MIDTERM STUDY GUIDE: PART-1

 

            TOPICS Covered

• Chalazions
• Blepharitis
• Conjunctivitis
• Hand-foot-mouth syndrome
• Strep pharyngitis
• Kawasaki disease
• Rheumatic fever
• Milia
• Port-wine stain/Nevus flammeus
• Salmon patch
• Café-au lait spot
• Impetigo
• Molluscum Contagiosum
• Verruca Vulgaris
• Herpetic Whitlow

 

CHALAZIONS – Benign, chronic lipogranulomatous inflammation of the eyelid

 

Causes – blockage of the meibomian cyst

 

Risk – hordeolum or any condition which may impede flow through the meibomian gland. Also mite species that reside in lash follicles

 

Assessment – PAINLESS, NOT INVOLVING LASHES

Lid edema, or palpable mass

Red or grey mass on the inner aspect of lid margin

 

Prevention – good eye hygiene

 

Treatment – warm, moist compresses 3x per day

Antibiotics not indicated because chalazion is granulomatous condition, if secondarily infected consider SULFACETAMIDE, ERYTHROMYCIN

 

Follow up – 2-4 weeks, if still present after 6 weeks follow up with ophthalmologist

 

BLEPHARITIS – Inflamation/infection of the lid margins (chronic problem)

 

 

 

2 types – seborrheic (non ulcerative) : irritants (smoke, make up, chemicals)

s&s – chronic inflammation of the eyelid, erythema, greasy scaling of anterior eyelid, loss of eyelashes, seborrhea dermatitis of eyebrows and scalp

 

                   Ulcerative– infection with staphylococcus or streptococcus

s&s – itching, tearing, recurrent styes, chalazia, photophobia, small ulceration at eyelid margin, broken or absent eyelashes

• the most frequent complaint is ongoing eye irritation and conjunctiva redness

 

Treatment – clean with baby shampoo 2-4 times a day, warm compresses, lid massage (right after warm compress)

 

For infected eyelids – antistaphyloccocal antibiotics BACITRACIN, ERYTHROMYCIN 0.05% for 1 week AND QUIONOLONE OINTMENTS

 

For infection resistant to topical – TETRACYCLINE 250 MG PO X4

DOXYCYCLINE 100 MG PO X2

 

CONJUCTIVITIS – inflammation or irritation of conjuctiva

 

Bacterial (PINK EYE) – in peds bacteria is the mosts common cause, contact lens, rubbing eyes, trauma,

S&S – purulent exudate, initially unilateral, then bilateral

Sensation of having foreign body in the eye is common

Key findings – redness, yellow green, puru,ent discharge, crust and matted eyelids in am

Self limiting 5-7 days. Eye drops – polytrim, erythromycin, tobramycin or cipro

Improvement 2-4 days

Most common organism H. influenza <7

 

Viral – adenovirus, coxsackie virus, herpes, molluscum

S&S – profuse tearing, mucous discharge, burning, concurrent URI, enlarged or tender preauricular nose

Antihistamines/decongestant

Improvement, self limiting, 7-14 days

 

Chlamydial – chlamydia trachomatis

S&S – profuse exudate, associated with genitourinary symptoms, 1-2 weeks after birth

Gonococcal – 2-4 days after birth, most concern can cause blidness

PO azithromycin, doxycycline (tetracyclines increase photosensitivity, don’t use in pregnancy)

Improvement 2-3 weeks

 

Allergic – IgE mast cell reaction, environmental, cosmetics

S&S – marked conjuctival edema, severe itching, tearing, sneezing

Topical antihistamine or topical steroids

Improvement 2-3 days

 

Chemical –thimerosal, erythromycin, silver nitrate

S&S conjuctival erythema, 30 minutes afer prophylactic antibiotics drops

Avoid contact

Can consider steroids

Conjunctivitis never accompany vision changes

 

Diagnostic studies: swap and scraping must be done, gram and Giemsa staining, ELISA, PCR testing, newborn < 2 weeks needs to be tested for gonorrhea

 

Non –pharm – clean towels, change pillows, warm compress, no contacts, no eye make up – mascara

