what’s your diagnosis??

What’s Your Diagnosis??What’s Your Diagnosis??

Ben Taub Float

Department of Pediatrics

Baylor College of Medicine

August 20, 2007

Case Scenario # 1Case Scenario # 1

A 9 month old infant presents with numerous excoriated, erythematous papules and pustules on the wrists, abdomen, periaxillary skin, ankles, and feet. Some of the lesions appear to be infected secondarily. The patient appears uncomfortable. Mother reports that her other children only have a few pruritic lesions. Mother denies any lesions but habitually rubs the interdigital webs of her hand.

ScabiesScabies Etiology: Hypersensitivity reaction to mite—Sarcoptes scabiei Rash:

Pruritic papules, pustules, vesicles, and burrows Distribution:

Sides & webs of the fingers, lateral & posterior aspects of feet Flexor aspects of the wrists & extensor aspects of the elbows, extensor surface of

the knees Axillary folds Periumbilical areas, waist, genitalia

Treatment: Permethrin to all household members Antihistamines to control itching Disinfection of recently used clothing, linens, stuffed animals


A mother brings her son in with c/o poor feeding. Mother states that the patient developed a low grade fever a few days prior and then began to refuse to eat. She thinks he has a sore throat and she has noticed a new rash on his hands and feet.

Hand, Foot, Mouth DiseaseHand, Foot, Mouth Disease

Etiology: Coxsackie virus A16

Clinical Features: Fever Sore throat and pain with swallowing Oral lesions:

Vesicles and ulcers surrounded by erythematous base Posterior pharynx, tonsillar pillars, soft palate, uvula,

tongue

Vesicular lesions of hands and feet


A 4 year-old male with h/o eczema presents with high fever and a 2 day h/o worsening skin rash. Mother states that the rash initially developed similar to an usual eczema exacerbation, but then rapidly worsened with development of papules and pustular lesions which then ruptured and crusted over.

Eczema HerpeticumEczema Herpeticum Etiology:

Primary HSV infection of skin In patients with chronic skin disorder

Clinical Presentation: Fever Skin Lesions:

Appear in crops At site of currently or recently infected skin Papulespustulesrupture and form crust Occasionally lesions become hemorrhagic

Treatment: Acyclovir, hydration

Complications: Dehydration, secondary infection


A mother brings her son to the office because of a facial rash. He is “feeling fine” and has only a low grade fever. Mother states that the rash started a few days ago as bright red bumps and then coalesced together to give very red cheeks. Yesterday, he developed lacelike looking pink areas on his arms.

Fifth’s DiseaseFifth’s Disease Etiology: Parvovirus B19

Clinical Presentation: Prodrome: Fever, coryza, HA, nausea, diarrhea Rash: Progresses in 3 stages

1) Erythema of cheeks (“slapped cheeks”)

2) Erythematous maculopapular reticular rash involving arms and spreading to trunk and legs

3) Fluctuations in severity of rash

Complications: Aplastic crisis Fetal hydrops and death during pregnancy Arthritis, hemolytic anemia, encephalopathy


A 12 month old with no significant past medical history is brought in by his mother because for the past day he has had a runny nose. When he gets mad and agitated he barks like a seal and has a lot of trouble breathing.

CroupCroup Etiology:

Parainfluenza viruses types 1, 2, 3 Influenza viruses A & B Respiratory syncytial virus Adeonovirus Measles

Clinical Presentation: Prodrome: Fever, rhinorrhea, pharyngitis, cough Upper airway obstruction: “Barking cough,” stridor, hoarseness

Treatment: Mild: Mist treatment Moderate: Steroids, racemic epinephrine Severe: Intubation

Case Scenario # 6 Case Scenario # 6

A mother brings her 4 year-old son to clinic due to a two day h/o high fever and refusal to eat or drink. Mother has also noted the development of “sores in and around his mouth” and copious drooling.

HSV GingivostomatitisHSV Gingivostomatitis

Etiology: Herpes simplex virus types 1 & 2

Clinical Features: Ulcerative lesions on buccal mucosa, gums, palate, tongue Fever Mouth pain and anorexia Regional adenopathy

Therapy: Pain relief Hydration +/- Acycolvir


A mother brings her daughter to clinic for evaluation of a rash. Mother reports a 2 week history of rash on the arms, legs, diaper area, and face. Numerous topical agents have been used with no improvement in the rash. Mother remembers that the patient had a low grade fever and URI symptoms prior to the development of the rash.

