complications

Ovsyannikov D.YU.Khaled M.

Enhances parameters of immune function

Improves antibody production

Activates T-cells

Produces cytokines

Enhances neutrophil and macrophage function

Metamizole (analigine)  incidence rate of metamizole-induced agranulocytosis Metamizole was banned in Sweden in 1974, and in the United States in

1977. Since then, more than 30 countries (including Japan, Australia, Iran, and several of the European Union member nations) have followed suit. In these countries, metamizole is still occasionally used as a veterinary drug

In Germany, Hungary, Italy, Portugal and Spain it is a prescription drug. In other countries including Brazil, Bulgaria, Chile, Egypt, India, Israel, the

Republic of Macedonia, Mexico, Poland, Russia, Spain, and Turkey, metamizole is still widely available over-the-counter, remains one of the most popular analgesics, and plays an important role in self-medication. For example, metamizole and metamizole-containing drugs account for 80% of OTC analgesic market in Russia, whereas ibuprofen accounts for 2.5%

non-steroidal anti-inflammatory drugs

(ibuprofen) + chickenpox

also known as (Flesh-Eating Disease) Necrotising Fasciitis Associated with Non-Steroidal Anti-Inflammatory

Drugs A case-control study conducted in Washington State and evaluating NF and

ibuprofen use, investigated the use of ibuprofen and other risk factors for NF, in the setting of primary varicella

This study suggests an association between ibuprofen use and the development of NF among children with varicella, and also an association between ibuprofen use and severe complications of NF.

Febrile seizures

Dehydration

Cerebral edema

90% occur between 6 months and 6 years. Usually 6 mo – 5 years of age

◦ Peak occurrence is in children 18 - 24 months of age

Majority (65 to 90%) of these are simple febrile seizures

Vaccination is rarely followed by febrile convulsion and mainly after:

DTP after one day of vaccination in 6-9/100000 MMR after 8-14 day of vaccine in 25-35/100000

Illnesses associated with febrile seizureCommonest clinical diagnosis

Upper respiratory tract infection

Less common clinical diagnoses

Otitis media

Bronchopeumonia

Pertussis

Gastroenteritis

Measles

Exanthem subitum

Scarlet fever

In most cases it is generalized tonic clonic convulsion.

Febrile convulsion is divided into three main groups based on symptoms of the seizure:

Simple febrile convulsion Complex febrile convulsion Febrile status epilepticus.

Simple febrile seizure ◦ Lasts less than 15

minutes◦ Occurs once in a 24-hour

period Generalized Focal◦ No previous neurologic

problems

Complex febrile seizure◦ Lasts 15 minutes or

longer◦ Occurs more than once

in a 24-hour period◦ Patient has known

neurologic problems, such as cerebral palsy

RISK FACTORS(Nelson & Ellenberg Study – 1978) Change

Young age (<12 Months)

Epilepsy in 1st degree relatives

Initial Seizure – Complex Febrile

6%

22%

49%

Risk of future epilepsy in children with febrile seizures

2.5%

NO RISK 1 RISK 2 RISK 3 RISKFACTORS FACTORS FACTORS FACTORS

The prevalence of meningitis among patients with febrile seizures was 1-2%

◦ The absence of any remarkable findings on the history or physical examination makes bacterial meningitismeningitis unlikely as the cause of the fever and seizure

Strongly admit for lumbar puncture or treatment if any of the following factors present:1. Age under 18 months (may have meningitis

with no signs).2. If signs of meningitis present.3. Child is toxic.4. Current treatment with antibiotics because

may mask meningeal signs5. Complex convulsion6. Parents wish (anxious)

Current guidelines do not recommend the use of continuous or intermittent therapy with neuroleptics or benzodiazepines after a simple febrile seizure

No medication has been shown to reduce the risk of an afebrile seizure after a simple febrile seizure

Control fever by antipyretics (paracetamole or ibubrufen) + cold compressors.

Rectal diazepam rarely need to abort febrile convulsion because convulsion most of the time is short in duration but prolonged give it.

