Team DFTB. Don’t Forget The Christmas Quiz: the crossword answers, Don't Forget the Bubbles, 2020. Available at:
How did your teams fare in our Christmas crossword? Here are the answers and the hidden word.
1. Signs of abnormal breathing and hypoxaemia are valuable clinical findings when diagnosing pneumonia – hypoxaemia
Children with pneumonia may present with fever, tachypnoea, difﬁculty in breathing, cough, wheeze or chest pain. Tachypnoea is a non-specific sign in children; iIt may be present with fever, with pain or distress and in many non-respiratory cases. Cough and fever are non-specific symptoms and are not grounds for diagnosing lower respiratory tract infections on their own. The Rational Clinical Examination Systematic Review concludes that more important than tachypnoea and auscultatory findings are hypoxia (saturations ≤ 96%) and increased work of breathing/abnormal breathing. Read more on pneumonia in the DFTB Pneumonia Module.
2. An alternative to Levetiracetam for the management of status epilepticus – phenytoin.
The ConSEPT and EcLiPSE trials were published concurrently in May 2019. ConSEPT concluded that Levetiracetam is not superior to phenytoin as a second line agent for convulsive status epilepticus and EcLiPSE concluded that there is no significant difference between phenytoin and levetiracetam in the second-line treatment of paediatric convulsive status epilepticus for any outcome, including time to seizure cessation. Read more about these studies in the Seizing the Truth post and learn more about seizures with the DFTB Seizure module
3. Constipation can lead to this, and as such the two can, and often do, co-exist – UTI (Urinary tract infection)
In a child with abdominal pain, the diagnosis of UTI makes constipation more likely. Constipation can lead to urinary retention and UTI, and as such the two can, and often do, co-exist. A positive urine dip or culture doesn’t rule out constipation as a cause of abdominal pain. Don’t forget to think about constipation in the child with a history of recurrent UTI. Check out our DFTB Constipation module for more information.
4. A test which detects tuberculosis exposure. Mantoux
Tuberculin skin test (TST), or Mantoux test, and new immunological assays such as IGRAs detect Tuberculosis exposure. A Mantoux is performed by injecting 0.1ml of tuberculin purified protein derivative (PPD) intradermally into the inner surface of the forearm. The skin reaction produced by the PPD should be read between 48 and 72 hours and the reaction is measured in millimetres of induration, not redness. Read more about Tuberculosis and causes for prolonged fever by visiting the DFTB PUO module
5. Characteristic feature of the scarlet fever rash – sandpaper
The symptoms of scarlet fever start with fever (over 38.3°C), sore throat and general fatigue, headache and nausea. 12-48 hours later a rash appears on the abdomen and spreads to the neck and extremities. Characteristic features of the rash are a rough texture (like sandpaper) and worse in the skin folds e.g. groin, axilla, neck folds (Pastia’s lines). Read more about common childhood exanthems in the DFTB Common Rashes Module
6. An uncommon pathogen causing pneumonia – mycoplasma
Atypical pneumonia refers predominantly to an uncommon pathogen causing pneumonia, of which Mycoplasmas are one example. There is also fungal pneumonia which in addition to common bacterial and viral pathogens are considered uncommon and opportunistic microorganisms in a ‘poly-microbial mix’ seen mainly in immunocompromised children such as in HIV-exposed or infected children. While lower respiratory infection decreases with age, the prevalence of atypical infections increases, with a median age of about 7. Read more about Mycoplasma pneumonia in our DFTB Pneumonia Module
7. This rash in this viral exanthem classically presents after a fever and mild upper respiratory symptoms – Roseola
Roseola results in an acute febrile illness lasting between 3 and 7 days, which is then followed by the characteristic rash in around 20% of infected children. The prodrome to the rash is a high fever (39-40 °C), palpebral oedema, cervical lymphadenopathy and mild upper respiratory symptoms. The child appears well and as the fever subsides the exanthem appears. Read more about roseola at the DFTB Common Rashes Module
8. The organism most often associated with the viral exanthem in question 7 – HHV6 (Human Herpes Virus 6)
Roseola is caused most commonly by human herpesvirus 6 (HHV-6) and less commonly by human herpesvirus 7 (HHV-7). Human herpesvirus 7 (HHV-7) was discovered in 1989 as a new member of the beta-herpesvirus subfamily. Primary infection occurs early in life and manifests as exanthema subitum, or other febrile illnesses mimicking measles and rubella. Thus, HHV-7 has to be considered as a causative agent in a variety of macular-papular rashes in children. In addition, HHV-7 was found in some cases of other inflammatory skin disorders, such as psoriasis. Learn more about rashes at our Skin Deep website
9. “Scalpel, finger, bougie” is the recommended technique for front of neck access in children over 8 years in which national society’s guideline? DAS (Difficult Airway Society) UK
DAS UK guidelines suggest that children over 8 should have a “scalpel, finger, bougie” technique used to gain front of neck access. Under 8, the cricothyroid membrane is so small that needle jet insufflation should be utilised. You can read the technique for this as described by DFTB in our RSI and the difficult airway module
10. What do you get if you eat mistletoe? Tinsillitis
A common complaint in Santa’s Grotto.
