How Do Mycoplasma pneumoniae Infections Present?

Patient Presentation
A 17-year-old female came to clinic with severe left ear pain for 1 day.
She had had a low grade fever, cough and rhinorrhea for about 1 week.
The cough was worsening but was not productive. Her throat was also sore for 3 days.
Several of her friends had strep throat and another had pneumonia.
The past medical history was non-contributory.
The review of systems was negative including no rashes.
The pertinent physical exam showed a teenage female who was in some pain. Her temperature was 38.5° C and respiratory rate was 38 but with no respiratory distress.
Her pharynx was erythematous without exudate. Her left tympanic membrane had blood behind it with distorted landmarks and no mobility. Her right tympanic membrane had opaque fluid behind it and little mobility.
There was moderate clear to yellow rhinorrhea. She had shoddy anterior cervical lymph nodes. Her lungs had scattered rales bilaterally and mild end expiratory wheezing.
The rest of her examination was negative.
The laboratory evaluation included a rapid strep test that was negative.
The diagnosis of hemorrhagic myringitis and community-acquired pneumonia was made with Mycoplasma pneumoniae as the probably etiology. It was known that mycoplasma was spreading throughout the community.
She was begun on azithromycin and pain relievers. She was counseled about signs and symptoms to monitor and call about. She was also counseled about ways to try to decrease the spread to other persons.

Discussion
Mycoplasma pneumoniae is a common infection in children and adults. It is spread through respiratory droplets from person to person and the incubation period is ~3 weeks.
Mycoplasma pneumoniae causes ~20% of pneumonias in middle/high school children and up to 50% in college students. It is highly contagious and immunity is not long lasting.

Titres rise 7-9 days after infection and peak at 3-4 weeks. Positive testing is defined as a 4x or more rise in the titre (IgM, IgG) with paired sera or a single titre of greater or equal to 1:32.
Antigen and polymerase chain reaction testing can also be performed and are generally more sensitive.

Treatment for mycoplasma is usually with macrolide antibiotics such as erythromycin (30-40 mg/kg/day divided in 4 doses/day for 10 days), azithromycin (10 mg/kg on day one, 5 mg/kg on days 2-5 for a total of 5 days, each dose given once daily) and clarithromycin (15 mg/kg/day divided in 2 doses/day for 10 days).
Supportive and specific treatments for different problems may be required such as steroid treatment for hematological or neurological problems.
Prophylactic antibiotics for close contacts are usually not recommended.

Learning Point
Mycoplasma pneumoniae presents clinically in many different ways. The prodrome is usually gradual with malaise, low grade fever, chills and headache.
Presentations include:

  • Asymptomatic
    • Respiratory (may have a constellation of findings)
      • Cough – non-productive
      • Pharyngitis
      • Pneumonia
      • Otalgia – bullous myringitis, hemorrhagic myringitis
      • Rhinorrhea
      • Sinusitis – often asymptomatic and coexistent with pneumonia
      • Wheezing – may worsen asthma symptoms
    • Cardiac
      • Conduction abnormalities on electrocardiogram
      • Congestive heart failure
      • Chest pain
      • Myocarditis
      • Pericarditis
      • Rhythm abnormalities
    • Dermatologic
      • Rash – highly variable from mild macular-papular to vesicular to Stevens-Johnson syndrome. It is commonly seen associated with respiratory symptoms and may be worsened by some antibiotics
    • Hematologic
      • Anemia secondary to hemolysis – due to cold agglutinin antibody production
    • Nephrologic
      • Glomerulonephritis
    • Neurologic – occurs in 0.1 % of patients, but may have significant morbidity and mortality
      • Cerebellar ataxia
      • Cranial nerve palsies
      • Aseptic meningitis
      • Meningoencephalitis
      • Peripheral neuropathy
      • Transverse myelitis
    • Gastrointestinal
      • Abdominal pain, generalized
      • Pancreatitis
    • Rheumatologic
      • Arthritis – often polyarthritis
      • Myositis

    Questions for Further Discussion
    1. What are typical findings on chest radiograph for mycoplasma?
    2. What are typical findings on the complete blood count for mycoplasma?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Pneumonia

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Hammerschlag MR. Mycoplasma pneumoniae infections.
    Curr Opin Infect Dis. 2001;14(2):181-6.

