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. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. 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