Pre-hospital, rectal diazepam (a single dose of 0.5 mg per kg for children two to five years of age)

diazepam (0.2 to 0.5 mg per kg of weight intravenously every 15 minutes for a cumulative dosage of 5 mg in children 1 month – 5 years of age) often is effective

Lorazepam (0.1 mg per kg up to 4 mg) is another intravenous medication, and it has a longer duration of action compared with diazepam

This is an excess accumulation of water in the intra- and/or extra cellular spaces of the brain.

Clinical signs of cerebral oedema begin to Clinical signs of cerebral oedema begin to appear when the intracranial pressure exceeds appear when the intracranial pressure exceeds 30mm Hg30mm Hg

Early warning signs of cerebral edema include: headache (especially new onset of headache

during treatment), irritability or altered behaviour.

Drowsiness, decreasing level of consciousness.   Abnormalities of the vital signs (bradycardia,

hypertension) and blurred disc margins are late signs. If left untreated, it can lead to death.

Osmotherapy

The most rapid and effective means of decreasing tissue water and brain bulk is osmotherapy

Osmotic therapy is intended to draw water out of the brain by an osmotic gradient and help to decrease blood viscosity.

Mannitol is the most popular osmotic agent.Mannitol is thought to decrease brain volume by decreasing overall water content, and to reduce blood volume by vasoconstriction. Mannitol may also improve cerebral perfusion by decreasing viscosity or altering red blood cell rheology. Lastly mannitol may exert a protective effect against biochemical injury.

1.The boy 6 years of age. Sickness began sharply with increasing temperature up to 39,8 º C, complaining of headaches , become lethargic, moody, decreased appetite .On the second day of the disease appeared dry painful cough . By the beginning of day 3 of the disease appeared mucous discharge from the nose .

Examination by Pediatrician: the temperature was 37,9 º C. Sluggish and irritating . Scleral vessels injected . Skin is clean , flushing of the cheeks. Nasal breathing is difficult , moderate mucous discharge . Moderate hyperemia of the throat with previous cyanotic discoloration , Gritty(granular) posterior pharyngeal wall . Lymph nodes in the neck are not enlarged , painless on palpation. Heart sounds melonormaland rhythmic . HR 118 per minute. In the lungs – harsh breathing and wheezing. Respiratory Rate 28-30 per minute. The abdomen was soft and painless on palpation. The liver and spleen were not palpable . Urination is free. No Meningeal symptoms.

In kindergarten,there was quarantine for influenza due to the excess of the epidemic threshold . questions : 1.Diagnose , select the form and the severity of the disease.What is the basis of your diagnosis. 2.What is the etiology of the disease. 3 . What investigation should be carried out ? What will be the results . 4 . What diseases should be a differential diagnosis. 5 . Assign treatment. 6. What methods of specific prevention of the infection do you know?

2. A boy of 5 years, was admitted to a pediatric hospital with a diagnosis of right-sided

community-acquired pneumonia. Fell sick the night before –There was marked rise in temperature to 39,5 º C, disturbed dry cough, complained of pain in the knee joints and headaches. Was hospitalized.

When examined in the department - a state of moderate severity. T 38,6 º C. Skin was pale and clean. Hyperemia of the throat.Harsh breathing. When percussion – lung sound.In the lower right lung in the

paravertebral region – dullness during percussion and weal breathing during, auscultation. Respiratory rate 36 per minute. Muffled heart sounds.. HR 106 per minute. The abdomen was soft, painless on palpation. The liver, spleen not enlarged. Stools are normal. Urine output is adequate.

Complete blood count: Hb - 116 g / l, RBC - 4,01012 / liter.WBC - 3,5109/lBand neutrophils. - 1%, segmented neutrophils. - 22% lymphs. -76%, mon. - 1%, Thromb. -234 109/ l, ESR - 10 mm / h

Radiographs of the chest: defined no uneven darkening projection in SIV, V of right lung.Right Lungs well defined and moderately deformed . The root of the right lung is deformed and expanded. The middle shadow of the heart is not displaced. The sinuses are free. In the dynamics ,in 4 days - Focal infiltrates not determined, increased vascular pattern in the projection of SIV, V of right lung.

