Dr. Rafah F. SayyedPEC - Al Sadd, Doha

Q-PEM: Jan 2017

Visual Diagnosis

DISCLOSURE

I do not have any relevant financial

relationship with commercial interest to

disclose.

• Speed and Accuracy of Diagnosis is the key to saving lives in

emergency and critical care medicine.

• Careful Visual Inspection of the Patient, and Related Clues

help providers choose the right diagnosis and ultimately the

best treatment.

Introduction

Objectives

123

4

Clarify the Visual Clues and their

Clinical Significance

Recognize Common Pediatric

Dermatologic Conditions

Learn to Recognize Common Pediatric

Rashes

Learn to Recognize Emergent Rashes

2-yrs old boy previously healthy presented with:

Diffuse rash over bilateral LL for the past 2 days

that is progressing to his trunk and UL

He is otherwise playful and well with no fever

His parents deny new creams, or drug exposures

His parents report mild URTI 1 week ago

Case Presentation 1

Picture Title

Physical Exam:

Multiple diffuse lesions with central clearing

The lesions on palms and soles but are

most prominent on his bilateral LL

No conjunctival injection ,no sores in or

around his mouth or genitalia

Case Presentation 1 – Continued

Picture Title

What is the next most appropriate

management strategy at this time?

A: Obtain complete blood count (CBC) and blood culture, administer

ceftriaxone, and admit for observation

B: Obtain CBC and blood culture, but do not treat with antibiotics

C: Discharge to home with diphenlhydramine as needed for itching

D: Consult dermatology emergently

E: Administer subcutaneous epinephrine immediately

Question:

Picture Title

Answer: “C”Erythema multiform (minor)

EM Hypersensitivity reaction

Lesions - symmetric, palms and soles,

extensor surfaces of the UL&LL

macular, urticarial, or vesicobullous

Prototypical lesion: target lesion with a

dusky center

The rash lasts 1 week - 6 weeks

Patients are asymptomatic, sometimes

itching or involvement of the oral mucosa

Carder KR. Hypersensitivity reactions in neonates and infants. Dermatol Ther 2005;18(2):160–75.

Erythema multiform (minor)

EM The causes of EM: infectious causes, HSV

The DD of EM: pemphigus, urticaria, or other viral exanthema

Treatment: supportive (antihistamines, NSAIDS, steroids)

Evaluate mucosal surfaces to differentiate EM minor or major

EM minor: involves the skin and only one mucosal surface

EM Major (Stevens–Johnson): involves the eye, oral cavity,

genital mucosa, upper airway, or esophagus.

Carder KR. Hypersensitivity reactions in neonates and infants. Dermatol Ther 2005;18(2):160–75.

Case Presentation 2 :

8-years old boy presents to PEC with

Rash for 2 days and an inability to ambulate

due to bilateral ankle pain

Rash began on his legs and is now more

generalized, It is not painful nor pruritic.

Case Presentation 2 :

On Exam:

The child is well with normal vital signs

Lesions are palpable and do not blanch with pressure

The ankles are warm and have minimal periarticular

swelling

The right wrist is painful and warm and swelling.

The rest of the exam is normal

Laboratory tests: Normal CBC, Coag. studies, elect,

and UA, Blood culture is pending.

Case Presentation 2 :

Question:

What would be the next step in managing this patient?

A - Discharge home with close follow-up by the primary

care doctor and anti-inflammatory medications for the

joint pain

B - Admit for observation

C - Admit for intravenous antibiotic therapy

D - Consult orthopedics for an ankle arthrocentesis

E - Administer subcutaneous epinephrine

Answer: “A”Henoch–Schönlein Purpura (HSP)

HSP is benign vasculitic disease of childhood

Over 6 weeks, Relapses ( 16–40%) of patients

Clinical manifestations of HSP

Cutaneous involvement: 100%

Palpable Purpura at LL and rash can involve UL

Joint involvement: 50–80%

Large lower extremity joints

Gastrointestinal involvement: 65–70%

Colicky abd. pain and vomiting, rarely intussusception.

