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Visual DiagnosisRakesh D. Mistry, MD, MS

Division of Emergency MedicineChildren’s Hospital of Philadelphia

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8 mo. with fever and diaper rash

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8 mo. with fever and diaper rash

Differential Diagnosis– Bullous impetigo– S. aureus scalded skin– Erysipelas– Perianal group A strep– Stevens-Johnson– Partial-thickness burn

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Erysipelas

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10 y.o. male with rash on leg

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Ecthyma

• Local necrotizing skin infection

• Microbiology– Streptococcus pyogenes

(GABHS)– S. aureus– Pseudomonas aeurginosa

• Systemic– Ecthyma gangrenosa– Immune deficiency

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Ecthyma

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Bullous impetigo

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4 y.o. girl with progressive facial swelling and fever

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Facial Swelling

• Dental abscess• Facial cellulitis• Parotitis• Sinusitis• Lymphadenitis• Insect bite

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Another view…

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Facial Cellulitis

• Microbiology– Staphylococcus aureus– Group A ß-hemolytic Streptococcus (GABHS)– Haemophilus tnfluenzae type B

• Treatment:– Cephalosporins, clindamycin– Consider IV

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6 y.o. male with fever, neck swelling, pain with eating

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Parotitis• Displaces ear• Obscures inferior border

and angle of mandible • Microbiology

– S. aureus– Oral flora– Infuenzae– Coxsackie/Enteroviruses– Mumps– HIV

• Consider imaging for abscess

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Lymphadenitis• Microbiology

– GABHS– H. influenzae– S. aureus– Oral flora

• Treatment– Ampicillin/Sulbactam– Clindamycin– Consider imaging for

abscess

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12 mo. female with “rash”

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Popsicle Panniculitis

• Extended contact with cold• Subcutaneous fat necrosis• Benign condition: Reassurance

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5 y.o. girl with blood in underwear

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• Pre-pubertal girls

• Associated with constipation, increased abdominal pressure

• Management– Sitz baths and reassurance– Topical estrogen cream– Urology follow-up

Urethral Prolapse

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13 y.o female with 6 months of episodic abdominal pain

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Hematocolpos

• Imperforate hymen• Primary amenorrhea• Abdominal mass• Treatment: Surgical

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Electrical Burn

• Differential– Caustic ingestion– Infectious

• Risk for delayed labial artery bleed

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15 y.o. fever, sore throat, abdominal pain

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15 y.o. fever, sore throat, abdominal pain

• Differential Diagnosis– GABHS– N. gonorrhea– Adenovirus– Influenza– Mononucleosis

• Epstien-Barr Virus (EBV)

• Cytolomegalovirus (CMV)

• Diagnosed GABHS (+)• Placed on penicillin

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Non-compliant…Returns in 5 days

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Peritonsillar Abscess

• Older children and adolescents• “Hot-potato” voice• Trismus and drooling• Management

– Needle aspiration– Antibiotic therapy

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14 y.o. male with fever, neck pain, and dysphagia

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Ludwig’s Angina

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Ludwig’s Angina

• Submandibular/sublingual infection• Rapidly progressive• Management

– Monitor airway– IV antibiotics– Surgical drainage

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18 mo. “not using hands”

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18 mo. “not using hands”

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Vitamin D Deficiency

• Hypocalcemia• Dietary• Skeletal findings

– Bowing– Epiphyseal widening– “Rachitic rosary”

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3 y.o. girl not using right arm

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Radial Head Subluxation

• Typical appearance of well-appearing child not using affected arm

• Reduction– Supination-Flexion– Pronation-Extension

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8 y.o. female with fatigue and dyspnea on exertion for 2 weeks

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Pallor

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Anemia

• Typically appears with hemoglobin ~8 gm/dL

• Anemia– Nutritional– Blood loss– Malignancy– RBC destruction

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Infant with severe diarrhea

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Central Cyanosis

• Severe pulmonary disease• Shock• R L cardiac shunt• Polycythemia• Abnormal hemoglobin states

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Methemoglobinemia

• Oxidative stress: diarrhea, dehydration, acidosis

• Methemogobin cannot carry O2 tissue hypoxia

• Fluid resucitation

• Methylene blue

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Fever and spreading rash

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Petechiae

• Meningococemia• Viral exanthem• Rocky Mountain Spotted Fever

(Rickettsia rickettsi)• Immune Thrombocytopenic

Purpura• Mechanical

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5 y.o. male casted 3 days ago for presumed fracture, now with rash

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Henoch-Schonlein Purpura

• Presentation– Palpable purpura– Joint swelling and pain– Abdominal Pain– Renal involvement

• Management– Pain control– Urinalysis– Consider steroids

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Malar Rash: Systemic Lupus Erythematosus (SLE)

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14 year old boy with painful rash on face and eye pain

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Herpes Zoster

• Dermatomal distribution

• Pain control

• IV or PO Acyclovir

• Trigeminal nerve: suspect ocular disease

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3 y.o. with “finger infection”

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Herpetic Whitlow

• Differential Diagnosis– Paronychia– Bullous impetigo

• Do not incise

• Treat symptomatically

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2 y.o. history of dry skin, now red painful rash

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Eczema Herpeticum

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3 y.o. girl with rash on face

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Herpes Keratoconjunctivitis

• Analgesia

• Topical Acyclovir

• Do not use steroids!

