Dermatology

Question 1

Enterovirus rash (hand-foot-mouth)

Causative agent: location:
description:
Timing:
Fever:

Answer 1

What is this rash?

Causative agent: Coxsackie
location: palms & soles +/- petechial; ulcers in the mouth
description: erythematous, maculopapular, vesicular
Timing: late summer, early fall
Fever: 3-5days, HIGH

Rash is NOT painful and should not cause refusal to walk.

Question 2

Erythema infectiosum (fifth disease)
Causative agent: location: 
description: 
Timing:
Fever:

Answer 2

What is this rash?

Causative agent: Parvovirus B19
location: face
description: face = “slapped cheek”; body = erythematous macular; with central clearing - ‘lacy’ appearance. Lasts longest in extremitites
Timing:
Fever: low-grade fever
OTHER: pain & swelling in joints = polyarthropathy syndrome

1) fever
2) 7-10d - rash “slapped cheek”
3) rash spreads to trunk

Question 3

Measles
Causative agent: location: 
description: 
Timing:
Fever:

Answer 3

What is this rash?

Causative agent: location: neck, behind the ears, along hairline
description: maculopapular, with buccal mucosal red lesions + bluish white spots in center (Koplik spots).
Timing:
Fever: fever & URI symptomatic

1) Eyes w/ conjunctivitis
2) Neck, behind the ears, along hairline
3) 2-3d - spread downward, reaching feet

Question 4

pt with immuno deficiency + infection with ParvoB19 - what is the risk?

Answer 4

aplastic anemia

Question 5

Pt presents with very classical measles story and spread of rash from top to bottom. However, he does not have the Koplik spots. What’s going on?

(do you know what Koplik spots look like)?

Answer 5

Koplik spots = buccal mucosal red lesions + bluish white spots in center

This the initial rash. they have frequently disappeared by the time the pt presents to medical attention

Question 6

Meningoccocemia

Causative agent: location: 
description: 
Timing:
Fever:
Other

Answer 6

What is this rash?

Causative agent: Neisseria meningitidis
location: generalized
description: (1) urticarial, maculopapular, petechial (hemorrhagic spots) --> (2) fulminant, purpuric, large hemorrhages on skin
Timing: Would arise quickly (<3d)
Fever: Abrupt
\+ chills, malaise, prostration

Prevention = immunization

Question 7

Roseola (exanthem subitum) sixth disease

Causative agent: location:
description:
Timing:
Fever:

Answer 7

What is this rash?

children 6 mo - 2yo
unlikely after 4 yrs
Causative agent: 6th disease; HHV6 location: (1) trunk, (2) arms & neck
description: maculopapular rash 
Timing:
Fever: HIGH then rash develops 

1) High fever = 38.5-40.5, +/- rhinorrhea
2) 3-4d - rash (no fever) + resolution of fever
3) bulging fontanelle
+/- febrile seizure

Question 8

Scarlet fever

Causative agent: location:
description:
Timing:
Fever:

Answer 8

What is this rash?

Causative agent: Group A strep location: (1) groin, axillae, neck –> (2) generalized
description: very fine papules (“sandpaper”)
Timing:
Fever: HIGH, <5d

self-limited = lasts 10d (5d fever, 5d rash)
Tx = Bacitracin / penicillin
Complications = non-suppurative complications (rheumatic fever)

Question 9

Varicella (chicken pox)

Causative agent: location:
description:
Timing:
Fever:

Answer 9

What is this rash?

Causative agent: location: (1) trunk –> (2) extremities, head
description: (1) erythematous macule –> (2) papule –> (3) vesicle –> (4) pustule –> (5) crusted. Various stages of development in the same area
Timing:
Fever: Mild

self-limited; lasts 1w
Prevention: immunize

Question 10

diffdx unilateral cervical lymphadenopathy

Answer 10

INFECTIOUS

• oral inflammatory / infectious reactive lymph node
• bacterial cervical adenitis
• cat scratch disease
• mycobacterial infection

NONINFECTIOUS
- Kawasaki disease

Question 11

diffdx for “strawberry tongue”

Answer 11

“strawberry tongue” = erythematous tongue with prominent papillae –> due to desquamation of minor papillae ; subsequent prominence of major papillae (strawberry red with white “flecks”)

• strep pharyngitis +/- infectious mononucleosis
• Kawasaki disease
• toxic shock syndrome

Question 12

diagnostic criteria for kawasaki disease (sxs)

Answer 12

1) HIGH FEVER for >/- 5d
2) Changes in oral mucosa (“strawberry tongue”) - NON-PURULENT
3) extremity changes (acute - swelling; chronic - redness/dequamation). PAINFUL; REFUSAL TO WALK
4) U/L cervical lymphadenopathy
5) rash in groin; perineum; palms; soles (non-pruritic; palpable).
6) conjunctival injection (“limbic sparing = radiating red lines out from iris except for where iris meets with sclera) - NON-PURULENT

non-indicative of infectious / bacterial etiology

Question 13

diagnostic criteria for kawasaki disease (acute labs)

Answer 13

–> high ESR, CRP

1) high ALT
2) high WBC (neutrophils); nml MCV
3) high Plts [esp. in chronic, @ 2-3w]
4) low Hgb (norm,norm)
5) sterile pyuria ==> with irritation at the urethra (not bladder)
6) hypoalbuminemia

Question 14

Complications of Kawasaki

Answer 14

1) CNS = irritability, lethargy, aspetic meningitis (90%)
2) coronary aneurysm (25% in untreated)
3) liver dysfunction (40%)
4) arthritis (30%)
5) hydrops of the gallbladder (10%)
6) Effusions (pleural, pericardial).

