Peds pathology (Phumiruk) Flashcards
Erythema toxicum
Common rash-first few days after birth
- Small blotchy erythematous areas with a raised yellow/white center
May be anywhere, including palms and soles, esp. on trunk
- Usually in first week to ten days of life; up to 4 weeks
Dissipate without treatment in 5-7 days
Cause is unknown
- Harmless
Milia
40% of newborns
Most often on the nose and cheek
Benign blocked skin pores & disappear by 1-2 months of age
Miliaria
“heat rash”
2 common forms
Miliaria crystallina
Small clear fluid filled vesicles that rupture and leave scale
Miliaria rubra
Clear fluid filled vesicles that are surrounded by red areas
Usually found on head, neck, trunk and in skin folds
* Blocked sweat gland ducts
Resolves on its own
Reoccurs w/ increased heat/humidity/bundling in warm clothing
Neonatal acne
> 30% of newborns
Begins at 3-4 weeks of age & lasts to 4-6 months of age
Cause is maternal androgens prior to birth
No treatment needed
Seborrheic dermatitis
= cradle cap (aka baby dandruff)
Scaling of scalp or eyebrows
Treatment:
baby oil, Nizoral shampoo or cream, Selsun shampoo
Frequent hairwashing with baby shampoo, soft brush
Transient neonatal pustular melanosis
Present at birth
Cause unknown
Tiny 1-2mm pustules on face, neck, ext, palms & soles
Can have scale around them
No erythema or inflammation
Rupture in first few days of life & leave behind freckles which fade in 3 weeks to 3 months
No treatment needed
Diaper rashes
Irritant diaper dermatitis
Reddish area in groin from urine or heat
* Treatment: barrier ointment (zinc oxide), air dry, frequent changes
Moniliasis (monilial diaper dermatitis)
Classically described as * “beefy red with satellite lesions”
Nystatin ointment
Mongolian spots
Blue-gray flat birthmark that is most often found in dark skinned infants
Entrapment of melanocytes in dermis during migration from neural crest cells into the epidermis
Usually over the back and buttocks but can be anywhere
Big variation in size
Most fade by 2-3 years of age; they may persist into adulthood
Atopic Dermatitis (eczema)
“the itch that rashes”
3-5% of children 6 mo to 10 yr
Ill-defined, red, pruritic, papules/plaques
- Diaper area spared
Acute: * erythema, scaly, vesicles, crusts
Chronic: scaly, lichenified, pigment changes
Cause: unknown; ? Combination of dry, irritated skin w/ malfunction of immune system; ?genetic basis ?food causes flare
treatment for atopic dermatitis
TREAT WITH TOPICAL STEROIDS!
Antihistamines for itching
After showers, moisturize with thick ointments QUICKLY afterwards, don’t wipe completely dry
Vaseline, Aquaphor, Cetaphil, Eucerin, Vanicream
Dove unscented soap
Alopecia areata vs tinea capitis
Alopecia areata may have associated nail changes
R/o hypothyroidism
No broken hairs
Tinea capitis: black dots or gray patches
bad case- Kerion: inflammatory reaction
Acne
Common condition characterized by the * blockage and inflammation of the pilosebaceous units of the face & trunk and activity of Propionibacterium acnes Black heads (open comedones) White heads (closed comedones) Pustular/cystic/nodules
Treatment: unplug the follicles and kill the bacteria!
- Hygeine: clean with antibacterial soap and water – facial products should be noncomedogenic and oil-free
- Keratolytic:
benzoyl peroxide based solutions, Tretinoin (a vitamin A derivative) also useful - Topical or oral antibiotic
Molluscum contagiosum
Viral
Usually no treatment recommended when less than 50 lesions or not on face
Pearly pink dome-shaped papules with central umbilication
Verruca Vulgaris
Pare, pare, pare!
Benign neglect (may go away in 2 yrs)
Salicylic acid topically
Cryotherapy
HSP (Henoch-Schonlein Purpura)
= “anaphylactoid purpura” characterized by 2-10mm erythematous hemorrhagic papules in a symmetric acral distribution, over the buttocks, and extremities –>* palpable purpura
Systemic vasculitis of small vessels of skin, GI tract, kidneys, joints
Abdominal pain, rash on legs, arthritis in ankles
* Urinalysis, which may be positive for blood or protein in 50% of the patients (other labs usually normal)
DDx: drug reactions, erythema multiforme, urticaria, and even physical abuse, other causes of purpura such as bleeding disorders, and/or infection (meningococcemia)
- Renal involvement is the most frequent and serious complication, usually acute glomerulonephritis. Hypertension is uncommon.