Gonococcal conjunctivitis: newborn – give Ceftriaaxone IM once (don’t give if hyperbilirubinemia,

 

Non-gonococcal – erythromycin 0.5% ointment

Consider fluorescein staining if abrasion suspected

 

CDC recommends prophylactic administration of antibiotic eye ointment (ERYTHROMYCIN) 1 hour after delivery

 

Refer to ophthalmologist if herpes, hemorrhagic conjunctivitis or ulcerations present

May return to work/school 24 hours after topical

 

HAND-FOOT-AND-MOUTH DISEASE – HIGHLY CONTAGIOUS, viral illness

 

 

clinical entity evidenced by fever, vesicular eruptions in the oropharynx that may ulcerate and a maculopapular rash involving hands and feet, the rash evolves to vesicles, especially on the dorsa of the hands and feet. Last 1 to 2 weeks.

lesions appear on the buccal mucosa, palate, palms of hands, soles of feet and buttocs

 

most common cause – COXSACKIE A 16

common in children <5

 

S&S – low grade fever, malaise, abdominal pain, enlarged anterior cervical nodes or submandibular

Oral – small red papules on the tongue and buccal mucosa, which will progress to ulcerative vesicles

EXANTHEM (papulovesicular) – occurs 1-2 days after oral lesions

 

Differential – herpangina, Stevens- Johnson syndrome

 

Treatment – maintain hydration, cool liquids, avoid spicy food, rest

Topical aluminum hydroxide/ magnesium hydroxide gel with diphenhydramine applied to painful lesions

Topical anesthetics – Kank A, Orabase

 

Resolution with 7 days

 

STREP PHARYNGITIS – An acute inflammation of pharynx/tonsils, associated with crowding (school)

 

rare in children <3

 

Viral – rhinovirus, adenovirus, parainfluenza, Epstein-barr virus

 

Bacterial- group A beta hemolytic streptococcus

 

Risk – family hx of rheumatic fever, day care

 

S&S – sore throat, tonsillar exidate, malaise

 

Strep: cervical adenopathy, fever >102F, no cough or nasal congestion, petechiae on soft palate, “Beefy Red” tonsils, “sandpaper” rash (nose, neck and torso), abdominal pain, headache

 

Suggestive of viral : conjunctivitis, nasal congestion, cough, diarrhea

When cough  – almost always exclude Streptococcus

 

Tests – rapid strep test

CBC: WBC shift to left

Monospot if mono suspected

 

Treatment: gargling with salt water, change toothbrush, incubation period 2-5 days

PCN – one IM or 10 days treatment PO

First generation cephalosporins – 10 days treatment

Azithromycin (if PCN allergy)

 

Consult/referral – evidence of acute renal failure and reddish, tea collared urine (2-3 weeks post infection)

No longer contagious after 24 hours on antibiotics, peak fever on days 2and 3, last 4-10 days

 

KAWASAKI DISEASE (also known as mucocutaneous lymph nodesyndrome or infantile polyarteritis– an acute, febrile, immune-medicated, self-limited disease characterized by vasculitis. Leading cause of acquired heart disease in children

 

 

 

85% <5 years old

most prevalent in Japan

 

S&S

Stage 1 -Acute (1-2 weeks) – high fever 103-105 for at least 5 days unresponsive to antibiotics, oral mucosa lesions may last 1-2 weeks, perineal rash, non-tender cervical adenopathy, painful rash and edema on feet

Diagnosis requires fever for 5 days and 4 of these criteria:

Edema or erythema of hands and feet, conjuctival injection (bilat), cervical adenopathy, rash (non-vesicular and polymorphous), exudative pharyngitis, diffuse oral arythema, STRAWBERRY TONGUE, crusting of lips and mouth

 

Stage 2 – Subacute (2-8 weeks after onset) – without treatment: desquamation of palms, feet, periungual area, coronary artery aneurysm, joint aches and pains, acute MI may be seen, Pancardidis, diarrhea, jaundice, hepatosplenomagaly, platelet couns >10, 000 000 per mm

 

Stage 3 – Convalescent – clinical signs have resolved, completed when all lab values are normal, however nail changes include Beau lines (deep transverse grooves across the nails)

