Pediatric emergency medicine trisk 587

trimethoprim intravenously every 6 hours) should be considered if there are
respiratory symptoms, with or without a positive chest radiograph. Treatment for
suspected PCP should not be delayed because of concern of interfering with the
diagnostic workup. Fungal infections, with the exception of oral thrush, are
uncommon in HIV-infected children. However, candidal sepsis should be
considered in hospitalized patients who do not improve with antibiotics.
Chronic fever is common in HIV-infected children and has a broad differential
diagnosis. The major focus of such an evaluation in the ED is to rule out acute
bacterial infection. A careful history and physical examination should be
followed by a CBC, urinalysis, chest and sinus films, and blood, urine, and stool
cultures. Recurrent otitis media is commonly seen, and some children may have
recurrent parotitis or sinusitis. If no source is recognized on examination and the
initial testing is negative, more unusual infections need to be considered.
Tuberculosis, although common among HIV-infected adults, is uncommon in
children but may be more likely among adolescents. Mycobacterium avium
complex may cause chronic fevers in HIV-infected children. This pathogen is
often associated with anemia secondary to bone marrow infiltration and can be
cultured from blood, stool, and bone marrow. Numerous viruses can cause
chronic infections associated with fever in these children. EBV and CMV are
among the more common, with CMV often presenting with chronic hepatitis and
bloody diarrhea. It may also cause pneumonia and retinitis. A blood buffy coat
specimen can be sent for quantitative CMV-antigen detection. Most HIV-positive
children with fever of unknown origin are hospitalized to facilitate the diagnostic
process. The possibility of drug fever must also be considered.
Two OIs warrant special attention: PCP and lymphoid interstitial pneumonitis
(LIP). PCP is caused by a fungal pathogen and is the most common initial
manifestation of HIV in the perinatally infected infant. The infant or child
typically is febrile, with marked tachypnea, wheezing, rhonchi, and diminished
breath sounds. Rales are not usually part of the PCP picture, and cough may be
absent. When coughing is present, it is typically dry and nonproductive. Over
hours to days, the patient develops hypoxia and increased respiratory distress.

Initial ED evaluation should include beginning supplemental oxygen, obtaining
pulse oximetry, an arterial blood gas, a chest radiograph, and serum LDH levels.
Radiographs may show a diffuse interstitial (“ground-glass”) pattern, but infants
may develop patchy infiltrates or complete opacification of the lung fields. The
diagnosis often requires bronchoscopy with specimens sent for silver stains.
However, if the ED physician suspects PCP, it is appropriate to start IV TMPSMZ at a dosage of 5 mg/kg/dose of TMP every 6 hours. The child should be


hospitalized for close observation and further evaluation as needed. In general,
patients with PCP do not respond rapidly to antibiotic therapy. Patients intolerant
of TMP-SMZ can be treated with systemic (not aerosolized) pentamidine (4
mg/kg/day as a single daily dose) or atovaquone, but these should be considered
second-line agents. Corticosteroid therapy in children with severe PCP improves
survival and is generally recommended for patients with PaO2 less than 70 mm
Hg or an alveolar–arterial gradient of greater than 35 mm Hg. Standard
precautions are indicated.
LIP is a lymphoid hyperplastic condition associated with both HIV and EBV
infections. LIP results in a slowly progressive hypoxemic condition in children
outside infancy. The most common symptoms are chronic cough, mild
tachypnea, generalized adenopathy, marked hypoxemia, and digital clubbing.
Chest radiography reveals an interstitial nodular pattern, and bronchiectasis can
be seen on high-resolution CT of the chest. The diagnosis is confirmed via
biopsy. Fever is an unusual manifestation of LIP and should prompt evaluation
for secondary pyogenic bacterial infections. Therapy may be with antiretroviral
therapy; in acute respiratory compromise, empiric corticosteroid therapy may be
warranted. If the PaO2 is less than 65 mm Hg, LIP is treated with 1 to 2
mg/kg/day of prednisone (maximum: 60 mg/day) for 2 to 4 weeks and
subsequently tapered to maintain the PaO2 above 70 mm Hg. If the patient is
febrile, tuberculosis or MAI must be ruled out before beginning steroid therapy.
Management: Whenever a child with HIV infection presents with high-grade

fever (temperature higher than 39°C or 102.2°F), a complete blood cell count
(CBC) with differential and blood culture is recommended. If the child is still in
diapers, a urine sample should be obtained for analysis and culture. Older
children who are toilet trained usually complain of dysuria or frequency if they
have a UTI. If the child has any respiratory signs or symptoms, including
isolated tachypnea, or if the CBC has an elevated leukocyte count with a shift to
left, regardless of the presence of respiratory signs, pulse oximetry and a chest
radiograph should be ordered. The WBC count is best evaluated in relation to
baseline counts because many HIV-infected children have some degree of
leukopenia. If it is known that the child is not leukopenic or the baseline is not
available, a WBC count of 15,000/mm3 or more should be considered suggestive
of bacterial infection. If the child appears well and the evaluation has not
revealed a source for the fever that requires hospitalization, the child may be sent
home (if the child’s caregiver can be easily contacted and has the means to return
if necessary) with instructions to return if symptoms worsen or if the patient


