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Pediatrics > The infant or child with a rash > Flashcards

The infant or child with a rash Flashcards

1
Q

Etiology

A 
1. Viral
Chicken pox
EBV
CMV
Fifth disease
Roseola
HIV
Hepatitis B/C
HFM
Rubella
Measles
HSV
Molluscum contangiosum
2. Inflammatory
Atopic dermatitis, seborrhoeic, contact, psoriasis, pityriasis rosea, mastocytosis
3. Bacterial
Impetigo
Folliculitis
4. Fungal
Tinea corporis
Scabies
Candidiasis
5. Tick borne
RMSF
Lyme disease
6. Drug eruptions
7. Systemic bacterial
Meningicoccal, syphillis, gonorrhea, endocarditis
SSS
Scarlet fever
TSS
8. Hypersensitivity
9. Vasculitis/rheumatological
Kawasaki
JA
HSP
SLE, RF, Sarcoidosis
10. Child abuse
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2
Q

Important history

A 
Is the child well
Could this be an inset bite or allergic reaction
Morphology
Duration
Distribution, progression
Pruritis
Systemic features
Recent viral infection/Strep throat
Family history
Recurrent
Contact, travel, exposures
Complete medical history, medications
Treatment attemtps
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3
Q

Unwell child systemic, erythematous rash etiology

A
  1. Erythematous rash
    a. Hypersenitivity->insect, bites, allergies, medications
    b. Scarlet fever->desquamating, pharyngitis, contact history
    c. SSS->superficial desquamation, recent infection, fever, malaise, tender skin
    d. TSS->trunk, palms, soles, hyperemic oral mucosa, tampon use
    e. SJS
    f. RF
    g. JA
    h. SLE
    i. Sarcoidosis
    j. Lyme
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4
Q

Unwell child systemic, maculopapular

A

a. Meningicoccal septicemia
b. Bacterial endocarditis
c. Systemic hypersensitivity syndrome
d. Kawasaki
e. Measles
f. HBV/HCV acute
g. HIV
h. RMSF->wrists, ankles, palms and soles, spreads central, spares face, outdoor

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5
Q

Unwell child systemic, vesiculobulous

A

a. SJS/TEN

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6
Q

Unwell child systemic, pertehchiael/purpuric

A

a. Meningicoccal
b. Leukemia
c. HSP
d. RMSF

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7
Q

Well child, mild systemic

A 
Erythema multiforme
Roseola
Erythema infectiosum
Drug reaction
CMV
EBV
Rubella
VZ
HFM
Syphilis
Gonorrhea
ITP
Child abuse
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8
Q

Well child no systemic

A 
Psoriasis
Pityriasis rosea
Contact/irritant
Nappy rash
Atopic dermatitis
Seberroiec
Tinea
Scabies
Impetigo
Folliculitis
Mastocytosis
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9
Q

Physical examination

A

General, systemic involvement
Describe the rash: raised/flat, crusty/scaly, colour, blanching, size, distribution
Full examination->including LN, CVS, RS, abdominal, ENT

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10
Q

Acute rash onset history

A 
Well/febrile
Itchy
Associated symptoms? Bleeding, arthritis and abdominal pain, stridor and urticaria
PMH
Immunisations
Contact
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11
Q

Investigations

A 
Generally not required
Rubella serology in pregnant
Cultures if systemic/sepsis
FBC/PLT, coagulation in ITP
Widespread urticaria->RAST consider
FBC, ESR, CRP, biochemical/urinalysis in systemic
Serology->ASOT, anti-DNAse B, IgM/IgG for lyme, ELISA for S aureus in SSS
Serology HIV, HBV, HCV
Blood cultures
LP
Echo->RF, BE, Kawasaki
CXR->RF, sarcoidosis
Biopsy->SSS, SJS, DRESS, HSP
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12
Q

Features of scarlet fever: rash, presentation, treatment

A 
Sandpaper
Blanching
Neck, axilla, groin
Face spared
Red tongue
Fever, headace
Group A strep infection, 12 hours post tonsilitis

Treatment: phenoxymethylpenicillin 15mg/kg up to 500mg BD for 10 days

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13
Q

Features of measles rash, management

A

Face->trunk
Koplik spots
Fever, ill, lymphadenopathy
Cough, coryza, conjunctivitis

Notifiable
Supportive care + vitamin A supplementation
Measles IgM/IgG serology

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14
Q

Features of rubella rash, complications in congenital rubella

A

Tiny macules->face to trunk
Generally well child
Suboccipital LN
IP of 14-21 days

