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1 in Pediatric Medicine Martin Belson, MD Pediatric Emergency Medicine Associates, LLC Pediatric Sedation Services, LLC Children s Healthcare of Atlanta, Scottish Rite and Egleston Wellstar Hospital Systems
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4 Objectives Identify common pediatric rashes Identify signs of child abuse Identify common illnesses using radiographs and other imaging Children s Healthcare of Atlanta 4
5 Infant rashes Children s Healthcare of Atlanta 5
6 Neonatal acne 20% of newborns Etiology: maternal and endogenous androgens Lesions involute within 1-3 months Treatment usually unnecessary Children s Healthcare of Atlanta 6
7 Children s Healthcare of Atlanta 7
8 Erythema Toxicum Neonatorum Benign, self-limiting Presents at 1-4 days of life usually fades in 1 week Solitary pustule or papule on erythematous base Children s Healthcare of Atlanta 8
9 Children s Healthcare of Atlanta 9
10 Transient Neonatal Pustular Melanosis Benign, self-limited, idiopathic rash at birth Mainly African American infants Vesicles, pustules rupture quickly leaving pigmented macules Children s Healthcare of Atlanta 10
11 Children s Healthcare of Atlanta 11
12 Neonatal Herpes Simplex Virus Most caused by HSV type 2 3 forms: 1. SEM: skin, eyes, mouth 2. Disseminated: affects organs (e.g., liver) 3. CNS: encephalitis Manifestations generally occur at 1-3 weeks Children s Healthcare of Atlanta 12
13 Diaper Dermatitis Children s Healthcare of Atlanta 13
14 Diaper Dermatitis Candidal: Beefy red plaques, satellite papules, superficial pustules In the skin folds Antifungal topical agents (nystatin, miconazole BID/TID) Children s Healthcare of Atlanta 14
15 Diaper Dermatitis Perianal Strep: GroupAStrep Sharply demarcated, painful/pruritic, erythematous, perianal rash NO satellite lesions TX: Amoxicillin (40mg/kg div BID x 10d) Children s Healthcare of Atlanta 15
16 Children s Healthcare of Atlanta 16
17 Scabies Itch mite, highly contagious Finger webs, wrist flexor, elbow and knee extensor surfaces, genital region, axillary region 5% Permethrin cream x 2 applications 1-2 weeks apart Children s Healthcare of Atlanta 17
18 Children s Healthcare of Atlanta 18
19 Pityriasis Rosea Herald Patch (50-90% of cases) followed by smaller daughter patches that follow skin lines Christmas tree pattern Pruritic No tx needed, lasts 6-8 weeks Children s Healthcare of Atlanta 19
20 Children s Healthcare of Atlanta 20
21 Eczema (atopic dermatitis) Chronic inflammatory skin condition Family hx common Pruritic, red, scaly, crusted Infants: face, extensor surfaces Older: flexural distribution TX: Skin Hydration Topical steroids PO in severe cases Children s Healthcare of Atlanta 21
22 Children s Healthcare of Atlanta 22
23 Eczema herpeticum Skin that is affected by eczema comes into contact with the herpes virus It is most often caused by contact with a cold sore (HSV-1) Herpetic keratitis - infection in the cornea of the eye Treatment: Acyclovir, possible hospitalization Children s Healthcare of Atlanta 23
24 Children s Healthcare of Atlanta 24
25 Herpetic Infections: Varicella Chicken Pox Fever, malaise, pharyngitis, anorexia Generalized vesicular rash, pruritic CROPS of lesions in VARYING stages TX: Antihistamines, Tylenol Acyclovir (20mg/kg PO QID within 24 hrs of rash in severe presentations) Children s Healthcare of Atlanta 25
26 ,... J'.&.n..A. Children's Healthcare of Atlanta Dedicated to All Better
27 Herpetic Infections: Shingles Reactivation of latent Varicella within sensory ganglia Unilateral, painful, dermatomal distribution Prodromal pain/burning sensation TX: w/in 72hrs valacyclovir 1000mg TID Children s Healthcare of Atlanta 27
28 Children s Healthcare of Atlanta 28
29 Impetigo likely to develop when their skin is already irritated by another problem, such as eczema, poison ivy, insect bites two types: non-bullous (crusted) and bullous (large blisters) Staph, Strep treated with antibiotics Children s Healthcare of Atlanta 29
