Healthy Baby Practical advice for treating newborns and toddlers.

Management of a Digital World: From Felons to Fungus Stan L. Block, MD, FAAP

ost practitioners think that underneath the bullous lesion. In addition, do not observe any small circular fiery red rashes and lesions of the fin- he has no history of or exposure to herpes herpetic-like lesions. However, you remem- M gers are relatively straightfor- simplex cold sores or lesions. It certainly ber that for fingertip bullous lesions you ward to diagnose and manage. But you appears to be a straightforward case of bul- must readjust your therapy specifically and will likely encounter some real “stumpers” lous impetigo — but is it? You decide to accordingly. Why? in your lengthy careers that will produce start empiric antibiotic therapy, but only af- much consternation and confusion. You ter you have incised the lesion with a needle Case 2 must be willing to consider the unusual di- or blade and have also obtained a bacterial A 12-year-old white girl presented to agnosis, pathogen, or medication response. culture. When the lesion is unroofed, you your office with both classic types of im- Each one of the following eight cases will hopefully teach some of the nuances about the pediatric “digital” world. Unless oth- erwise stated, each of the following cases was age-appropriately fully vaccinated and had a normal physical examination and vi- tal signs.

CASES Case 1 This previously healthy 2-year-old white boy presented to your office with a painful blister on the lateral edge of the index fin- Images courtesy of Stan L. Block, MD, FAAP. gertip within the past 24 hours (see Figure Figure 1. A 2-year-old white boy with painful pus-filled blister of the left index finger for the past 24 1). The lesion is only slightly reddened at hours. the base of the bullous lesion, which makes a herpetic whitlow less likely to be hiding

Stan L. Block, MD, FAAP, is Professor of Clinical Pediatrics, University of Louisville, and University of Kentucky, Lexington, KY; President, Kentucky Pedi- atric and Adult Research Inc.; and general pediatri- cian, Bardstown, KY.. Address correspondence to Stan L. Block, MD, FAAP, via email: [email protected]. Disclosure: Dr. Block has no relevant financial Figure 2. A 12-year-old white girl with a 3-day history of blisters on her right leg. The proximal lesion has relationships to disclose. burst, developing into typical impetigo, whereas the distal blister remains intact and is representative doi: 10.3928/00904481-20130619-05 of the uncommonly observed bullous impetigo (similar to Figure 1).

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petiginous lesions: the honey-crusted red- based round flat lesion of impetigo simplex proximally, and the early singular pus- filled blister of “bullous impetigo” distally (see Figure 2, page 271). You are aware that most impetigo sores — even the bullous le- sions — are caused by Staphylococcus au- reus. However, about 10% to 25% may be also caused by Streptococcus pyogenes, ei- ther as a sole pathogen but mostly as a co- Figure 3. A 10-year-old white boy presenting Figure 4. A 4-year-old white girl with a deep cat pathogen. Similar to most US locales, you with a painful and reddened paronychia of the scratch of the finger pad that has now developed also have observed a 75% rate of methicil- index finger. into a painful, red, swollen, pus-filled pocket over the past 48 hours. lin-resistant S. aureus (MRSA) among the S. aureus skin lesions in your area. Thus, 24 hours, the lesion has developed into a you will most likely opt for antibiotic cov- deeper, very painful “pointing” abscess of erage of MRSA in this case, instead of a the index finger pad, which has swollen to cephalosporin that only has coverage for double the size of the comparative middle both S. pyogenes and methicillin-sensitive finger (see Figure 4). She was unable to S. aureus.1 For outpatients, choosing cover- sleep last night. You remember something age for MRSA means choosing between a particularly worrisome about this type of very poorly palatable antibiotic (clindamy- finger pad lesion, but the details escape cin) or an antibiotic with no S. pyogenes you. She has good range of motion of the coverage (trimethoprim-sulfamethoxazole finger but is in moderately severe pain at [TMP-SMX]). The latter choice will often the fingertip. Not only must you decide require obtaining a bacterial culture of the which pathogen to target (as many other lesion, in case the pathogen is S. pyogenes. organisms are potential causes, especial- With the clindamycin choice, you must ly after any bites or scratches2), but also also keep in mind that occasional strains whether to hospitalize the child. Why? of MRSA have developed resistance as well.1 Thus, careful follow-up, at least by Case 5 Figure 5. A 4-month-old white infant with small blisters and vesicles on the right hand and fingers. phone contact, over the next few days may A 4-month-old white girl has devel- be prudent. oped multiple small vesicles over her palms and soles (see Figure 5). She has ister acetaminophen and to force fluids Case 3 had a fever to 102.5°F for the past 3 days into the baby. A 10-year-old healthy boy presented to and has been drinking poorly, drooling, your office with this very painful, mildly and is very cranky. On physical examina- Case 6 reddened lesion of the proximal lateral tion, she has several small, round, cen- By contrast, a previously healthy nail (see Figure 3). You surmise that it is a trally yellow, red-based blisters in her 10-year-old black girl from rural Ken- commonly observed paronychia, most of posterior pharynx and buccal mucosa. tucky has developed a quite ominous set which are caused by S. aureus, and in par- Although you contemplated a fleeting of petechiae on her palms and soles, along ticular MRSA. Thus, you elect to treat this diagnosis of mucocutaneous herpes sim- with a low-grade fever and sore throat patient similar to the child with impetigo plex infection, you are quite familiar (see Figure 6, page 273). Interestingly, in Case 2. with these particular patterns of lesions on physical examination, she also has a being part of the hand-foot-mouth syn- few small vesicles in her posterior phar- Case 4 drome caused by one of the many entero- ynx, similar to those described in Case 5. By contrast, a previously healthy viruses. You are quite comfortable with As most pediatricians know, a heavy crop afebrile 4-year-old girl received a deep reassuring the family about your diagno- of petechiae might portend more serious scratch 2 days ago from a cat. In the past sis, and for them to continue to admin- disease processes and infections, such as