Congenital->in first trimester= death, retardation, CHD, deafness, cataracts

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15
Q

Features of Fifth disease

A

Slapped cheeks
Lacy appearance
Mild fever
Lasts up to 6 weeks

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16
Q

Presentation of chicken pox

A

IP 10-21 days
Prodromal fever, lethargy, anorexia, then 3-5 days of eruption
Papules->vesicular->crusting in 10 days
+On scale, face, trunk, mouth and conjunctiva

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17
Q

Complications of chicken pox

A 
Pneumonia
Arthritis
Hepatitis
Encephalitis
Superinfection
Cerebellitis
Reye

+in infants, >15 yo and immunocompromised children

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18
Q

Management of chickenpox

A
  1. Consider admission IV aciclovir, discussion with consultant:
    - ->immunocompromised,
    - ->steroid received,
    - ->prematures,
    - ->impaired mental state,
    - ->cough/tachyP/dys and CXR shows pneumonia/nitis (add antibiotics)
  2. If none of these features, >12 yo->discuss and consider oral aciclovir if
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19
Q

Exposure porphylaxis in chickenpox

A

Exposed, no rash

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20
Q

Symptomatic management of chickenpox

A 
Calamine lotion
Cool compresses
Keeping skin cool
Oral antihistamines for sleep
Don't scratch, cut nails short
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21
Q

Infection precautions in hickenpox

A

Infectious 1-2 days prior to rash appearing, until fully crusted over. Exclude from school until fully recovered->at least one week after eruption first occurs

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22
Q

Types of nappy rash (4)

A
  1. Ammoniacal->irritant, papulovesicular, fissure, erosisons
  2. Candidial
  3. Seborrhoeic
  4. Psoriatic
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23
Q

Factors which contribute

A

Excess hydration–>water in nappy and stool, nappy change frequency
Skin trauma
Ammonia, feces, soap/deterhen, nappy wiped, napkin powders and creams

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24
Q

Treatment of nappy rash

A

Disposable nappies
+Frequency of nappy changing and cleansing
Disposable towel/face washers soaked in water/olive oil to cleanse
Apply barrier cream atevert change->parrafin, vaseline. Apply +++thickness
Let child sleep as long as can without nappy->lay on absorbent sheet, change when wet
If candida->imidazole/nystatin cream +/- hydrocortisone cream

Consider differential

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25
Q

Differential diagnosis of nappy rash

A 
Seberrhoiec
Atopic
Psoriasis
Perianal cellulitis
Zinc deficiency
Threadworms
Langerhands cell histiocytosis
Malabsorption
Crohns
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26
Q

Meningicoccal rash presentation

A

Petechiael, purpuric, morbilliform

Shock/coma

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27
Q

History and examination assessment of meningicocemia

A

History:
Rapid, fever, malaise, lethargy, vomiting, myalgia, -ve LOC

Examination:
May be shocked, rash, leg pain, neck stiff, photophobia

Blanching does not exclude
Preceeding viral does not exclude

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28
Q

Investigations in meningicoccal

A

Blood culture (if possible before antibiotics)
Meningicoccal PCR
Glucose, UEC, coagulation
VBG/ABG

Consider LP if meningitis

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29
Q

Acute management of meningicocemia

A
  1. ABC, get help
  2. IV access
  3. Blood cultures and Ix
  4. Ceftriaxone or cefotaxime 50mg/kg
  5. IVF->shock management, consider 2/3 maintenance following if suspect meningitis
  6. Urinary catheter if shock
  7. Hydrocortisone if considering meningitis (within 1 hour of antibiotics)
  8. Regular analgesia, may need morphine infusion
  9. If necrosis, involve plastics early
  10. Admission
    Isolate until >12 hours antibiotics
  11. Contact tracing and prophylaxis for those within 24 hours (contact in last 7 days)->rifampicin, ceftriaxone if contraI or pregnant
  12. Monitor vitals and response
30
Q

ITP general, presentation, workup and management

A 
Most common cause of childhood thrombocytopenia
Autoimmune hemorrhagic disorder
1. Petechial rash
2. Bleeding
3. Preceeding viral infection

FBC, PLT low, +coagulation studies

Management:
Mostly self limiting
If ++thrombocytopenia, ongoing bleeding may need admission + steroids

31
Q

Pathogenesis of HSP and epidemiology

A

Small vessel leukocytoclastic vasculitis w/ IgA deposition within affected organs

Most often in winter following strep infection
More in males, 2-8 years

32
Q

HSP triad

A

Purpuric rash on extensor surfaces
Joint pain
Abdominal pain

33
Q

Assessment of HSP

A
  1. Purpura->if atypical or unwell, consider meningiC, thrombocytopenia, other vasculitis
  2. Joint pain->large joints
  3. Abdominal pain usually resolves in 72 hours->look out for intussusception, bloody stool, hematemesis, perforation, pancreatitis
  4. Renal involvement->hematuria
  5. Subcutaneous edema of scrotum, hands, feet, sacrum
  6. Rare complications of pulmonary and CNS
34
Q

