Skin Disorders Flashcards
A 3-year-old is brought into accident and emergency on a Monday morning because she has developed several bruises on her buttocks, left leg and right arm. She is seen with her nanny who reports finding the bruises when she was getting her dressed this morning. Recently the girl has not been herself. She has had several colds over the past 2 months and has been more lethargic lately. The nanny is worried she is losing weight. On examination she appears withdrawn, pale and has a bruise on the left buttock which is 5 cm × 8 cm. She has three other bruises on her left leg and right arm which are of varying colours. She also has some fine petechiae on her neck and cheeks. She has a runny nose and a cough but the chest is clear. What is the most likely diagnosis?
A. Non-accidental injury
B. Leukaemia
C. Idiopathic thombocytopenia
D. Henoch–Schönlein purpura
E. Accidental injury
B. Leukaemia
1 B This child is presenting with bruising on the buttocks and limbs as well as petechiae which raise alarm bells that the child may have low platelets. The two options on the list with low platelets are idiopathic thrombocytopenia (ITP) (C) or leukaemia (B). This child has a background of being unwell with a suggestion of weight loss which points to leukaemia as the most likely diagnosis (B). Henoch Schönlein purpura (D) does not produce low platelets but could produce the bruising on the buttocks: this would normally be associated with joint and abdominal pains as well as haematuria. It is a small vessel vasculitis which typically occurs 1–2 weeks after a throat infection. ITP (C) also is often triggered after a viral infection and it would be unusual for the child to be unwell at presentation with the bruises. If the full blood count comes back normal that would raise concerns of non-accidental injury (A). The petechiae in the head and neck could be produced by strangulation and the bruises of multiple ages as well as sited on the buttocks is unusual for an accidental injury (E); combined with a withdrawn child this should raise the suspicion of non-accidental injury (A). As you have not been given the full blood count results and the child is unwell with weight loss and recurrent illnesses, the single best answer is leukaemia (B).
On the day 1 baby check a mother is very concerned about a rash on her baby’s face. Over the right eye, forehead and temple there is a pink-red, flat area of erythema. He is opening the eye, and his eye movements seem intact. The child’s observations and rest of the examination are normal. What should you tell the mother?
A. This is a strawberry naevus and it may get bigger before it goes away by about 5 years of age
B. This is a port wine stain and the baby needs an MRI scan to check for intracranial involvement
C. This is a capillary haemangioma (stork mark) and is normal; it will fade over the first year or so of life
D. This is orbital cellulitis and he needs intravenous antibiotics
E. This is erythema toxicum which is a normal baby rash and will go away within the first few weeks
B. This is a port wine stain and the baby needs an MRI scan to check for intracranial involvement
2 B This is likely to be a port wine stain or naevus flammeus (B) which is a capillary vascular malformation in the dermis, present from birth and will persist for life. When present in the trigeminal distribution, a small proportion of children will have underlying brain involvement (Sturge–Weber syndrome) and should have an MRI brain to look for this as the child will be at risk of seizures and developmental problems. A strawberry naevus (A) or cavernous haemangioma is not usually present at birth and typically appears in the first month. Strawberry naevi will grow larger before shrinking and disappearing, typically before the age of 5 years. They may compress neighbouring structures as they grow and sometimes ulcerate with troublesome bleeding. They are not flat. A capillary haemangioma or ‘stork bite’ (C) is a pink macule found on the eyelids, central forehead or nape of the neck which is due to distension of the dermal capillaries; they mostly fade over the first year. Those on the neck may persist but will be covered by hair. They are not found on the lateral face; therefore this is not the right answer. The child is well, with normal observations, making cellulitis (D) very unlikely. In addition you have been given no information on whether the lesion feels warm, which you would expect in infection. Erythema toxicum (E) is a common innocent rash of the newborn which has an erythematous base with small pustules. It comes and goes all over the body for the first few weeks of life.
A mother brings her 6-month-old, formula-fed baby to see the GP complaining that the olive oil she is using is not helping his persistent cradle cap and worsening rash on his face and arms. On examination he has extensive cradle cap and eczematous changes on his cheeks, neck, chest and arms. The neck skin creases are red and oozing with yellow crusts. He is miserable and feels warm to touch. What is the most appropriate management?