Gianotti-Crosti Gianotti-Crosti (Papular Acrodermatitis)(Papular Acrodermatitis)

Etiology: Associated with viral infections

Clinical Presentation: Prodrome:

Fever, malaise, URI symptoms, diarrhea +/- Hepatomegaly

Rash: Appears abruptly Discrete, firm papules with flat tops Flesh colored, pink, red, dusky, coppery, purpuric Symmetric over the extremities, buttocks, and face Spare the trunk, scalp, and mucous membranes


An 8 year-old male presents to clinic with a two day history of fever and sore throat. His mother noted that his tongue was initially white and is now red. The patient also developed a goose bump type rash overnight.

Scarlet FeverScarlet Fever Etiology: Group A Streptococcus

Clinical Presentation: Fever, chills, headache, sore throat, abdominal pain Rash:

Erythematous, finely punctate, blanches, “sandpaper rash” Initially on trunk and then generalizes Circumoral pallor Pastia’s lines Fades over one week followed by desquamation

Strawberry tongue Pharyngeal erythema, +/- exudate, +/- palatal petechiae

Treatment: Penicillin x 10 days

Complications: Rheumatic fever Post-streptococcal gloumerulonephritis Pyogenic complications: Adenitis, otitis, sinusitis, abscess


Parents bring their child in for evaluation due to acute development of high fever, malaise, and lethargy. On exam, the patient is mottled with poor perfusion, tachycardic, and has developed a new rash.

MeningococcemiaMeningococcemia Etiology: Neiserria meningitidis

Clinical Presentation: Prodrome:

URI symptoms, pharyngitis, fever Lethargy, headache, vomiting Myalgias, arthralgias

Septicemia: Abrupt worsening of prodromal symptoms Rash: Tender pink macules, petechiae, purpurafrank necrosis Shock: Mottling, poor perfusion, +/- hypotension DIC

Meningitis

Treatment: 3rd generation cephalosporin Supportive care: Fluid replacement, pressors as needed

Clinical Scenario # 10Clinical Scenario # 10

Mother brings in her 5 year old who has had complaints of thigh pain for the past 2 months. She notices now when he walks that he steps with his left foot, his right hip and butt seem to drag toward the ground. He reports no history of fever or trauma.

Legg Calve Perthes DiseaseLegg Calve Perthes Disease

Etiology: Idiopathic avascular necrosis of the hipClinical Presentation:

Limp Pain Limited internal rotation of hip Atrophy of thigh muscles

Treatment: Referral to orthopedics Poorly defined management


Several weeks ago, a boy presented with fever, malaise, headache, and a skin lesion. The lesion began as a red papule and slowly enlarged to form a large annular ring with a flat erythematous border. Today he complains of recurrent joint pains that are particularly severe in his knees. He spent the beginning of the summer at a camp in Connecticut.

Lyme DiseaseLyme Disease Etiology: Borrelia burgdorferi Clinical Findings:

Early, localized disease: Erythema migrans Fever Headache, fatigue Arthralgias/Myalgias

Early, disseminated disease: Multiple erythema migrans Aseptic meningitis Cranial neuropathies

Late, persistent infection: Asymmetric, pauciarticular arthritis Polyneuropathy, encephalopathy

Treatment: Doxycycline Complications: Chronic arthritis, chronic neurological disease


A newborn, small for gestational age infant, is noted to have microcephaly, jaundice, hearing loss, and a non-blanching rash on exam. Mother had no known infection during pregnancy and is Rubella immune.

Congenital CMVCongenital CMV Etiology:

Cytomegalovirus 1% of infants are born with congenital CMV

Clinical Presentation: 90% are asymptomatic Small for gestational age Microcephaly Thrombocytopenia, petechiae, purpura Hepatosplenomegaly Hepatitis, jaundice Intracranial calcifications Chorioretinitis Sensorineural hearing loss “Blueberry muffin” appearance


A 5 year-old female presents with complaints of fever, dry cough, runny nose, watery/red eyes x 4 days. Yesterday, she developed a rash that started on the forehead and has since spread down the face and trunk. The patient appears acutely ill with severe malaise and anorexia.