Usually managed as outpatients. Severe abdominal pain, gastrointestinal hemorrhage, intussusception, and severe renal involvement are indications for admission.
Common benign murmurs - Infants
Closing ductus
- Newborn
- Transient, soft, ejection
- Location: upper left sternal border
Peripheral pulmonary flow murmur
(= PPBS or peripheral pulmonic
branch stenosis)
- Newborn to 1 year
- Soft, slightly ejectile, systolic
- Location: to the left of upper left sternal border & in lung fields & axillae upper left sternal border.
- High pitched - best heard with the diaphragm
- Also seen in adolescents or in children with pectus excavatum.
how do benign murmers sound?
Low pitched (non-turbulent, not high velocity)
Common benign murmurs in Older child
- Still’s
- Low-pitched sounds heard at the lower left sternal area, * “musical.”
- Most commonly between age 3 and adolescence
Best heard with the bell of the stethoscope. - Changes with alteration of position and then can decrease or disappear with the Valsalva maneuver.
No clicks are present.
Venous hum:
- Low-pitched continuous murmurs made by blood returning from the great veins to the heart
- Listen with bell
Ductus Arteriosus Closure
Premature infants - closure up to 2 years
Full term infants - closure rarely after first week of life w/o intervention
Indomethacin or surgery
Patent Ductus Arteriosus
Failure of closure of ductus arteriosus within a few days after birth
Girls>boys
More common in premature infants, neonatal respiratory distress, infants w/ genetic d/o (such as Down syndrome) & those w/ congenital heart lesions
Small PDAs usu. asymptomatic
Large PDAs:
**
Bounding pulse, “machine-like” murmur Tachypnea Poor feeding habits Shortness of breath Sweating while feeding Tiring very easily Poor growth
Hypertrophic Cardiomyopathy
Asymmetrical thickening of left ventricle
Causing increase work on heart to pump
Inherited
Younger people are likely to have a more severe form
Sx: Chest pain Dizziness Fainting, especially during exercise Heart failure (in some patients) High blood pressure Light-headedness, especially with or after activity or exercise Palpitations Shortness of breath
- Sudden collapse/death occurs due to arrhythmia or blockage of blood flow
Cyanotic Congenital Heart Disease
5 T’s: Tetralogy of Fallot (like an “aortic takeover”) 1. VSD 2. Overriding aorta 3. RV outflow obstruction 4. RV hypertrophy
Transposition of the Great Arteries
TAPVR
Truncus arteriosus
Tricuspid Atresia
Neonatal Respiratory Distress Syndrome
Sx: (seen within minutes to a few hours after birth) - Cyanosis - Apnea - Decreased urine output - Grunting, nasal flaring - Puffy or swollen arms or legs - Rapid breathing &/or shortness of breath CXR: * ground glass appearance Tx: * surfactant, intubation or CPAP
- Most common complication seen in premature infants that affects breathing
- Due to lack of surfactant
- Most cases seen in premies under 28 weeks
- Increased risks of RDS:
A brother or sister who had RDS
Diabetes in the mother
Cesarean delivery
Delivery complications that lead to acidosis in the newborn at birth
Multiple pregnancy (twins or more)
Rapid labor
Upper Respiratory Infections (Colds)
Acute, self-limiting viral syndrome of the upper respiratory tract
Children younger than six years have an average of * six to eight colds per year (up to one per month, September through April), with a typical symptom duration of 14 days
Young children in * daycare appear to have more colds than children cared for at home. However, when they enter primary school, children who attended daycare are less vulnerable to colds than those who did not.
