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
Objectives Identify common pediatric rashes Identify signs of child abuse Identify common illnesses using radiographs and other imaging Children s Healthcare of Atlanta 4
Infant rashes Children s Healthcare of Atlanta 5
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
Children s Healthcare of Atlanta 7
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
Children s Healthcare of Atlanta 9
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
Children s Healthcare of Atlanta 11
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
Diaper Dermatitis Children s Healthcare of Atlanta 13
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
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
Children s Healthcare of Atlanta 16
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
Children s Healthcare of Atlanta 18
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
Children s Healthcare of Atlanta 20
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
Children s Healthcare of Atlanta 22
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
Children s Healthcare of Atlanta 24
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
,... J'.&.n..A. Children's Healthcare of Atlanta Dedicated to All Better
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
Children s Healthcare of Atlanta 28
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
Children s Healthcare of Atlanta 30
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
Children s Healthcare of Atlanta 32
Parvovirus B19 Fifth disease, Erythema Infectiosum Fever, coryza, headache Rash 2-5 days after fever onset slapped cheeks Children s Healthcare of Atlanta 33
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
15 yo female presents with fever, vomiting, myalgia, and confusion. Vitals: hypotension Labs: - elevated LFTS and Creatinine -thrombocytopenia Children s Healthcare of Atlanta 35
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
Children s Healthcare of Atlanta 37
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
Children s Healthcare of Atlanta 39
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
... J'.& n... ".A. Children's'" Healthcare of Atlanta Dedicated to All Better
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
Children s Healthcare of Atlanta 43
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
Children s Healthcare of Atlanta 45
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
'r.., I
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
Children s Healthcare of Atlanta 49
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
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
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
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
Brown Recluse Children s Healthcare of Atlanta 63
Children s Healthcare of Atlanta 64
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
Children s Healthcare of Atlanta 66
Omphalitis Most are polymicrobial Mean age 5-9 days Complications: necrotizing fasciitis, myonecrosis, sepsis Treatment: Vancomycin, aminoglycoside Children s Healthcare of Atlanta 67
Children s Healthcare of Atlanta 68
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
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
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
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
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
Belt
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
Classic Metaphyseal Fractures Corner or bucket handle fractures Children s Healthcare of Atlanta 81
Spiral Fracture Children s Healthcare of Atlanta 82
Children s Healthcare of Atlanta 86
Children s Healthcare of Atlanta 88
Pattern Burns 90
(1111111111111111111p1111111111111111111111111111111111111q1111111111111111111111111111q111111111111111111111111111111 10 o 30 40 so o 10 so o ioo 11o m
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
Physical findings INFLICTED ACCIDENTAL Sparing Symmetry Solid Withdrawal Asymmetry Splash, Flow Children s Healthcare of Atlanta 93
Sparing Children s Healthcare of Atlanta 94
Withdrawal Signs of motion No pattern Random, hard to reproduce Asymmetry Children s Healthcare of Atlanta 95
Symmetry Children s Healthcare of Atlanta 96
Splash, flow Line of flow with variable thickness Children s Healthcare of Atlanta 97
Variable depth - partial thickness to first Reproducible with flowing liquid Sparing not always from flexion Children s Healthcare of Atlanta 98
Children s Healthcare of Atlanta 99