Measles (rubeola)Measles (rubeola) Etiology: Measles virus (paramyxovirus)

Clinical Presentation: Prodrome: Malaise, fever, cough, coryza, conjunctivitis, photophobia Enanthem: Koplik’s spots Exanthem: Erythematous maculopapular rash beginning on head and

spreading cephalocaudally

Complications: Pneumonia Post infectious encephalomyelitis Subacute sclerosing panencephalitis Otitis media Laryngotracheobronchitis Myocarditis, pericarditis, hepatitis


A 4 year-old boy presents with a h/o 2-4 mm flesh colored papules, some with central umbilication, of several months duration. The parents explain that new lesions appear occasionally. The lesions are located on the face, proximal extremities, and trunk.

Molluscum contagiosumMolluscum contagiosum Etiology: Poxvirus

Clinical Presentation: Firm, dome shaped papules with an umbilicated center Pearly grey, shiny, flesh colored lesions Commonly involve the trunk, axillae, antecubital and popliteal

fossae, and crural folds Spare the palms and soles

Treatment: Self-resolution within 6 months Cryotherapy Curettage Laser therapy


A 6 year-old male presents with complaints of a red, swollen, tender bump in his right armpit. He loves to play outside, plays with stray animals, and recently spent a week at his grandparents farm. On exam, you find a febrile child with a small papule and healing scratches on his arm and swollen, tender lymph nodes in his axilla

Cat Scratch DiseaseCat Scratch Disease Etiology:

Bartonella henselae Clinical Presentation:

Cutaneous manifestations: Primary inoculation lesion Lymphadenopathy Visceral organ involvement: +/- hepatosplenomegaly Fever of unknown origin Ocular manifestations:

Parinaud's oculoglandular syndrome Neuroretinitis

Neurologic manifestations: Encephalopathy Myelitis, radiculitis, cerebellar ataxia

Arthropathy


An 8 year-old male that you are evaluating in a refugee camp has been complaining of fever, sore throat, and difficulty swallowing.

DiphtheriaDiphtheria

Etiology: Corynebacterium diphtheriae

Clinical Presentation: Presenting symptoms: Fever, sore throat, malaise Diphtheric pseudomembrane Systemic manifestations: Myocarditis, neurologic toxicity Cutaneous diphtheria: Chronic, non-healing ulcers

Treatment: Diphtheria antitoxin Penicillin or erythromycin


A 13 year old obese male presents with complaints of pain for 2 weeks in the groin and anterior thigh. He stands and walks with pain and his x-ray shows the following.

Slipped Capital Femoral EpiphysisSlipped Capital Femoral Epiphysis Etiology:

Portion of proximal femur distal to the physis is displaced anterolaterally and superiorly

Occurs when shearing forces applied to the femoral head exceed the strength of the capital femoral physis

Clinical Presentation: Pain Abnormal gait

Treatment: Referral to orthopedics Stabilization with screw pinning

Complications: Osteonecrosis Chondrolysis


An 11 year-old female presents with complaints of recent development of abdominal pain, joint pain, and a new skin rash. Her stool is guaic positive.

Henoch-Schonlein PurpuraHenoch-Schonlein Purpura Etiology: Vasculitis secondary to immune complex deposition

Clinical Features: Rash:

Begins as erythematous, macular, or urticarial Evolves into ecchymoses, petechiae, and palpable purpura Located in gravity/pressure-dependent areas

Abdominal pain Arthritis Renal involvement

Treatment: Supportive +/- Hospitalization Symptomatic Therapy: NSAIDS, Glucocoricoids Follow up


A 9 year-old boy presents to your office with a h/o “a swelling on the right side of his face.” Mother states that ~ 2 days ago he had a fever (101.8F) with c/o anorexia, headaches, and generalized aches and pains. The swelling began over the right side of his face and continued to enlarge.

MumpsMumps Etiology: Mumps virus (paramyxovirus) Clinical Features:

Prodrome: Fever, headache, malaise, anorexia Parotid gland pain and swelling

Complications: Meningoencephalitis Orchitis, oopheritis Pancreatitis Unilateral deafness Nephritis Arthritis Myocarditis


A 8 day-old male is brought to the urgent care clinic for evaluation of eye discharge. Mother states she had an uneventful pregnancy and there were no problems after birth. On DOL#6, the mother noted a purulent discharge from the infant’s eyes and increasing redness and swelling of the eyes since yesterday. The infant is otherwise well.