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RESOLUTION OF CASES 1, 4, 6, 7, 8 Case 1 (Figure 1) This child’s solitary lateral purulent blister of the distal finger is caused by “blistering distal dactylitis.” The caus- ative pathogen in most cases is solely S. pyogenes.3 Thus, your antibiotic choice must avoid the use of TMP-SMX, which although appropriate for most MRSA A B outpatient infections, has absolutely no Figure 6. (A) A 10-year-old black girl with petechiae on the hands, fingers, and feet who is febrile and has a sore throat during the summer in rural Kentucky. (B). The same patient as in part A, who has a role in the treatment of S. pyogenes. You heavy crop of petechiae on the soles of her feet and also her lower legs (not shown). start an oral cephalosporin, and open up the blister and find that the culture grows S. pyogenes at 24 hours, confirming your suspicion.

Case 4 (Figure 4) This child has an early, moderately severe finger infection termed “felon,” or pulp space abscess, which occurs most commonly on the thumb or index finger. A B Although the area of swelling, cellulitis, and redness is limited to distal phalanx Figure 7. (A) A 7-year-old black boy with a disturbing-looking eroded, slightly reddened, itchy rash on the left index mid-finger that has been unresponsive to steroid and antifungal creams over the past 3 early on, it can lead to “ischemic necro- weeks. (B) The same patient as in part A, with a lateral view of the infected finger. sis of surrounding tissue, osteomyelitis, flexor tenosynovitis [pain on any motion of the finger flexor tendon], or septic -ar Rocky Mountain spotted fever (RMSF), Case 8 thritis.”3 You easily open up the “pointing meningococcemia, idiopathic thrombo- This 4-year-old otherwise healthy wound” by needle puncture, and express cytopenia (ITP), leukemia, etc. You order white boy presents to your office with a 3 mL of purulent material for culture. a complete blood count, blood cultures, constellation of findings that seem to fit no Your two dilemmas are now which an- and comprehensive metabolic panel. This particular pattern. He has a history of fe- tibiotic to choose and whether to hospi- type of petechial rash always makes you ver, sore throat, and fine red maculo-papu- talize the patient. You decide that the ac- exceedingly nervous. lar rash on his abdomen and axilla for the cumulation of a large amount of purulent past 24 hours, along with a “bubbly” clear, material this quickly most likely indicates Case 7 vesicular pruritic rash localized mostly on a gram-positive infection, so you initiate The erosive-looking pruritic but only his hands and feet for the past 48 hours outpatient therapy with oral clindamycin, slightly erythematous rash on the index (see Figure 8, page 274). Besides the rash- which also might cover a potential bone finger is quite perplexing in this other- es, his physical examination reveals only infection as well. Although a cat scratch wise healthy 7-year-old black boy, as you a red pharynx and mildly swollen, tender was involved, you decide to wait 24 to expected either the steroid or antifungal anterior lymphadenopathy. A rapid strep 48 hours before covering for Bartonella cream (miconazole) to dissipate the rash. test confirms that he has strep throat, but with azithromycin and before obtaining However, it has continued to worsen over you are still befuddled by his extremity a finger radiograph, which is unlikely to 3 weeks to the current status as seen in rash, which is definitely not a part of his show any bony changes so quickly. You Figure 7. Is a trial of antistaphylococcal scarlet fever-like rash on the trunk. You ask the family to return the next day. antibiotics needed? You also consider the initiate therapy with amoxicillin for strep The culture grows MRSA, but the possibility that this could be a severe her- and certirizine for itching. You are unde- mother, whom you learn works most petic infection. cided as to whether to start oral steroids. days, does not return to the office the