    American Academy of Pediatrics. Mycoplasma pneumoniae Infections, In Pickering LD, Baker CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2006;468-470.

    Zaleznik DF, Vallejo JS. Mycoplasma pneumoniae infection in children. UpToDate. Available from the Internet at http://www.uptodate.com/(rev. 8/1/2007, cited 1/17/08)

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    Date
    February 25, 2008

  • What Are Some of the Common Overgrowth Syndromes?

    Patient Presentation
    A 2-month-old male came to clinic for his health supervision visit.
    The parents were concerned because they had noted a small red spot on his arm that was growing over the past month.
    He was otherwise well.
    The past medical history and review of systems were non-contributory.
    The family history was positive for a paternal cousin that died late in-utero, another cousin who had an omphalocoele repaired as a newborn, atopic dermatitis, heart disease and stroke.
    The pertinent physical exam showed a smiley infant with growth parameters in the 50-90% and he was tracking along these percentiles.
    His skin examination showed a 0.5 cm superficial hemangioma on his right upper arm. There were no underlying vascular structures detected on palpation or transillumination.
    Limb size was grossly symmetric. He had some minor dry skin on his flexural creases but the rest of his examination was normal.
    The diagnosis of a healthy infant with a superficial infantile hemangioma was made. The parents were counseled regarding the natural history and when to return.
    They were also instructed to use emollients for his dry skin.
    When the resident physician was discussing the patient with the attending physician, they talked about what aspects of a vascular lesion would cause concern and warrant further workup.
    Discrepant limb size was discussed as a cause for concern which lead to a conversation on overgrowth syndromes.
    Although they knew this patient did not have an overgrowth syndrome, the resident and attending physicians used the Online Mendelian Inheritance in Man genetic library from the National Library of Medicine to look up the latest information about Klippel-Trenaunay-Weber and also Beckwith-Wiedemann syndrome as there was a family history of omphalocoele.

    Discussion
    Infantile hemangiomas are common skin conditions that parents often bring to attention because they develop after the birth of the child.
    Usually they have a benign course with increased growth up until about 1 year of age (but sometimes longer), and then recede.
    The hemangiomas are usually gone by 5 years but can take up to 9 years to resolve.
    They usually are 0.5-5 cm, well-circumscribed, nearly flat, and mostly telangiectatic.

    About 50-60% resolve incompletely leaving telangiectasia, superficial vein dilation, stippled scarring and other abnormalities.
    Generally they are benign but may cause problems because of location (i.e. eyelid blocking vision, high trauma location causing repetitive bleeding) or because they grow so fast that they bleed frequently.
    Treatment for problem hemangiomas is by laser surgery or surgical excision in consultation with a dermatologist and/or surgeon.
    Examination of the lesion should determine if it is a simple infantile hemangioma or if there are other vascular elements present such as a venous or lymphatic malformation.
    While these lesions may still have a benign natural history, they usually should be evaluated by a dermatologist and monitored more closely as they may need further evaluation and treatment.

    Online Mendelian Inheritance in Man from the National Library of Medicine at the National Institutes of Health and is a comprehensive genetic library that is free to use and continually updated.
    It is available at http://www.ncbi.nlm.nih.gov/sites/entrez?db=omim.

    Learning Point
    Overgrowth syndromes are a heterogeneous group of conditions clinically and genetically. Patients may be large at birth or have excessive growth postnatally.
    The overgrowth may be localized or generalized. Some syndromes are associated with an increased risk for malignancies and some also have mental retardation.
    Some syndromes have vascular malformations causing the hypertrophy. Although the gene locus is noted below, new studies are finding common mutations between some of these syndromes.

