About Wendy Wendt, MD

Assistant Professor of Pediatrics
Medical College of Wisconsin

SAEM Clinical Images Series: A Rare Pediatric Scalp Rash

rash

The patient is a 3-month-old, full-term male who presents with a rash on his head. The rash started one day prior to presentation on his forehead and spread to the rest of his head. Today, it developed a central clearing with surrounding redness. He has a history of sensitive skin since birth with patches of eczema and cradle cap. He treats these with Aquaphor and Honest Co. Cream; he has never been prescribed topical steroids for his rashes. Denies fever, cough, rhinorrhea, congestion, decreased appetite, diarrhea, and decreased urination. He had an uncomplicated birth history.

General: Well appearing, no distress.

Skin: Large, serpiginous rash on the left forehead and scalp with central clearing and peripheral erythema as well as areas of erythematous plaques. He has some erythema of the left medial epicanthus. He also has a large erythematous patch at the base of his skull. The remainder of his skin is clear.

CV: Normal rate and rhythm, no murmur.

White blood cell (WBC) count: 8.4

Hemoglobin: 12.4

Hematocrit: 37.1

Platelet Count: 468

Complete metabolic panel (CMP): ALT 30, AST 60, Alk phos 266, Tbili 0.7, Total Protein 6.4

The image is of the cutaneous manifestation of neonatal lupus erythematosus. Neonatal lupus erythematosus is an autoimmune disease caused by transplacental passage of maternal autoantibodies to Sjögren’s syndrome A or B autoantigens (SS-A/SS-B). It can present with reversible changes including cutaneous lesions (most common, in up to 40% of patients), hepatobiliary disease, and cytopenias, which resolve once maternal autoantibodies have been cleared.

All infants that present with concern for neonatal lupus erythematosus should have screening labs performed to evaluate for hematologic, cardiac, and hepatobiliary involvement including a CBC with differential, liver enzymes, and antibody testing. In addition, an EKG is essential given that neonates can present with irreversible total atrioventricular heart block, which can present in utero or after birth.

The rash typically presents in the first few weeks of life but can present as late as 2-3 months of life (usually within 1-2 days of first sun exposure). Eighty percent of cases are not clear at birth and present in the first month of life. The rash appears as a coalescing rash with raised margins, with annular and discoid erythema involving the head in 95% of cases. It is often misdiagnosed as skin infections or eczema if the mom is asymptomatic. Fifty percent resolve by four months of life and 100% by one year.

Any neonate with a slow fetal heart rate or the postnatal diagnosis of atrioventricular heart block warrants immediate maternal testing for these autoantibodies. Most cardiac changes from neonatal lupus are diagnosed before 26 weeks gestation, with <20% later in pregnancy and 2% detected postnatally.

Take-Home Points

  • While cutaneous findings of neonatal lupus most commonly present in the first month of life, they can present as late as 2-3 months.
  • The cutaneous findings associated with neonatal lupus most of the time resolve in 4-6 months (when maternal antibodies are cleared from the infant’s circulation).
  • Any baby with findings concerning for neonatal lupus should have an EKG performed. Around 2% of infants present with heart block postnatally within the first month.

  • Diaz-Frias J, Badri T. Neonatal Lupus Erythematosus. [Updated 2021 Jun 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526061/
  • Lee LA. Neonatal lupus erythematosus: clinical findings and pathogenesis. J Investig Dermatol Symp Proc. 2004 Jan;9(1):52-6. doi: 10.1111/j.1087-0024.2004.00827.x. PMID: 14870986.

By |2023-04-05T14:00:29-07:00Apr 10, 2023|Dermatology, Pediatrics, SAEM Clinical Images|

SAEM Clinical Images Series: Facial Swelling

facial swelling

A 5-year-old male with a history of recent frontal sinusitis associated with preseptal cellulitis requiring surgery presented with facial swelling. Swelling developed in the 24 hours prior to presentation without facial pain, nausea, or emesis. Denied facial trauma as well as any neurologic deficits, loss of consciousness, headaches, or fever/chills. At the time of his prior surgery, he presented with swelling localized to the left eye along with worsening pain, nausea, and emesis. After surgery, he was discharged in stable condition on antibiotics for 10 days. He has been in his usual state of health since that time.