30 Children s Healthcare of Atlanta 30
31 Coxsackie: Hand, Foot, Mouth Painful red lesions, high fever, drooling, flu-like illness Most commonly kids under 5 yo TX: Supportive care Children s Healthcare of Atlanta 31
32 Children s Healthcare of Atlanta 32
33 Parvovirus B19 Fifth disease, Erythema Infectiosum Fever, coryza, headache Rash 2-5 days after fever onset slapped cheeks Children s Healthcare of Atlanta 33
34 Roseola (HHV): Sixth disease 6months 2yrs 3-5 days HIGH fever Abrupt resolution Followed by rash neck/trunk predominantly Children s Healthcare of Atlanta 34
35 15 yo female presents with fever, vomiting, myalgia, and confusion. Vitals: hypotension Labs: - elevated LFTS and Creatinine -thrombocytopenia Children s Healthcare of Atlanta 35
36 Toxic Shock Syndrome Etiology: Staph aureus, Grp A Strep Desquamation 1-2 weeks post onset TX: Supportive care Clindamycin + Vancomycin Children s Healthcare of Atlanta 36
37 Children s Healthcare of Atlanta 37
38 Meningococcemia Neisseria meningitides Bacteremia and/or meningitis Nonspecific prodrome >> Non blanching, petechial rash Often to trunk and legs first, rapid progression Treatment: Supportive care, 3rd generation cephalosporins Children s Healthcare of Atlanta 38
39 Children s Healthcare of Atlanta 39
40 Staph Scalded Skin Syndrome Exfoliative toxins spread hematogenously Typically < 6 years of age Fever, malaise Painful erythroderma >> blisters >> sheets of peeling skin (Nikolsky sign) Spares mucosal membranes TX: Staph coverage (Clinda for inhib of endotoxin production) Fluids/supportive care Children s Healthcare of Atlanta 40
41 ... J'.& n... ".A. Children's'" Healthcare of Atlanta Dedicated to All Better
42 Erythema Multiforme Target lesions Etiology: Idiopathic Infections (HSV, Mycoplasma) Medications (Sulfa, anticonvulsants) EM minor - no mucosal involvement EM major (not Steven-Johnson) one or more mucous membranes Children s Healthcare of Atlanta 42
43 Children s Healthcare of Atlanta 43
44 Stevens Johnson Syndrome Minor form of Toxic Epidermal Necrolysis (TEN) with < 10% BSA detachment Etiology: idiopathic, infections (EBV), drugs (antibiotics) Prodrome: cough, HA, malaise, fever Rash: erythematous/purpuric macule or targets, painful, blistering, sloughing Mucosal involvement, eye complications Treatment: Supportive, ocular therapy Children s Healthcare of Atlanta 44
45 Children s Healthcare of Atlanta 45
46 Toxic Epidermal Necrolysis (TEN) Widespread blisters predominant on the trunk and face, presenting with erythematous or pruritic macules and one or more mucous membrane erosions Epidermal detachment < 10% TBSA for Steven- Johnson Syndrome Epidermal detachment of > 30% TBSA for TEN Overlapping SJS/TEN for 10-30% TBSA Children s Healthcare of Atlanta 46
47 'r.., I
48 Urticaria Pruritic, erythematous plaque, raised, often with central pallor Waxes and wanes TX: Removal of offending agent, benadryl, steroids Children s Healthcare of Atlanta 48
49 Children s Healthcare of Atlanta 49
50 HSP (IgA vasculitis) Self limited, 3-15yo Palpable purpura Normal PLT count, normal coags Arthritis/arthralgia Abdominal Pain Increased incidence intussusception Renal disease CBC, BMP, UA, +/- abd US TX: supportive care, NSAIDS for pain, +/- steroids Children s Healthcare of Atlanta 50
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54 Kawasaki disease Symptoms: Fever >39.4C > 5 days Conjunctival injection Mucous membranes Extremity changes Erythroderma Cervical nodes TX: Hospitalization IVIG 2gm/kg Aspirin 100mg/kg/day Children s Healthcare of Atlanta 54
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58 RMSF Dog, wood tick Maculopapular rash 2-4 days after fever onset Palms and soles; starts wrists and ankles Low Na, elev LFTs, thrombocytopenia TX: Doxycycline Children s Healthcare of Atlanta 58