1. What group of conditions cause focal pain, typically in areas such as the tibial tuberosity and inferior pole of the patella? Apophysitis
Apophysitis of the tibial tuberosity (Osgood Schlatter disease) or inferior pole of patella (Sinding-Larsen-Johansson) have a typical history of gradual onset localised pain in a child from 10-16 years of age. Pain is exacerbated by activity and initially improves with rest. The typical patient is highly active and may be overtraining. Examination will typically reveal point tenderness over the area involved with possibly some mild swelling. Read more about apophysitis and other non-traumatic musculoskeletal (MSK) injuries at our DFTB non-traumatic MSK injuries module
2. A tropical infection characterised by prolonged fever, splenomegaly and pancytopaenia – Leishmaniasis
Leishmaniasis is a parasitic disease spread by the sand-fly. Main symptoms are fever, enlargement of spleen and liver and pancytopenia. Leishmaniasis is the second-largest parasitic killer in the world after malaria. Diagnosis is made by histological finding of amastigotes on spleen aspiration/bone marrow aspiration and RK39 Antigen detection. Read more about the causes of prolonged fever in the DFTB PUO Module
3. In paediatric migraine, analgesia and an antiemetic together are more effective than either alone.
In the acute setting, evidence points to antiemetics as an effective migraine symptom reliever. Analgesia and antiemetics together are even more beneficial. Read more about combination therapy and the role of Chlorpromazine in the management of Paediatric migraine in the DFTB Headache Module
4. Significant weight loss, vomiting, lethargy, hypoglycaemia, jaundice and hepatomegaly point to which diagnosis in a neonate? Galactosaemia
Galactosaemia is an inherited metabolic disorder characterised by a defect in the enzyme galactose-1-phosphate uridyl transferase (GALT). It presents after the affected neonate receives the sugar galactose, present in milk. Accumulation of galactose-1-phosphate results in damage to the brain, liver, and kidney. The affected neonate presents with vomiting, hypoglycaemia, seizures due to an inability to metabolise glucose, irritability, jaundice, hepatomegaly, liver failure, cataracts, splenomegaly, and Escherichia coli sepsis. Read more about other inherited metabolic disorders and how to identify them in the ED by reading our DFTB Inherited Metabolic Disorders Module
5. This c-spine rule, when validated in children under 16, has a specificity of 19.9%. NEXUS (National Emergency X-radiography Utilization Study)
NEXUS is a validated clinical decision instrument designed to identify patients who are at extremely low risk of cervical spine injury (CSI). The Viccelilo study looked at the performance of NEXUS in the paediatric subgroup under 18 years. All patients with low risk for CSI were correctly identified (100% sensitivity) but a large proportion were also incorrectly identified as having a CSI (19.9% specificity) making this study unreliable in children under 9 years. Read more about c- Spine injuries here.
6. One of the three types of brain tumours associated with tuberous sclerosis – tubers
Tuberous sclerosis (TS) is a rare multisystem genetic disease affecting the kidneys, heart, eyes, liver and skin. A combination of symptoms may include seizures, developmental delay, intellectual disability and skin conditions. The three types of brain tumors associated with TS include giant cell astrocytomas, cortical tubers and subependymal nodules. Want to know more about seizures or developmental delay? Take a look at our DFTB Seizure Module or this fantastic DFTB post on developmental delay.
7. What does Santa suffer from if he gets stuck in the chimney? Claustraphobia
And the hidden word?
Bauble, a type of Christmas bubble.