Renal involvement: 20–34%

Microscopic Hematuria, RF in ( 1–5% )

Lanzkowsky S, Lanzkowsky L, Lanzkowsky P. Henoch– Schoenlein purpura. Pediatr Rev 1992;13(4):130–7. 2 Saulsbury FT. Henoch–Schonlein purpura in

children. Report of 100 patients and review of the literature. Medicine 1999;78(6):395–409.

HSP

Henoch–Schönlein Purpura (HSP)

Management:

Supportive care

Weekly BP, U/A throughout the course of disease

2/3 of patients resolve their symptoms within 1mo

No evidence supports use of glucocorticoids for

treatment of abdominal pain.

DD:

meningococcemia, ITP, SBE, HUS.

Lanzkowsky S, Lanzkowsky L, Lanzkowsky P. Henoch– Schoenlein purpura. Pediatr Rev 1992;13(4):130–7. 2 Saulsbury FT. Henoch–Schonlein

purpura in children. Report of 100 patients and review of the literature. Medicine 1999;78(6):395–409.

HSP

Case Presentation-3

2-years old male presented with:

6-day history of fever (38.5°C and more) and

irritability

Rash distributed along his face, trunk,

and flexural surfaces of his extremities

Non-exudative conjunctivitis

dry, cracked, erythematous lips

large (2.0 cm), firm, mobile, tender, left-

sided anterior cervical LN

hands and feet appear edematous.

Case Presentation-3

Question:

Which of the following is associated

with this clinical syndrome?

A: Hemorrhagic gastritis

B: Acute renal failure

C: Intracranial abscess

D: Coronary artery aneurysms

E: Pancytopenia

Answer: “D”Kawasaki disease (KD)

Small and medium vessel vasculitis before age 5.

Common cause of acquired heart disease in children (15–25%)

Etiology remains unknown

Classic diagnosis of KD: ”Warm CREAM”

Need:

Warm: Fever > 5 days

Plus 4 of 5 :

1: Conjunctivitis (bilateral, non purulent)

2: Rash (erythematous and maculopapular)

3: Erythema palms and soles (swelling and peeling)

4: Adenopathy (cervical, unilateral node)

5: Mucous Membrane (dry, cracked, red lips and strawberry tongue)

Further reading 1 Royle J, Burgner D, Curtis N. The diagnosis and management of Kawasaki disease. J Paediatr Child

Health 2005;41(3):87–93. 2 Newburger JW, Fulton DR. Kawasaki disease. Curr Opin Pediatr

KDKD

Kawasaki disease (KD)

Don’t Forget: “A-Typical” KD

Prolonged fever (with < 4 of the above symptoms,

infants)

laboratory findings:

ESR , UA (sterile pyuria), Platelet

Echo (coronary artery abnormalities)

Treatment: IVIG, Aspirin

Further reading 1 Royle J, Burgner D, Curtis N. The diagnosis and management of Kawasaki disease. J Paediatr Child

Health 2005;41(3):87–93. 2 Newburger JW, Fulton DR. Kawasaki disease. Curr Opin Pediatr

KDKD

Approach to:

Patient with Rash

History:

1

2

3

4

What does patient think is causing rash?

Where did the lesions originate?

When did the lesion first develop? What has been the progression of rash?

Was there any prodromal to the lesions? Qu

es

tio

ns

5 What are the associated symptoms?

History:

1

2

3

4

Does it itch , hurt?

What treatment was applied if any?

Is there h/o atopy in family?

What medication do they take regularly or intermittently?