 

It is a fatal disease in small % of children who develop coronary artery problems despite treatment

 

Differentials:

Group A strep: scarlet fever

Measles

Epstein barr

Toxic shock

Rocky mountain spotted fever

Steven-johnson syndrome

Juvenile RA

 

Tests: based on S&S and diff

CBC, anemia, platelets 50% > 450 000

ESR >100

C-reactive protein

EKG – prolonged PR intervals, decrease QRS

Chest Xray – dilated heart, pleural effusion

Pyuria/mild proteinuria

 

Pharmacology

IVIG single dose of 2g/kg for over 12 hours in the first 10 days

Aspirin 80-100 mg/kg/d in 4 doses (Reye’s syndrome)

 

Complications

MI

Development and rupture of coronary artery aneurysm may lead to emboli, HF, heart valve problems, dysrhythmias, myocarditis

 

RHEUMATIC FEVER – An inflammatory disease that develops in 1-3% of children who have untreated infection with group A strep (GAS). This can affect the heart, blood vessels, joints , skin, CNS, connective tissues

 

 

S&S – hx of pharyngitis 2-4 weeks prior onset of symptoms.

Modified Jones criteria used to diagnose patient:

2 major, or 1 major and 2 minor criteria must be presented as evidence

 

Major – carditis: 65% have with murmurs

Polyarthritis:75%

Chorea: 15%

Erythema marginatum (macular rash with erythematous border

Subcutaneous nodules

 

Minor

Fever 101-104F

Artharlgias

Elevated ESR, C-reactive protein

Prolonged PR intervals on EKG

 

Tests: throat cultures, negative antigen test

ESR, C-reactive protein

ASO tites

EKG

Chest xray

CBC

 

Treatment: first line PCN, if allergic Azithromycin

Prednisone

Aspirin

AHA 2010 no longer recommends prophylaxis treatment for endocarditis in those with rheumatic fever

 

PEDIATRIC BENIGN SKIN LESIONS

 

MILIA (superficials cysts filled with keratin)

 – white papules found on the forehead, face, chin, and cheeks of infants, 1-2 mm in size, disappear few weeks after birth, may appear on palate – EPSTEIN’S PEARLS’S

 

 

PORT-WINE STAIN (Nevus flammeus) – permanent defect that grows with child, if forehead and eyelids are involved, there is potential for multiple symptoms, includidng Sturge-Weber, Klippel-Trenaunay-Weber and Parkes Weber.

Flat port wine stain- dark red to deep purple lesions present at birth, frequently found on face, do not fade with time

 

SALMON PATCH – fade with time, usually by 5 or 6 years old, no treatment needed.

 

Salmon patches (called a “stork bite” at the back of the neck or an “angel’s kiss” between the eyes) are simple nests of blood vessels (probably caused by maternal hormones) that fade on their own after a few weeks or months. Occasionally stork bites never go away.

 

CAFÉ AU LAIT SPOT – smooth, regular borders,

Child > 5, 6 or more , >1.5 cm  – possible Von Recklinghausen’s disease (90 -100%) *LEOPARD syndrome (Lentigines, Electrographic abnormalities, Ocular hypertelorism, Pulmonary stenosis, Abnormalities of genitalia, Retardation of growth, Deafness

In child <5 years, 5 or more , 0.5 cm suggests neurofibromatosis

Smaller 1-4 cm in diameter I axillae ( axillary freckling or Crow’s sign) rare but diagnostic sign of neurofibromatosis

 

 

HEMANGIOMA – (dilation of capillaries) – raised, cavernous: appear bluish, located deep beneath the skin, NOT present at birth, appear within a few month and then disappear before the end of first decade of life.

