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Toronto Notes 2019 Infectious Diseases Pediatrics P47
• metastasesarecommonatpresentation(>50%presentwithadvancedstagedisease):
■ usually to bone or bone marrow (presents as bone pain, limp)
■ can also present with periorbital ecchymoses, abdominal pain, emesis, fever, weight loss, anorexia,
hepatomegaly, “blueberry muffin” skin nodules
• paraneoplastic:HTN,palpitations,sweating(fromexcessivecatecholamines),diarrhea,FTT(from
vasoactive intestinal peptide secretion), opsomyoclonus
Management
• dependsonprognosticfactorsandmayincludecombinationof:surgery,radiation,chemotherapy, autologous stem cell transplantation, immunotherapy
Prognosis
• prognosisisoftenpoorduetolatedetection
• goodprognosticfactors
■ “age and stage” are important determinants of better outcome: <18 mo, stage I, II, IV-S disease (“S” designates a “Special” classification only pertaining to infants)
■ primary site: posterior mediastinum and neck
■ lowserumferritin
■ more differentiated histology
■ tumour cell markers: aneuploidy, absent MYCN oncogene amplification
Bone Tumours
• seeOrthopedics,OR46
Cancer Predisposition Syndromes
• suspectedincasesofmultipleprimaryneoplasms,especiallyearlyonsetforcancertypeand/orfamily history consistent with known cancer predisposition syndrome (critical to obtain family history and refer if syndrome suspected)
• cancerpredispositionsyndromeswithpediatriconsetincludeLi-Fraumenisyndrome(softtissue sarcomas, osteosarcoma, CNS tumours and adrenal cortical carcinoma), hereditary retinoblastoma, and Fanconi anemia (leukemias)
Infectious Diseases
Fever
Definition
• fever:apracticaldefinitionis>38oC/100.4oForalorrectal
• feverwithoutasource/focus:acutefebrileillness(typically<10dduration)withnocauseoffevereven
after careful history and physical
• feverofunknownorigin:dailyorintermittentfeversforatleast2consecutivewkofuncertaincause
after careful history and physical, and initial laboratory assessment
Etiology
• infectious:anatomicapproach(CNS,ears,upperandlowerrespiratorytract,GI,GU,skin,softtissue, bones and joints, etc.)
• inflammatory:mainlyautoimmune(Kawasakidisease,JIA,IBD,SLE,etc.)
• malignancy:childhoodcancers(leukemia,lymphoma,neuroblastoma,etc.)
• miscellaneous:dehydration,drugsandtoxins,post-immunization,familialdysautonomia,factitious
disorder, etc.
Diagnosis
• history:duration,heightandpatternoffever,associatedsymptoms,exposures,constitutional symptoms, recent antipyretic use, ethnic or genetic background, day care, sick contacts, travel, tick bites, age of child
• physicalexam:toxicvs.non-toxic,vitals,growth,completeexamsoftheskin,HEENT,chest,abdomen, lymph nodes, genitalia
• investigations:guidedbyhistory,physicalexam,andclinicalsuspicion
Evaluation of Neonates and Infants with Fever
• severalprotocolsexistthatattempttoidentifyneonatesandyounginfantsatlowriskofseriousbacterial infection (e.g. Rochester Criteria)
■ such protocols are not as sensitive in the 1-28 d age group; therefore, febrile neonates should be considered high risk regardless of clinical presentation and laboratory findings