Older children and adults have an average of two to four colds per year, with a typical symptom duration of five to seven days
Symptoms: rhinorrhea, congestion, sneezing, and may include fever
Acute Otitis Media
Fever, otalgia, cough, rhinorrhea
Symptoms may be nonspecific in infants (feeding difficulties, irritability)
Older children have more classic presentation
May be a complication of URI
Tympanic membrane shows evidence of acute inflammation
Pathogens:
Viral
Bacterial top three organisms:
* Strep pneumoniae,
* Moraxella catarrhalis
* H. flu nontypables
Treatment:
First line: * amoxicillin (high dose = 80-90 mg/kg/day)
Second line: amoxicillin-clavulinic acid (Augmentin)
or second generation cephalosporin
Sinusitis
Diagnosis is based on:
1. Persistence of nasal discharge: if the child has a very congested and/or runny nose for 10 days without improvement, especially when it is associated with a daytime cough (may also have a night cough) 2. Severe symptoms: if the child has a high fever (over 39 C, which is 102.2 F) for 72 hours or has a high fever and is not eating or drinking and is difficult to calm 3. Worsening symptoms: a child's cold got better and then in a day or two the child is suddenly much more ill with a fever and/or pus-filled nasal discharge
Croup
= laryngotracheobronchitis
- Steeple sign (if you get an xray)
*** Subglottic narrowing of trachea
Most common cause of inspiratory *stridor in peds
Viral in origin
Most commonly parainfluenza
Sx:
Coryza 1-2d prior to * croupy cough, hoarseness, & stridor
Tx: if severe, inhaled racemic epinephrine & oral steroids
Bacterial tracheitis
Invasive exudative bacterial infection of the soft tissues of the trachea
= Acute bacterial laryngotracheobronchitis – similar to croup but worse
Pathogens:
- Staphylococcus aureus,
- Streptococcus pneumoniae
- Gram-negative enteric bacteria
- Pseudomonas aeruginosa
Predisposing viral infections with: * influenza A, influenza B, respiratory syncytial virus (RSV), parainfluenza virus, measles, and enterovirus
Acute Pharyngitis- Viral
CMV
Adenoviruses
HSV
Influenza viruses
Enterovirus
EBV
- Monospot testing is not accurate under 4-5 years of age or before 2nd week of illness
- Really long incubation period (4-6 wks)
- Exudative pharyngitis is accompanied by fever, generalized adenopathy, hepatosplenomegaly, heterophile antibodies
– Sometimes treated with steroids in complicated cases
Supportive care
Acute Pharyngitis- Bacterial
Group A beta hemolytic streptococcus
- 15 to 30 percent of all cases of pharyngitis in children between the ages of 5 and 15 years
- Peaks during the winter and early spring
- Rapid strep in office, back up culture
Other bacterial pathogens
- Group C and group G strep: acute rheumatic fever is not a complication of infection due to these organisms
- Arcanobacterium hemolyticum
- Corynebacterium diphtheriae
- Tularemia
Strep pharyngitis
History:
- Typically has an abrupt onset of symptoms
- Typically the school aged child
* Sore throat
* Fever
* Headache
* GI symptoms: abdominal pain, nausea, and vomiting
Poor oral intake
** NO cough or rhinorrhea!! Aka, no viral symptoms ( coryza, conjunctivitis, hoarseness, anterior stomatitis, discrete ulcerative lesions or vesicles).
Younger children may present with fever, abdominal pain, vomiting
Physical:
* Exudative pharyngitis or erythema of posterior orophayngeal mucosa
- Enlarged tender * anterior cervical lymph nodes
Palatal * petechiae
Inflamed uvula
* Scarlatiniform rash
* Pastia’s lines
Work Up:
* Rapid strep with back up culture if negative
How can you possibly get a sample??