Chlamydial ConjunctivitisChlamydial Conjunctivitis

Etiology: Chlamydia trachomatis

Clinical Presentation: Eyelid edema and erythema Mucopurulent discharge Unilateral or bilateral Associated pneumonia in 10-20%

Treatment: Erythromycin PO x 14 days


A mother brings her infant in for evaluation of a diaper rash. Mother states that the patient suffered from diarrhea last week and then developed the rash. She has been treating him with over the counter Boudreaux’s Butt Paste with no improvement in the rash.

Candidal DermatitisCandidal Dermatitis

Etiology: Candida albicans

Clinical Presentation: Erythematous rash in inguinal region Confluent erythema with papules and plaques Satellite lesions

Treatment: Topical antifungal agent


A tall, thin 18 year-old male comes in with sudden episode of chest pain on the left side and trouble breathing. He denies any unusual activities today, denies trauma, and has never experienced this pain before.

Spontaneous PneumothoraxSpontaneous Pneumothorax Definition:

Collection of air that is located within the thoracic cage between the visceral and parietal pleura

Results from air leak through the visceral or parietal pleura Clinical Presentation:

Most often occurs at rest or with minimal exertion Sudden onset of dyspnea and chest pain Diminished breath sounds on affected side Hyperresonance to percussion on affected side Signs of respiratory compromise (tachypnea, cyanosis, WOB) Deviated trachea

Treatment: Observation Supplemental O2 Needle thoracentesis Thoracostomy tube Surgical intervention


An 8 month old boy presents to your clinic with a 3 day h/o fever to 103. Last night his mother noted rhythmic motions of both arms and legs that lasted < 1 minute. He was febrile at the time and she did not know if it was seizure activity or shivering. This morning, he was without fever and developed a rash. He is non-toxic, and his exam is normal with the exception of the rash.

Roseola infantumRoseola infantum

Etiology: Human herpes virus 6 (HHV-6)

Symptoms: Fever:Abrupt high fever Rash: Develops with resolution of fever

Macular/maculopapular

Develops on trunk and spreads peripherally

Treatment: Supportive

Complications: Febrile seizures


A 3 year-old girl presents with recent history of URI symptoms followed by the rapid appearance of an “itchy” rash. The lesions appeared in groups, initially on the trunk and then spread peripherally.

ChickenpoxChickenpox

Etiology: Varicella zoster virus

Clinical Feature: Mild fever, malaise, anorexia Rash:

Pruritic, occur in crops Papules-->Vesicles-->Ulcerative lesions-->Crust Begin on trunk and spread peripherally

Complications: Encephalopathy, pneumonia, hepatitis, secondary infection


A 10 year old boy presents for evaluation of a new rash on his ankle. The patient and his family recently returned from a trip to the Caribbean where the patient spent the majority of his day on the sandy beaches.

Cutaneous Larva MigransCutaneous Larva Migrans Etiology: Ancylostoma brazilense (dog or cat hookworm)

Clinical Presentation: Pruritic, erythematous papule at site of larva entry Severely pruritic, elevated, serpiginous, reddish-brown lesions appear

as the larvae migrate Pulmonary manifestations

Treatment: Topical thiabendazole OR Systemic ivermectin OR albendazole


An 10 month old girl is brought to the ER for evaluation after acute refusal to bear weight on her lower extremities. Parents report that the patient fell off of the bed the day prior to presentation.

Spiral Femur FractureSpiral Femur Fracture

High suspicion for non-accidental trauma

Result of twisting action which is uncommon in accidental falls in young children

Other skeletal injuries related to child abuse: Bucket handle or corner fracture Posterior rib fracture Acromion fracture Fracture of spinous processes Fracture of sternum Skull fractures


A 20 month old boy presents to the ER with a six day h/o fever, “red eyes”, and a rash. On exam, the patient is fussy with a T=103. He has the following physical exam findings.

Kawasaki DiseaseKawasaki Disease Vasculitis of unknown etiology Diagnostic Criteria:

Fever > 5 days Four of the following:

Bilateral conjunctival injection Mouth involvement (erythematous mouth and pharynx, strawberry

tongue, red/cracked lips) Cervical lymphadenopathy Changes in extremities (edema, erythema) Rash

Exclusion of other diseases with similar findings Treatment: IVIG, high dose aspirin Complications: Coronary artery aneurysm

what’s your diagnosis??

Documents

mother states

pruritic lesions

feverskin lesions

swallowingoral lesions

new rash

facial rash

pustular lesions

mother reports