SAEM Clinical Image Series: Pediatric Rash

pediatric rash

A previously healthy 8-year-old female presents to the pediatric emergency department due to a rash. Her symptoms started three days prior to presentation with a painful rash on her lower extremities. The rash subsequently spread to the buttocks and upper extremities, and she developed intermittent diffuse abdominal pain, a nonproductive cough, and pharyngitis. The patient denies subjective fever. Known sick contacts include the patient’s mother, who tested positive for COVID-19 two and a half weeks prior.

 

Vitals: T 98.5°F; HR 93; BP 115/68; RR 16; O2 sat 100% on room air

Constitutional: Well-developed and in no acute distress

HEENT: Normocephalic, atraumatic; moist mucus membranes; no conjunctival injection; posterior pharyngeal erythema without exudates; tonsils are three bilaterally; lips are not cracked; no “strawberry tongue”;

Neck: Normal range of motion; no lymphadenopathy

Cardiovascular: Regular rate and rhythm; normal heart sounds and pulses

Pulmonary: Effort is normal; normal breath sounds; no wheezing

Abdominal: Abdomen is flat; minimal tenderness to palpation without guarding; no organomegaly

Skin: Diffuse petechial rash and painful, palpable, nonblanching purpura in the dependent regions (most notable on the buttocks and lower extremities)

COVID-19: Detected

Complete blood count (CBC): WBC 10K, hemoglobin 13, platelets 469

Comprehensive metabolic panel (CMP): Na 138, K 4.1, Cl 103, CO2 26, BUN 7, Cr 0.38, Glucose 94, ALT 23, AST 26, Albumin 4.5

Lipase: 10

Urinalysis (UA): Normal

C-reactive protein (CRP): 3.4

Erythrocyte sedimentation rate (ESR): 24

Procalcitonin: 0.03

Fibrinogen: 363

BNP: <10

Troponin: 0.00

Ferritin: 83

Triglycerides: 37

 

  • COVID-19-Associated Multisystem Inflammatory Syndrome in Children (MIS-C): According to CDC criteria, patients must be under 21 years of age, with a fever higher than 38°C/subjective fever for longer than 24 hours, laboratory evidence of inflammation, severe illness requiring hospitalization, and two or more organ systems involved (cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic, or neurologic), with no alternative plausible diagnoses and recent COVID-19 infection.
  • Immunoglobulin A Vasculitis (Henoch-Schönlein Purpura): According to the EULAR/PRINTO/PRES criteria, symptoms must include cutaneous findings (palpable purpura or petechiae without the presence of thrombocytopenia), plus at least one of the following: diffuse abdominal pain with acute onset, arthritis/arthralgia, renal involvement in the form of proteinuria or hematuria, or deposition of Immunoglobulin A seen on renal histology.
  • Kawasaki Disease: The diagnostic criteria include fever for five days or longer and four of the following: bilateral conjunctival injection, cervical lymphadenopathy, polymorphous rash, oral mucous membrane changes (including fissured lips, pharyngeal erythema or strawberry tongue), peripheral extremity changes (edema of the hands/feet or desquamation).

Immunoglobulin A (IgA) Vasculitis.

This patient presented with palpable purpura and petechiae without the presence of thrombocytopenia, as well as diffuse abdominal pain. The majority of cases of IgA Vasculitis are preceded by a respiratory pathogen, with the most common being streptococcus, staphylococcus, and parainfluenza virus. Although not well-documented due to its recent conception, COVID-19 is likely to be the cause of this patient’s vasculitis. Usual management of IgA Vasculitis is supportive care, with admission and specialty referral for complications including intussusception and glomerular involvement. Given the severity of the differential diagnoses, this patient was admitted to the hospital for observation and discharged the following day with close follow-up

Take-Home Points

  • COVID-19 can cause a variety of rashes in the pediatric population, and appropriate workup including inflammatory markers, complete blood count, and comprehensive metabolic panel must be initiated to rule out severe disease. Consider obtaining a troponin, EKG, chest x-ray, echocardiogram, ferritin, prothrombin time, partial thromboplastin time, international normalized ratio, fibrinogen, urinalysis and cultures to assess for end-organ damage. If positive, and the patient appears ill, consider Multisystem Inflammatory Syndrome in Children (MIS-C).
  • IgA Vasculitis is usually caused by a respiratory pathogen. Keep it on your differential when assessing children who test positive for Covid-19.
  • Complications of IgA vasculitis include intussusception, heme-positive stool, microscopic hematuria, and periarticular disease.

