On fever with rash

Apatient with streptococcal pharyngitis developstender red bumps along her entire tibia.What is the most likely diagnosis?

(1)

(A) sarcoidosis(B) cellulitis(C) thrombophlebitis(D) insect bites(E) erythema nodosum

(E) The patient most likely has erythemanodosum, which is characterized by pretibial tender erythematous nodules. Common infectious diseases that have been associated with erythema nodosum are

streptococcal pharyngitis,tuberculosis, and other infectious diseases due to Yersinia, histoplasmosis, and coccidioidomycosis

Other associated noninfectious diseases are inflammatory bowel disease, sarcoidosis,and spondyloarthropathy. (Behrman, 794)

You are called to the newborn nursery to see a 3-day-old that has a rash. The parents are concerned because they did not notice the rash until this morning and are sure that it was not present the first 2 days of life. You find a well-appearingbaby who has scattered red papules all over the body and are in clumps on the cheeks and on the trunk, some of them even look like vesicles. You take a scraping of one of the vesicles to examine under the microscope and find that these vesiclescontain a large number of eosinophils. What is the recommended treatment for this patient?

(A) acyclovir(B) topical steroids(C) antidandruff shampoo(D) phototherapy(E) observation

(2)

(E) Careful examination, close observation, and reliable follow-up represent an importantapproach to many pediatric complaints. Thiscase describes erythema toxicum neonatorumwhich is a benign rash of the neonate that isself-resolving and requires no treatment (E).

The rash typically starts out as papules of 2–3 mm in diameter and progresses to vesicles and then resolves over 2 weeks. The vesicles are noted to contain a large number of eosinophils when looked at under a microscope. Acyclovir (A) is the treatment for cutaneous herpes simplex infection,this patient’s history and microscopic findingsare not consistent with this diagnosis.

Topical steroids are often used for eczema and atopic dermatitis (B). Antidandruff shampoo is the first-line treatment for seborrhea (cradle cap).Phototherapy is the first-line treatment for hyperbilirubinemia(D). (McMillan, 461)

(3)

rose spots typhoid

(4)

erythema marginatum rheumatic fever

(5)

(6)

(7)impetigo-contagiosa

(8)herpes simplex

A 4-year-old male presents with a 1-day historyof abdominal pain and vomiting.

He is afebrile and has no diarrhea. He complains of knee pain bilaterally, and there is some tenderness of the knee joints but no effusions.Within 24 hours he develops a rash on his legs and buttocks which is petechial and purpuric,and his platelet count is normal. What is themost likely diagnosis?

(A) hemolytic uremic syndrome(B) Henoch-Schِnlein purpura(C) acute glomerulonephritis(D) Kawasaki disease(E) systemic lupus erythematosis

(9)

(B) The most common form of systemic vasculitis in childhood is Henoch-Schِnlein purpura.

The most consistent sign is the presence of the purpuric rash on the lower extremities. Unfortunately, this rash does not necessarily develop at the beginning of the illness.

Frequently a child is evaluated for arthritis or abdominal pain for 1–2 days before the onset of the rash makes the diagnosis apparent.

The renal disease associated with HSP typically is variable, with most children having complete recovery. However, 3–4% of children will developend-stage renal disease. (Rudolph CD, 842,1689)

A 3-year-old girl is seen in the emergency department for bruising. Her family denies fever or weight loss but states she had a “cold” 3 weeks ago. She isafebrile and the remaining vital signs are normal. She is happy and playful and has generalized ecchymoses and petechiae.

1. What should be the first test you obtain?(A) bone marrow aspirate(B) Neiserria meningitidis latex assay of the cerebrospinal fluid(C) Rickettsia rickettsiae serology(D) skeletal survey looking for healing fractures(E) complete blood count and differential

2. The laboratory results return and the platelets are 10,000/mm3. A bone marrow aspirate demonstrates increased megakaryocytes but is otherwisenormal. Which of the following is an indication for WinRho (anti-RhoD antibodies)?(A) platelet count less than 100,000/mm3(B) fever greater than 39°C(C) splenomegaly(D) epistaxis(E) bone marrow with megakaryocyte hypoplasia

(9)

(E) In a well-appearing child with a recent viral illness and without fever, toxicity, or systemic signs of illness who presents with unexplained petechiae and ecchymoses, (ITP) is the most likely diagnosis. Acomplete blood count is indicated to establish the presence of thrombocytopenia and assess the other cell lines.

When other cell lines are affected, a bone marrow may be needed to rule out leukemia and other hematologic disorders.

Trauma presenting only with generalized petechiae would be rare. Rickettsial or neisserial infections can cause petechiae but most affected patients have other symptoms. (Rudolph CD,1556–1557)

(D) The presence of isolated thrombocytopenia and increased megakaryocytes on bone marrow examination establishes the diagnosis of idiopathic thrombocytopenic purpura.

If examination of the bone marrow reveals a lack of megakaryocytes, the diagnosis is not ITP and other causes of thrombocytopenia should be pursued. Several treatment options for ITP exist,including simple observation.

Corticosteroids, intravenous immunoglobulin, and anti-Rho antibodies have all been used with success.Indications for treatment include evidence of bleeding, thrombocytopenia less than 50,000, or prolonged thrombocytopenia. The presence of fever is not relevant to the treatment decision.

The mechanism of action of anti-Rho antibodies is uncertain. However, it is thought that reticuloendothelial Fc receptor blockade is involved.This type of therapy will only be effective in patients that are Rh-positive. (Rudolph CD, 1556–1557)

erysipelas