Visual Diagnosis. Q-PEM: Jan Dr. Rafah F. Sayyed PEC - Al Sadd, Doha

Transcription

1 Visual Diagnosis Q-PEM: Jan 2017 Dr. Rafah F. Sayyed PEC - Al Sadd, Doha

2 DISCLOSURE I do not have any relevant financial relationship with commercial interest to disclose.

3 Introduction Speed and Accuracy of Diagnosis is the key to saving lives in emergency and critical care medicine. Careful Visual Inspection of the Patient, and Related Clues help providers choose the right diagnosis and ultimately the best treatment.

4 Objectives Clarify the Visual Clues and their Clinical Significance Recognize Common Pediatric Dermatologic Conditions Learn to Recognize Common Pediatric Rashes Learn to Recognize Emergent Rashes

5 Case Presentation 1 Picture Title 2-yrs old boy previously healthy presented with: Diffuse rash over bilateral LL for the past 2 days that is progressing to his trunk and UL He is otherwise playful and well with no fever His parents deny new creams, or drug exposures His parents report mild URTI 1 week ago

6 Case Presentation 1 Continued Picture Title Physical Exam: Multiple diffuse lesions with central clearing The lesions on palms and soles but are most prominent on his bilateral LL No conjunctival injection,no sores in or around his mouth or genitalia

7 Question: Picture Title What is the next most appropriate management strategy at this time? A: Obtain complete blood count (CBC) and blood culture, administer ceftriaxone, and admit for observation B: Obtain CBC and blood culture, but do not treat with antibiotics C: Discharge to home with diphenlhydramine as needed for itching D: Consult dermatology emergently E: Administer subcutaneous epinephrine immediately

8 Answer: C Erythema multiform (minor) EM Hypersensitivity reaction Lesions - symmetric, palms and soles, extensor surfaces of the UL&LL macular, urticarial, or vesicobullous Prototypical lesion: target lesion with a dusky center The rash lasts 1 week - 6 weeks Patients are asymptomatic, sometimes itching or involvement of the oral mucosa Carder KR. Hypersensitivity reactions in neonates and infants. Dermatol Ther 2005;18(2):

9 Erythema multiform (minor) EM The causes of EM: infectious causes, HSV The DD of EM: pemphigus, urticaria, or other viral exanthema Treatment: supportive (antihistamines, NSAIDS, steroids) Evaluate mucosal surfaces to differentiate EM minor or major EM minor: involves the skin and only one mucosal surface EM Major (Stevens Johnson): involves the eye, oral cavity, genital mucosa, upper airway, or esophagus. Carder KR. Hypersensitivity reactions in neonates and infants. Dermatol Ther 2005;18(2):

10 Case Presentation 2 : 8-years old boy presents to PEC with Rash for 2 days and an inability to ambulate due to bilateral ankle pain Rash began on his legs and is now more generalized, It is not painful nor pruritic.

11 Case Presentation 2 : On Exam: The child is well with normal vital signs Lesions are palpable and do not blanch with pressure The ankles are warm and have minimal periarticular swelling The right wrist is painful and warm and swelling. The rest of the exam is normal Laboratory tests: Normal CBC, Coag. studies, elect, and UA, Blood culture is pending.

12 Case Presentation 2 : Question: What would be the next step in managing this patient? A - Discharge home with close follow-up by the primary care doctor and anti-inflammatory medications for the joint pain B - Admit for observation C - Admit for intravenous antibiotic therapy D - Consult orthopedics for an ankle arthrocentesis E - Administer subcutaneous epinephrine

13 Answer: A Henoch Schönlein Purpura (HSP) HSP is benign vasculitic disease of childhood HSP Over 6 weeks, Relapses ( 16 40%) of patients Clinical manifestations of HSP Cutaneous involvement: 100% Palpable Purpura at LL and rash can involve UL Joint involvement: 50 80% Large lower extremity joints Gastrointestinal involvement: 65 70% Colicky abd. pain and vomiting, rarely intussusception. Renal involvement: 20 34% Microscopic Hematuria, RF in ( 1 5% ) Lanzkowsky S, Lanzkowsky L, Lanzkowsky P. Henoch Schoenlein purpura. Pediatr Rev 1992;13(4): Saulsbury FT. Henoch Schonlein purpura in children. Report of 100 patients and review of the literature. Medicine 1999;78(6):

14 Henoch Schönlein Purpura (HSP) Management: HSP Supportive care Weekly BP, U/A throughout the course of disease 2/3 of patients resolve their symptoms within 1mo No evidence supports use of glucocorticoids for treatment of abdominal pain. DD: meningococcemia, ITP, SBE, HUS. Lanzkowsky S, Lanzkowsky L, Lanzkowsky P. Henoch Schoenlein purpura. Pediatr Rev 1992;13(4): Saulsbury FT. Henoch Schonlein purpura in children. Report of 100 patients and review of the literature. Medicine 1999;78(6):

15 Case Presentation-3 2-years old male presented with: 6-day history of fever (38.5 C and more) and irritability Rash distributed along his face, trunk, and flexural surfaces of his extremities Non-exudative conjunctivitis dry, cracked, erythematous lips large (2.0 cm), firm, mobile, tender, leftsided anterior cervical LN hands and feet appear edematous.

