PNP Management: Hepatitis and Tuberculosis

-Hepatitis A
-Hepatitis B
-Hepatitis C
-Hepatitis D
-Hepatitis E

-Causes primary infections in the liver
-Transmitted easily in homes and childcare centers through person-to-person contact via fecal matter found on contaminated surfaces

12 to 23 months

-Personal contact with an infected individual:
can be spread to adults easily because children <6yrs are asymptomatic
-International travel
-Food-borne outbreaks

-Older children often present with similar symptoms to adults
-Nausea
-Vomiting
-Anorexia
-Fever
-Right upper quadrant pain (dull)
-Jaundice in the icteric phase
-Hepatomegaly
-Splenic tenderness
-Adenopathy

-Children may also have darkened urine and clay-colored stools
-Infants may have diarrhea, while constipation is more common in older children

-Preicteric phase:
acute febrile illness
malaise
nausea
vomiting
digestive complaints
-Icteric phase:
jaundice
dark urine
clay-colored stools
poor weight gain

-Supportive teatment
-Hep A vaccine or immunoglobulin for post exposure prophylaxis within 14 days of exposure
-Immoglobulin can be used for kids <2 years
-Immunoglobulin can be administered in some high exposure cases or prophylactically, in conjunction with HAV vaccine for those traveling internationally

-Household contacts and sexual partners of known cases
-Oersons accidently inoculated with a contaminated needle
-Newborn infants of infected, jaundiced mothers
-People with open lesions directly exposed to body secretions of known cases
-Children in schools where more than one case is reported

-All children and employees of child care centers where a case reported
-Custodial care residents and staff in close contact with an active case
-Persons traveling to developing countries for <3 months
-Can give HAV vaccine concurrently with IG if warranted, for those traveling internationally

-Prevention includes:
good hygiene
safe drinking water
HAV vaccine for children 12 months and older
-Children 2–18 years of age who have not received the HAV vaccine may receive the vaccine
-Good hand hygiene with toileting and diaper changes are important to prevent transmission in the home and childcare center

-Highly contagious and preventable with vaccine administered during infancy
-Development of chronic HBV is determined by age of initial acute HBV infection and the rate of loss of HBcAg
-More than 90% of infants infected with HBV develop chronic infection
-Approximately 25–50% of children aged 1–5 years old who develop HBV infections will go on to develop chronic infection

-Transmitted via percutaneous or permucosal exposure, including blood, semen, vaginal secretions, cerebrospinal, and pleural fluid
-It can be transmitted via birth from an infected mother, sexual contact with an infected person, personal hygiene items such as toothbrushes or razors, and infected medical equipment

-Lack of immunization among children who have immigrated to the United States from sub-Saharan Africa and East Asia, or other areas of the world with endemic states of HBV
-IV drug users and those who engage in sexual contact with infected persons -Healthcare workers exposed to contaminated bodily fluids
-Tattooing and body piercing with infected equipment

-Children who are infected with HBV at an early age are less likely to present with symptoms
-Gradual onset of nonspecific symptoms includes fever and nausea
-Hepatomegaly
-Tenderness of the liver
-Rash
-Papular acrodermatitis in infants
-Jaundice of the skin, mucous membranes, and sclera

-Newborns who mothers are HBsAg positive
-Household contacts <12 months old who have received only one prior HBV vaccine and the second dose is not due
-Sexual contact or needle-sharing with known HBsAg positive cases, including secual assault or abuse victims
-Individuals with percutaneous or permucosal exposure to body secretions of known cases

-If a mothers HBsAg is unknown before delivery, infants should receive HBV vaccine and HBIG in 2 different sites within 12 hours of birth or 24 hours of blood exposure
-HBIG can be given within 7 days of delivery if the mother tests positive for HBsAg postpartum but its less effective
-Give HBIG and HBV vaccine up to 14 days after last exposure and repeat vaccine at 1 to 6 months for sexual partners of known cases
-In <12 months with household contacts, give HBIG and 3 doses of HBV vaccine
-Hepatitis B vaccine can be used for postexposure prophylaxis if given within 12 to 24 hours after exposure

->12 months:
interferon-alfa
->3 years:
lamivudine
->12 years:
adefovir
tenofovir
->16 years:
entecavir

-Yearly liver ultrasounds
-Liver function and a-fetoprotein concentration testing
-HAV vaccines
-HBIG and corticosteroids are not found useful for chronic Hep B

-Hepatitis C infection causes most cases of chronic hepatitis
-About half of people infected with HCV are unaware of their infection and most who become infected with HCV develop chronic hepatitis C
-The incidence of chronic pediatric liver failure increases with the duration of infection

-Transmitted via blood
-The primary source of HCV infections in children is perinatal transmission, however about half of the children who become infected in this way typically see resolution between 24 months and 7 years of age