  • Centers for Disease Control and Prevention, Health Alert Network. (2020). Case Definition for Multisystem Inflammatory Syndrome in Children (MIS-C). [online] Available at: https://emergency.cdc.gov/han/2020/han00432.asp.
  • Trnka P. Henoch-Schönlein purpura in children. J Paediatr Child Health. 2013 Dec;49(12):995-1003. doi: 10.1111/jpc.12403. Epub 2013 Oct 18. PMID: 24134307.
  • Ozen S, Pistorio A, Iusan SM, Bakkaloglu A, Herlin T, Brik R, Buoncompagni A, Lazar C, Bilge I, Uziel Y, Rigante D, Cantarini L, Hilario MO, Silva CA, Alegria M, Norambuena X, Belot A, Berkun Y, Estrella AI, Olivieri AN, Alpigiani MG, Rumba I, Sztajnbok F, Tambic-Bukovac L, Breda L, Al-Mayouf S, Mihaylova D, Chasnyk V, Sengler C, Klein-Gitelman M, Djeddi D, Nuno L, Pruunsild C, Brunner J, Kondi A, Pagava K, Pederzoli S, Martini A, Ruperto N; Paediatric Rheumatology International Trials Organisation (PRINTO). EULAR/PRINTO/PRES criteria for Henoch-Schönlein purpura, childhood polyarteritis nodosa, childhood Wegener granulomatosis and childhood Takayasu arteritis: Ankara 2008. Part II: Final classification criteria. Ann Rheum Dis. 2010 May;69(5):798-806. doi: 10.1136/ard.2009.116657. PMID: 20413568.
  • Royle J, Burgner D, Curtis N. The diagnosis and management of Kawasaki disease. J Paediatr Child Health. 2005 Mar;41(3):87-93. doi: 10.1111/j.1440-1754.2005.00555.x. PMID: 15790316.

 

SAEM Clinical Image Series: A Rapidly Spreading Rash

spreading rash

A 40-year-old male with a past medical history of HIV presented for evaluation of a non-pruritic rash. Six days ago, he suddenly felt a stinging sensation at the back of his head and neck similar to a bug bite. He then noticed bumps were starting to form and developed a shock-like pain in the area. Three days ago, the rash spread from the back of his head towards his chest. Yesterday, the rash spread further and now extends medially and upwards covering most of his left neck and ear. The pain continued to worsen, at which point the patient shaved the left side of his head in an attempt to help the rash. Today, the pain became unbearable, which prompted his visit to the emergency department for further evaluation and management.

Head: Normocephalic, atraumatic; left side of patient’s head is shaved.

Eye: Pupils equal, round, reactive to light; extraocular movements intact; no corneal ulcers or dendritic lesions with fluorescein staining.

Visual acuities: Right 20/25, left 20/25, baseline 20/25

Ear, nose, throat: Mucous membranes are dry; oral thrush and tonsillar erythema appreciated; localized erythema, crusting and blistering rash of varying sizes and ages along with the outer ear including the tragus, antihelix, and antitragus; helix mildly swollen. On otoscopy, the tympanic membranes appear pearly grey, shiny, translucent with no bulging, and without cerumen impaction.

Neck: Full range of motion appreciated but both horizontal and vertical movement is slow secondary to pain; no lymphadenopathy.

Neurological: Awake, alert, and oriented to date, place, and person; moves all extremities; cranial nerves II through XII grossly intact; strength 5/5 in all extremities; gait steady; no ataxia, dysmetria, or dysarthria.

Skin: Erythematous, localized, crusted, blistering vesicular rash of various sizes and ages appreciated along the left V3 distribution, C3 to T3 dermatomes anteriorly, and C2 to C6 dermatomes posteriorly.

HIV-1 antibody: positive

CD4 helper t-cells: 48 (L)

HIV-1 RNA PCR: 36,490

The lesions can be characterized as vesicles in various stages of healing. Some lesions are crusted, others are bullous, and a few are pustular. The C2-C6 dermatomes are affected posteriorly, and the C2-T3 dermatomes are involved anteriorly.