Rapid test for influenza (throat swab, RIF) - positive. Questions: 1.Put and justify the diagnosis. 2.What is the differential diagnosis. What explains the changes in the lungs? 3.Make a plan of treatment. 4.What specific complications of the infection do you know? Are their development associated with the

pathogenesis? 5.Specify the characteristics of the disease in newborns and infants.

3. Girl 4 months. A child from the first pregnancy without complications. Term delivery, was

discharged from the hospital on the 4th day. Breastfeeding,and complementary feeding were given at the right age.Sick for 2 days. Complaints about the emergence of a abundant watery discharge from the nose, loss of appetite, anxiety, insomnia.Elder brother of school age fell sick at home (runny nose, dry cough).When examined– Temp- 37,3 º C. Restless, on examination,there was negative reaction. Face slightly swollen. Injection of Vessels of conjunctival .Skin clean with small portion of maceration in the vestibule of the nose. Nasal breathing is difficult, abundant Muco-purulent discharge from the nasal passages. Posterior wall of the pharynx and the front arch Hyperemic. Lymph nodes are not enlarged. Cough. In the lungs breath puerilnoe, wheezing is not heard. A little dyspnoe during anxiety, RR 40 min. Heart tones are loud, rhythmic. Abdomen soft, painless.liver and spleen are not enlarged. Urination, stool normal.

The General analysis of a blood: Hb - 113 g/l, RBC. - 4,2110(12)/l, WBC. - 9,4310(9)/l, band neutrophils. - 2%, segmented/I neutrophils. - 27%, Lymph. - 68%, Mon. - 3%, Thromb. - 189 10(9)/l, ESR 9 mm/h;

Questions:1.Put the diagnosis.2.Whatanatomico-physiological features of respiratory predispose to this course of the disease?3.Evaluate the result of a General analysis of the blood.4.Indicate the most likely etiology of the disease.5.What diseases can be used for differential diagnosis.6.Assign treatment.7.Estimate the prognosis of this disease.

4. Boy, 1 year 3 months was examined by pediatrician p on the 4th day of illness. From history we know that the disease began with the appearance of acute rhinitis, decreased appetite, the temperature rose to 38,9 º C. On the third day of illness mother noted the appearance of hyperemia of the eyelids, scant serous drainage from the left

eye, on the 4th day - the appearance of discharge from the right eye. On examination - Body

temperature   38,2 º C, restless. Pale skin, clean, flushing of the cheeks.  Nasal breathing rapidly is difficult, profuse serous discharge. Throat moderately Hyperemic, follicular hyperplasia of the posterior pharyngeal wall. Palpable enlarged submandibular lymph nodes. In the lung-breathing puerilnoe, carried out uniformly, no wheezing. Heart sounds are normal and rhythmic, heart rate

130 minute. Liver +1,5-2,0 cm from the costal margin, the spleen was not palpable. Physiological functions are normal.   Questions: 1.Formulate a diagnosis and to justify it. 2.What is the most likely etiology of the disease. Give the epidemiological characteristics

of the disease. 3.What are the possible methods of diagnosis of this disease. 4.The differential diagnosis. 5.Assign treatment.

5.  Boy, 1 year 8 months, acutely ill after contact with sick ARD, conjunctivitis father. The body

temperature rose to 38,2 º C, there was repeated vomiting. Complaints of pain in the umbilical region. His mother called an ambulance.

On examination - a state of moderate severity.Sluggish. Decreased appetite, nasal breathing is difficult, discharge profuse muco-purulent. The posterior wall of the throat is swollen, hyperemia, follicular hyperplasia. Cough. In the lungs - puerilnoe breath, no wheezing. RR 32 per minute. Heart sounds normal and rhythmic. HR 124 per minute. On palpation of the abdomen - moderate pain in the right iliac and umbilical areas. Symptom Shchetkina-Blomberg weakly positive.Liver + 2 cm from the costal margin, the spleen 1 cm from the costal margin. Stool 3-4 times a day. Urination is free.

