Transcript What’s the Diagnosis?? - CHAOS Student Education

What’s Your Diagnosis??
Ben Taub Float
Department of Pediatrics
Baylor College of Medicine
August 20, 2007
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.
Scabies
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Etiology: Hypersensitivity reaction to mite—Sarcoptes
scabiei
 Rash:
 Pruritic papules, pustules, vesicles, and burrows
 Distribution:
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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
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.
Hand, Foot, Mouth Disease
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Etiology: Coxsackie virus A16
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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
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.
Eczema Herpeticum
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Etiology:
 Primary HSV infection of skin
 In patients with chronic skin disorder
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Clinical Presentation:
 Fever
 Skin Lesions:
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Appear in crops
At site of currently or recently infected skin
Papulespustulesrupture and form crust
Occasionally lesions become hemorrhagic
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Treatment: Acyclovir, hydration
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Complications: Dehydration, secondary infection
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.
Fifth’s Disease
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Etiology: Parvovirus B19
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Clinical Presentation:
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Prodrome: Fever, coryza, HA, nausea, diarrhea
Rash: Progresses in 3 stages
1)
2)
3)
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Erythema of cheeks (“slapped cheeks”)
Erythematous maculopapular reticular rash involving arms
and spreading to trunk and legs
Fluctuations in severity of rash
Complications:
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Aplastic crisis
Fetal hydrops and death during pregnancy
Arthritis, hemolytic anemia, encephalopathy
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.
Croup
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Etiology:
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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
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Treatment:
 Mild: Mist treatment
 Moderate: Steroids, racemic epinephrine
 Severe: Intubation
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 Gingivostomatitis
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Etiology: Herpes simplex virus types 1 & 2
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Clinical Features:
 Ulcerative lesions on buccal mucosa, gums, palate, tongue
 Fever
 Mouth pain and anorexia
 Regional adenopathy
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Therapy:
 Pain relief
 Hydration
 +/- Acycolvir
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.
Gianotti-Crosti (Papular Acrodermatitis)
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Etiology: Associated with viral infections
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Clinical Presentation:
 Prodrome:
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Fever, malaise, URI symptoms, diarrhea
+/- Hepatomegaly
 Rash:
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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
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.
Scarlet Fever
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Etiology: Group A Streptococcus
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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
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Treatment: Penicillin x 10 days
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Complications:
 Rheumatic fever
 Post-streptococcal gloumerulonephritis
 Pyogenic complications: Adenitis, otitis, sinusitis, abscess
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.
Meningococcemia
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Etiology: Neiserria meningitidis
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Clinical Presentation:
 Prodrome:
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URI symptoms, pharyngitis, fever
Lethargy, headache, vomiting
Myalgias, arthralgias
 Septicemia:
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Abrupt worsening of prodromal symptoms
Rash: Tender pink macules, petechiae, purpurafrank necrosis
Shock: Mottling, poor perfusion, +/- hypotension
DIC
 Meningitis
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Treatment:
 3rd generation cephalosporin
 Supportive care: Fluid replacement, pressors as needed
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.
Legg Calve Perthes Disease
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Etiology: Idiopathic avascular necrosis of the hip
 Clinical Presentation:
 Limp
 Pain
 Limited internal rotation of hip
 Atrophy of thigh muscles
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Treatment:
 Referral to orthopedics
 Poorly defined management
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.
Lyme Disease
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Etiology: Borrelia burgdorferi
Clinical Findings:
 Early, localized disease:
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Erythema migrans
Fever
Headache, fatigue
Arthralgias/Myalgias
 Early, disseminated disease:
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Multiple erythema migrans
Aseptic meningitis
Cranial neuropathies
 Late, persistent infection:
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Asymmetric, pauciarticular arthritis
Polyneuropathy, encephalopathy
Treatment: Doxycycline
Complications: Chronic arthritis, chronic neurological disease
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.
Congenital CMV
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Etiology:
 Cytomegalovirus
 1% of infants are born with congenital CMV
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Clinical Presentation:
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90% are asymptomatic
Small for gestational age
Microcephaly
Thrombocytopenia, petechiae, purpura
Hepatosplenomegaly
Hepatitis, jaundice
Intracranial calcifications
Chorioretinitis
Sensorineural hearing loss
“Blueberry muffin” appearance
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.
Measles (rubeola)
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Etiology: Measles virus (paramyxovirus)
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Clinical Presentation:
 Prodrome: Malaise, fever, cough, coryza, conjunctivitis, photophobia
 Enanthem: Koplik’s spots
 Exanthem: Erythematous maculopapular rash beginning on head and
spreading cephalocaudally
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Complications:
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Pneumonia
Post infectious encephalomyelitis
Subacute sclerosing panencephalitis
Otitis media
Laryngotracheobronchitis
Myocarditis, pericarditis, hepatitis
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.