-Injection drug use
-Men who have sex with men are also at increased risk
-Vaginal births and breastfeeding do not increase the chances of HCV transmission

-Most children with HCV do not exhibit any symptoms
-Older children may have flu-like symptoms, such as nausea or anorexia
-Exam findings may include jaundice and RUQ abdominal pain

-Children with HCV who take acetaminophen or antiretrovirals should be closely followed and their hepatic transaminases monitored
-Children diagnosed with HCV should still receive the HAV and HBV immunizations
-They may still attend daycare as usual
-Discourage alcohol consumption in adolescents and young adults with HCV infection because of the potential for further liver injury
-Education regarding not sharing razors and toothbrushes should be given as well
-Educate young adults about using condoms to prevent spreading the infection if they are sexually active

-Uncommon in children
-It involves concomitant infection with Hepatitis B, as HDV requires the Hepatitis B virus to replicate
-HDV will either be a coinfection or super infection with Hepatitis B
-HDV is transmitted through mucosal, sexual, parenteral, or percutaneous contact with infected blood
-No vaccine is currently available, however, the HBV vaccine also prevents against HDV because of the comorbidity with HBV

-Drug use
-Hemophilia
-Immigration from southern Italy, some parts of Eastern Europe, South America, Africa, and the Middle East

-It can also be found in zoonotic hosts such as swine and nonhuman primates
-It is transmitted through the fecal-oral route, most commonly via contaminated water
-Children are typically asymptomatic or mildly symptomatic
-Older adolescents and young adults are typically symptomatic
-Patients usually make a complete recovery and chronic infections are considered rare
-Mortality rate is very low but increases for pregnant females

Most cases in the United States are found in immigrants or visitors from India, the Middle East, some areas of Africa, Southeast Asia, and Mexico

-Presents similarly to other hepatitis infections, and usually within 15–60 days of infection
-Malaise
-Anorexia
-Fever
-Abdominal pain
-Arthralgia
-May be jaundiced

-HEV management includes supportive management
-There is no approved vaccine.

Good hand hygeine

-HIV enters cells to target a CD4+ T cell
-Converts RNA into DNA using the reverse transcriptase enzyme
-Integrates with the T cell DNA within the cell nucleus
-Permanent infection of the host cell

-Found in blood, CSF, pleural fluid, cervical secretions, human milk, feces, saliva, and urine
-Transmission of the virus can occur via blood, semen, cervical secretions, and human milk

-This accounts for 30% of infections
-It is associated with early and severe newborn disease
-This usually occurs by 10 weeks gestation.

-This accounts for at least 60% of infections
-It results from exposure to infected blood and cervicovaginal secretions in the birth canal or due to micro transfusions between the infected mother and infant during labor

-This accounts for approximately 15% of infections in the United States
-It occurs via breast milk

-Flu-like symptoms:
fever
rash
sore throat
muscle pain
-Failure to thrive
-Chronic or recurrent diarrhea
-Pneumonia
-Recurrent bacterial infections in older kids

-Newborn exams are usually normal
-Lymphadenopathy hepatosplenomegaly
-Oral candidiasis
-Chronic parotid swelling
-Progressive neurologic deterioration

-Within 48 hours
first HIV DNA PCR or HIV qualitiative RNA assay from peripheal blood and comfirm if positive using the same test on another blood sample
-Within 14 to 21 days
optional HIV DNA PCR or HIV qualitative RNA assay, confirm if positive
-1 to 3 months
second HIV DNA PCR or HIV qualitative RNA assay, confirm if positive
-4 to 6 months
third HIV DNA PCR or HIV qualitative RNA assay, confirm if positive
-12 to 24 months
fourth HIV DNA PCR or HIV qualitatitive RNA assay, confirm if positive

-Suppression of viral replication to undetectable levels
-Restoring or preserving immune function
-Reduction of HIV-associated sequelae
-Minimization of drug toxicity
-Promotion of normal growth and development
-Promotion of treatment regimen adherence
-Improving quality of life

-PCP’s role is to boost adherence rates and possibly monitor for side effects from drug regimen
-Factors associated with lower adherence to treatment regimen include mental health issues, age, homelessness, inconsistent access to antiretroviral therapy, and stigma
-Factors associated with greater adherence to treatment regimen include trust and satisfaction with HIV provider

-Current treatment regimen recommendations are at least three oral antiretroviral drugs from at least two drug classes
-Generally 2 nucleoside reverse transcriptase inhibitors (NRTIs) plus either a non-nucleoside reverse transcriptase inhibitor (NNRTIs) or protease inhibitor (PI) often with low-dose ritonavir
-Management specifics are determined by the specialist