Qu

es

tio

ns

What kind of exposure do they have? 5

Physical Exam:

1

2

3

4

Examine in well-lit area

Careful inspection of the skin,

Examine the entire skin surface

Description of rash Ph

ys

ica

l E

xa

m

Description of rash

1

2

3

4

Morphology

Color

Configuration

Distribution

RA

SH

Morphology:

Primary lesions

secondary

lesions

uncomplicated abnormalities which

represent initial pathologic change

reflect progression of disease such as

excoriation , infection, or keratinization

Primary Lesions-1

Macule

Papule

Patch

circumscribed flat

discoloration

-circumscribed

--superficial solid

-elevated lesion

circumscribed flat

discoloration

(gathering of Macule)

elevated flat top

superficial lesion

(gathering of Papule)

< 1cm in diameter

< 1cm in diameter

> 1cm in diameter

> 1cm in diameter

ash-leaf spots, flat

nevi and freckle

warts, elevated nevi

insect bites

Molluscum contagiosum.

vitiligo,

tinea versicolor

Psoriasis

pityriasis rosea. Plaque

Primary Lesions - 2

Pustule

Nodule

Bulla

fluid filled lesion

vesicle with purulent

exudates

circumscribed solid

elevated lesion with

depth

fluid filled lesion

<1cm in diameter

< 1cm in diameter

< 1cm in diameter

> 1cm in diameter

herpes simplex

varicella

acne , folliculitis

secondary / tertiary

syphilis

SSSS and bullous

impetigo

Vesicle

Primary lesions-3

Purpura

Ecchymosis

Wheal

pinpoint flat red spots

under the skin surface

visible collection blood

visible collection blood

transient edematous

papule or plaque with

pale center and pink

margin

<2mm in diameter

>2mm- 1cm in

diameter

> 1cm in diameter

> 1cm in diameter

ITP/HSP

ITP

Blood disease,

vessels

hives and insect bites

Urticaria

Petechiae

Secondary Lesions:

1234

Scale

s

Crust

Excoriation

Fissure

Dry and greasy masses of keratin (fine – coarse);

pathologic process in epidermis

Dried exudates ( pus or blood)

Linear abrasion caused by scratching

Linear crack or cleavage on skin with sharply defined margins

56

Ulcer

Scar

Depressed lesion with epidermal & dermal loss

Permanent lesion result from process of repair

by replacing connective tissue

Configuration:

1

2

3

Grouped papule in Molluscum contagiosum

Shape annular plaque of Tinea corporis

Grouped vesicles-Herpes simplex

Gen

era

l sh

ap

e o

r th

e p

att

ern

in

wh

ich

th

e le

sio

n a

re a

rra

ng

ed

Distribution:

RASH:

YES Infection/Dermatological Disease

NO Purpura/Petechie=Blood/vessel Disease

Blanching?

Feverish

Texture

Nikolskys sign

YES mostly Systemic infection

NO mostly local dermatological disease

sandpaper texture in scarlet fever

Epithelial shearing caused by lateral pressure to un-

blistered skin

Algorithmic Approach

for

Rash

Algorithmic Approach I:

Maculo-papular Rash

Central Distribution Peripheral Distribution

Lesion DistributionTarget lesions

Extensor

PsoriasisE

cz

e

m

a

MeningiococcemiaSJS

EMViral

Exanthem Pityriasis

Febrile, illY

E

S

N

O YESN

O

Y

E

S

N

O Flexor

Algorithmic Approach II:

Vesiculobullous Rash

Diffuse

DistributionLocalized

Distribution

SJS

EM

Febrile Afebrile

Varicella

Purpura fulminans

Bollous Pemphigoid

Pemphigus vulgaris

Contact Dermatitis

Herpes Zoster

Necrotizing fascitis

HFM-disease

Algorithmic Approach III

Petechial/Purpuric Rash

Palpable

Febrile ,toxic Afebrile ,nonetoxic

ITP

Meningiococcemia

HSP

TTP

DIC

Autoimmune Vasculitis

Emergent Rashes in Pediatrics

Toxic Epidermal Necrolysis (TEN)

Stevens Johnson Syndrome (SJS)

Staphylococcal Scalded Skin Syndrome (SSSS)

Toxic Shock Syndrome (TSS)