Investigations in HSP

A

FBC
UEC
Blood culture

35
Q

When does Atopic dermatitis usually present, grow out of

A

Usually presents before 12 months, and will often grow out of it by age 5

36
Q

Diagnosis of atopic dermatitis

A 
Itch + three of
1. Involvement of skin creases
2. Personal hx of asthma/hay fever
3. Dry skin in last year
4, Onset under 2 (not used if under 4 years)
5. Visible flexural eczema
37
Q

What system is used to graded severity in eczema

A

SCRAD

38
Q

Management of eczema

A
  1. Every day and avoid triggers
    - >avoid heat, prickly, dry skin
    - >Regular moisturises twice a day
    - >Daily cool bathing->add salt, bleach 4% for chronic infected and bath oil
    - >Consider oral vitamin D supplementation
  2. Flaring treatments:
    - >Topical steroids hydrocortisone 1%
    - >Tar creams for lichenification
    - >Antibiotics/virals for infection
    - >IN bactroban if nasal swabs +ve for S aureus
    - >Wet dressings
    - >Cool compress with moisturiser post compress
39
Q

Infected eczema management

A

Remove the crust, cool compress and soak in bath
Cortison over open skin
Cephalexin/flucloxacillin oral antibiotics. IV if unwell
King bleach 4% to cool bath water, wash scalp and face while bathing
Pool salt can be addedd

For HSV infection->start treatment w/i 48 hours oral acyclovir, IV may be required if severe/immunocompromised.

40
Q

Advice to parents about their child’s eczema

A
  1. Identify and avoid triggers->prickly, heat, detergents, soaps, antiseptics
  2. Moisturise the skin->twice daily, oils, soap free
  3. Reduce itchiness with wet dressing and cool compresses
    - cool towel/cloth for 10-15 minutes
    - distract
    - ovoid overheating
    - moisturise
    - keep nails short
    - apply wet dressing to limbs at bedtime
    - cotton clothing, remove woolen, keep house cool, educate others about dressing your child
    - All foods considered innocent until guilty
41
Q

WIll the treatment cure eczema

A

Not for cure, to help control

Will continue for many years in most cases

42
Q

Advice on swimming

A

Yes, if the eczema is not flaring up. Prior to swimming, apply a layer of moisturiser from top to toe. Soon after swimming, wash the skin thoroughly in a cool shower or bath with some bath oil then reapply the moisturiser. If the eczema flares that night, apply a wet dressing just before your child goes to bed.

43
Q

Define cellulitis, most common causes and predisposing

A

Spreading infection of subcutaneous tissue
Most common causative agents: GABHS, SA
Skin abrasions, lacerations, burns, eczematous skin

44
Q

When is cellulitis unlikely and allergic/dermatitis often misdiagnosed

A

Itching only and not tender

45
Q

Who is primarily affected by SSSS, level affected, early features

A

Neonates and young children
Splits upper epidermis, epidermolytic toxin
Fever and tender erythematous skin early features->discomfort when touched
Exudation and crusting early around the mouth

46
Q

What is impetigo

A

Highly contagious of epidermis
Common in young children
GABHS and S aureus

47
Q

What is Nikolsky sign

A

Rubbing normal skin, peels off

48
Q

When does Nikolsky occur

A

SJS

SSSS

49
Q

Complications in SSS

A

DeH and electrolyt
Cellulitis
Sepsis
Temperature instability

50
Q

Scabies: causative agent, signs and symptoms, relation to ARF

A

Sarcoptes scabiei var. hominis
Soft hairless areas
School-aged, indigenous, resisdential
Itching, post strep, excoriations, secondary bacterial, rash
Allergic reaction to mite causes the signs and symptoms
Secondary infection->Streptococcal->ARF

51
Q

Treatment of scabies in children older than 6 months

A

permethrin 5% cream (adult and child 6 months or older) topically to dry skin from the neck down, paying particular attention to hands and genitalia. Apply under the nails using a nailbrush. Leave on for a minimum of 8 hours (usually overnight) and reapply to hands if washed. Application time may be increased to 24 hours if there is a history of treatment failure. Repeat treatment in 7 days

52
Q

Assessment in scabies

A 
Complete history
Clinical observations
BP++
Urine
Signs of secondary
In recurrent/secondary infection->weight, BP, urinalysis->if abnormal manage/refer to pediatrics
Consider skin scraping/dermatoscopy
53
Q

Treatment of scabies

A

permethrin 5% cream topically to the entire body, including the scalp but avoiding eyes and mouth. Cover hands to avoid the child sucking the medication. Leave on for 8 hours. Repeat treatment in 7 days

Or 2% sulfur

54
Q

Treatment in scabies immunocompromised

A

ivermectin (adult and child 15 kg or more) 200 micrograms/kg orally with fatty food, once weekly until scrapings from a burrow are negative and there is no further clinical evidence of infestation.