develops lethargy or will not take adequate amounts of fluids. Clinicians can
choose to offer empiric antibiotics (e.g., ceftriaxone) for children being
considered for outpatient care. A follow-up evaluation by telephone or a revisit
to the child’s regular provider or the ED should be scheduled for the next day.
HIV-infected children with severe immunosuppression (CD4% <15%) should
receive antiviral prophylaxis within 48 hours of exposure to a patient with
influenza.
PEP: Providers may be asked by families about PEP after children are
exposed to HIV via contact with blood or other body fluids, after contact with
discarded needles in a nonhealthcare setting, or after sexual assault. The risk
after specific exposures is reviewed in Table 94.23 . It is important for families
to realize that risk of drug-associated adverse events, estimated to cause
treatment cessation in over one-third of HIV-infected patients, is substantially

higher than the risk of transmission. PEP is not recommended for needlesticks
from discarded needles, nor is it suggested that needles are sent for testing for
HIV. Consultation with a local HIV specialist is recommended prior to the PEM
provider initiating prophylaxis.

Syphilis, Congenital
Congenital syphilis has an incidence of 23 per 100,000 live births in the United
States. The incidence has more than doubled since 2012. Risk factors for a child
being born with congenital syphilis include birth in Southern states and birth to
African-American mothers. Clinical findings early in congenital syphilis can
range from very profound (stillbirth) to initially asymptomatic. The rate and the
severity of infection correlate with the staging in the mother. Women with
untreated early syphilis are estimated to have a 40% rate of spontaneous
abortion. The rate of transmission to the fetus is very high in maternal secondary
syphilis but decreases for mothers with latent or tertiary syphilis. The most
common symptoms and the diagnostic criteria for congenital syphilis are
summarized in
e-Table 94.31 . Other findings include diffuse bilateral
pneumonia (pneumonia alba), chorioretinitis, nephritis, and testicular masses.
Late findings of congenital syphilis include dental changes (Hutchinson teeth—
small hypoplastic teeth with enamel anomalies; mulberry molars—
maldevelopment of the cusps), other bony changes (frontal bossing, prominent
mandible, shortened maxilla, saddle nose, saber shins), swelling of the
sternoclavicular joint (Higouménakis sign), sensorineural hearing loss, and
interstitial keratitis. Any infant whose mother has inadequately treated syphilis,


or the infant with any symptoms consistent with congenital syphilis and positive
serologic tests for syphilis, should be managed as a presumptive case.
The treatment of choice for syphilis and the only accepted regimen for

pregnant women is penicillin. Treatment recommendations are summarized in
e-Table 94.32 . Treatment for nonpregnant adolescents and adults who are
penicillin-allergic is doxycycline 100 mg twice daily for 14 days for primary,
secondary, or early latent syphilis and for 4 weeks for late latent or latent syphilis
of unknown duration. Contact precautions should be used for infants with
congenital syphilis, as nasal secretions and dermatologic manifestations are
heavily laden with spirochetes for up to 24 hours after completion of therapy.

Syphilis, Acquired
Acquired syphilis is stratified into stages based on clinical manifestations and
serologic findings. The clinical and laboratory findings present at different stages
are summarized in
e-Table 94.33 , and the treatment recommendations by
stage are reviewed in
e-Table 94.32 . One cause of confusion relates to
serologic testing for syphilis. Two broad categories of tests exist. The first test
developed were nontreponemal tests, which measure primarily IgG. These
include the rapid plasma reagin (RPR) and the venereal disease research
laboratory (VDRL); the former is a serum test, the latter performed on CSF.
These tests have the advantage of being inexpensive (optimal for screening tests)
and decreasing in response to therapy, allowing for serial monitoring. These tests
have disadvantages including false-positive results, which have been best
described in patients with anticardiolipin antibody, autoimmune disease, HIV
infection, and pregnancy; and false-negative results in some patients with
secondary syphilis and in many patients with late-stage syphilis. The second
class is treponemal tests. These include the FTA-ABS (fluorescent treponemal
antibody absorption), MHA-TP (microhemagglutination test for antibodies to
Treponema pallidum), and the TP-PA (Treponema pallidum particle
agglutination). These tests are confirmatory assays when nontreponemal tests are
positive, and also are useful in the diagnosis of late stages of syphilis. They are

as sensitive as nontreponemal tests for late disease, and are much more specific.
These tests cannot be used to monitor response to therapy, as they do not revert
to negative with therapy. All patients with syphilis should be screened for HIV
and other STIs. Contact precautions should be used for any syphilis patient with
open lesions or secretions.
Suggested Readings and Key References