Use two swabs at once; double tongue depressor for stronger kids, have smaller child pant like a puppy dog
Wear a mask because you’ll probably get coughed on
Deep neck infections-
Peritonsillar abscess
- Most common deep neck infection in children and adolescents, accounting for at least 50 percent of cases – can be a complication of strep pharyngitis
Symptoms:
Severe sore throat (usually unilateral)
Fever - “Hot potato” or muffled voice
Pooling of saliva or drooling may be present - Trismus
Neck swelling and pain - Asymmetric tonsils on exam
Treatment: needle aspiration: antimicrobial therapy (amoxicillin/clavulinic, cephalosporins, and clindamycin), and supportive care (hydration, analgesia)
Deep neck infections- Retropharyngeal abscess
Most commonly in * young children between the ages of two and four years
Symptoms:
Difficulty swallowing (dysphagia)
pain with swallowing (odynophagia)
drooling with decreased oral intake
Unwillingness to move the neck secondary to pain (torticollis), particularly unwillingness to extend the neck
* “hot potato” quality [dysphonia]
Gurgling sound, or stertor (snoring sound)
Respiratory distress (stridor, tachypnea, or both); * stridor develops as disease progresses
Neck swelling, mass, or lymphadenopathy
* Trismus (in approximately 20 percent)
Respiratory syncytial virus (RSV)
Respiratory virus affecting nasal passages and lungs
Almost all children will be infected by 2 years of age
Recovery within 1-2 weeks of infection
May be severe in premature or very young infants
- Risk factors for severe disease:
young age
— preterm birth (specific guidelines for immunization with Synagis = palivizumab)
- low birth weight
- chronic pulmonary disease
- cyanotic or complicated cardiac disease
- neurologic disease
- immunodeficiency or immunosuppression
congenital defects of the airway
Newborns with bronchiolitis may present with apnea
- RSV is the most common cause of bronchiolitis
- -> Inflammation of small airways of lung
Other causes of bronchiolitis include: * rhinovirus * parainfluenza * influenza * human metapneumovirus * adenovirus Seen most often in fall, winter & early spring
Foreign body
- Important cause of chronic cough in toddler
Nasal
- Unilateral purulent drainage
- Foul smelling
Lower respiratory tract
- DDx: recurrent viral infections and asthma
- PE and CXR may be unrevealing
Gastroesophageal Reflux (GER)
Often begins in infancy
Signs/symptoms:
- Vomiting
- Poor weight gain
- Substernal CP
- Abdominal pain
- Dysphagia
- Esophagitis
- Diagnosis often based on clinical presentation
Tests:
- Upper GI (r/o other abnormalities)
- 24 hr esophageal pH probe
Treatment:
- Smaller feedings more frequently, positioning post feeds
- Acid suppressive meds
- OMT
Viral Gastroenteritis
Rotavirus
- Most common cause of diarrhea in young children throughout the world
- Normally self-limiting but can cause severe dehydration
- Sx: fever, vomiting, diarrhea
- Highly contagious, lasting 3-9 days
Fecal-oral spread
Vaccination in early infancy
Rotateq 3 dose series
Rotarix 2 dose series
Esophageal foreign bodies
in the esophagus- coin lays flat
in the trachea on its side
Urgent or emergent intervention:
When the object is sharp, long, or consists of magnets
When the object is a * disk battery in the esophagus
If * airway compromise, such as tracheal compression, is present
If there is evidence of esophageal obstruction (eg, the patient is unable to swallow secretions)
If there are signs or symptoms suggesting inflammation or intestinal obstruction (fever, abdominal pain, or vomiting)
If the object is in the esophagus and the suspected ingestion occurred 24 or more hours prior to the evaluation, or if the time of ingestion is unknown
Buried penis
Neonates
Result of thick suprapubic fat
Resolve as infant grows
Hypospadius
1:250 male births
Infants should not be circumcised
- Dorsal preputial skin may be needed for repair
Repair usu. at 6 months of age
Labial adhesions
Common in prepubertal age group
Fusion of labia minora
?inflammation of thin labial mucosa that adheres in midline
Severe fusion may result in dysuria& urinary problems including UTIs
- Tx: mechanical separation then petroleum ointment to diminish irritation
- estrogen creams (Premarin)
Vesicoureteral reflux (VUR)
Congenital
Normal valve mechanics of ureterovesicular junction is impaired
Reflux from bladder to ureter or kidney
Grades I –> III high rate of spontaneous resolution
Suppressive prophylactic antibiotics
UTI
Girls>boys
- Don’t trust a culture from a bag urine sample!!
Catheterized sample only in infants
- Infants may present with vomiting only
Clean catch if potty trained
Febrile seizure
3-5% of healthy toddlers will have seizure caused by fever (9m-5 yrs)
Tends to run in families
- Likely to have more than one febrile seizure if:
- There is a family history of febrile seizures
- The first seizure happened before age 12 months
- The seizure occurred with a fever below 102oF
Types of febrile seizures
- Simple febrile seizure
- Lasts a few seconds to 5-10 minutes
- Generalized
Followed by a period of drowsiness or confusion (30 minutes post-ictal) - Complex febrile seizure
- Lasts longer than 15 minutes
- Focal - in just one part of the body
- Occurs again during the same illness
Duchene’s Muscular Dystrophy
Progressive degeneration of skeletal muscle
1:3500 male births
X-linked recessive
Early onset, symmetrical, begins w/ pelvic/pectoral girdle involvement
Confined to wheelchair by adolescence
Death from cardioresp. Insufficiency by age 20
* Gower maneuver
