What’s Your Diagnosis??

1. What’s Your Diagnosis?? Ben Taub Float Department of Pediatrics Baylor College of Medicine August 20, 2007

2. Case 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.

4. Scabies • 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

5. Case Scenario # 2 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.

9. Hand, 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

10. Case Scenario # 3 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.

12. Eczema 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 • Papulespustulesrupture and form crust • Occasionally lesions become hemorrhagic • Treatment: Acyclovir, hydration • Complications: Dehydration, secondary infection

13. Case Scenario # 4 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.

16. Fifth’s Disease • Etiology: Parvovirus B19 • Clinical Presentation: • Prodrome: Fever, coryza, HA, nausea, diarrhea • Rash: Progresses in 3 stages • Erythema of cheeks (“slapped cheeks”) • Erythematous maculopapular reticular rash involving arms and spreading to trunk and legs • Fluctuations in severity of rash • Complications: • Aplastic crisis • Fetal hydrops and death during pregnancy • Arthritis, hemolytic anemia, encephalopathy

17. Case Scenario # 5 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.

19. Croup • 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

20. 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.

22. HSV 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

23. Case Scenario # 7 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.

25. Gianotti-Crosti (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

26. Case Scenario # 8 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.

28. Scarlet 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

29. Case Scenario # 9 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.

31. Meningococcemia • 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, purpurafrank necrosis • Shock: Mottling, poor perfusion, +/- hypotension • DIC • Meningitis • Treatment: • 3rd generation cephalosporin • Supportive care: Fluid replacement, pressors as needed

32. Clinical 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.

34. Legg Calve Perthes Disease • Etiology: Idiopathic avascular necrosis of the hip • Clinical Presentation: • Limp • Pain • Limited internal rotation of hip • Atrophy of thigh muscles • Treatment: • Referral to orthopedics • Poorly defined management

35. Case Scenario # 11 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.

37. Lyme 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

38. Case Scenario # 12 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.

40. Congenital 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

41. Case Scenario # 13 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.

43. 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

44. Case Scenario # 14 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.

46. Molluscum 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

47. Case Scenario # 15 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

49. Cat 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

50. Case Scenario # 16 An 8 year-old male that you are evaluating in a refugee camp has been complaining of fever, sore throat, and difficulty swallowing.