-6 week course of zidovudine (Retrovir) prophylaxis protocol for HIV-exposed newborn from birth to 6 weeks
-Ensure bloodwork is done prior to antibiotic prophylaxis
-Should be prescribed trimethoprim-sulfamethoxazole prophylactically to prevent Pneumocystis jirovecii beginning at 4–6 weeks of age through the first year of life

-Adolescents who are HIV positive should use condoms during sexual incounters
-Risk of sharing needles

-Caused by M. tuberculosis
-Transmitted by droplet contamination from coughing, sneezing, or talking
-Droplets can stay in the air for hours

-Latent TB:
the child is infected but not contagious
-Active TB:
the disease is present and contagious

-Immigration
-International adoptees or travelers from high-prevalence regions such as Asia, Africa, Latin America, and the former Soviet Union countries for 1 week or more
-Homelessness
-Alcoholism
-IV drug use

-Persons in correctional facility
-Recent TB infection within the last two years
-Immunocompromised IV drug use
-Comorbid chronic conditions such as lymphoma and diabetes, chronic renal failure, and inflammatory bowel disease

4 to 8 weeks

48 to 72 hours

-Induration (5mm or greater) in children who are:
in close contact with an individual with active or previously active TB cases
have a chest X-Ray with signs of active or previous TB
clinical findings
have immunosupprressive disorder or HIV
receiving immunosuppressive drugs

-Induration (10mm or greater) in children <4 years with any high risk factors
-Induration (15 mm or greater) in children >4 years without any risk factors
-If the skin test shows induration onset after 72 hours, it should be interpreted as positive

IGRA that includes QuantiFERON TB Gold In-Tube and T-SPOT.TB

-Immunocompetent children >5 years to confirm suspected LTBI or active disease
-A positive result indicates TB infection: a negative IGRA should not rule out infection or disease if clincial signs and symptoms suggest otherwise
-Children >5 years who received BCG vaccine
-Children >5 years who are unlikely to return for TST reading
-If the initial TST is positive in children >5 years who received BCG vaccine, in whom additional evidence is needed to improve compliance, or if nontuberculous mycobacterial disease is suspected
-Might be used with other diagnostic tests in an infant suspected of having congenital TB

-Most children ages 3–15 years with primary TB are asymptomatic
-Symptoms may present 1–6 months after the infection begins:
low-grade fever, malaise, and decreased appetite
nonproductive cough, dyspnea (in infants), night sweats, and chills
erythema nodosum, phlyctenular keratoconjunctivitis

-Extrapulmonary symptoms can be present in approximately 25% of children:
meningitis
granulomatous inflammation of the lymph nodes, middle ear, or mastoid
worsening pulmonary infection may present as recurrent cough, stridor, and wheezing

Disproportionately enlarged regional lymph nodes compared with a relatively small pleural focus

-TB aspirate from gastric aspirates, sputum, bronchial washings, pleural fluid, CSF, urine, body fluids, or biopsy
-Induce coughing for children >5 years and older with hypertonic saline
-If they are <5 years, early morning gastric aspirates, collected on 3 seprate mornings and analyzed by fluorescent staining

-Progressive pulmonary disease
-Miliary disease
-Pleural effusions
-TB meningitis

-Consult a Pediatric TB specialist if the child has a positive TST, suspected TB, or TB contact
-First-line treatment is administered orally and includes specific regimens of isoniazid, rifampin, pyrazinamide, and ethambutol
-The primary care provider should be familiar with their patient’s specific antitubercular drug regimen and see the patient monthly to monitor their response to treatment
-PCP should monitor drug adherence and for signs of hepatitis

-Primary care providers should promote strict adherence to treatment regimen to prevent drug resistance
-Educate patient and family about warning signs of hepatotoxicity while on an anti-tubercular drug regimen
-Rifampin may cause orange secretions in urine, vomiting, hepatitis, flulike symptoms, thrombocytopenia, and pruritis
-Patients on oral contraceptives will need to use a backup birth control method while on rifampin

Children with TB can be given measles and other attenuated live virus vaccines at age-appropriate times, unless they are on high-dose corticosteroids, are severely ill, or have another contraindication

-Hypotonia in infancy
-Hearing loss
-Developmental delays
-Short stature
-Small ears
-Small mouth and protruding tongue
-Clinodactyly (finger or toe turns sideways)

-If there is a positive history for an inherited disorder for which the child is at risk
-Physical findings/dysmorphic features on physical exam consistent with a known syndrome
-Known inborn errors of metabolism
-Noted developmental, growth, and/or structural anomalies

-Upslanting palpebral fissures
-Epicanthal fold
-Open mouth with protruding tongue
-Brachycephaly (head is shorter than normal in the front-to-back dimension)
-Redundant skin
-Small ear with overfolded helix
-Flat facial profile