Question 15

In a child with Kawasaki’s, what’s the timeline of presentation for a coronary aneurysm

Answer 15

end of 1st week - 4w after onset of disease

Question 16

Management of Kawasaki

Answer 16

1) IVIg
2) ASA (high dose until fever breaks, then low dose 6-8w)= to minimize risk of coronary aneurysm
3) Echo during acute phase to look for aneurysm (diagnostic and monitoring)

4) Watch for bleeding, stomachache, blood in stool.
5) flu vaccine
6) Pain - prescribe anti-inflammatory meds; physical therapy
7) monitor for fever

8) f/up at 1-2w for repeat ECHO (since coronary artery aneurysms, if they develop, do so within 4w).
9) f/up in another 2w for another ECHO

–> then no more if all is normal

Question 17

Rocky Mountain spotted fever 
Description:
Fever:
Rash:
Other

Answer 17

What is this?
Description: tick-borne bacterial infection (Rickettsia Rickett
Fever:
Rash (95%): (1) ankles, wrists –> centrally –> palms & soles. Maculopapular –> petechial
Other: Myalgia

Question 18

A 5yo pt presents with rash that is on his palms and soles. He cries when you touch it, and his parents have to carry him to your office. what is it?

(and what is it not?)

Answer 18

Kawasaki == kids find it painful, to the point of no wanting to walk

NOT enterovirus

Question 19

In which of the diffdx for fever + rash would you see elevated liver enzymes?

Answer 19

Kawasaki

Stevens Johnson syndrome

Question 20

why is it important to diagnose pharyngitis 2/2 group A beta-hemolytic strep (as opposed to any other etiology)?

Answer 20

b/c complication of rheumatic fever

Question 21

diagnostic tests for group A beta-hemolytic strep

Answer 21

1) “rapid strep” teest –> strep antigen from swab of tonsils and posterior pharynx
2) if NEGATIVE ==> throat culture

Question 22

If you suspect group A beta-hemolytic strep (but have no documentation yet), should you treat it?

What with?

Answer 22

1) should document GAS, then treat
2) IF there is strong pretest probability (sick contacts at home, high score with only sore throat and no other sxs, etc.) –> can treat based on clinical diagnosis
3) If neg rapid strep - then culture - then treat

treat within 9d from start of acute illness

Treatment options

1) Oral amoxicillin (10d)
2) IM penicillin (1 dose)
3) oral penicillin (b/c the taste sucks)

Question 23

treatment of Kawasaki disease

Answer 23

1) IVIg - single dose of 2g/kg over 10-12h –> decreased incidence of coronary artery aneurysm

2) Aspirin
(a) high dose (80-100mg/kg) ==> for anti-inflammation to decrease fever
(b) low dose aspirin (3-5mg/kg) ==> for antiplatelets for a total of 6-8w if no coronary changes seen in f/up echos.

if + coronary artery abn –> lifetime low dose aspirin

Question 24

Can you give ibuprofen and aspirin at the same time in Kawasaki for antipyretic effects?

Answer 24

NO

1) other antipyretics (v. aspirin) have not been effective for fever control
2) ibuprofen antagonizes the irreversible platelet inhibition induced by aspirin ==> AVOID in children esp. with coronary aneurysms taking aspirin for antiplatelet effects

Question 25

if you suspect kawasaki, which should you do first?

a. treatment with IVIg and ASA
b. echocardiogram to look for coronary artery aneurysm

Answer 25

A

realistically, it takes a while to get the echo, and in the meantime, you can just start the meds

Question 26

A 5-year-old female, previously healthy, presents with an erythematous, vesicular rash on the palms and soles and a high fever for several days. Upon examination, she is also found to have ulcers in her mouth. A few days later, the fever and rash resolve. What is the most likely pathogen?

A		Herpes simplex virus 1 (HSV-1)	
B		HIV	
C		Enterovirus	
D		Human herpesvirus 6 (HHV-6)	
E		Group A strep

Answer 26

C. cocksackie A, an enterovirus. Following an incubation period of three to five days, patients have fever, tender vesicles on their hands and feet, and oral ulcers. Sometimes the rash also occurs on the buttocks and the genitals. The infection resolves spontaneously within three days, and is spread from person to person via saliva, fluid from the vesicles, stool, or nasal discharge.