16 Case Presentation-3 Question: Which of the following is associated with this clinical syndrome? A: Hemorrhagic gastritis B: Acute renal failure C: Intracranial abscess D: Coronary artery aneurysms E: Pancytopenia

17 Answer: D Kawasaki disease (KD) KD KD Small and medium vessel vasculitis before age 5. Common cause of acquired heart disease in children (15 25%) Etiology remains unknown Classic diagnosis of KD: Warm CREAM Need: Warm: Fever > 5 days Plus 4 of 5 : 1: Conjunctivitis (bilateral, non purulent) 2: Rash (erythematous and maculopapular) 3: Erythema palms and soles (swelling and peeling) 4: Adenopathy (cervical, unilateral node) 5: Mucous Membrane (dry, cracked, red lips and strawberry tongue) Further reading 1 Royle J, Burgner D, Curtis N. The diagnosis and management of Kawasaki disease. J Paediatr Child Health 2005;41(3): Newburger JW, Fulton DR. Kawasaki disease. Curr Opin Pediatr

18 Kawasaki disease (KD) KD KD Don t Forget: A-Typical KD Prolonged fever (with < 4 of the above symptoms, infants) laboratory findings: ESR, UA (sterile pyuria), Platelet Echo (coronary artery abnormalities) Treatment: IVIG, Aspirin Further reading 1 Royle J, Burgner D, Curtis N. The diagnosis and management of Kawasaki disease. J Paediatr Child Health 2005;41(3): Newburger JW, Fulton DR. Kawasaki disease. Curr Opin Pediatr

19 Approach to: Patient with Rash

20 Questions History: 1 What does patient think is causing rash? 2 Where did the lesions originate? 3 When did the lesion first develop? What has been the progression of rash? 4 Was there any prodromal to the lesions? 5 What are the associated symptoms?

21 Questions History: 1 Does it itch, hurt? 2 What treatment was applied if any? 3 Is there h/o atopy in family? 4 What medication do they take regularly or intermittently? 5 What kind of exposure do they have?

22 Physical Exam Physical Exam: 1 2 Examine in well-lit area 3 Careful inspection of the skin, Examine the entire skin surface 4 Description of rash

23 RASH Description of rash 1 2 Morphology 3 Color Configuration 4 Distribution

24 Morphology: Primary lesions uncomplicated abnormalities which represent initial pathologic change secondary lesions reflect progression of disease such as excoriation, infection, or keratinization

25 Primary Lesions-1 Macule circumscribed flat discoloration < 1cm in diameter ash-leaf spots, flat nevi and freckle Papule -circumscribed --superficial solid -elevated lesion < 1cm in diameter warts, elevated nevi insect bites Molluscum contagiosum. Patch circumscribed flat discoloration (gathering of Macule) > 1cm in diameter vitiligo, tinea versicolor Plaque elevated flat top superficial lesion (gathering of Papule) > 1cm in diameter Psoriasis pityriasis rosea.

26 Primary Lesions - 2 Vesicle fluid filled lesion <1cm in diameter herpes simplex varicella Pustule vesicle with purulent exudates < 1cm in diameter acne, folliculitis Nodule circumscribed solid elevated lesion with depth < 1cm in diameter secondary / tertiary syphilis Bulla fluid filled lesion > 1cm in diameter SSSS and bullous impetigo

27 Primary lesions-3 Petechiae pinpoint flat red spots under the skin surface <2mm in diameter ITP/HSP Purpura visible collection blood >2mm- 1cm in diameter ITP Ecchymosis visible collection blood > 1cm in diameter Blood disease, vessels Wheal transient edematous papule or plaque with pale center and pink margin > 1cm in diameter hives and insect bites Urticaria

28 Secondary Lesions: 1Scale 2 s Crust 3 4 Dry and greasy masses of keratin (fine coarse); pathologic process in epidermis Dried exudates ( pus or blood) Excoriation Linear abrasion caused by scratching Fissure Linear crack or cleavage on skin with sharply defined margins 5 6 Ulcer Scar Depressed lesion with epidermal & dermal loss Permanent lesion result from process of repair by replacing connective tissue

29 General shape or the pattern in which the lesion are arranged Configuration: 1 Grouped papule in Molluscum contagiosum 2 Shape annular plaque of Tinea corporis 3 Grouped vesicles-herpes simplex

30 Distribution:

31 RASH: Blanching? Feverish YES NO YES NO Infection/Dermatological Disease Purpura/Petechie=Blood/vessel Disease mostly Systemic infection mostly local dermatological disease Texture sandpaper texture in scarlet fever Nikolskys sign Epithelial shearing caused by lateral pressure to unblistered skin