55
Q

Treatment of norweigan scabies

A

ivermectin (adult and child 15 kg or more) 200 micrograms/kg orally with fatty food, for 3, 5 or 7 doses depending on severity and clinical response in the first week
for a 3-dose regimen, give on days 1, 2, 8
for a 5-dose regimen, give on days 1, 2, 8, 9 and 15
for a 7-dose regimen give on days 1, 2, 8, 9, 15, 22 and 29.

56
Q

Other aspects of scabies treatment

A
  1. Family treated
  2. All linen/bed sheets
  3. Warn itch can continue for weeks
  4. Repeat treatment in a week
57
Q

Assessment and investigations of cellulitis->defining feature of inpetigo, erysipelas NF

A

Impetigo->bullious
NF->tender beyond skin signs, thrombocytopenia
Erysipelas->well defined

Ix:
Swab
BC + FBE if fever
ESR, XR if suspect osteoM
USS if fluctuant
Surgical if suspect NF or abscess
58
Q

Antibiotic treatment of cellulitis, impetigo, NF

A

Cellulitis->Flucloxacillin or cephalexin
Impetigo->wash off crusts, apply 2% muporicin ointment tds, exclude from school/daycare etc until started treatment and cover with tegaderm
SSS->as for cellulitis
NF-> IV flucloxacillin + clindamycin, surgical consult for debridement

59
Q

Investigations and management in SJS

A 
Skin biopsy
Blood cultures
UEC
FBC
LFT
ABG->hypoxemia, acidosis
Management:
ABC, urgent evaluation from senior
IV access, ABG, oxygen
Removal of causative agent
Dressings, topical antibacterial, emolient
Fluids and electrolyte, strict fluid balance
Nutritional support
Oral hygeine->lidocaine mouthwash
Analgesia
IVIG
OT and physiotherapy
60
Q

What is kawasaki disease

A

Systemic vasculitis, of unknown origin

61
Q

Major concern with Kawasaki

A

Risk of coronary aneurysm

62
Q

Diagnostic criteria for kawasaki

A
  1. Fever > 5 days

4/5 of

  1. Polymorphous rash
  2. B/L non purulent conjunctivitis
  3. Mucosal membrane changes
  4. Peripheral changes->feet/soles
  5. Cervical lynphadenopathy->usually SSS, TSS
    - Strep->Scarlet fever, TSLS
    - Juvenile RA
    - Measles, +other viral exanthems
    - SJS
    - Drug reaction
63
Q

Investigations in kawasaki

A

ASOT/Anti-DNAase B
EchoC->initial and 6-8 weeks post
PLT-> low

FBC->+neutrophils, normocytic/normochromic anemia
ESR/CRP +
+LFTs
Low albumin

64
Q

Management of Kawasaki

A
  1. Admit
  2. IVIG over 12 hours
  3. Aspirin daily for 6-8 weeks
  4. Investigations->++Echo
  5. Analgesia for pain
  6. Organise F/U echo in 6-8 weeks following D/C
  7. If your child is due a routine MMR (measles, mumps, rubella) immunisation, this should be delayed until 11 months after the gammaglobulin treatment.
  8. Most children recover normally
65
Q

Important information about molluscum and management

A 
Viral
Self limiting
6-9 months until resolution
No restriction in activity
Mostly doesn't need treatment
If dermatitis->topical steroids
To ++immune response: consider benzyl peroxide, aluminium acetate solution (Burrow's solution), imiquimod
66
Q

Assessment of urticaria

A

Extravasation of plasma into dermis

  1. Onset
  2. Events leading up to
  3. Medication, interaction, infections, foods, bites, pressure, cold, exercise
67
Q

Examination in urticaria

A

General->ensure airway patent, no respiratory distress

Circular, general/localised, polymorphic, transien

68
Q

What to consider when recurrent angioedema without wheals

A

c1 esterase inhibitor deficiency

69
Q

DDX for urticaria and distinguishing features

A

Erythema multifore->not itchy, mucosal involvement, persistent, target lesions

Mastocytosis
Flushing
Juvenile rheumatoid arthritis
Vasculitis
Pityriasis rosea
70
Q

Investigationsin chronic urticaria

A

FBE
ESR
ANA

71
Q

Management of urticaria

A
  1. Remove causative agent
  2. Cool compress
  3. Education, explanation and reassurance
  4. Modification to diet not necessary until causative agent determined
  5. Anti-histamine
  6. Promethazine or cetirizine (X in

Pediatrics (58 decks)

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