Pediatric Visual diagnoses

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  • Id reaction – itchy, fine, papulovesicular rash on trunk, face or hands caused by hypersensitivity reaction to the fungus
  • Fever for 5 or more days Presence of 4 of the following: Bilateral conjunctival injection Changes in the oropharyngeal mucous membranes injected pharynx, injected lips, dry or cracked lips, strawberry tongue Changes of the peripheral extremities – peripheral edema or erythema, desquamation, periungual dequamation Rash - mostly truncal, polymorphic but not vesicular Cervical lymph node
  • As of 1994, only one controlled study looking at steroids in HSP Mollica et al 1992 – 168 ptts , half given pred for 2 weeks – none of these dev’d nephritis; but 12% untreated dev’d nephritis
  • Pediatric Visual diagnoses

    1. 1. Pediatric Visual Diagnosis Ilana Greenstone MD Division of Emergency Medicine Montreal Children’s Hospital McGill University Health Center
    2. 2. Objectives <ul><li>Recognize common pediatric dermatologic conditions </li></ul><ul><li>Expand differential diagnosis </li></ul><ul><li>Review treatment plans </li></ul><ul><li>Identify skin manifestations of systemic disease </li></ul>
    3. 3. Terminology <ul><li>Macules, Papules, Nodules </li></ul><ul><li>Patches and Plaques </li></ul><ul><li>Vesicles, Pustules, Bullae </li></ul><ul><li>Colour </li></ul><ul><li>Erosions – when bullae rupture </li></ul><ul><li>Ulcerations and excoriations </li></ul>
    4. 8. Atopic Dermatitis <ul><li>3-5% of children 6 mo to 10 yr </li></ul><ul><li>Described in 1935 </li></ul><ul><li>Ill-defined, red, pruritic, papules/plaques </li></ul><ul><li>Diaper area spared </li></ul><ul><li>Acute: erythema, scaly, vesicles, crusts </li></ul><ul><li>Chronic: scaly, lichenified, pigment changes </li></ul>
    5. 10. Atopic Dermatitis <ul><li>Hints to diagnosis </li></ul><ul><li>Generalized dry skin </li></ul><ul><li>Accentuation of skin markings on palms and soles </li></ul><ul><li>Dennie-Morgan lines </li></ul><ul><li>Fissures at base of earlobe </li></ul><ul><li>Allergic history </li></ul>
    6. 15. Atopic Dermatitis Treatment <ul><li>Moisturize </li></ul><ul><li>Baths only </li></ul><ul><li>Anti-histamine </li></ul><ul><li>Topical steroids to red and rough areas </li></ul><ul><ul><li>Prevex HC </li></ul></ul><ul><ul><li>Desacort </li></ul></ul><ul><li>Immune modulators </li></ul>
    7. 17. Superinfected Eczema <ul><li>Red and crusty </li></ul><ul><li>Usually S. aureus </li></ul><ul><li>Cephalexin 40 mg/kg/day divided TID for 10 days </li></ul><ul><li>More potent topical steroid </li></ul><ul><li>Topical antibiotic – Fucidin </li></ul><ul><li>Anti-histamine </li></ul><ul><li>Refer to Dermatology </li></ul>
    8. 22. Scabies <ul><li>Intense pruritus </li></ul><ul><li>Diffuse, papular rash </li></ul><ul><ul><li>Between fingers, flexor aspects of wrists, anterior axillary folds, waist, navel </li></ul></ul><ul><li>May be vesicular in children < 2 years </li></ul><ul><ul><li>Head, neck, palms, soles </li></ul></ul><ul><ul><li>Hypersensitivity reaction to protein of parasite </li></ul></ul>
    9. 23. Scabies Treatment <ul><li>5% permethrin cream for infants, young children, pregnant and nursing mother </li></ul><ul><ul><li>Kwellada-P or Nix </li></ul></ul><ul><ul><li>Cover entire body from neck down </li></ul></ul><ul><ul><li>Include head and neck for infants </li></ul></ul><ul><ul><li>Wash after 8-14 hours </li></ul></ul><ul><li>Can use Lindane for older children </li></ul>
