Which one of the following is an indication for a second dose of pneumococcal polysaccharide vaccine in children?
Correct Answer D:
Patients with chronic illness, diabetes mellitus, cerebrospinal fluid leaks, chronic bronchopulmonary dysplasia, cyanotic congenital heart disease, or cochlear implants should receive one dose of pneumococcal polysaccharide vaccine after 2 years of age, and at least 2 months after the last dose of pneumococcal conjugate vaccine. Revaccination with polysaccharide vaccine is not recommended for these patients. Individuals with sickle cell disease, those with anatomic or functional asplenia, immunocompromised persons with renal failure or leukemia, and HIV-infected persons should receive polysaccharide vaccine on this schedule and should be revaccinated at least 3 years after the first dose.
A 15-month-old male is brought to the emergency department following a generalized tonic clonic seizure at home. The parents report that the seizure lasted 5 minutes, with confusion for the next 15 minutes. This is the child’s first seizure. There is no family history of seizures. His medical history is normal except for a 1-day history of a URTI.
While initially lethargic in the emergency department, the child is now awake and playful, with a temperature of 39.5°C (103.2°F) and a normal examination. Appropriate diagnostic tests are performed, including a blood glucose level, which is 5.3 mmol/L (96 mg/dL).
Which one of the following would be most appropriate to administer at this point?
Correct Answer C:
This child has had a simple febrile seizure, the most common seizure disorder of childhood. Treatment includes finding a source for the fever; this should include a lumbar puncture if meningitis is suspected. The most common infections associated with febrile seizures include viral upper respiratory infections, otitis media, and roseola. Antipyretics are the first-line treatment. Antibiotics are indicated only for appropriate treatment of underlying infections. Phenytoin and carbamazepine are ineffective for febrile seizures.
Phenobarbital is sometimes used for prevention of recurrent febrile seizures, but is not indicated as an initial therapy. Only 30%-50% of children with an initial febrile seizure will have recurrent seizures.
A 2-year-old boy presents to the emergency department for evaluation following a witnessed seizure. The seizure was described as generalized, lasting less than 10 minutes with a short postictal period. The child has no history of seizures, no family history of seizures, and no history of head injury. His exam currently is normal, except for a red, bulging right tympanic membrane and a temperature of 39°C.
What is the most appropriate management for this patient?
Correct Answer B:
This patient most likely experienced a simple febrile seizure. Most febrile seizures last less than 10 minutes, are generalized and nonfocal, and do not recur within 24 hours. These simple febrile seizures do not require evaluation beyond determining and treating the source of the fever and educating parents.
A. There is no need for neuroimaging studies in a case of simple febrile seizure.
C. There is no need for an EEG in the case of a simple febrile seizure with a negative family history, normal neurologic exam, and normal development.
D. Although anticonvulsant medications are sometimes used for recurrent episodes of febrile seizures, the initial simple febrile seizure does not warrant treatment with anticonvulsant drugs.
E. A lumbar puncture is not indicated in this patient unless the physical exam revealed symptoms suggestive of meningitis or encephalitis. In this case, the examination is normal except for the otitis media, the source of the fever.
You see a 20-month-old male approximately 1 hour after he had a generalized seizure that lasted 2-3 minutes according to his mother. His past medical history is unremarkable except for two episodes of otitis media. On examination his temperature is 38.9°C (102.0°F), and he is awake, interactive, and consolable, with obvious otitis media of the left ear. A neurologic examination is unremarkable, and there are no meningeal signs.
Which one of the following would be most appropriate at this point?
Correct Answer E:
This patient had a classic simple febrile seizure and no additional diagnostic studies are recommended (choice E).
→ Lumbar puncture (choice A) is unnecessary in most well-appearing children who have returned to a normal baseline after a febrile seizure. LP should be performed when there are meningeal signs or symptoms or other clinical features that suggest a possible meningitis or intracranial infection or when the patient is on antibiotics because antibiotic treatment can mask the signs and symptoms of meningitis. It should also be considered in infants between 6 and 12 months if the immunization status for Haemophilus influenzae type b or Streptococcus pneumoniae is deficient or undetermined.
→ There is no evidence to suggest that routine blood tests (choice D) or neuroimaging studies (choice C) are useful in a patient following a first simple febrile seizure, and it has not been shown that electroencephalography (choice B) performed either at the time of presentation or within the following month will predict the likelihood of recurrence.
A 2-year-old girl presents because of an apparently absent vagina. Examination reveals normal external genitalia except for a midline fusion.
The most probable diagnosis is:
Labial adhesion occurs in children when the inner vaginal lips (labia minora) fuse to each other. It often gives the appearance that the opening of the vagina has closed off. It may be noticed incidentally by a parent or by a physician during a medical examination, or the child may complain of irritation or difficulty urinating.
Because the fusion sometimes creates a little pouch in front of the vagina where urine can collect, some children experience dribbling when they stand up after urinating. Occasionally a child will get a bladder infection or will have difficulty passing urine due to the obstruction but most often labial adhesions are not significant enough to obstruct the flow of urine.
The most likely cause is that inflammation of the labia minora creates two raw surfaces at the edges of the lips, which eventually heal together in the middle, partly or fully covering the opening of the vagina.
Many factors can lead to inflammation and irritation of the vaginal lips. Exposure to irritants like fabric softener residue, perfumed soaps, or bits of stool; or a prolonged exposure to damp (as in wet diapers) all can cause irritation of the area. The lack of estrogen (which is normal before puberty) probably plays a role in this process.
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