A. Advise using emollients and a soap substitute
B. Start emollients with a topical antibiotic
C. Refer to hospital for intravenous antibiotics
D. Recommend a trial of switching to soya based formula as he may be cow’s milk protein allergic
E. Start topical steroids on the inflamed areas, and intensive emollient treatment
C. Refer to hospital for intravenous antibiotics
3 CThis child has infected eczema, characterized by red inflamed skin with yellow crusts which suggests a staphylococcal infection (but eczema herpeticum also needs to ruled out). He is systemically unwell, with misery and most probably a fever. He therefore needs intravenous antibiotics and must be referred to hospital (C). If he was not unwell, starting emollients with oral antibiotics would be appropriate, but topical antibiotics are to be avoided since they may rapidly select for resistant organisms and they may themselves be sensitizing (B). This child’s eczema is severe and exploring other contributory factors such as cow’s milk protein sensitivity is part of good management, but a trial of soya based formula without any clear history or investigations is inappropriate (D). He should be started on emollients and soap substitute (A) but this is not the best answer as he needs systemic antibiotics as well. Steroids (E) should not be started until the infection has been treated but he will require steroid creams to help treat his eczema once the infection has resolved.
A 4-year-old is brought into accident and emergency by very anxious parents. She has had a bad cough which makes her vomit and a fever for 2 days. She has now developed a rash on her face which does not pass the ‘glass test’, in that the spots are still visible when a glass is pressed against the skin. On examination she is alert and comfortable at rest, with fine petechiae on her cheeks and neck which are non-blanching. She has red, enlarged tonsils without pus and the chest is clear. What is the most likely cause of her rash?
A. Meningococcal sepsis
B. Idiopathic thrombocytopenia
C. Henoch–Schönlein purpura
D. Non-accidental injury
E. Capillary rupture secondary to raised pressure in the superior vena cava distribution
E. Capillary rupture secondary to raised pressure in the superior vena cava distribution
4 E This child’s parents have done ‘the glass test’ by pressing a tumbler against the skin, to check if the rash is blanching or not. They are very anxious because they have been taught that a positive glass tests means meningitis, usually caused by meningococcal sepsis (A). However, she is well in herself making this less likely. It would be sensible to admit her for observation even if antibiotics are not started. She has petechiae in the superior vena caval distribution (E) which often occur in situations of raised pressure such as coughing or vomiting but can also be seen in shaken babies or strangulation injuries. In young children coughing bouts often trigger vomiting, but vomiting is a warning sign of meningitis, so she should be monitored. ITP (B) is often triggered about 1 week after a throat infection and it would be unusual for the child to still be unwell and only have petechiae on the face. A strangulation injury by an angry caregiver could produce this pattern of injury; however her coughing and vomiting give a plausible explanation of the lesion, making non-accidental injury (D) unlikely. Henoch–Schönlein purpura (C) is a vasculitis of the capillaries and typically causes a macular papular purpuric rash over the buttocks and extensor surfaces of the limbs, so the distribution of the rash in this case is wrong.
A 2 year old was seen in accident and emergency by the senior house officer with a short history of fever, malaise and now vomiting. She had a blanching rash on her arms and abdomen. She looked unwell but had no clear focus for her fever. She was tachypnoeic but her chest was clear. A urine sample was requested which showed a trace of leukocytes and two plus of ketones. Forty-five minutes later the paediatric registrar came to review the child who appears lethargic with a capillary refill centrally of 6 seconds and the rash on her abdomen is now non-blanching. What is the most likely diagnosis?
A. Urinary tract infection (UTI)
B. Idiopathic thrombocytopenia
C. Meningococcal sepsis
D. Human herpes virus 6 infection
E. Diabetic ketoacidosis
C. Meningococcal sepsis
5 CThis child is rapidly becoming unwell with impending shock (capillary refill 6 seconds). The expanding rash quickly becomes non-blanching and suggests that she has disseminated intravascular coagulation, often seen with meningococcal sepsis (C). Idiopathic thrombocytopenia (B) is usually seen in well children following a recent upper respiratory tract infection. While the urine dipstick has a trace of leukocytes, this is most likely non-specific due to her being so unwell and in the absence of nitrites is not strongly suggestive of a UTI (A). Human herpes virus 6 infection is a very common cause of fever and rash in this age group, not infrequently associated with febrile convulsions, but it does not cause shock and the rash would remain blanching (D). Tachypnoea without chest signs is an indicator of acidosis but the urine dipstick did not have any glucose in it, so this presentation is not due to diabetic ketoacidosis (E).
A 2 year old is brought in by ambulance after pulling a pot of boiling water off the stove down on top of himself. He has significant burns to the whole of his face, torso and right arm. Estimate the percentage body surface area affected.
