CASE PRESENTATION Pediatrics Rotation By Stephanie Piotrovsky, PA-S

The Case Presentation A seven year old male comes to the clinic with multiple crusted lesions around the mouth, nose, and on the trunk. The patient has no other complaints. Vital signs are within normal limits. No fever at this time. No past surgical, medical history Immunizations up to date

DIFFERENTIAL DIAGNOSIS IMPETIGO Bullous Vs. Nonbullous ECTHYMA HSV-1 VARICELLA DERMATITIS TINEA CAPITUS

The History (HPI) (Elicited from mother and child) How long have the lesions been present? Approximately, one week Has their appearance changed? Mom states that it started out as small pink bumps around his nose and mouth one week ago. A few days later, he had blisters in the same areas and also on his chest and right arm. Two days ago, she noticed the crusting and it hasn’t changed since. Do the lesions itch, burn or hurt? The child said that they only itch and hurt a little bit.

The History (HPI) (Elicited from mother and child) Is anyone else around the child sick or have similar skin problems? NO Does the child have any underlying illness or condition ( Diabetes, HIV/AIDS, chemo, gluccoicorticoid use, etc…) that causes immune compromise? Has any attempt made to self treat the rash? Is the child currently on any medications?

The History (HPI) (Elicited from mother and child) Does the child have any known allergies? NO Has the child been sick recently? A runny nose and nasal congestion for the past week. No fever, sore throat, ear aches, headaches, body aches, chills, night sweats, SOB or cough. Has the child ever experienced this before?

The Physical Exam General: Non-toxic appearing, NAD, A&OX3 Skin: Warm, moist Multiple yellowish-brown crusted lesions approximately 1-3cm in diameter with a slightly erythematous base. Several lesions around mouth and nose most 1-2cm in diameter. One lesion on right forearm and one in the right midclavicular region, both approximately 3cm in diameter HEENT: Turbinates slightly erythematous Mild-moderate nasal congestion with clear nasal discharge Rest of exam within normal limits

The Physical Exam NECK: Supple Submandibular and submental adenopathy-- soft, nontender, mobile CHEST: Lungs CTA B/L without adventitious sounds Symmetrical -No accessory mm use HEART: RRR No murmurs, gallops, clicks auscultated ABDOMEN: Positive bowel sounds x 4 quads Soft, nontender No masses, hepato-/spleno- megally

IMPETIGO The most common bacterial skin infection in children Superficial infection of the epidermis Most commonly involves the face (mouth and nose), extremities, hands, and neck Peak incidence in summer and early fall Children with poor hygiene and malnutrition Contagious and will spread from one part of the body to another through scratching Usually appears on previously traumatized skin or skin that has a preexisting break in its integrity (psoriasis, eczema, atopic dermatitis)

IMPETIGO--Nonbullous form ETIOLOGY: 1. Staph (S.aureus) 2. Combo Strep and Staph 3. Strep (S.pyogenes) Usually on predisposed skin (varicella, bites, cuts, burns) CLINICAL FEATURES: Discrete, fragile vesicles surrounded by an erythematous border. The vesicles become pustular, rupture, and discharge a honey colored fluid that quickly forms a crust Little or no erythema, pruritis, or constitutional symptoms Regional adenopathy (90%) Leukocytosis (50%)

IMPETIGO--Nonbullous form

IMPETIGO--Bullous Form ETIOLOGY: Staphlococcus aureus Occurs sporadically on intact skin as a manifestation of localized toxin production CLINICAL PRESENTATION: Flaccid, transparent bullae that quickly become purulent and rupture spontaneously Most commonly on the skin of moist intertriginous areas No regional adenopathy, erythema, or constitutional symptoms

IMPETIGO--Bollous Form

IMPETIGO--DIAGNOSIS History Physical exam Culture, gram stain, biopsy using histopathic evaluation when unsure Usually emperic

IMPETIGO--Treatment Mupirocin (Bactroban) ointment Cephalexin (Keflex) Apply to affected area TID for 10 days Cephalexin (Keflex) 25-50 mg/kg/day for 10 days for children 500 mg BID for adults Alternatives Pen VK Second generation Cephalosporins Macrolides Bullous Impetigo of a NB Oxicillin, Augmentin…PO

IMPETIGO--Complications Can persist for months if untreated Pigmentary changes with or without scarring Acute glomerulonephritis (Group-A- Beta hemolytic Strep) 3 weeks after pyoderma -children 2-6 years old headache, anorexia, dull back pain, edema and HTN, proteinuria, hematuria, and RBC casts Cellulitis Rapidly spreading infection of the dermis and subcutaneous tissue Warmth, tenderness, localized erythema No sharply demarcated borders Lymphangitis Inflammation of the lymphatic channels from invasion by pathogenic organisms (Group-A-Beta-hemolytic Strep) Erythematous, irregular linear streaks from primary site to regional lymph nodes

ECTHYMA Deeper and more chronic infection than impetigo More frequently on the legs S. pyogenes Initial vesicles with erythematous base==>erode through dermis to form a thick crusted ulcer with elevated margins surrounded by a red rim. Tx= same as impetigo

Herpes simplex virus Initial episode with systemic symptoms Gingivostomatitis and adenopathy Painful erosions or ulcers on the lips, tongue, gingivae, buccal mucosa, cheeks, and nose Initial inflammation, tenderness and/or itching of the skin followed by grouped vesicles on an erythematous base. They rupture to leave a small cluster of erosions Diagnosis= Tzank test shows Multinucleated giant cells

VARICELLA Prodrome of low grade fever, Upper respiratory sxs, and mild malaise followed by the appearance of a prurtic exanthem. Initially on trunk and scalp Tiny erythematous papules ==> thin-walled, superficial central vesicles surrounded by red halos ==> drying, umbillicated appearance, and crust form Hallmark = three stages Peak in late fall through early spring

DERMATITIS (Atopic and Contact) Redness, edema, vesiculation, scaling, lichenification, pigmentation changes Eczema (Infantile)= red, itchy papules and plaques that ooze and crust over the cheeks, forehead, extremities, scalp, trunk --usually symmetrical Contact Dermatitis=well/ demarcated erythema, crusting, and/or blistering contact with irritant

Tinea Capitus Kerion form=raised, tender boggy plaques or masses with pustules that stimulate absess formation Occipital, postauricular, posterior cervical adenopathy Involve the scalp or hair line

CONCLUSION From the case presentation, history, and PE the diagnosis was IMPETIGO--Nonbullous form Although the presentation was similar to that of ecthyma and bullous impetigo, all forms are treated similarly The child was given Bactroban ointment TID for 10 days and Keflex po for 10 days Child kept out of school until he was on the oral antibiotic for 24 hours

PATIENT EDUCATION AND FOLLOW UP The mother was told to remove the scabs (with warm water soak if needed) and to wash the areas with antibacterial soap before ointment application. After ointment application, she was instructed to cover the lesions with an adhesive bandage to avoid further spread and scratching. Mom was also advised to discourage the child from touching the lesions and to constantly wash his hands with antibacterial soap. To prevent spread to family members, avoid sharing towels or wash clothes with child. Advised that the lesions should heal within one week Advised to return if the impetigo worsens, is not completely healed in one week, or the child develops a fever or sore throat

QUESTIONS???