Red Stick ID Visual Diagnosis Questions August 22, 2014 James H. Brien, DO
Case #1 The setting is a Pediatric Clinic in San Antonio, Texas on a Saturday in 1989. However, it could have been yesterday in many places around the world, including here.
12-Year-Old Female 5-day Hx of worsening fever, cough, nasal congestion (coryza) and conjunctivitis & 1-day Hx of rash. No Hx of N/V/D, joint pain, or sore throat and is on no medications. Family Hx is unremarkable. Immunizations are up to date (1989).
12-Year-Old Female Examination Temp = 104 F Nasal congestion. Conjunctival injection with mild discharge. Has a dry cough with clear breath sounds. Maculopapular rash as shown:
Pathognomonic Hint
12-Year-Old Female Lab Tests CBC Urinalysis Quick group A strep test Chest radiograph All normal or negative
What s Her Diagnosis? A. Rubeola (1 st disease) B. Strep. scarlet fever (2 nd disease) C. Rubella (3 rd disease) D. Filitov-Dukes disease (4 th disease) E. Erythema infectiosum (5 th disease) F. Roseola (6 th disease)
Case #2 Thanks to Roberto P. Santos, M.D. Pediatric Infectious Diseases Albany Medical Center Albany, New York
4-Year-Old Male To primary for evaluation of lesions on his cheek, hand and flank area. First noticed on face and hand while visiting relatives in Iran several weeks earlier. Treated locally with cryotherapy without much improvement returned to U.S. PMHx previously healthy; no prior skin problems or sick contacts.
Exam positive only for: - crusting, ulcerative lesions on face,
Exam positive only for: - crusting, ulcerative lesions on face, hand,
Exam positive only for: - crusting, ulcerative lesions on face, hand, and right flank.
What s Your Diagnosis? A. New World Cutaneous Leishmaniasis B. Cutaneous Myiasis C. Old World Leishmaniasis D. Leprosy
Case #3
18-Month-Old Male C/O right-sided facial swelling. Onset 2 weeks ago and progressive. Denies fever or pain. Was observed without treatment. 2-weeks later, fever of 102 F. Swelling more discrete 3 X 2 cm lump.
18-Month-Old Male Treated 10 days with Azithromycin for presumed Cat Scratch Disease. Not better and referred to ENT who ordered a CT scan.
18-Month-Old Male Fine-needle aspiration specimen cultured for bacteria, fungi and AFB organisms. Stains were all negative. Histopathology necrotic granulomatous lymphadenitis. PMHx unremarkable no wt. loss no sick contacts.
18-Month-Old Male 3-weeks later (2-mo after onset) culture reported positive. Sent to Ped. ID Clinic. Exam: Normal VS Normal exam except for large, fluctuant, suppurative neck mass.
What s Your Diagnosis A. Bartonella henselae B. Mycobacteria avium-intracellularae C. Staphylococcus aureus D. Mycobacteria tuberculosis
Case #4 A Case I Had Not Seen in over 30 years.
3-Week-Old Male Neonate CC Admitted for fever and rash. HPI: Previously well when on the day PTA, began having a rash. Was seen by primary that afternoon, who saw some erythema about the lips, but focused on his fussiness with feeding, and Dx with reflux and Rx ranitidine (zantac ).
3-Week-Old Male Neonate CC Admitted for fever and rash. HPI: Perioral erythema was Rx mupirocin (Bactroban ) TID, with next day follow-up arranged. The baby was fussy all night, and was taken to the ER in the early morning, where he was 103 F, and cultures were done and admitted.
3-Week-Old Male Neonate CC Admitted for fever and rash. PMHx: Term uncomplicated P, L and SV Delivery. Prenatal testing was NL. Review of Systems: Fever, fussiness and the rash. Rest was normal.
3-Week-Old Male Neonate CC Admitted for fever and rash. PMHx: Immunizations: Hep B #1 in NSY. Allergies: none. Medications: none preceding CC.
3-Week-Old Male Neonate CC Admitted for fever and rash. Family Hx: Unremarkable, with no sick contacts. No travel. No animal contact or insect bites.
3-Week-Old Male Neonate CC Admitted for fever and rash. Examination: VS: T = 99.6 F, RR = 48, Pulse = 170. General Alert and active, but very irritable when picked up or handled, even by mother.
3-Week-Old Male Neonate CC Admitted for fever and rash. Examination: Rest is positive only for bright red skin from head to foot, with some redundant skin from ruptured blisters and mild nasal congestion / drainage. All mucous membranes are clear.
3-Week-Old Male Neonate Lab Tests: CBC = WNL CRP = 4.8 mg/l CMP = WNL UA = WNL BC, UC, Nasal culture pending. Imaging: None.
3-Week-Old Male Neonate Summary of pertinent findings Previously healthy neonate with sudden-onset of fever and rapidly progressive, painful, blistering rash. Blisters very flaccid & rapidly rupture. No previous medications given. Nasal congestion & discharge. Clear mucous membranes.
What s Your Diagnosis? A. Lyell Disease B. Kawasaki Disease C. Stevens-Johnson Syndrome D. Ritter Disease
Case #5
32-Week Preterm Newborn Female Prolonged ROM with C-S delivery due to failure to progress. Maternal fever with chorioamnionitis. Pregnancy and PMHx normal. Prenatal screening all negative. No Hx of STI s (STD S), including herpes. Examination of baby was normal. BC sent and Amp + Gent started.
32-Week Preterm Newborn Female Baby did well till 5-days of age: Noted some blistering sores on her low back as shown - - -
What s Your Diagnosis? A. Neonatal Lupus B. Neonatal Herpes C. Langerhans Cell Histiocytosis D. Neonatal Candidiasis
Case #6
11-Year-Old Male CC Poison Ivy on his Face. HPI: Had been hiking with grandparents, and did see some poison ivy. That evening, his face began to swell with light erythema. The next morning, it was worse with intense pruritis and more erythema, swelling & blisters.
11-Year-Old Male CC Poison Ivy on his Face. HPI: Was taken to primary got steroids; IM, PO & topical, + Benadryl. By that evening, he was worse and taken to the ER and given a dose of injectable antibiotic (because of his past history of Staph infection with poison ivy) and sent for admission.
11-Year-Old Male CC Poison Ivy on his Face. PMHx: Previously healthy, with no significant illnesses or injuries. Did have previous reaction to poison ivy with a Staph infection in past. Immunizations are up to date. No recent injuries.
11-Year-Old Male CC Poison Ivy on his Face. Examination: Vital Signs are normal. Positive for skin findings of patches of erythema with swelling and some vesicles and weeping areas on the face, with similar patches of erythema on neck, and groin. Rest of exam is normal.
What s Your Diagnosis? A. Poison Ivy with 2º Staph cellulitis. B. Poison Ivy dermatitis. C. Sunburn. D. Eczema Herpeticum