A. 20 per cent
B. 30 per cent
C. 40 per cent
D. 50 per cent
E. 60 per cent
C. 40 per cent
6 CIn children, the head represents a larger proportion of the body and the Lund–Browder chart is used to assess the burn percentage. The whole head would account for 18 per cent. This child has burned the anterior head = 9 per cent, the anterior torso = 18 per cent and the whole right arm = 9 per cent, which is not quite 40 per cent (C). In an adult, the whole head represents only 9 per cent of the body and therefore this same burn would be closer to 30 per cent (B). Just the torso would be about 20 per cent (A). Burns of 50 (D) or 60 per cent (E) are extremely extensive.
Which of the following is not a cause of erythema nodosum?
A. Oral contraception
B. Tuberculosis infection
C. Hepatitis B infection
D. Streptococcal infection
E. Sarcoidosis
C. Hepatitis B infection
7 CThe oral contraceptive pill (A), tuberculosis (B), streptococcal infections
(D) and sarcoidosis (E) are all known causes of erythema nodosum, which produces tender red nodules on the shins. Hepatitis B (C) does not cause erythema nodosum. It may produce non-specific rashes and jaundice.
A 3 year old is brought to see the GP with multiple pearly raised papules with central umbilications. They have been there for more than a month on his torso and upper legs. His mother is worried he has warts. What is the most likely diagnosis?
A. Molluscum contagiosum
B. Congenital warts
C. Scabies
D. Melanocytic naevi
E. Guttate psoriasis
A. Molluscum contagiosum
8 AThis child has a common condition of molluscum contagiosum (A) caused by a pox virus. They are usually self-limiting and will self-resolve within a year. Occasionally one may become superinfected with bacteria and require antibiotics. Particularly stubborn cases may be treated with cryotherapy to hasten resolution. ‘Congenital warts’ (B) is a term that usually refers to genital or anal warts, and the distribution and description of the lesions in this child are not consistent with this diagnosis. There is some controversy regarding the maximum incubation period for genital warts that are acquired from contact with maternal genital warts during delivery. These may take over a year or two to evolve and when they appear, child sexual abuse may erroneously be suspected. Scabies (C) cause itchy rashes due to the burrows of the mite in the skin, usually on the hands, axillae or groin and often involving the web spaces between the fingers. A melanocytic naevus (D) would be a hyperpigmented papule which would not usually have a central punctum. Guttate psoriasis (E) often follows an upper respiratory tract infection and produces raindrop-like scaly pink patches on the torso and arms.
On a newborn baby check of an Asian, 36-hour-old baby you note a large bruise coloured area on the buttocks and lower back which seems non-tender. The mother does not know how it got there. He is handling well and the rest of the baby check is unremarkable. What is the most likely explanation?
A. Non-accidental injury
B. Mongolian blue spot
C. Neonatal sepsis with disseminated intravascular coagulation
D. Idiopathic thrombocytopenic purpura
E. von Willebrand’s disease
B. Mongolian blue spot
9 B This is a Mongolian blue spot (B) and is more commonly found in darker skinned races. Mongolian blue spots are classically found on the buttocks and lower back and fade as the child grows up. It is not bothering the baby so it is unlikely to be an injury (A). The child is well on examination which makes sepsis with disseminated intravascular coagulation highly unlikely (C). Idiopathic thrombocytopenic purpura (D) is not seen in newborns as it requires a preceding infection to trigger the immune response, and maternal antibodies are protecting the baby. However, maternal autoantibodies against platelets could produce thrombocytopenia and purpura but this is not an answer choice. Von Willebrand’s disease (E) is a clotting defect controlling the binding of platelets to damaged endothelium and typically presents with mucosal bleeding or menorrhagia.
A 5-day-old baby is brought to see the GP because she has had a rash for the past 3 days which started on her chest, is spreading to her face and getting worse. On examination she handles well and is alert. There is an erythematous rash on her face, torso and right arm with little pustules. What is the most likely diagnosis?
A. Infected eczema
B. Neonatal sepsis
C. Neonatal acne
D. Molluscum contagiosum
E. Erythema toxicum
E. Erythema toxicum
10 E This is a typical presentation of erythema toxicum (E), a common innocent rash of the newborn which has an erythematous base with small pustules. It comes and goes all over the body for the first few weeks of life. The baby is well so an infection ((A) or (B)) is unlikely. Neonatal acne (C) is typically confined to the face and peaks at about 2 months. Molluscum contagiosum (D) does not have erythema or pustules, it produces pearly growths with a central punctum.