Vitals: BP 93/59 (Sitting); HR 84; Temp 37.3 °C (99.1 °F) (Oral); Resp 12; Wt 20.6 kg (45 lb 6.6 oz)

General: Active, alert, normal development, and in no acute distress

HEENT: Swelling over the forehead and nasal bridge. Tenderness to palpation over the forehead. No erythema or overlying skin changes.

Nose: Normal appearance. No congestion or rhinorrhea.

Mouth/Throat: Mucous membranes are moist. Oropharynx is clear.

White blood cell (WBC) count: 8.9 x 10^3/uL

Hemoglobin: 11.5 g/dL

Platelets: 365 x 10^3/uL

ANC: 4.490 x 10^3/uL

ESR: 15 mm

CRP: <0.5 mg

In the initial management of this patient, CT imaging of the head with contrast should be used to characterize the lesion and evaluate for intracranial involvement. In our patient, the CT scan showed frontal bone osteomyelitis with possible extension into the subdural space. He was admitted on broad-spectrum antibiotics and surgical washout was performed the following day.

Pott’s Puffy Tumor is a rare but serious complication of sinusitis with potential intracranial involvement. Complications include orbital cellulitis, intracranial abscess, meningitis, and cavernous sinus thrombosis.

Take-Home Points

  • Pott’s Puffy Tumor is a rare potential complication of sinusitis. Early diagnosis and treatment are essential to reduce morbidity.
  • CT of the head with contrast is the initial imaging that should be obtained in the emergency department.

  • Blumfield E1, Misra M. Pott’s puffy tumor, intracranial, and orbital complications as the initial presentation of sinusitis in healthy adolescents, a case series. Emerg Radiol. 2011 Jun;18(3):203-10. PMID: 21380513.
  • Palabiyik FB1, Yazici Z, Cetin B, Celebi S, Hacimustafaoglu M. Pott Puffy Tumor in Children: A Rare Emergency Clinical Entity. J Craniofac Surg. 2016 May;27(3):e313-6. PMID: 27100642.

By |2022-12-08T22:22:41-08:00Dec 19, 2022|HEENT, Pediatrics, SAEM Clinical Images|

SAEM Clinical Images Series: ‘Tis Not the Season to be Wheezing

wheezing

A 2-year-old male with a history of solitary kidney presented with greater than one month of daily coughing, wheezing, and decreased appetite. The patient was previously seen by his primary care physician after three weeks of symptoms where he was prescribed albuterol as needed for viral bronchospasm. The patient’s wheezing did not improve after two weeks of albuterol treatment so a chest x-ray was ordered. The patient’s mother denied any fevers, vomiting, diarrhea, weight changes, or night sweats.

Vitals: BP 131/60; Pulse 148; Temp 36.7 °C (98.1 °F) (Axillary); Resp 28; Wt 15.7 kg (34 lb 9.8 oz); SpO2 95%

General: Alert; well appearing

HEENT: Pupils equally reactive to light; moist mucous membranes; nares with normal mucosa without discharge

Cardiovascular: Regular rate; regular rhythm; normal S1, S2; no murmur noted; distal pulses 2+

Pulmonary: Good aeration throughout all lung fields; clear breath sounds bilaterally; prolonged expiratory phase; stridor with agitation

Abdomen: Soft; non-tender; non-distended

White blood cell (WBC) count: 56.1/uL (Blasts 58%)

Platelets: 288/uL

Uric acid: 8.3 mg/dL

LDH: 2231 iU/LD

D-Dimer: 3.22 ug/mL

Fibrinogen: 463 mg/dL

Bronchospasm, bronchiolitis, viral infection, pneumonia, foreign body aspiration, space-occupying lesion, vocal cord dysfunction, cardiac dysfunction, and acute chest in patients with sickle cell disease.

The radiograph shown demonstrates a mediastinal mass. This patient was ultimately diagnosed with T-cell acute lymphoblastic leukemia. T-ALL can present with fatigue, fevers, weight loss, easy bleeding/bruising, paleness, or a mediastinal mass. Mediastinal masses found on chest x-ray require further evaluation to determine the diagnosis, location, and treatment. If malignancy is suspected, an oncology referral and bone marrow sample will be necessary.

