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.