1. CASE PRESENTATION Pediatrics Rotation
By Stephanie Piotrovsky, PA-S

2. 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

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

4. 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.

5. 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?

6. 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?

7. 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

8. 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

9. 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)

10. IMPETIGO--Nonbullous form
ETIOLOGY:
1. Staph (S.aureus) 2. Combo Strep and Staph 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%)

11. IMPETIGO--Nonbullous form

12. 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

13. IMPETIGO--Bollous Form

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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

25. QUESTIONS???