Take-Home Points

  • In patients with first-time wheezing that does not improve with bronchodilator therapy, consider alternative diagnoses and further evaluation.
  • A mediastinal mass is found at the time of diagnosis in 10% to 15% of children with acute lymphoblastic leukemia.

  • Steuber, P (2021). Overview of common presenting signs and symptoms of childhood cancer.UpToDate. Retrieved January 2, 2021.2.
  • Juanpere, S., Cañete, N., Ortuño, P., Martínez, S., Sanchez, G., & Bernado, L. (2013). A diagnostic approach to the mediastinal masses. Insights into imaging, 4(1), 29–52.https://doi.org/10.1007/s13244-012-0201-0

SAEM Clinical Images Series: An Enlarging Scalp Mass

scalp mass

A 27-day-old female infant born at 34 weeks 4 days with a prenatal history of maternal syphilis treated with penicillin presented with an enlarging scalp mass since birth. Since birth, the patient has had a 1 cm erythematous and flat lesion on her scalp. Since that time, the lesion has continued to grow and develop scales. On the day of presentation, the lesion was noted to be 7-8cm in diameter with multiple surrounding smaller lesions. There is some clear to bloody drainage coming from the main lesion. The patient has otherwise been growing and developing normally. No fevers or other sick symptoms. Feeding well. Mom has no concerns with bowel movements or voiding habits.

General: She is active. She is not in acute distress. She is well-developed.

HEENT: No congestion or rhinorrhea. Mucous membranes are moist. No posterior oropharyngeal erythema.

Cardiovascular: Normal rate and regular rhythm. Normal pulses. No murmur heard.

Pulmonary: Respiratory effort is normal. No retractions. Normal breath sounds. No wheezing.

Skin: Skin is warm. Capillary refill takes less than 2 seconds. On the left side of the scalp, there is a large raised keratinized plaque with a stuck-on appearance. Some red blood is noted when tapped with a white sheet. The plaque is firm and non-tender. On the rest of the scalp, there are several peeling flat lesions with hair attached, and intermittent alopecia.

Neurological: No focal deficit present. She is alert. Suck is normal.

Scalp ultrasound: Posteriorly exophytic left parietal lesion is peripherally echogenic, possibly representing a calcified lesion or cephalohematoma. CT or MRI may be useful for further evaluation, as clinically indicated.

a. Seborrheic Dermatitis: A common, self-limiting eruption consisting of erythematous plaques with greasy, yellow-colored scales that distribute to the areas of the body with sebaceous glands.

b. Atopic Dermatitis: Erythematous, scaly, crusted lesions that are poorly demarcated. It is pruritic and commonly involves the cheeks, scalp, and extensor surfaces.

c. Psoriasis: Uncommon in infants, but can mimic seborrheic dermatitis with sharply demarcated, shiny, erythematous plaques with fine silvery scales in non-intertriginous regions.

d. Tinea Capitis: While rare, tinea can present with a scaly scalp rash in infants. There may be a mild to moderate inflammatory reaction associated as well as hair loss.

e. Langerhans Cell Histiocytosis (LCH): LCH can present as refractory seborrheic dermatitis. There may also be papules or reddish-brown nodules that appear with the rash.

Pityriasis Amiantacea secondary to Seborrheic Dermatitis with a significant build-up of crust and scale. Pityriasis amiantacea is an exaggerated inflammatory response to regional dermatitis, most often seborrheic dermatitis. Treatment consists of a keratinolytic and antibacterial ointment. In this patient, 1:4 part vinegar and water soaks were recommended twice daily, followed by mupirocin ointment until the resolution of the lesions.

Take-Home Points

  • Seborrheic dermatitis is a commonly presenting rash in infancy.
  • When rashes are refractory to conservative management, additional diagnoses and sequelae need to be considered.

  • Amorim GM, Fernandes NC. Pityriasis amiantacea: a study of seven cases. An Bras Dermatol. 2016 Sep-Oct;91(5):694-696. doi: 10.1590/abd1806-4841.20164951. PMID: 27828657; PMCID: PMC5087242.
  • Olanrewaju O. Falusi; Seborrhea. Pediatr Rev February 2019; 40 (2): 93–95. https://doi.org/10.1542/pir.2017-0215. PMID: 30709979.

By |2023-03-22T12:13:28-07:00Nov 7, 2022|Dermatology, Pediatrics, SAEM Clinical Images|
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