1). PFAPA (periodic fever, aphthous
Histoplasmosis
stomatitis, pharyngitis, and cervical adenitis) is an idiopathic periodic
Cryptococcosis
fever syndrome that occurs predictably every 2-8 weeks. The onset of
PFAPA is usually before the age of 5 years. In addition to aphthous
stomatitis and pharyngitis, PFAPA is characterized by high fever lasting
4-6 days. Individual episodes resolve spontaneously but may respond