HSV1 - gingivostomatitis + fever and malaise == but no lesions on hands and feet

HIV = no lesions on hands and feet

HHV6 = roseola: fever THEN macular / maculopapular rash - but it begins on the trunk –> then to extremities, NO ORAL LESIONS

Group A strep - scarlet fever - more “sandpaper,” and it’s all over

Question 27

A 2-year-old girl presents to the urgent care clinic with a 7-day history of high fever to 38.5 C, a maculopapular rash that began on the palms and soles of her feet, red eyes without discharge, and unilateral cervical adenopathy. What other symptom/sign might you discover on further history and exam?

A		Tonsillar exudates	
B		Headache	
C		Erythematous and edematous feet	
D		White spots on buccal mucosa	
E		Dysuria

Answer 27

C - Kawasaki –> + strawberry tongue

If tonsillar exudates –> strep paryngitis / tonsilitis [the mentioned is too widespread]

if HA –> rocky mountain spotted fever [only if with fever & rash in palms & soles]

If white spots on buccal mucosa (Koplik spots ) –> measles [but would also have cough, coryza; rash usually head down]

if dysuria –> UTI [the mentioned has too many sxs of something else.]

Question 28

A 3-year-old male presents with fever to 103 F for the past week, injected eyes, and a refusal to walk for the past two days. On physical exam, you note conjunctival injection without pus or exudates bilaterally, prominent papillae of his tongue with redness as well as redness of his hands, and feet. He also has a new non-diffuse maculopapular rash on his torso that gets worse with fever. On examination of the swollen extremities, you are unable to elicit any tenderness or effusions in any joints. Which of the following is the most likely diagnosis?

A		Rocky Mountain Spotted Fever (RMSF)	
B		Bone or joint infection	
C		Kawasaki disease (KD)	
D		Scarlet fever	
E		Systemic onset juvenile idiopathic arthritis

Answer 28

C

likely “incomplete” Kawasaki b/c doesn’t have U/L cervical lymphadenopathy

Rocky mountain spotted fever = headache, fever, myalgia, and a centrally progressing petechial rash originating on the wrists and ankles.

Bone / joint infection (makes sense with refusal to walk) == but should have lower fever, with warmth / tenderness / effusion

Scarlet fever = sore throat, fever, “strawberry tongue” and a blanching, erythematous rash with desquamation of the affected areas about six to seven days later as the rash begins to disappear.

SJIA = should have hx of spiking fevers and “salmon” rash occurring when child is febrile; disappearing as fever fades. Also should have tenderness & effusion of joint.

Question 29

A 5-year-old male comes to the clinic with a chief complaint of four days of progressively worsening fever and that has been minimally responsive to acetaminophen. The patient complains of sore throat and decreased appetite. His sister had a positive rapid strep test and is now being treated with amoxicillin. Your concern is for Group A strep. What is the next best step in management?

A Start antibiotic treatment
B Send blood cultures
C Advise parents to give patient acetaminophen with return precautions
D Rapid strep test with back-up culture if negative
E Chest x-ray

Answer 29

1 - do the test –> to allow for correct diagnosis prior to empiric antibiotic treatment

D

Question 30

A 3-year old girl comes to the clinic with a chief complaint of fever (104F) for over a week. Her mom reports that she has been fussy and inconsolable since she became febrile. She has a red tongue, with large papillae, conjunctivitis, a palmar rash, unilateral cervical adenopathy, as well as swollen feet. Given the most likely diagnosis, what is the most important follow-up for this patient over the next few weeks?

A Ophthalmology follow-up to determine extent of eye damage and determine need for corticosteroids
B Physical therapy follow-up to help prevent long-term joint deformities and ensure long-term functionality
C Cardiology follow-up to rule out presence of rheumatic fever
D Echocardiogram to look for coronary artery aneurysm
E Neurology follow-up to evaluate partial paralysis of lower extremities

Answer 30

D. Kawasaki disease are at high risk for coronary artery aneurysm formation and should receive an echocardiogram within four weeks of the onset of their illness. Use of IVIG for the treatment of Kawasaki disease has decreased the risk of coronary artery aneurysms significantly. Kawasaki disease is diagnosed when there is a fever plus four of the following: changes in oral mucosa (e.g., strawberry tongue), extremity swelling or redness, unilateral cervical adenopathy, conjunctivitis, and rash. Infectious and rheumatologic causes must be excluded in order to make the diagnosis of Kawasaki disease.

NOT concerned for rheumatic fever b/c would be Scarlet fever = erythematous, blanching, sandpaper-like rash” with very fine papules secondary to infection with Group A streptococcus. It may start in the groin, axilla, or neck, before spreading rapidly over the trunk and extremities. Fever can be high, but generally resolves within five days.

Question 31

6 month old presents with what you think is roseola. however, he also has a bulging fontanelle. should you be worried?

Answer 31

bulging fontanelle is an unusual finding of roseola

==> should r/out meningitis

Question 32

how are HHV6 and febrile seizures related?

Answer 32

HHV6 fever is HIGH (38.5-40.5)

primary HHV6 infection associated with ~20-30% of first febrile seizures in children