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60 Erythema Migrans Lyme Disease B. burgdorferi Early manifestation Bells Palsy, Arthritis, Carditis TX: Doxycycline (under 8yo may consider Amoxicillin if no concern for RMSF) Children s Healthcare of Atlanta 60
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63 Brown Recluse Children s Healthcare of Atlanta 63
64 Children s Healthcare of Atlanta 64
65 Neonatal Mastitis Staph aureus in most cases Usually full-term, < 2 months of age Over 50% with an abscess Antibiotic choices dependent on severity/ complications, gram stain Children s Healthcare of Atlanta 65
66 Children s Healthcare of Atlanta 66
67 Omphalitis Most are polymicrobial Mean age 5-9 days Complications: necrotizing fasciitis, myonecrosis, sepsis Treatment: Vancomycin, aminoglycoside Children s Healthcare of Atlanta 67
68 Children s Healthcare of Atlanta 68
69 Umbilical granuloma Scar tissue develops once cord falls off May develop if cord on for more than a few weeks Drainage may be present Treatment: silver nitrate Children s Healthcare of Atlanta 69
70 Child Abuse >1 million substantiated cases/year Estimated that 2-5 cases go unsubstantiated for every one proven 2,000 deaths/year 18,000 permanently disabled/year 150,000 serious injuries/year Leading cause of trauma-related death <4 years of age Children s Healthcare of Atlanta 70
71 General Characteristics of Child Abuse Injury inconsistent with history or child development Changing or evolving history Delay in seeking care Inappropriate affect of caregiver Children s Healthcare of Atlanta 71
72 Physical Findings of Abuse Bruises in unusual number, location, pattern Burn characteristics Orthopedic injuries (multiple injuries of different ages) Retinal hemorrhages Intracranial hemorrhages Children s Healthcare of Atlanta 72
73 Bruises Most common physical finding in cases of abuse Present in >90% of abuse cases Normal bruises: 1. Bony prominences (shins/elbows/chin/forehead) 2. Ambulatory children 3. No patterns Children s Healthcare of Atlanta 73
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77 Belt
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80 Concerning Fractures Classic Metaphyseal Fractures (CMFs) Spiral fractures Rib fractures Skull fractures associated with intracranial bleed Multiple fractures and in various stages of healing Children s Healthcare of Atlanta 80
81 Classic Metaphyseal Fractures Corner or bucket handle fractures Children s Healthcare of Atlanta 81
82 Spiral Fracture Children s Healthcare of Atlanta 82
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86 Children s Healthcare of Atlanta 86
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88 Children s Healthcare of Atlanta 88
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90 Pattern Burns 90
91 ( p q q o so o 10 so o ioo 11o m
92 Scald Burns Accidental Consistent with history and developmental level Scalds should flow Asymmetric, often splash Inflicted Patterns more definite Linear circumferential burns without splash marks consistent thickness burns Other stigmata of abuse Children s Healthcare of Atlanta 92
93 Physical findings INFLICTED ACCIDENTAL Sparing Symmetry Solid Withdrawal Asymmetry Splash, Flow Children s Healthcare of Atlanta 93
94 Sparing Children s Healthcare of Atlanta 94
95 Withdrawal Signs of motion No pattern Random, hard to reproduce Asymmetry Children s Healthcare of Atlanta 95
96 Symmetry Children s Healthcare of Atlanta 96
97 Splash, flow Line of flow with variable thickness Children s Healthcare of Atlanta 97
98 Variable depth - partial thickness to first Reproducible with flowing liquid Sparing not always from flexion Children s Healthcare of Atlanta 98
99 Children s Healthcare of Atlanta 99
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THE PATIENT PRESENTS WITH
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DEFINITION Impetigo vulgaris is a highly contagious, superficial bacterial infection of the skin.
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