Kawasaki Disease (KD)

Anaphylaxis

Purpura Fulminans

Toxic Epidermal Necrolysis (TEN)

Sudden onset, generalization in 24 – 48 hrs

Sever form of EM

Confluent erythema ,skin tenderness

Absence of target lesion , blister formation

Nikolskys sign positive

Fever, inflammation of eyelid, conjunctivae, mouth precedes skin lesion

Complicated by dehydration shock, electrolyte imbalance septicemia

Stevens - Johnson Syndrome (SJS):

Erythema , edema of lips , buccal mucosa

Then develops bullae ulceration hemorrhagic crusting

Skin lesions are bullae denuded skin

More widespread than EM

Skin tenderness is minimal to absent

Mucosal ulceration is painful

Systemic involvement present

Staphylococcal Scalded Skin Syndrome (SSSS)

Caused by Staphylococci

Common in infant and young children's

Localized bullous impetigo -to- generalized

Begins as erythema then desquamation after 5 days

Diffuse sterile flaccid blisters

Intact bullae are sterile unlike in bullous impetigo

Absence of inflammatory infiltrate is characteristics

Treated with ABC( beta - lactamase resistant)

Meningococcemia:

Fever

Rash typically petechiae & purpura

Hypotension, Adrenal failure

Multi-organ failure

Meningitis feature

Mortality rate 40%

CAUTION!!Fever + Purperic Rash (non blanching) =

Meningococcemiauntil proved otherwise

Anaphylaxis:

Life Threatening Allergic Reaction

Face - Urticaria, Swelling, angioedema

Airway- Wheezing, dyspnea

Stomach-abdominal pain, vomiting

Total body –anxiety, dizziness, hypotension

All these in few seconds to minutes

think FAST

then ACTEpinephrine

IVF

Common Rashes in Pediatrics:

MEASLES

Roseola Infantum (6th Disease)

Scarlet Fever

Kawasaki disease (KD)

Herpes Simplex

Chickenpox

MEASLES

IP:1-2 weeks

Fever: high-40, 4 days then rash

Conjunctivitis + cough

Koplik spots: 2 days before rash

opposite 2nd molars

Rash: Cephalo - caudal

Maculo - papular

Infectious: from fever to 4 days after rash, Droplet

Investigation: measles IgM, IgG

ttt: supportive + IVF+ Vitamin A

Roseola Infantum (6th Disease)

High Fever 4 days suddenly disappears

Then Rash begins

Infant 6 -12 months

T- shirt distribution: trunk and extremities

ttt: supportive

Scarlet Fever

Fever

Pharyngitis / Tonsillitis

Strawberry tongue + Circumoral pallor

Sandpaper-like skin rash

Pastia lines

Desquamation of the palms

Investigation: ASO, CBC, Throat swap

ttt – Antibiotics (oral / IV)

Herpes Simplex

Type1 = Skin& mucous membranes

Type 2 = Genitalia (child abuse)

Cold sores: (vesicular lesion in nasolabial fold)

Gingivostomatitis: (painful mouth ulcers+ fever)

Conjunctivitis + Corneal Ulcers

Meningoencephalitis (neonate)

Eczema Herpeticum (vesicular rash)

Investigation: PCR, Culture

ttt: supportive+ Acyclovir (systemic, local)

Chickenpox

Varicella - Zoster Virus

No Prodrom (usually)

Rash: Itchy

Vesicle + red base

( macule papule vesicle/crust

Scalp, face, trunk, proximal limbs, palms, soles, mm

Complication: 2ry bacterial infection (imptigo/cellulitis)

Spread of infection: chest, heart, CNS

Thrompocytopenia

ttt: supportive + Acyclovir (systemic, local)

Conclusion

Treating Pediatric Dermatology Patient in ED may appear

daunting, however, with a Systemic Approach one can more

readily and successfully diagnose and manage patient

effectively.

QUESTIONS?

THANK YOU!