MCQ NO 1: Fever & pain abdomen
A 12-year-old previously healthy boy is brought to the emergency department with a 6-day history of high-grade fever, abdominal pain, vomiting, and diarrhea. His parents report that he had a mild respiratory illness 5 weeks ago after several family members tested positive for COVID-19. On examination, he is febrile (39.5°C), tachycardic, hypotensive, and has bilateral non-purulent conjunctivitis, cracked lips, and a generalized erythematous rash. Laboratory investigations reveal markedly elevated CRP, ferritin, D-dimer, and troponin levels. Echocardiography demonstrates mild left ventricular dysfunction.
Which of the following is the most likely diagnosis?
A. Acute COVID-19 pneumonia
B. Kawasaki disease
C. Multisystem Inflammatory Syndrome in Children (MIS-C)
D. Septic shock due to bacterial infection
E. Toxic shock syndrome
Correct Answer: C. Multisystem Inflammatory Syndrome in Children (MIS-C)
Discussion: Multisystem inflammatory syndrome in children ( MIS-C)
MIS-C is a severe post-infectious hyperinflammatory syndrome occurring typically 2–8 weeks after SARS-CoV-2 infection. The condition is characterized by persistent fever, elevated inflammatory markers, gastrointestinal symptoms, mucocutaneous findings, cardiovascular dysfunction, and evidence of recent COVID-19 infection or exposure.
The distinguishing features in this case include:
Recent COVID-19 infection (5 weeks earlier)
Persistent fever
Gastrointestinal symptoms
Rash and conjunctivitis
Shock
Elevated inflammatory markers
Myocardial involvement (elevated troponin and ventricular dysfunction)
These findings strongly support MIS-C rather than acute COVID-19 infection.
MCQ NO 2: Fever& breathlessness
A 10-year-old boy presents with fever, severe myalgia, headache, and progressive breathlessness for 48 hours. Examination reveals hypoxemia and bilateral crepitations. Chest radiograph shows diffuse bilateral reticulonodular infiltrates. Total leukocyte count is 4,200/mm³. Three days earlier, his younger sibling recovered from a similar febrile illness. Blood cultures are negative.
Which of the following is the most appropriate pharmacologic therapy?
A. Amoxicillin-clavulanate
B. Clarithromycin
C. Oseltamivir
D. Prednisolone
E. Trimethoprim-sulfamethoxazole
Correct Answer: C. Oseltamivir
Discussion: Influenza associated viral pneumonia
This child most likely has influenza-associated viral pneumonia. The diagnosis is suggested by the acute onset of fever, severe myalgia, headache, respiratory symptoms, and recent exposure to a household contact with a similar illness. The presence of leukopenia, diffuse bilateral reticulonodular infiltrates on chest radiography, and the absence of evidence supporting bacterial infection further favor a viral etiology, particularly influenza.
Influenza pneumonia can range from mild respiratory illness to severe hypoxemic respiratory failure. Children requiring hospitalization should receive oseltamivir, a neuraminidase inhibitor effective against influenza A and B viruses. Antiviral therapy is recommended for all hospitalized patients with suspected or confirmed influenza, even if presentation occurs more than 48 hours after symptom onset, as clinical benefit may still be achieved in severe disease.
Prompt antiviral treatment can reduce viral replication, shorten disease duration, decrease complications, and improve outcomes when combined with appropriate supportive care, including oxygen therapy and fluid management.
Why the Other Options Are Incorrect
A. Amoxicillin-clavulanate
This antibiotic is used for bacterial respiratory infections and has no activity against influenza viruses. The clinical presentation and radiological findings are not typical of bacterial pneumonia.
B. Clarithromycin
Clarithromycin is effective against atypical bacterial pathogens such as Mycoplasma pneumoniae and Chlamydia pneumoniae. These infections usually have a more gradual onset and are less commonly associated with severe myalgia and leukopenia.
D. Prednisolone
Routine corticosteroid therapy is not recommended in influenza pneumonia and may be associated with prolonged viral shedding and an increased risk of secondary infections.
E. Trimethoprim-sulfamethoxazole
This drug is used for infections such as Pneumocystis jirovecii Pneumonia and certain bacterial infections. The clinical scenario does not suggest an opportunistic infection or immunocompromised state.
Key Learning Point
Influenza pneumonia should be suspected in a child with acute fever, prominent myalgia, leukopenia, diffuse bilateral interstitial infiltrates, and recent exposure to a similar viral illness. Oseltamivir is the treatment of choice for hospitalized children with suspected or confirmed influenza pneumonia, regardless of the duration of symptoms.