Complete blood count: Hb - 118 g / l, RBC. - 4,1 * 10(12) / liter wbc. - 7,9 * 10(9 )/ l, band neutrophils. - 2%, segmented neutrophils. - 32% lymphs. - 62% of ESR - 1%, mon. - 3%, thromb -216 * 10(9) / L, erythrocyte sedimentation rate - 4 mm / h

Ultrasonography of the abdomen: Pancreas: head 9 mm, 7 mm body, the tail 12 mm. Echogenicity

A bit increased,echostructure moderately heterogeneous. The gallbladder is not increased, the wall is thin,lumen is clean. Liver: left lobe of 40:15 mm. Slightly increased echogenicity. Echostructure is gritty or granuler.

Vascular pattern is moderately enhanced. Multiple enlarged mesenteric lymph nodes. Questions: 1.Formulate diagnosis. 2.Make a plan for examination and treatment. 3.Which specialist should be consulted? 4.What diseases should differentiate this disease? 5.What is the pathogenesis of the abdominal pain syndrome? 6.Assign treatment

6. Boy, 2 years and 3 months, acutely ill. The disease began with the rise in body

temperature to 37,5 º C, became irritable, decreased appetite. On the same day his mother noticed

the emergence of nasal congestion, mild mucous discharge from the nostrils. Appeared rough drycough.Child examined by a pediatrician at home. The condition is satisfactory. The body temperature of 37,6 º C. Skin is pale , clean, moderately moist. In oropharynx - poor flushing of the palatine arches and the posterior pharyngeal wall.

The back wall of the pharynx is granular. Hoarse voice, but on the high sound. Peripheral lymph

nodes were not enlarged. Breathing through the nose is slightly more difficult. Cough rough, "barking." At  anxiety - a slight retraction of the jugular fossa. In the lungs - breathing harsh, held

evenly, wheezing. RR 30 per minute. Heart sounds are normal and rhythmic. HR 115 minute. The abdomen was soft and painless. The liver and spleen were not enlarged.

Stool is normal. Urination is free. Questions: 1.Put the clinical diagnosis and the most likely etiology of the disease. 2.Name and describe the main phases of the pathogenesis of SARS. 3.Which methods of examination can clarify the etiology of the disease? 4.The differential diagnosis. 5.Assign treatment.

7.   Boy, 7 months. examined by a pediatrician on the third day of acute respiratory illness. Complaints about the child's anxiety, occasionally shrill screams. During feeding,he

get tired quickly, making sucking movements 3-4, throws back his head and begins to cry. There was a repeated vomiting, double soft stools.

On examination - the temperature of 37,8 º C. Consciousness is clear. Skin is pale , clean. Nasal breathing is difficult, mucous discharge. Throat moderately hyperemic. Front palpable cervical lymph nodes up to 0.7 cm in diameter are not fused to the surrounding tissues, painless. When pressed on the left tragus - a sharp discomfort for the child. In the lungs - puerilnoe breath, no wheezing. Heart sounds are snormal and rhythmic, heart rate 130 per minute. The abdomen was soft, not distended. The liver at 1.0 cm from the costal margin, the spleen was not palpable. Urination is free. Stool is soft.

Questions: 1. Put the diagnosis and justify it.  2.What are the etiological factors associated with the development of the disease? 3. What further tests should be carried out to confirm the diagnosis? What are you

expecting to find? 4. Assign treatment. 5.Does the child need antibiotic therapy  and why? Justify the choice of antibiotic.