    Some common overgrowth syndromes:

    • Associated with Chromosome 5
      • Parkes Weber syndrome
        • Clinical features include multiple micro arteriovenous malformations under the skin resulting in a cutaneous flush with soft tissue and skeletal hypertrophy of the affected limb.
        • Gene locus 5q13.3

      • Soto Syndrome
        • Clinical features include characteristic facial features (i.e. high broad forehead, long narrow face, down-slanting palpebral fissures, prominent jaw, sparse front-temporal hair, malar flushing), macrocephaly, and mental retardation. Head circumference, length or both are generally in the 98% or greater.
        • Associated with childhood tumors
        • Gene locus 5q35

      • Weaver Syndrome
        • Clinical features include accelerated growth and bone maturation, unusual craniofacial appearance, unusual cry (i.e. hoarse and low-pitched), hypertonia, mental retardation, looseness of skin with finger deformities, and hernias.
        • Gene locus 5q35
    • Associated with Chromosome 8
      • Klippel-Trenaunay-Weber Syndrome
        • Clinical features are large cutaneous hemangiomata with hypertrophy of the related bones and soft tissues.
        • Gene locus 8q22.3
    • Associated with Chromosome 10
      • Bannayan-Riley-Ruvalcaba Syndrome
        • Clinical features include macrocephaly, pseudopapilledema, and multiple hemangiomata, lipomas or similar dermatological problems.
        • Gene map locus 10q23.31

      • Proteus Syndrome
        • Clinical features are highly variable including asymmetric and disproportionate overgrowth of one or more body regions, vascular malformations, nevi and abnormal adipose tissue.
        • Gene locus 10q23.31
    • Associated with Chromosome 11
      • Beckwith-Wiedemann Syndrome
        • Clinical features are exomphalos, macroglossia, and gigantism. Hypoglycemia often occurs in the first few days of life also.
        • It is associated with childhood cancers.
        • Most cases are sporadic.
        • Gene locus 11p15.5,5q35

      • Hemihyperplasia, isolated
        • Previously called hemihypertrophy
        • Clinical features: caused by abnormal cell proliferation that causes asymmetric overgrowth of one or more regions of the body.
        • Incidence is estimated at 1:86,000.
        • It is associated with childhood cancers.
        • Gene locus 11p15

      • Silver-Russell Syndrome
        • Clinical features are characteristic facial features (i.e. triangular shaped face with a broad forehead and pointed, small chin with a wide, thin mouth), growth retardation (i.e. short stature, low birth weight, intrauterine growth retardation), hemihyperplasia
        • Gene locus 11p15.5, 7p11.2

      • WAGR Syndrome
        • Clinical features are Wilms tumor, aniridia, genitourinary abnormalities, and mental retardation. Hemihypertrophy is also common.
        • Gene map locus 11p13

    Questions for Further Discussion
    1. What aspects of a vascular lesion would cause concern and warrant further workup?
    2. What screening evaluation should be done for patients with overgrowth syndromes associated with malignancies?
    3. What genetic counseling should be offered to families of patients with overgrowth syndromes?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Benign Tumors and Birth Defects.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    National Library of Medicine. Online Mendelian Inheritance in Man.

    Enjolras O, Chapot R, Merland JJ. Vascular Anomalies and the Growth of Limbs: a Review. J. Pediatric Orthopaedics 2004;13:349-357.

    Cytrynbaum CS, Smith AC, Rubin T, Weksberg R. Advances in Overgrowth Syndromes: Clinical Classification to Molecular Delineation in Sotos Syndrome and Beckwith-Wiedemann Syndrome. Curr Opin Pediatr. 2005;17:740-746.