    10. 26. Tinea corporis Ringworm <ul><li>Face, trunk or limbs </li></ul><ul><li>Pruritic, circular, slightly erythematous </li></ul><ul><li>Well-demarcated with scaly, vesicular or pustular border </li></ul><ul><li>Id reaction </li></ul><ul><li>Mistaken for atopic, seborrheic or contact dermatitis </li></ul><ul><li>Treament: Terbinafine (Lamisil) </li></ul>
    11. 28. Pityriasis Rosea <ul><li>Begins with herald patch </li></ul><ul><ul><li>Large, isolated oval lesion with central clearing </li></ul></ul><ul><li>More lesions 5-10 days later </li></ul><ul><li>Christmas tree distribution </li></ul><ul><li>Treatment: anti-histamines </li></ul>
    12. 29. Eczema <ul><li>Differential Diagnosis </li></ul><ul><ul><li>Atopic dermatitis </li></ul></ul><ul><ul><li>Scabies </li></ul></ul><ul><ul><li>Tinea corporis </li></ul></ul><ul><ul><li>Pityriasis rosea </li></ul></ul><ul><li>If vesicular, check for HSV1, HSV2, VZV </li></ul><ul><li>Beware of superinfection </li></ul><ul><li>Think of immune deficiency if difficult to treat </li></ul>
    13. 32. Urticaria <ul><li>Transient, well-demarcated wheels </li></ul><ul><li>Pruritic </li></ul><ul><li>Part of IgE-mediated hypersensitivity reaction </li></ul><ul><li>May leave central clearing </li></ul><ul><li>Triggers are numerous </li></ul>
    14. 37. Kawasaki Disease Diagnostic Criteria <ul><li>Fever for 5 or more days </li></ul><ul><li>Presence of 4 of the following: </li></ul><ul><ul><li>Bilateral conjunctival injection </li></ul></ul><ul><ul><li>Changes in the oropharyngeal mucous membranes </li></ul></ul><ul><ul><li>Changes of the peripheral extremities </li></ul></ul><ul><ul><li>Rash </li></ul></ul><ul><ul><li>Cervical adenopathy </li></ul></ul><ul><li>Illness can’t be explained by other disease </li></ul>
    15. 38. Kawasaki Disease Lab Features <ul><li> WBC </li></ul><ul><li> ESR, positive CRP </li></ul><ul><li>Anemia </li></ul><ul><li>Mild  transaminases </li></ul><ul><li> albumin </li></ul><ul><li>Sterile pyuria, aseptic meningitis </li></ul><ul><li> platelets by day 10-14 </li></ul>
    16. 39. Kawasaki Disease Differential Diagnosis <ul><li>Measles </li></ul><ul><li>Scarlet fever </li></ul><ul><li>Drug reactions </li></ul><ul><li>Viral exanthems </li></ul><ul><li>Toxic Shock Syndrome </li></ul><ul><li>Stevens-Johnson Syndrome </li></ul><ul><li>Systemic Onset Juvenile Rheumatoid Arthritis </li></ul><ul><li>Staph scalded skin syndrome </li></ul>
    17. 40. Kawasaki Disease Difficulties with Diagnosis <ul><li>Clinical diagnosis </li></ul><ul><li>No single test </li></ul><ul><li>Diagnosis of exclusion </li></ul><ul><li>Atypical KD </li></ul><ul><ul><li>Do not fulfill all criteria </li></ul></ul><ul><ul><li>More common in < 1 year and > 8 years </li></ul></ul>
    18. 41. Kawasaki Disease Treatment <ul><li>Admit to monitor cardiac function </li></ul><ul><li>Complete cardiac evaluation </li></ul><ul><ul><li>CXR, EKG, echo </li></ul></ul><ul><li>IV Ig </li></ul><ul><li>ASA </li></ul>
    19. 42. Kawasaki Disease Treatment <ul><li>IV Ig 2 g/kg as single dose </li></ul><ul><ul><li>Expect rapid resolution of fever </li></ul></ul><ul><ul><li>Decrease coronary artery aneurysms from 20% to < 5% </li></ul></ul><ul><li>ASA - low dose vs high dose </li></ul><ul><ul><li>80-100 mg/kg/day until day 14 </li></ul></ul><ul><ul><li>3-5 mg/kg/day for 6 weeks </li></ul></ul><ul><li>Repeat echocardiogram at 6 weeks </li></ul>