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21 mo.female with right eye swelling and fever

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Eye Swelling

• Conjunctivitis• Periorbital cellultiis• Orbital cellulitis• Insect bite• Allergic reaction• Hypoproteinemia (Nephrotic Syndrome)• Epstien-Barr Virus

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Poked in eye at school

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Open Globe Injury

• Iris plugs defect misshapen pupil• Stop examination immediately

Cover eye with hard protective shield

Consult ophthalmology

Avoid increases in intraocular pressure

No ointments or drops

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Neonate with fever and pus from umbilical stump

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Omphalitis

Differential• Infected urachal cyst• Umbilical hernia• Patent omphalomesenteric

duct

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4 y.o. backseat passenger in motor vehicle crash

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Seatbelt/Lapbelt Injury

• Abdominal or pelvic bruising• Intra-abdominal injuries

• Hollow viscus• Solid organs

• Lumbar spine fracture (Chance fracture)• Management

• Abdominal CT• Admit for serial exams

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20 mo. male was “playing rough” with brother

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Child Abuse

• Multiple bruises

• Soft tissues-not over bony prominences

• Shape of fist or pinch

• Loop-belt or cord marks

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3 week-old with eye swelling

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3 week-old with eye swelling

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Orbital Tumor

• Neuroblastoma

• Retinoblastoma (usually within globe)

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Ophthalmia Neonatorum

• Chlamydia trachomatis

• Neisseria gonhorrheae

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12 mo. female with rash

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12 mo. female with rash

• Differential Diagnosis– Urticaria– Stevens-Johnson Syndrome– Erythema Migrans (Lyme Disease)– Erythema Multiforme

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Erythema Multiforme Minor

• Infectious– Epstein-Barr Virus (EBV)– Mycoplasma

• Serum sickness• Autoimmune disease• Malignancy

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Teenager with fever, rash, red eyes

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Teenager with fever, rash, red eyes

• Differential Diagnosis– Adenovirus– Kawasaki syndrome– Stevens-Johnson

Syndrome

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Stevens-Johnson Syndrome

• Erythema multiforme major• Mucosal surfaces• Etiology: infections? medications?• Severe cases: exfoliating, similar to burn

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12 y.o. male with painful leg rash

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Erythema Nodosum

• Painful, well- circumscribed nodules

• Etiology– Infectious– Medications– Inflammatory bowel

disease– Malignancy

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Uvular Swelling

• Allergic/angioedema• Infection (GABHS)• Trauma• Thermal or Chemical irritation

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Recurrent infection of outer ear

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The other ear…

• Pre-auricular sinus and cyst

• Diagnosis– Neonatal period– Infection later in life

• Associated with deafness

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8 y.o. fever, headache, vomiting

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8 y.o. fever, headache, vomiting

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Pott’s Puffy Tumor

• Sinusitis with:– Scalp swelling – Osetomyelitis and anterior erosion– Extradural abscess– Intracrania abscess

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2 y.o. thigh pain and redness

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2 y.o. thigh pain and redness

• Differential Diagnosis– Cellulitis– Skin abscess– Osteomyelitis with fistula – Retained foreign body– Spider bite

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Skin Abscess

• Methicillin-resistant S. aureus (MRSA)

• Incision and drainage paramount

• Clindamycin or trimethoprim-sulfa

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Venomous Snake Bite

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Venomous Snake Bite

• Crotalinae family, or “pit vipers”– Vertical, elliptical pupils– Triangular head– Single row of caudal

plates, or rattle

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Venomous Snake Bite

• Immobilize extremity below heart

• Anti-venin required

• NOT indicated– Incision and suction– Tourniquet– Cryotherapy

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10 y.o. girl with fever, left eye pain, and diplopia

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Orbtal Myositis

• Pain• Fever• Ocular muscle

paresis• Proptosis

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14 y.o. female with “uneven smile” noted this AM

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Peripheral Facial Nerve Palsy

• Common etiologies– Idiopathic (Bell’s Palsy)– Borrelia burgdorferi

(Lyme Disease)– Varicella-Zoster

(Ramsay Hunt Syndrome)– Herpes Simplex Virus– Epstein-Barr Virus (EBV)

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Peripheral Facial Nerve Palsy

• Treatment– Fluoroscein eye– Eye patching and lubricant– Presence of Otitis media is ENT emergency!– Treat underlying condition if noted– Empiric steroids and acyclovir controversial