    Antaya, RJ. Infantile Hemangioma. eMedicine
    Available from the Internet at http://www.emedicine.com/derm/topic201.htm (rev. 3/29/07, cited 1/14/08).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
    16. Learning of students and other health care professionals is facilitated.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    Date
    February 18, 2008

  • What Type of Life Jacket Should She Wear?

    Patient Presentation
    A 3-year-old female came to clinic with a 1 day history of ear pain and pulling on her left ear. She also had some yellowish discharge on her pillowcase that morning.
    She had no upper respiratory tract symptoms or fever, and had been playing in a lake.
    The past medical history, and review of systems was negative.
    The pertinent physical exam showed a happy female who was afebrile with normal growth parameters.
    Her left external auditory canal had watery, yellow discharge and the canal was red and swollen with whitish debris. The tympanic membrane was not visualized due to the debris.
    The pain was reproducible when pushing on the tragus.
    The right external auditory canal had some mild erythema but no obvious discharge and the tympanic membrane was normal.
    The rest of her examination was normal.
    The diagnosis of left otitis external was made. Ciprofloxacin otic drops were prescribed along with information about the natural history and ways to prevent the recurrence.
    The father then asked about what type of life jacket he should buy as they were invited to a boating party.
    The pediatrician spoke with the father about general water safety including all persons wearing life jackets while on the water and needing to use a U.S. Coast Guard approved life jacket that was based on the weight of the child.
    He also emphasized that boating operators should not be drinking alcoholic beverages, and that he recommended designating another adult in the boat to help monitor the water for other boats and people who may be around.

    Discussion
    Otitis externa, also known as swimmer’s ear, is a common infection, especially in school age children.
    Moisture in the ear causes edema, skin breakdown and bacteria to grow. Swelling and debris may obstruct the external canal exacerbating the problem.
    Common predisposing factors include swimming (especially in water with high bacterial counts), foreign body (including hearing aids, retained cerumen, insects, etc.), dermatitis, viral infections and local trauma (i.e. finger nails, cotton-tipped applicators, etc.).
    Otitis externa is most commonly caused by Pseudomonas aeruginosa and Staphylococcus aureus, which often co-exist. Treatment with topical antibiotics such as ciprofloxacin and ofloxacin and pain treatment with acetaminophen or ibuprofen usually is all that is needed.

    Learning Point
    Drowning is the second leading cause of death for children between the ages of 1 to 14 years. In 2002, 832 children died from drowning in the U.S..

    Personal flotation devices (PFD, or often called life jackets) are based on the child’s weight.
    On the PFD label there should be a user weight such as less than 30 pounds, 30 to 50 pounds, and 50-90 pounds.
    Persons over 90 pounds usually can wear PFDs for adults.
    There also should be an approval statement such as “Approved for use on recreational boats and uninspected commercial vessels not carrying passengers for hire, by persons weighing __ lbs”.

    States have different regulations regarding PFD use.
    Generally one appropriately-sized PFD should be available for every person in a boat, and any boat 16 feet or longer must also carry a throwable device (PFD Type IV) such as a cushion or buoy.
    A PFD should be worn at all times if at all possible while using a boat, kayak, canoe, personal watercraft (also known as a jetski) or in any towed activities such as waterskiing or inner tubing.
    The labels of PFDs for personal watercraft and towed activities will be marked for these activities.
    If PFDs are not worn in the boat, they should be stored on the boat so they can be retrieved and put on immediately (i.e. not in locked containers or with gear stored on top of the PFDs).
    The throwable PFD must be immediately available for use.
    Individuals negaged in activities where a person is in the water such as personal watercraft or towed activities should wear a PFD at all times.

    PFDs come in different types:

    • Type I – designed for all types of water (calm or rough) and especially remote waters where rescue may be delayed. Designed to turn a person face up.
    • Type II – designed for calm, inland water or where there is a good chance of quick rescue. May turn a person face up. One of the most common and least expensive types.
    • Type III – designed for calm, inland water, or where there is a good chance of quick rescue. Designed so the person can put themselves in a face-up position. The person may have to tilt their head back to avoid turning face down.
    • Type IV – throwable device such as cushion, life ring, or buoy
    • Type V – special use – such as working on sailing boars, or offer hypothermia protection.