32 Algorithmic Approach for Rash

33 Algorithmic Approach I: Maculo-papular Rash Central Distribution Peripheral Distribution Y E S Febrile, ill N O Target lesions YES N O Lesion Distribution Y E S N O Flexor Extensor Viral Exanthem Pityriasis SJS EM Meningiococcemia E cz e m a Psoriasis

34 Algorithmic Approach II: Vesiculobullous Rash Febrile Afebrile Diffuse Distribution Localized Distribution Varicella HFM-disease Bollous Pemphigoid Contact Dermatitis Purpura fulminans Necrotizing fascitis SJS EM Pemphigus vulgaris Herpes Zoster

35 Algorithmic Approach III Petechial/Purpuric Rash Febrile,toxic Afebrile,nonetoxic Palpable TTP Autoimmune Vasculitis ITP Meningiococcemia HSP DIC

36 Emergent Rashes in Pediatrics Toxic Epidermal Necrolysis (TEN) Stevens Johnson Syndrome (SJS) Staphylococcal Scalded Skin Syndrome (SSSS) Toxic Shock Syndrome (TSS) Kawasaki Disease (KD) Anaphylaxis Purpura Fulminans

37 Toxic Epidermal Necrolysis (TEN) Sudden onset, generalization in hrs Sever form of EM Confluent erythema,skin tenderness Absence of target lesion, blister formation Nikolskys sign positive Fever, inflammation of eyelid, conjunctivae, mouth precedes skin lesion Complicated by dehydration shock, electrolyte imbalance septicemia

38 Stevens - Johnson Syndrome (SJS): Erythema, edema of lips, buccal mucosa Then develops bullae ulceration hemorrhagic crusting Skin lesions are bullae denuded skin More widespread than EM Skin tenderness is minimal to absent Mucosal ulceration is painful Systemic involvement present

39 Staphylococcal Scalded Skin Syndrome (SSSS) Caused by Staphylococci Common in infant and young children's Localized bullous impetigo -to- generalized Begins as erythema then desquamation after 5 days Diffuse sterile flaccid blisters Intact bullae are sterile unlike in bullous impetigo Absence of inflammatory infiltrate is characteristics Treated with ABC( beta - lactamase resistant)

40 Meningococcemia: Fever Rash typically petechiae & purpura Hypotension, Adrenal failure Multi-organ failure Meningitis feature Mortality rate 40% CAUTION!! Fever + Purperic Rash (non blanching) = Meningococcemia until proved otherwise

41 Anaphylaxis: Life Threatening Allergic Reaction think FAST Face - Urticaria, Swelling, angioedema Airway- Wheezing, dyspnea Stomach-abdominal pain, vomiting then ACT Epinephrine IVF Total body anxiety, dizziness, hypotension All these in few seconds to minutes

42 Common Rashes in Pediatrics: MEASLES Roseola Infantum (6th Disease) Scarlet Fever Kawasaki disease (KD) Herpes Simplex Chickenpox

43 MEASLES IP:1-2 weeks Fever: high-40, 4 days then rash Conjunctivitis + cough Koplik spots: 2 days before rash opposite 2 nd molars Rash: Cephalo - caudal Maculo - papular Infectious: from fever to 4 days after rash, Droplet Investigation: measles IgM, IgG ttt: supportive + IVF+ Vitamin A

44 Roseola Infantum (6 th Disease) High Fever 4 days suddenly disappears Then Rash begins Infant 6-12 months T- shirt distribution: trunk and extremities ttt: supportive

45 Scarlet Fever Fever Pharyngitis / Tonsillitis Strawberry tongue + Circumoral pallor Sandpaper-like skin rash Pastia lines Desquamation of the palms Investigation: ASO, CBC, Throat swap ttt Antibiotics (oral / IV)

46 Herpes Simplex Type1 = Skin& mucous membranes Type 2 = Genitalia (child abuse) Cold sores: (vesicular lesion in nasolabial fold) Gingivostomatitis: (painful mouth ulcers+ fever) Conjunctivitis + Corneal Ulcers Meningoencephalitis (neonate) Eczema Herpeticum (vesicular rash) Investigation: PCR, Culture ttt: supportive+ Acyclovir (systemic, local)

47 Chickenpox Varicella - Zoster Virus No Prodrom (usually) Rash: Itchy Vesicle + red base ( macule papule vesicle/crust Scalp, face, trunk, proximal limbs, palms, soles, mm Complication: 2 ry bacterial infection (imptigo/cellulitis) Spread of infection: chest, heart, CNS Thrompocytopenia ttt: supportive + Acyclovir (systemic, local)

48 Conclusion Treating Pediatric Dermatology Patient in ED may appear daunting, however, with a Systemic Approach one can more readily and successfully diagnose and manage patient effectively.

49 QUESTIONS?

50 THANK YOU!