-Review newborn screen for hypothyroidism and annual review for hypothyroidism
-Evaluate routinely for critical congenital heart disease
-Monitor growth using the Down syndrome specific growth chart
-Monitor eye exams for signs of cataracts
-Monitor hearing with routine hearing evaluations
-Monitor for neurologic complications such as seizures or moyamoya
-Monitor for signs of atlantoaxial instability

-Dwarfism
-Vaulting of the skull
-Frontal bossing
-Hydrocephalus
-Hypotonia
-The infant may have developmental delays as well
-Macrocephaly
-Bowing of legs

-Short stature
-Shortening of limbs
-Short foot and toes
-Macrocephaly
-Frontal bossing
-Depressed nasal bridge
-Characteristically short hands that have a “trident” position in extension

-Growth management using syndrome specific growth chart
-Monitor for hydrocephalus, particularly during the first two years of life when it is more likely to present
-Monitor for sleep apnea
-Follow annual hearing evaluations as middle ear dysfunction is common
-Prescribe medication dosages that are appropriate for the child’s age and size

-Educate parents/caregivers about macrocephaly and skeletal dysplasia as well as increased risk for cranio-cervical junction compression
-Advise to use rear-facing car seats
-Educate parents/caregivers about the risk of lower extremity bowing and thoracolumbar kyphosis
-Advise to avoid devices that cause curved sitting like umbrella strollers
-Advise to avoid jumpers and walkers until the child can sufficiently bear weight
-Advise to avoid living at high elevations due to restrictive pulmonary disease

-Neurodevelopmentally normal with phenotypic variability, including variable facial features
-Facial features vary and include:
long, narrow facies
downward slanting eyes
micrognathia
-Tall for their age with long extremities that are disproportionate to their trunk
altered arm-span: height ratio

-Skeletal issues such as:
pectus deformities
scoliosis
pes planus
increased joint laxity

-Aortic root dilatation
-Spontaneous pneumothorax
-Reduced pulmonary reserve
-Sleep apnea
-Recurrent hernias
-Retinal detachment

-The PNP should closely monitor growth using syndrome-specific growth charts
-Monitor for musculoskeletal deformities as well, including scoliosis, pectus deformities, joint laxity, and pes planus
-Ensure appropriate ongoing cardiac screening to evaluate for aortic dilatation, including an echocardiogram
-Beta blockers can be used for treatment
-Advise restricted involvement in contact and competitive sports
-Aerobic activities should be done in moderation

-Intellectual disability
-Hand flapping
-Spontaneous persistent social smile or fits of laughter
-Speech delay with appropriate receptive language
-Abnormal sleep

-Fascination with water
-Abnormal gait with arms held high and flexed elbows
-Hypotonic trunk with hypertonic limbs
-Microcephaly
-Seizures
-Feeding and growth problems

-Monitor for developmental delays and speech problems
-Absent or near-absent speech
-They may not ever develop expressive speech, but can understand basic commands and older children may communicate with gestures
-Monitor for seizure activity
-Monitor for scoliosis

-Hypotonia and feeding problems in infancy
-Behavioral problems: tantrums, stubborn and rigid personality, ADHD, high pain tolerance, and skin picking
-Mild intellectual disability, motor and language delays, and poor coordination
-Short stature
-Failure to thrive
-Central obesity
-Sleep apnea
-Scoliosis
-Strabismus

-High pain threshold, which creates challenges for PCP to address illness/injury in timely manner
-Children with Prader-Willi syndrome rarely vomit
-Reduced salivation leads to early increased risk for dental caries
-Hypogonadism and premature adrenarche are common

-Monitor growth using standard growth charts
-Monitor for injury due to high pain tolerance
-Monitor for failure to thrive
-Assist families with behavioral issues including:
hyperphagia
tantrums
obsessive behavior
elopement

-Intellectual disability
-Language delays
-Behavioral problems such as anxiety and aggression
-Stereopathies
-Autism spectrum disorder
-Prominent forehead
-Long, narrow face
-Prominent jaw

-High arched palate/dental crowding
-Protuberant ears
-Short stature
-Connective tissue dysplasia
-Obstructive sleep apnea
-Recurrent/chronic OM
-Seizures

-Closely monitor development
-Cognitive deficits can be moderate to severe
-Monitor for hypersensitivity to sensory stimuli
-Monitor for seizure activity as there is an increased risk for seizure (decreases in adolescence)

-Evaluate infants for congenital hip dysplasia, clubfoot, and hypotonia
-They may need orthopedic referral for connective tissue dysplasia such as scoliosis or hypermobile joints
-Evaluate for inguinal hernias as children with Fragile X are at increased risk
-Ensure annual ophthalmologic evaluation