    Examples of these products can be found from the Wisconsin Department of Natural Resources at: http://www.dnr.state.wi.us/org/es/enforcement/safety/pfd.htm

    Many PFDs are made of foam and generally not compressible. These can be bulky to wear for some people.
    Some PFDs are inflatable and may be more comfortable to use. Inflatable PFDs should only be used by persons 16 years and older.
    There are also hybrid PFDs with foam and inflation which are available for adults and children.
    Overall, the best PFD is one that is rated for the weight of the child and can be worn comfortably at all times.

    Parents should be reminded that PFDs must fit snugly on a child. To check for a good fit, pick the child up by the shoulders of the PFD. If the PFD fits right, the child’s chin and ears will not slip through.
    PFDs are also not babysitters and a responsible adult should also be closely monitoring the children.
    PFDs are not toys and toys are not PFDs. PFDs should be used for their intended purpose and not played with as they can be damaged. Inflatable toys and rafts should not be used instead of a proper PFD.

    Questions for Further Discussion
    1. At what age can a person operate or be a passenger on a personal watercraft (i.e. jetski)?
    2. At what age can a child truly learn to swim?
    3. Where can a person take a boating safety course in the local community?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Water Safety and Ear Infections.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    United States Coast Guard. Teach Your Children Well.
    Available from the Internet at http://www.uscg.mil/hq/g-m/mse4/pfdchild.htm (rev. 5/23/02, cited 1/10/08).

    United States Coast Guard. Federal Requirements and Safety Tips for Recreational Boats.
    Available from the Internet at http://uscgboating.org/safety/fedreqs/equ_pfd.htm (rev. 2005, cited 1/10/08).

    Yuma P, Carroll J, Morgan M. A guide to personal flotation devices and basic open water safety for pediatric health care practitioners. J Pediatr Health Care. 2006;20(3):214-8.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Systems Based Practice

    25. Quality patient care and assisting patients in dealing with system complexities is advocated.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    Date
    February 11, 2008

  • What Causes Nosebleeds?

    Patient Presentation
    A 7-month-old male living in the upper-Midwest came to clinic in January after his mother found several spots of dried blood the size of a nickel on his sheets and dried blood on his nose when he awoke in the morning.
    He had a great deal of clear-yellowish rhinorrhea for 3 days. He was afebrile and was having some problems breast-feeding because of the rhinorrhea.
    His mother was using saline and bulb-suction frequently to clear his nose. She also was using a humidifier near his bed. He was otherwise well.
    The past medical history and review of systems were negative.
    The pertinent physical exam revealed an infant with obvious copious mucopurulent discharge from his nose. His vital signs and growth parameters were normal.
    He had increased tearing of his eyes. Tympanic membranes were grey with splayed light reflexes and normal mobility. His mouth was negative.
    His nose showed a small amount of dried blood around the entrance to the right nares. He had marked erythema of the anterior nose with several pinpoint areas of previous hemorrhage on the nasal septum.
    His mouth, skin and lung examinations were normal.
    The diagnosis of epistaxis secondary to rhinorrhea, dry environment and trauma due to bulb suctioning was made. His mother was counseled to use some petroleum jelly on the anterior nares 2-3 times per day with a cotton-tipped applicator or her little finger to promote healing.
    She was also counseled about the likelihood that the epistaxis could recur because of the nasal anatomy, and how she could try to stop the bleeding at home if it was a problem.
    She was also counseled about when to call or return to clinic and about upper respiratory infections in general.

    Discussion
    The nose has a rich vascular supply. The Kiesselbach plexus, or Little area, is located on the anterior septum forming a vascular plexus that is easily traumatized.
    This is the most common location causing epistaxis in the anterior nose.