The diagnosis is Disseminated Herpes Zoster. The rash in reactivation varicella zoster virus (VZV) is preceded by tingling, itching, or pain, and begins as maculopapular then progresses to vesicles, pustules, and bullae. The rash typically involves a single dermatome and does not cross the midline. Rash present in multiple dermatomes (>3) or a rash that crosses the midline signifies disseminated disease. Hutchinson’s sign is a lesion on the lateral dorsum and tip of the nose indicating the involvement of the nasociliary branch of the ophthalmic division of the trigeminal nerve. The nasociliary branch innervates the eye, thus these lesions are highly suspicious for herpes zoster ophthalmicus. Herpes zoster ophthalmicus on fluorescein examination appears as pseuododendritic lesions with no terminal bulbs (not to be confused with herpes simplex virus (HSV) keratitis, which has dendritic lesions with terminal bulbs). Vesicles in the auditory canal (herpes zoster oticus) may be a part of Ramsay Hunt syndrome with ear pain and paralysis of the facial nerve.

The patient is immunocompromised and requires hospitalization for intravenous (IV) antiviral therapy and pain management. VZV primary infection results in viremia, diffuse rash, and seeding of sensory ganglia where the virus establishes latency. Herpes zoster is the result of viral reactivation with spread along the sensory nerve in that dermatome. Antiviral therapy aids in the resolution of lesions, reduces the formation of new lesions, reduces viral shedding, and decreases the severity of acute pain, but does not affect the development of post-herpetic neuralgia.

Immunocompetent patients may receive Valacyclovir 1 g PO q8hrs (preferred) or Acyclovir 800 mg PO 5x/day x 7d if the onset of rash is <3 days or >3 days with the appearance of new lesions.

Immunocompromised, transplant, and cancer patients are all at high risk for dissemination, chronic skin lesions, acyclovir-resistant VZV, and multi-organ involvement. Immunocompromised patients and patients with disseminated zoster require aggressive multimodal treatment, admission to the hospital, and IV antiviral therapy regardless of the time of onset of rash. Recommended therapy is Acyclovir 10 mg/kg IV q8h or Foscarnet 40 mg/kg IV q8h for acyclovir-resistant VZV. All patients require adequate analgesia, typically with non-steroidal anti-inflammatory drugs, opioids, Gabapentin, Nortriptyline, and Lidocaine patches on intact skin.

Take-Home Points

  • Disseminated herpes zoster is defined as reactivation of VZV in three or more dermatomes. It requires admission, IV antiviral therapy, and pain control.
  • If VZV reactivation involves the face, one must evaluate for herpes zoster ophthalmicus and oticus.
  • Perform a thorough neuro exam including evaluation of cranial nerves V, VII, and VIII.
  • VZV requires airborne precautions.
  1. Cohen JI. Clinical practice: Herpes zoster. N Engl J Med. 2013 Jul 18;369(3):255-63. doi: 10.1056/NEJMcp1302674. PMID: 23863052; PMCID: PMC4789101.

 

 

 

SAEM Clinical Image Series: Silver Scales

A 6-year-old otherwise healthy female presented to the emergency department (ED) with a rash across all four extremities. She has had seven months of pruritic, expanding lesions starting on her shins, now beginning to expand on her forearms. No history of allergies or irritant exposure. Due to Covid-19, she has been unable to see a provider before today’s ED visit.

Vitals: T 98.3°F; BP 96/72; HR 92; RR 24; O2 sat 100%

Skin: Numerous patchy red lesions scattered across bilateral upper and lower extremities with silver plaque accumulation. No nailbed involvement. No mucous membrane involvement.

Non-contributory

Psoriasis vulgaris, plaque subtype, is a common dermatologic condition often seen in the outpatient setting. Plaques are most commonly noted on the knees, elbows, and lower back. The silvery plaques in characteristic locations are a hallmark of this diagnosis but are rarely seen to this extent. Unfortunately for this patient, this was the initial presentation due to the inability to access care during the COVID-19 pandemic.

Initial management is with high-potency topical corticosteroids. Systemic steroids should be avoided to prevent exacerbation or eruption of pustular psoriatic lesions. In this case, given the patient’s age and disease severity, she was seen in the ED by Dermatology and initiated on corticosteroid topical therapy. She was encouraged to establish care with rheumatology to be routinely screened for associated life-altering pathologies including psoriatic arthritis and uveitis.