8.   The mother of a 4 year old boy visited the pediatrician on third day of sickness. The

illness started with a rise in temperature to 37,4ºc, appeared profuse discharge from the nose, sore throat, worsened appetite. The next day, the body temperature -38,6ºС, productive cough. These symptoms persisted in the subsequent days.The examination showed febrile fever, restless. Skin pale pink, clean. Nasal breathing is difficult, excessive by serous discharge. Expressed conjunctival hyperemia. Hyperemia front arches and the tonsils, whitish, easily removal raids on the tonsils, the posterior wall of a pharynx is granular. Palpable enlarged anterior-cervical and submandibular lymph nodes up to 1 see The light-vesicular breathing, wheezing is not heard. The cardiac sounds sonorous, rhythmical, HR 128 per minute.Abdomen soft, painless.Liver + 2cm from the edge of a costal arch, spleen +0.5 cm from the edge of a costal arch. Chair normal. Urine light.Questions:1.Formulate the diagnosis and justify it.2.What are the likely etiology of the disease?3.Whichadditional methods of examination will be needed by child?4. The differential diagnosis. What are the peculiarities of this disease?5.Assign treatment.6..What are the possible complications?

9.Girl, 10 months, fell ill on the eve of the day when the body temperatureincreased to 38,7 º C, appeared phenomena rhinitis, and redness of the throat and conjunctiva.Parents gave the child paracetamol, temperatures decreased to normal values. However, towards the night the temperature again increased up to 39,4ºc, repeated dose ofparacetamolwithout effect. Parent called an ambulance. Duringtransportation of the child to the hospital for the first time in life suddenly developed a generalized tonic-clonic seizure with loss of consciousness, which lasted for about 4 minutes.On examination by a doctor at the reception Department -Depressed consciousness , pale skin with a marble pattern. Muffled heart sounds, HR 158 per minute. In the lungs- breathingpuerilnoe , conducted uniformly, wheezing is not heard, the Resp rate 64 per minute. Abdomen soft, painless at a palpation. Liver, spleen is not increased in size. Diuresis adequate.NoMeningeal signs. General blood analysis - without pathology. The level of glucose, calcium in the blood is normal.Questions:1.What is the diagnosis ?.justify.2.What is the algorithm of urgent measures in this case?3.What diseases can be accompanied by seizures? differential diagnosis.4.What is the prognosis of the disease?

10. Girl, 2 years, acutely ill, the body temperature rose to 38,8 degrees Celsius), appeared

obstruction of nasal breathing. On the background of the Patient taking Neurofen, temperature remained high, and after 3.5 hours, reached 39,7 º C. Father sick with flu at home.Suddenly evolved attack generalized seizures, which lasted 3 minutes. The parents called the ambulance on the way to hospital attack of convulsions repeated. When examined at the reception – depressed consicousness, flabby, muscle hypertonicity. Kermig symptom positive positive. I pale skin, single petechiae on the face. Hands and feet are cold when touched. Nasal breathing is difficult. In the lungs breathing harsh, is uniform, dryrales heard on both sides. RR 62 per minute. Heart sounds are muffled, HR 172 per minute. Abdomen soft, painless at a palpation. The stool was the day before. Urination free.The General analysis of a blood: RBC - 4,2х10(12) /l, hemoglobin - 118 g/l, platelets - 310 х10(9) /l, WBC - 6,1*10 (9)Band neutrophil/I - 7%, Segmented/I - 49%, EOS - 1%, Lymph - 39%, Mon- 4%, ESR - 6 mm/h;

Questions:1.Specify the diagnosis, justify. Select the main syndromes.2.Why is the child's condition severe? Describe the pathogenetic phase and predisposing anatomical and physiological factors in the development of this disease.3.What diseases is it necessary to differentiate this disease?4.what is the etiology of the disease.5.What additional medical examination does the child needs?6.Make a plan of urgent measures.