MCQ NO 3: Fever & tachypnea
A 6-year-old boy presents with fever, cough, and respiratory distress for 12 days. Chest radiography reveals a large right-sided pleural effusion. Pleural fluid analysis confirms empyema, and an intercostal chest drain is inserted along with intravenous antibiotics.
Five days later, he continues to have fever and tachypnea. Drain output has progressively decreased. Repeat pleural ultrasonography demonstrates multiple fibrinous septations and loculated pleural collections.
Which of the following is the most appropriate next step in management?
A. Continue intravenous antibiotics alone
B. Intrapleural fibrinolytic therapy through the chest drain
C. Remove the chest drain
D. Repeat diagnostic thoracentesis
E. Switch to oral antibiotics
Correct Answer: B. Intrapleural fibrinolytic therapy through the chest drain
Discussion: Complicated Empyema
The correct answer is B. Intrapleural fibrinolytic therapy through the chest drain.
This child has complicated parapneumonic effusion (empyema) in the fibrinopurulent stage. The prolonged duration of illness (12 days), persistent fever despite appropriate intravenous antibiotics, decreasing chest tube output, and ultrasonographic evidence of multiple fibrinous septations and loculated pleural collections indicate inadequate drainage of the infected pleural space.
Empyema evolves through three stages:
- Exudative stage (1–5 days): Free-flowing pleural fluid that often responds to antibiotics with or without drainage.
- Fibrinopurulent stage (5–10 days): Fibrin deposition leads to septation and loculation of pleural fluid, impairing effective drainage.
- Organizing stage (>2–3 weeks): Fibroblast proliferation and pleural peel formation may result in trapped lung.
This patient is in the fibrinopurulent stage, where fibrinous septations prevent adequate evacuation of infected fluid through the existing chest tube. Intrapleural fibrinolytic therapy (e.g., urokinase or alteplase, according to local protocols) helps lyse fibrin strands, improve drainage, facilitate lung re-expansion, and reduce the need for surgical intervention.
Pleural ultrasonography is the imaging modality of choice for identifying septations and loculations and guiding further management.
Why the Other Options Are Incorrect
A. Continue intravenous antibiotics alone
Persistent fever and evidence of loculated empyema despite chest drainage indicate failure of conservative management. Additional intervention is required to achieve adequate source control.
C. Remove the chest drain
The child still has ongoing pleural infection with residual loculated collections. Removing the drain would be inappropriate and may worsen the condition.
D. Repeat diagnostic thoracentesis
The diagnosis has already been established, and repeat aspiration is unlikely to effectively drain multiple loculated collections.
E. Switch to oral antibiotics
The child remains clinically unwell with active empyema requiring further invasive management. Oral therapy alone would be inadequate.
Key Learning Point
In a child with empyema who remains febrile despite chest tube drainage and intravenous antibiotics, and whose pleural ultrasound demonstrates fibrinous septations and loculated fluid collections, intrapleural fibrinolytic therapy is the preferred next step before considering surgical intervention such as VATS or decortication.
MCQ NO 5: Head injury
A 1-year-old boy was admitted to the Pediatric Intensive Care Unit after a fall from height resulting in head injury. He has been mechanically ventilated for the past 5 days. During the last 12 hours, he developed a high-grade fever. Chest examination is unremarkable except for findings on investigation. Chest X-ray shows right-sided pulmonary infiltrates. Complete blood count reveals hemoglobin 12 g/dL, total leukocyte count 23,000/µL with 82% neutrophils, 15% lymphocytes, 1% monocytes, and 2% eosinophils.
What is the most likely diagnosis?
A. Lung collapse
B. Post-traumatic meningitis
C. Ventilator-associated pneumonia
D. Rib fracture leading to pneumonia
E. Ventilator-associated pneumothorax
Answer: C. Ventilator-associated pneumonia
Discussion: Ventilator associate pneumonia (VAP)
This child has developed fever, neutrophilic leukocytosis, and a new pulmonary infiltrate after more than 48 hours of mechanical ventilation, which is characteristic of ventilator-associated pneumonia (VAP). VAP is defined as pneumonia that develops 48–72 hours or more after endotracheal intubation and is one of the most common nosocomial infections in the intensive care unit.
Why not the other options?
- A. Lung collapse: May occur in ventilated patients but typically causes volume loss and collapse on chest X-ray rather than infective infiltrates and marked leukocytosis.
- B. Post-traumatic meningitis: Can occur after head injury but does not explain the new pulmonary infiltrates seen on chest X-ray.
- D. Rib fracture leading to pneumonia: Trauma may predispose to pneumonia, but there is no evidence of rib fracture in the history or investigations.
- E. Ventilator-associated pneumothorax: Usually presents with sudden respiratory deterioration and absent breath sounds. Chest X-ray would show air in the pleural space rather than infiltrates.