Take-Home Points

  • When making a visual diagnosis of plaque psoriasis, evaluate for erythema, edema, or signs of superinfection.
  • Avoid systemic steroids given the risk of rash exacerbation, especially upon withdrawal.
  • Younger patients and those with more than 10% body surface area involvement should be evaluated by a dermatologist for initiation of topical corticosteroids and possible escalation to phototherapy, methotrexate, retinoids, or biologic agents.
  1. Menter A, Cordoro KM, Davis DMR, Kroshinsky D, Paller AS, Armstrong AW, Connor C, Elewski BE, Gelfand JM, Gordon KB, Gottlieb AB, Kaplan DH, Kavanaugh A, Kiselica M, Kivelevitch D, Korman NJ, Lebwohl M, Leonardi CL, Lichten J, Lim HW, Mehta NN, Parra SL, Pathy AL, Farley Prater EA, Rupani RN, Siegel M, Stoff B, Strober BE, Wong EB, Wu JJ, Hariharan V, Elmets CA. Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients. J Am Acad Dermatol. 2020 Jan;82(1):161-201. doi: 10.1016/j.jaad.2019.08.049. Epub 2019 Nov 5. Erratum in: J Am Acad Dermatol. 2020 Mar;82(3):574. PMID: 31703821.

 

 

 

SAEM Clinical Image Series: Sudden Onset of Facial Petechiae in Kindergartener

petechiae

A 6-year-old boy with no past medical history presented when his parents noticed facial petechiae after picking him up from school. He had a series of four recent upper respiratory infections within four months since starting public kindergarten. He occasionally also complains of leg pain.

General: Non-toxic, cooperative child

Skin: Petechial rash in periorbital and infra-auricular areas

HEENT: Normal; no lymphadenopathy

Musculoskeletal: Normal strength and range of motion

Hemoglobin: 12.6 g/dL

White blood cell (WBC) count: 6.7×103/mL

Platelets: 352,000/mL

Increased pressure in the dermis from actions such as extended Valsalva maneuver, vomiting, crying, or coughing.

This child had a stressful day in kindergarten. He was holding his breath for extended periods of time to suppress crying. The increased pressure caused the facial petechiae, which was completely unrelated to his recent viral infection or growing pains

Take-Home Points

  • Fine petechiae around the eyes, cheeks, and ears are most often caused by crying or similar behaviors that cause increased pressure in the subcutaneous vessels of the face.
  • Mucosal and cutaneous capillaries are fragile and can easily rupture, even with minor trauma. Usually, platelets can seal these immediately, so when petechiae show up, consider a problem with primary hemostasis.
  1. Kumar V, Abbas A, Aster J. Hemodynamic Disorders, Thromboembolic Disease, and Shock. Robbins & Cotran Pathologic Basis of Disease, 10th edition. 2021. Marcdante K, Kliegman R. Immunological Assessment. Nelson Essentials of Pediatrics, 8th edition. 2019

 

 

By |2021-07-22T22:10:34-07:00Aug 9, 2021|Dermatology, HEENT, Pediatrics, SAEM Clinical Images|

SAEM Clinical Image Series: What’s This Thing on My Face?

A 91-year-old female patient presented with her family after concern for multiple new lesions on her face and hands. The patient thinks the lesions grew over the course of a few months. There is no pain at the sites, no erythema, and no pruritis. She has caught the lesions on clothing and bedding, which has irritated the lesions on occasion, and the family is concerned/embarrassed by the growths on her face, which are harder to conceal than those on her hand.

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By |2021-02-21T07:51:46-08:00Feb 22, 2021|Academic, Dermatology, SAEM Clinical Images|

SAEM Clinical Image Series: Guess Who’s Back?

rash

A 27-year-old male with no significant past medical history presented to the emergency department with one week of progressively worsening, non-pruritic, and intermittently painful rash to his bilateral dorsal and plantar feet. The patient also described lesions to his left inguinal region and scrotal sac. There was no fever, chills, nausea, vomiting, chest pain, or shortness of breath. The patient was sexually active with men and women, with inconsistent condom use.

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SAEM Clinical Image Series: Sun-burnt Hands and Lips

blistering

A 44-year-old Caucasian male with a past medical history of hepatitis C presents with a complaint of pain, swelling, and skin blistering of his hands. He also notes skin sores on his nose, lower lip, and the tops of his ears. The patient claims that these have become progressively worse since starting work a month ago in outdoor construction. The patient denies the use of medications or illicit drugs and denies any medical allergies. He admits to tobacco use and daily alcohol use. The patient denies any other symptoms.

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