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Childhood Rashes That Present to the ED Part I: Viral and Bacterial Issues

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Childhood Rashes That Present to the ED Part I: Viral and Bacterial Issues March 2007 Childhood Rashes That Volume 4, Number 3 Author Present To The ED Part I: Viral Marc S. Lampell, MD University of Rochester School of Medicine and And Bacterial Issues Dentistry, Assistant Professor of Emergency Medicine, Assistant Professor of Pediatrics You’re managing to keep your head above water during the evening shift in the Peer Reviewers pediatric emergency department of a university hospital when you get a phone call Sharon Mace, MD Associate Professor, Emergency Department, Ohio from a local physician who’s sending you a dilemma that she’s been struggling State University School of Medicine, Director of with for three days. The case is a four-year-old girl who recently moved from Pediatric Education And Quality Improvement and Russia (unknown vaccination status) with persistent fever over 40oC for three Director of Observation Unit, Cleveland Clinic, Faculty, MetroHealth Medical Center, Emergency Medicine days. The child is “toxic” appearing and has impressive coryza and a non-produc- Residency tive cough. Her eyes are very red with scant non-purulent discharge for which the pediatrician prescribed antibiotic drops. The child developed a rather impressive Paula J. Whiteman, MD non-pruritic facial rash that rapidly spread to the trunk. Despite a negative “rapid Medical Director, Pediatric Emergency Medicine, Encino-Tarzana Regional Medical Center; strep” test and blood and urine cultures, the pediatrician’s concern for this “toxic” Attending Physician, Cedars-Sinai Medical Center, kid was sufficiently worrisome that she elected to start antibiotics. In the pediatric Los Angeles, CA ED, the child is noted to be normotensive, but is tachycardic (consistent with her CME Objectives febrile state). The exam confirmed the report by the pediatrician and found non- Upon completing this article you should be able to: exudative pharyngitis and pustules on the buccal mucosa opposite the molars. A 1. Recognize the different potencies of topical steroids. serologic test was sent that confirmed the suspicion of the attending on duty. 2. Review diagnostic techniques germane to dermatol- ogy. 3. Develop a differential diagnosis and management ediatric dermatology often poses a challenge to practitioners of plan for rashes which are a manifestation of infection Pemergency medicine. When making dermatologic diagnoses, it viral, bacterial, fungal, parasitic, or idiopathic. is important to examine the skin carefully, paying special attention Date of original release: March 1, 2007. to distribution and morphology of lesions, as well as hair, nail, and Date of most recent review: February 1, 2007. See “Physician CME Information” on back page. mucosal changes. Common cutaneous disorders may present differently in All figures in this article are African American patients; when compared with caucasians, the available to paid subscribers lesions of atopic dermatitis in African Americans often occur on the extensor rather than flexor surfaces, are grey rather than erythema- in color at www.ebmedicine.net tous, and are more elevated in appearance. Hypo and hyperpig- under “Topics”. Editorial Board Medicine, Morristown Chicago, Pritzker School of Department; Assistant Professor of Gary R. Strange, MD, MA, FACEP, Memorial Hospital. Medicine, Chicago, IL. Emergency Medicine and Pediatrics, Professor and Head, Department of Jeffrey R. Avner, MD, FAAP, Professor Loma Linda Medical Center and Emergency Medicine, University of Ran D. Goldman, MD, Associate Alson S. Inaba, MD, FAAP, PALS-NF, of Clinical Pediatrics, Albert Children’s Hospital, Loma Linda, CA. Illinois, Chicago, IL. Einstein College of Medicine; Professor, Department of Pediatric Emergency Medicine Director, Pediatric Emergency Pediatrics, University of Toronto; Attending Physician, Kapiolani Brent R. King, MD, FACEP, FAAP, Adam Vella, MD Service, Children’s Hospital at Division of Pediatric Emergency Medical Center for Women & FAAEM, Professor of Emergency Assistant Professor of Emergency Montefiore, Bronx, NY. Medicine and Clinical Children; Associate Professor of Medicine and Pediatrics; Chairman, Medicine, Pediatric EM Fellowship Pharmacology and Toxicology, The Pediatrics, University of Hawaii Department of Emergency Director, Mount Sinai School of T. Kent Denmark, MD, FAAP, FACEP, Hospital for Sick Children, Toronto. John A. Burns School of Medicine, Medicine, The University of Texas Medicine, New York Residency Director, Pediatric Honolulu, HI; Pediatric Advanced Houston Medical School, Martin I. Herman, MD, FAAP, FACEP, Mike Witt, MD, MPH, Attending Emergency Medicine; Assistant Life Support National Faculty Houston, TX. Professor of Pediatrics, Physician, Division