Capillary- STRAWBERRY hemangiomas : bright red vascular overgrowth, elevated, vary in size

Possible steroids

 

 

IMPETIGO – Superficial infection of the skin which begins as small superficial vesicles which rupture and form honey colored crust

2- 5 years

 

 

Bullous – is caused by Staphyloccocus aureus or group A strep

 

Non – Bullous – MRSA

1-2 mm vesicles which rupture and form honey colored crusts, weeping shallow red ulcer

common on mouth, face, nose, or site of insect bites

fluid filled vesicles <0.5 cm appear as red macules and papules or pustules

regional lymphadenopathy

 

Treatment: good hygiene, hand washing

 

Mupirocin (Bactroban) topical – 3x a day, don’t use <2 month

 

Retapamulin (Altabax) – >9 months, apply thin film 2 x a day

 

For large area- first generation cephalosporin, if unable to use PCN, consider macrolide

 

Resolve within 7-10 days

MOLLUSCUM CONTAGIOSUM

 

 

Molluscum contagiosum is an infection caused by a poxvirus (molluscum contagiosum virus). The result of the infection is usually a benign, mild skin disease characterized by lesions (growths) that may appear anywhere on the body. Within 6-12 months, Molluscum contagiosum typically resolves without scarring but may take as long as 4 years.

The lesions, known as Mollusca, are small, raised, and usually white, pink, or flesh-colored with a dimple or pit in the center. They often have a pearly appearance. They’re usually smooth and firm. In most people, the lesions range from about the size of a pinhead to as large as a pencil eraser (2 to 5 millimeters in diameter). They may become itchy, sore, red, and/or swollen.

Mollusca may occur anywhere on the body including the face, neck, arms, legs, abdomen, and genital area, alone or in groups. The lesions are rarely found on the palms of the hands or the soles of the feet.

The virus that causes molluscum spreads from direct person-to-person physical contact and through contaminated fomites. Fomites are inanimate objects that can become contaminated with virus; in the instance of molluscum contagiosum this can include linens such as clothing and towels, bathing sponges, pool equipment, and toys. Although the virus might be spread by sharing swimming pools, baths, saunas, or other wet and warm environments, this has not been proven.

 

TREATMENT- Because molluscum contagiosum is self-limited in healthy individuals, treatment may be unnecessary. Nonetheless, issues such as lesion visibility, underlying atopic disease, and the desire to prevent transmission may prompt therapy. Other options for topical therapy include iodine and salicylic acid, potassium hydroxide, tretinoin, cantharidin

 

VERRUCA VULGARIS – WART

 

painless, benign skin tumors which are viral and can be transmitted by touch

HPV 6 or 11

Common wart – rough surface, elevated, flesh-colored papules

Avoid contact with wart exudate from self

 

Treatment- paring and debridement of wart prior to any treatment

Soak in warm water, occlude with waterproof tape for 1 week and leave open to air for 8-12 hours, then reocclude for 1 week

 

Topical Duofil, Oclussal Hp must be applied up to 12 weeks

 

CRYOTHERAPY with liquid nitrogen ( 5 second freeze until an ice ball forms

 

Warts resistant to treatment – biopsy

 

                                          Herpetic Whitlow

• occurring on a finger or thumb, is a swollen, painful lesion with an erythematous base and ulceration resembling a paronychia.
• It occurs on fingers of thumb-sucking children with gingivostomatitis or adolescents with genital HSV infection.
• Lesions occur in children of all ages, are contagious as long as they are present, and have an incubation period of 2 to 12 days.
• Primary lesions usually occur before 5 years old, are more painful and extensive, and last longer.

S&S

• primary herpes, fever, malaise, sore throat, and decreased fluid intake
• Deep-appearing vesicles on fingers

Diagnostic Studies

• A Tzanck smear can be done on fluid from the lesions to identify epidermal giant cells, but does not distinguish HSV-1 from HSV-2.
• Viral cultures are the gold standard for definitive diagnosis.
• Direct fluorescent antibody (DFA) tests, enzyme-linked immunosorbent assay (ELISA) serology, and polymerase chain reaction (PCR) tests are usually only used with severe forms of HSV infection.

Management

• Burrow solution compresses three times a day to alleviate discomfort
• Oral acyclovir 200 mg five times a day for 5 to 10 days may speed healing of herpetic whitlow
• Antibiotics for secondary bacterial (usually staphylococcal) infection:
• Offer supportive care, such as antipyretics, analgesics, hydration, and good oral hygiene
• Recurrent, frequent, and severe HSV infection may be treated with acyclovir prophylaxis for 6 months.