    Epistaxis is a common complaint whose cause is often easily identifiable and usually easily treated. However, parents may be quite distressed because their “child is bleeding” and may feel inadequate to stop it or feel that it happens too frequently.
    Epistaxis often will spontaneously resolve or will resolve with direct pressure to the nose. These nosebleeds usually require no further treatment.

    Active bleeding should be treated by placing the child in the upright position leaning slightly forward with a basin or tissue to capture the blood.
    Direct pressure by external compression to the mid- to anterior nose for 5-10 minutes (with no let up at any time of the compression, i.e. “no-peeking”) often will resolve the epistaxis.
    If bleeding does not resolve, then cotton pledgets with a vasoconstrictor such as phenylephrine 0.25% can be inserted into the nares and again direct pressure applied.
    If the bleeding continues, cauterization with silver nitrate sticks can be used, applying the stick for no longer than 3 seconds to the bleeding site or sites. As cauterization can be difficult in children, consultation with otolaryngology is often needed.

    If bleeding continues the nose will need to be packed. There are various options including absorbable materials such as Gelfoam® and non-absorbable antibiotic-impregnated petroleum gauze strips.
    Packings are usually removed in 3-4 days. Other options include occlusion with a balloon such as a Foley catheter (especially if the location is in the posterior nose).
    If packing is necessary, otolaryngology should be consulted and the child should also have prophylactic antibiotics as there is an increased risk of sinusitis with packing.
    Surgical management with septoplasty or arterial ligation is sometimes necessary.
    Hospitalization is usually not necessary but children who are hemodynamically unstable need treatment and monitoring, and those with posterior packing need frequent monitoring so are often hospitalized.
    Children with a systemic illness such as a blood dyscrasia or oncological disease are also frequently hospitalized for overall management.

    Learning Point
    The differential diagnosis of epistaxis includes:

    • Environmental irritants – dry air, sudden changes in barometric pressure
    • Trauma – often due to nose picking or blunt external trauma, and one of the most common causes of epistaxis
    • Foreign body
    • Blood dyscrasias – coagulopathy, platelet dysfunction, sickle cell anemia, thrombocytopenia
    • Drug – anticoagulants, decongestant abuse, aspirin, non-steroid anti-inflammatory drugs, drugs of abuse especially inhaled
    • Idiopathic – up to 10% of cases
    • Infections
      • Diphtheria
      • Influenza
      • Measles
      • Mononucleosis
      • Pertussis
      • Streptococcal disease – scarlet fever, rheumatic fever
      • Syphilis
      • Tuberculosis
      • Typhoid fever
      • Rhinitis
      • Sinusitis
      • Upper respiratory infection
    • Nasal anatomy – nasal polyps, nasal septal deviation, nasal septal perforation, telangiectasia
    • Oncological diseases – localized (angiofibroma, angioma, granuloma, papilloma) or disseminated
    • Systemic disease – renal or hepatic disease in terminal stages, hypertension
    • Vascular anomalies – hemangioma, Osler-Weber-Rendu

    Questions for Further Discussion
    1. What history questions should make the physican think about a serious underlying cause for epistaxis?
    2. What physical examination finding should make the physican think about a serious underlying cause for epistaxis?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Nose Disorders and Common Cold and at Pediatric Common Questions, Quick Answers for this topic: Colds

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Stockman JA, Corden TE, Kim JJ. Pediatric Book of Lists: A Primer of Differential Diagnosis in Pediatrics. Mosby Year-Book, New York, NY, 1991;261-262.

    Inkellis SH. Epistaxis in Pediatrics a Primary Care Approach. Berkowitz C. ed. W.B. Saunders Co. Philadelphia, PA. 1996;191-195.

    Illingworth RS. Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1998:169-70.

    Nguyun QA. Epistaxis. eMedicine.
    Available from the Internet at http://www.emedicine.com/ent/topic701.htm (rev. 11/24/2007, cited 1/3/2008).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    Date
    February 4, 2008