of Emergency Professor of Emergency Medicine Representative, American Heart Division Critical Care and Robert Luten, MD, Professor, Medicine, Children’s Hospital Boston; and Pediatrics, Loma Linda Association, Hawaii & Pacific Emergency Services, UT Health Pediatrics and Emergency Instructor of Pediatrics, Harvard University Medical Center and Island Region. Children’s Hospital, Loma Linda, CA. Sciences, School of Medicine; Medicine, University of Florida, Medical School Assistant Director Emergency Andy Jagoda, MD, FACEP, Vice-Chair Jacksonville, Jacksonville, FL. Michael J. Gerardi, MD, FAAP, FACEP, Services, Lebonheur Children’s of Academic Affairs, Department of Ghazala Q. Sharieff, MD, FAAP, Research Editor Clinical Assistant Professor, Medical Center, Memphis TN. Emergency Medicine; Residency FACEP, FAAEM, Associate Christopher Strother, MD, Medicine, University of Medicine Program Director; Director, Mark A. Hostetler, MD, MPH, Clinical Professor, Children’s Fellow, Pediatric Emergency and Dentistry of New Jersey; International Studies Program, Assistant Professor, Department of Hospital and Health Center/ Medicine, Mt. Sinai School of Director, Pediatric Emergency Mount Sinai School of Medicine, Pediatrics; Chief, Section of University of California, San Medicine, Chair, AAP Section on Medicine, Children’s Medical New York, NY. Center, Atlantic Health System; Emergency Medicine; Medical Diego; Director of Pediatric Residents Department of Emergency Director, Pediatric Emergency Tommy Y Kim, MD, FAAP, Attending Emergency Medicine, California Department, The University of Physician, Pediatric Emergency Emergency Physicians. Commercial Support: Pediatric Emergency Medicine Practice does not accept any commercial support. All faculty participating in this activity report no significant financial interest or other relationship with the manfacturer(s) of any commercial product(s) discussed in this educational presentation. mentation are seen frequently in African American mary care visits. The most frequent were infections patients with atopic dermatitis.1-9 Another dermatosis (38.5%); fungal infections accounted for almost 15% that often has a unique clinical presentation in African of all complaints. Americans is pityriasis rosea where the lesions may be distributed in an “inverse” pattern, with the extremi- Diagnostic Tests ties and face being more involved than the trunk. 7-9 This article discusses specific common dermato- In making dermatologic diagnoses, certain techniques logic entities within the broad categories of infec- can be useful in confirming clinical suspicion. One of tious disease, eczematous disorders, inflammatory the most basic techniques used is the potassium disease, and neoplastic disease. hydroxide (KOH) preparation for the diagnosis of dematophytosis. For this technique, use a number 15 Epidemiology blade to scrape the skin from the outer border of a suspected tinea infection onto a glass slide. Then, The frequency of skin complaints is fairly constant place two drops of 10% KOH over the scale and heat despite the season of the year. Skin complaints over a flame for 15 to 30 seconds to fix the prepara- amount to almost a quarter of outpatient visits. tion. A survey of the slide under low power will As depicted in the table below, five general der- reveal suspected hyphae. 8,9,15 In the case of an equivo- matologic categories accounted for 81.5% of the pri- cal KOH preparation, a fungal culture can be sent for confirmation of the diagnosis. Table 1. A Study By Dr. Tunnessen From The Pediatric Outpatient Clinic At Upstate Medical Tzanck smears may be helpful in the diagnosis of Center In Syracuse, New York infections caused by the herpes virus family. Use a blade to unroof a vesicle and swab the base with a Diagnosis Percentage of Disorder cotton tipped applicator. Then, spread the material Bacterial Skin Infections 17.5 obtained from the base of the lesion onto a glass slide Impetigo 10 then heat fix. After fixation, apply any blue stain Cellulitis 6 (Giemsa or Wright) and leave on for five minutes, Folliculitis 1.5 Viral Skin Infections 6.5 after which time, wash the excess stain off. The find- Exanthem 4 ing of multinucleated giant cells indicates the pres- Warts 2 ence of herpes simplex or herpes zoster/varicella Molluscum 0.5 Fungal Skin Infections 14.5 virus; the Tzanck smear can not be used to distinguish Tinea Corporis 3 among these three infections. 8,9,15,27 Tinea Capitis 7 In a patient with suspected scabies, use a mois- Monilia 4.5 tened scalpel blade to vigorously scrape a burrow or Parasitic Skin Infestations 5.5 Pediculosis 2 papule. Spread the scrapings onto a slide and exam- Flea bites 2 in under low power for evidence of mites (no distin- Scabies 1.5 guishable head with four pairs of legs, and bristles Dermatitis Atopic Dermatitis 14.5 on its dorsal surface,
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