    20. 46. Coxsackie Virus Hand-Foot-and-Mouth <ul><li>Painful, shallow, yellow ulcers surrounded by red halos </li></ul><ul><li>Found on buccal mucosa, tongue, soft palate, uvula and anterior tonsillar pillars </li></ul><ul><li>Oral lesions without the exanthem = herpangina </li></ul><ul><li>Exanthem involves palmar, plantar and interdigital surfaces of the hands and feet +/- buttocks </li></ul>
    21. 48. Erythema Infectiosum Fifth Disease <ul><li>Parvovirus B19 </li></ul><ul><li>Mostly preschool age </li></ul><ul><li>Recognized by exanthem </li></ul><ul><li>Contagious before rash </li></ul><ul><li>Resolution between 3 and 7 days </li></ul>
    22. 50. Roseola <ul><li>6 to 36 months </li></ul><ul><li>Human herpesvirus 6 </li></ul><ul><li>High fever without source and irritability for 3 days </li></ul><ul><li>Rash develops as fever decreases </li></ul>
    23. 53. Impetigo <ul><li>Mostly face, extremities, hands and neck </li></ul><ul><li>Localized unless underlying skin disease </li></ul><ul><li>Strep or Staph </li></ul><ul><li>Honey-coloured crust </li></ul><ul><li>Treatment: topical and systemic antibiotics </li></ul>
    24. 56. Herpes Simplex <ul><li>Gingivostomatitis most common 1 º infection in children </li></ul><ul><ul><li>Fever, irritability, cervical nodes </li></ul></ul><ul><ul><li>Small yellow ulcerations with red halos on mucous membranes </li></ul></ul><ul><li>Involvement more diffuse – easy to differentiate from herpangina and exudative tonsillitis </li></ul><ul><li>Treatment: supportive </li></ul>
    25. 58. Herpetic Whitlow <ul><li>Lesions on thumb usually 2 ° to autoinoculation </li></ul><ul><li>Group, thick-walled vesicles on erythematous base </li></ul><ul><li>Painful </li></ul><ul><li>Tend to coalesce, ulcerate and then crust </li></ul><ul><li>May require topical or oral acyclovir </li></ul>
    26. 62. Henoch-Schonlein Purpura Clinical features <ul><li>Palpable purpura of extremities </li></ul><ul><li>Arthralgia or non-migratory arthritis </li></ul><ul><ul><li>No permanent deformities </li></ul></ul><ul><ul><li>Mostly ankles and knees </li></ul></ul><ul><li>Abdominal pain </li></ul><ul><ul><li>May develop intussusception </li></ul></ul><ul><li>Renal involvement </li></ul><ul><ul><li>Hematuria, hypertension, renal failure </li></ul></ul>
    27. 63. HSP Management <ul><li>Supportive </li></ul><ul><li>NSAIDs may control the pain and do not increase the risk of bleeding </li></ul><ul><li>Steroids – controversial </li></ul><ul><ul><li>Efficacy not proven re: abdo pain </li></ul></ul><ul><ul><li>No effect on purpura, duration of the illness or the frequency of recurrences </li></ul></ul><ul><ul><li>Unclear of protective effect on renal disease </li></ul></ul>
    28. 64. HSP Indications for admission <ul><li>R/O intussusception </li></ul><ul><li>Severe GI bleed </li></ul><ul><li>Severe renal disease </li></ul><ul><li>Need for renal biopsy </li></ul><ul><li>Hypertension </li></ul><ul><li>Pulmonary hemorrhage </li></ul>
    29. 66. Acute Hemorrhagic Edema of Infancy <ul><li>4-24 months </li></ul><ul><li>Recent URI or antibiotics </li></ul><ul><li>Non-toxic </li></ul><ul><li>Resolves in 1-3 weeks </li></ul><ul><li>small- vessel, leukocytoclastic vasculitis </li></ul><ul><li>Annular or targetoid pupura and edema on face and extremities </li></ul>
    30. 71. Conclusions <ul><li>Not all that itches is eczema </li></ul><ul><li>Treatment is often supportive for viral exanthems </li></ul><ul><li>Remember rashes as a sign of systemic illness </li></ul><ul><li>Careful history and physical essential for evaluation of bruises </li></ul>

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