11. The boy at the age of 2,5 months hospitalized due to ‘URVI. We know from history that

the boy from the woman with compromised gynecological (salpingo-oophoritis, erosion of cervix of the uterus), somatic (gastritis, peptic ulcer of the 12-d of the intestine) history, from the 3rd pregnancy (1-I - меdаbort, 2-I urgent deliveries), which progressed with SARS in the first trimester (received symptomatic therapy), toxicosis, threatening miscarriage in the second trimester. From 2 preterm independent births per week 32, body weight at birth - 1600, length - 38 cm, evaluation on Apgar scale 6/7 points. Status at birth heavy due to respiratory distress syndrome oppression. From birth within 5 days was on a ventilator. At the age of 28 days of life f was independent of oxygen. Was discharged home at the age of 1.5 months in a satisfactory condition and weight 2030 .WasIll 1 day prior to admission, noted the loss of appetite, appearance of dyspnea dry coughing and vomiting blood. In the house was in close contact with his seven-year-old brother was SARS patient.On admission,the condition became severe. T 37.,5S. pale skin with a marble pattern, perioral cyanosis. Nasal breathing is difficult, slimy discharge. Frequent small productive cough. Chest indrawing during breathing, the RR was 76 per minute. In lung percussion - box sound. On auscultation in the lung - breathing harsh, exhalation extended and is even on both sides. dry and wet fine basal rales heard. Heart sounds moderately muffled rhythmic. HR 150 per minute. Abdomen soft, liver +4,5 cm from the edge of a costal arch. Urinating on urethral catheter.

Results of the survey: Rapid test for RSV - positive. Complete blood count: Hb - 141 g / l, RBC - 5,13* 10(12 )/ liter wbc. - 11,62* 10(9) /

P/neutrophils. - 2%, S / I neutrophils. -35% lymphs. - 51%, mon. - 12%, ESR - 2 mm / h Sat O2 - 87% Radiographs of the chest:

questions: 1. Diagnose. Explain. Rate the severity of the disease. 2. What are the risk factors for the severe infection do you know? 4. What signs of respiratory failure are detected in the child? What determines the degree

of examination of respiratory failure? 5. Does the child needs oxygen therapy , and why? 6. Evaluate the result of a general analysis of blood. 7. EvaluateX-ray of the chest. What complications of this disease do you know? 8. What kind of therapy can be assigned to the child? What tools have proven efficacy in

this disease? 9. How is the prevention of RSV in children at risk of severe infection?

12. Girl, 2 years old, taken to the pediatric ward on the 1st day of illness with complaints of dry

cough intrusive, raising the temperature to 37,4 º C. Has inhalation beroduala, no pronounced effect.

On examination - a state of moderate severity.Cough, frequent, unproductive. Skin is palely, clean. Nasal breathing is moderately difficult, scanty discharge. Throat faintly hyperemic, clean.Percussion box sound. Auscultation of the lungs - breathing harsh, weakened on the left, during exhalation,hearddry wheezing in all fields, single finely wheezing. When breathing is marked retraction of the intercostal spaces.Respiratory rate 36 per minute. Heart sounds loud, rhythmic. HR 90 per minute. The abdomen was soft, painless on palpation. The liver and spleen were not enlarged. Physiological functions are normal.

  From history we know that at the age of 5 months, she suffered a left-sided pneumonia. The father - asthma.Results of the survey:

  Complete blood count - WBC 6.6 x 109 / L, lymph - 46%, mon - 10%, Eos - 7%, Seg / Neut - 37% RBC - 4.41 × 10(12) / L, Hb - 133 g / L, Throm - 238 x 109 / L, erythrocyte sedimentation rate - 3 mm / h.

Radiographs of the chest - focal and infiltrative shadows in the lungs is not defined. Lung fields of enhanced transparency. Vascular pattern is reinforced on both sides. The sinuses are differentiated. The heart shadow across not extended.

questions: 1.Diagnose. Explain. 2.What is the pathogenesis of this disease? 3.What predisposing factors of this disease do you know? 4.Evaluate the result of a general analysis of blood. 5..Expalinthe radiograph of the chest. 6.What diseases is necessary to make a differential diagnosis. Does the Child need a check up ? If so, which diease in particular? 7. Assign treatment.