Molluscum contagiosum
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Etiology: Poxvirus
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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
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Treatment:
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Self-resolution within 6 months
Cryotherapy
Curettage
Laser therapy
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
Cat Scratch Disease
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Etiology:
 Bartonella henselae
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Clinical Presentation:
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Cutaneous manifestations: Primary inoculation lesion
Lymphadenopathy
Visceral organ involvement: +/- hepatosplenomegaly
Fever of unknown origin
Ocular manifestations:
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Parinaud's oculoglandular syndrome
Neuroretinitis
 Neurologic manifestations:
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Encephalopathy
Myelitis, radiculitis, cerebellar ataxia
 Arthropathy
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.
Diphtheria
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Etiology: Corynebacterium diphtheriae
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Clinical Presentation:
 Presenting symptoms: Fever, sore throat, malaise
 Diphtheric pseudomembrane
 Systemic manifestations: Myocarditis, neurologic toxicity
 Cutaneous diphtheria: Chronic, non-healing ulcers
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Treatment:
 Diphtheria antitoxin
 Penicillin or erythromycin
Case Scenario # 17
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 Epiphysis
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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
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Clinical Presentation:
 Pain
 Abnormal gait
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Treatment:
 Referral to orthopedics
 Stabilization with screw pinning
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Complications:
 Osteonecrosis
 Chondrolysis
Case Scenario # 18
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 Purpura
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Etiology: Vasculitis secondary to immune complex deposition
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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
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Treatment:
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Supportive
+/- Hospitalization
Symptomatic Therapy: NSAIDS, Glucocoricoids
Follow up
Case Scenario # 19
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.
Mumps
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Etiology: Mumps virus (paramyxovirus)
 Clinical Features:
 Prodrome: Fever, headache, malaise, anorexia
 Parotid gland pain and swelling
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Complications:
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Meningoencephalitis
Orchitis, oopheritis
Pancreatitis
Unilateral deafness
Nephritis
Arthritis
Myocarditis
Case Scenario # 20
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 Conjunctivitis
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Etiology: Chlamydia trachomatis
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Clinical Presentation:
 Eyelid edema and erythema
 Mucopurulent discharge
 Unilateral or bilateral
 Associated pneumonia in 10-20%
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Treatment: Erythromycin PO x 14 days
Case Scenario # 21
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 Dermatitis
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Etiology: Candida albicans
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Clinical Presentation:
 Erythematous rash in inguinal region
 Confluent erythema with papules and plaques
 Satellite lesions
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Treatment: Topical antifungal agent
Clinical Scenario # 22
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 Pneumothorax
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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
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Clinical Presentation:
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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:
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Observation
Supplemental O2
Needle thoracentesis
Thoracostomy tube
Surgical intervention
Case Scenario # 23
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 nontoxic, and his exam is normal with the exception
of the rash.
Roseola infantum
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Etiology: Human herpes virus 6 (HHV-6)
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Symptoms:
 Fever: Abrupt high fever
 Rash: Develops with resolution of fever
Macular/maculopapular
Develops on trunk and spreads peripherally
 Treatment: Supportive
 Complications: Febrile seizures
Case Scenario # 24
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.
Chickenpox
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Etiology: Varicella zoster virus
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Clinical Feature:
 Mild fever, malaise, anorexia
 Rash:
 Pruritic, occur in crops
 Papules-->Vesicles-->Ulcerative lesions-->Crust
 Begin on trunk and spread peripherally
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Complications: Encephalopathy, pneumonia,
hepatitis, secondary infection
Case Scenario # 25
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 Migrans
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Etiology: Ancylostoma brazilense (dog or cat
hookworm)
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Clinical Presentation:
 Pruritic, erythematous papule at site of larva entry
 Severely pruritic, elevated, serpiginous, reddish-brown lesions
appear as the larvae migrate
 Pulmonary manifestations
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Treatment:
 Topical thiabendazole OR
 Systemic ivermectin OR albendazole
Clinical Scenario # 26
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 Fracture
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High suspicion for non-accidental trauma
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Result of twisting action which is uncommon in
accidental falls in young children
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Other skeletal injuries related to child abuse:
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Bucket handle or corner fracture
Posterior rib fracture
Acromion fracture
Fracture of spinous processes
Fracture of sternum
Skull fractures
Case Scenario # 27
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 Disease
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Vasculitis of unknown etiology
 Diagnostic Criteria:
 Fever > 5 days
 Four of the following:
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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
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Treatment: IVIG, high dose aspirin
 Complications: Coronary artery aneurysm