Pediatric Primary Care (98 page)

2.  Not associated with abdominal pain or pruritus.

E.  Diagnostic tests.

1.  Three of following four criteria establish diagnosis:

a.  Homogenous, white, adherent vaginal discharge.

b.  Vaginal fluid pH 4.5.

c.  Fishy odor before or after adding 10% KOH (whiff test).

d.  Clue cells (squamous vaginal epithelial cells covered with bacteria, causing granular appearance) on microscopic exam.

F.  Differential diagnosis.

1.  Characterized by white, thick, pruritic discharge with pH 4.5; pseudohyphae are seen under microscope when 10% KOH is added. Candida also causes erythema and edema of vulva-vagina.

2.  Rule out other STIs.

G.  Treatment.

1.  Not necessary in asymptomatic women.

2.  Recommended regimens:

a.  Metronidazole 500 mg PO bid for 7 days, OR

b.  Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days, OR

c.  Clindamycin cream 2%, one applicator intravaginally at bedtime for 7 days.

H.  Follow up.

1.  Recurrence is common.

I.  Complications.

1. May be risk factor for PID, HIV, preterm labor, postpartum endometritis.

J.  Education.

1.  Not clearly sexually transmitted.

2.  Partner treatment does not affect recurrence.

BIBLIOGRAPHY

Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2010.
MMWR.
2010; 59(No. RR-12):1–116.

Joffe A. Amenorrhea. In: Hoekelman RA, ed.
Primary pediatric care.
4th ed. St. Louis, MO: Mosby; 2001: 975–977.

Neinstein SN.
Adolescent health care, a practical guide.
4th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2002.

Peipert, JF. Genital chlamydial infections.
NEJM.
2003; 349:2424 -2430.

Pickering LK, ed.
Red book: 2003 report of the Committee on Infectious Disease.
26th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2003.

Sanfillippo JS et al.
Pediatric and adolescent gynecology.
Philadelphia, PA: W.B. Saunders; 2001.

Speroff L, Glass RH, Kase NG.
Clinical gynecologic endocrinology and infertility.
6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1999:421–485.

CHAPTER 29

Endocrine Disorders

Linda S. Gilman

I.  HYPERTHYROIDISM

A.  Clinical syndrome resulting from excessive exposure of body tissues to action of thyroid hormone.

B.  Etiology.

1.  Hyperthyroidism in childhood with few exceptions is due to autoimmune response to thyroid-stimulating hormone (TSH) receptors. This tissue response causes a condition known as Hashimoto thyroiditis. Graves' disease is a common cause of hyperthyroidism in children.

2.  Increases as adolescence approaches.

3.  No specific etiology known.

C.  Occurrence.

1.  About 5% of all patients are younger than 15 years old.

a.  Peak incidence in adolescence at 11-15 years of age.

b.  Five times higher in girls than boys.

c.  May be present at birth if mother thyrotoxic during pregnancy.

2.  Symptoms develop gradually; time between onset and diagnosis may be 6-12 months and longer in prepubertal children compared with adolescents.

D.  Clinical manifestations.

1.  Insomnia.

2.  Heat intolerance followed by diaphoresing.

3.  Weight loss, voracious appetite without weight gain.

4.  Increased sweating, palpitations, tachycardia.

5.  Muscle weakness and fatigue.

6.  Light menses or amenorrhea.

7.  Hyperactive GI tract with vomiting or frequent stooling.

8.  Tremors, nervousness, irritability, hyperactivity, emotional lability.

9.  Schoolwork suffers.

10.  Breathlessness.

11.  Blurred vision.

E.  Physical findings.

1.  Enlarged thyroid, thyroid bruits, thrills.

2.  Thinning of hair.

3.  Proptosis, exophthalmia, noticeable lid lag, lid retraction, periorbital edema.

4.  Diffuse enlarged goiter.

5.  Fast heart rate, cardiac enlargement, widening pulse pressure.

6.  Trembling hands, tremor of finger with extended arm.

7.  Staring gaze, loss of visual acuity.

8.  Flushed moist skin.

9.  Pedal edema.

10.  Palmer erythema.

11.  Increased deep tendon reflexes.

12.  Hypercalcemia osteoporosis.

F.  Diagnostic tests.

1.  TSH produced by pituitary gland.

2.  Thyroid hormones (T3, T4).

3.  Iodine thyroid scan.

4.  Antithyroid antibodies test.

G.  Differential diagnosis.

Pituitary tumor, 227.3

1.  Pituitary tumor.

H.  Treatment/management.

1.  Refer to endocrinologist.

2.  Antithyroid agents:

a.  Methimazole (Tapazole): to induce remission.

b.  Propylthiouracil (PTU): to induce remission.

c.  Propranolol (Inderal): to decrease adrenergic hyperresponsiveness symptoms.

3.  Subtotal thyroidectomy.

4.  Radioactive iodine (131-iodine).

I.  Follow up.

1.  Monitor for adverse side effects of antithyroid drugs such as skin reactions, leukopenia, agranulocytosis.

2.  Most serious side effect: agranulocytosis, usually occurs in first 3 months of therapy.

3.  Report rash, fever, chills, cough that does not resolve in 1 week.

4.  When patient is euthyroid as determined by lab tests of TSH and T4, a 6-month follow up should be instituted to assess for risk of relapse.

J.  Complications.

1.  Toxic reaction with drug therapy, most severe: hypersensitivity, agranulocytosis, hepatitis, hepatic failure, lupus-like syndrome, glomerulonephritis, vasculitis of skin, thyroid storm, or thyrotoxicosis.

K.  Education.

1.  Initial adjustment to therapy: Stress need to report side effects of therapy.

2.  Compliance to treatment: Do not miss doses; if dose is missed, take missed dose as soon as possible.