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next day. She does not return your phone calls over the weekend as you try to ob- tain an update on the infection. You had considered hospitalization if the child did not improve. Finally on Monday, your phone nurse learns per the mother (much to your relief) that the child is doing extremely well and is taking the medication without problem. A B

Case 6 (Figures 6A and 6B) Figure 8. A 4-year-old white boy with a peculiar, heavily vesicular, slightly pruritic rash of both hands (A) Every child with notable petechiae and ankles (B). He also has fever, pharyngitis, lymphadenopathy, and a scarlet fever rash over his entire torso. must be thoroughly evaluated; up to three-fourths of children with petechiae in a German series were hospitalized.4 as a single dose with a fatty meal for the the situation in this child. The rash may When you determine that this child has next month. At follow-up in 7 days, you last from 10 days to 12 weeks.5,6 The no meningismis, fever, or purpura; acts observe a much improved rash, with primary differential diagnosis is acro- healthy; has a normal leukocyte count nearly total resolution and surprisingly dermatitis enteropathetica due to zinc with an absence of bands and with nor- minimal scarring, despite the somewhat deficiency. General treatment of GCS in- mal platelets; and has normal sodium cratered appearance seen earlier (see cludes emollients and antihistamines. and liver functions, you feel relieved. Figure 7A, page 273). He also has the classic herpangina oral REFERENCES lesions. You know that this is almost as- Case 8 (Figures 8A and 8B) 1. AAP Committee on Infectious Diseases; Pick- ering LK, Baker CJ, Kimberlin DW, Long SS suredly not RMSF, meningococcemia, The acrodermatitis rash did resolve (eds). Red Book: 2012. Report of the Commit- or leukemia.5,6 Your literature search over 3 weeks, unlike the scarlet fe- tee on Infectious Diseases (Red Book Report shows that enteroviruses, particularly ver rash that resolved in 48 hours. You of the Committee on Infectious Diseases). echovirus 9 and Coxsackie A9 strains, elected not to treat with steroids initially 29th ed. Elk Grove Village, IL. American Academy of Pediatrics; 2012. account for up to 12% of strictly pete- in light of the streptococcal infection. 2. Ceroni D, Merlini L, Salvo D, Lascombes P, chial rashes.4-6 You still request follow- You did not figure out the etiology of Dubois-Ferrière V. Pyogenic flexor tenosy- up the next morning to re-examine the this child’s rash for nearly 1 year, until novitis of the finger due to Kingella kingaes. Pediatr Infect Dis J. 2013;32(6):702-703. child for any changes. you saw an identical case at a pediatric 3. Rich P, Jefferson JA. Overview of nail disorders. continuing medical education course. Available at: www.uptodate.com/contents/ Case 7 (Figures 7A and 7B) This was a case of Gianotti-Crosti syn- overview-of-nail-disorders?source=search_res ult&search=blistering+distal+dactylitis&selec Despite the lack of any response to drome (GCS), or papular acrodermatitis. tedTitle=1~1#H57682918. Accessed June 11, topical antifungals, you are seeing a This particular vesicular pruritic appear- 2013. notable number of cases of skin fun- ance is a variation known as “papulo- 4. Schneider H, Adams O, Weiss C, Merz U, gal infections unresponsive to the usual vesicular acro-located syndrome.”6 GCS Schroten H, Tenenbaum T. Clinical charac- teristics of children with viral single- and co- topical antifungals. You strongly think is associated with many viruses (eg, Ep- infections and a petechial rash. Pediatr Infect that this is probably fungal (eg, Tricho- stein-Barr and enterovirus). Current lit- Dis J. 2013;32:e186-191. phyton rubrum) and a deeper seeded erature suggests that it is rarely ever as- 5. Feigin RD, Cherry J, Demmler-Harrison GJ, Kaplan SL. Feigin and Cherry’s Textbook of infection, such as “Majocchi’s granu- sociated with hepatitis B virus, as it was Pediatric Infectious Diseases. 6th ed. Philadel- loma” (which is like a kerion or deeper in many older case series. Interestingly, phia, PA: Elsevier/Saunders; 2009. infection of the hair follicles).6 There- it has been associated with bacterial in- 6. Paller AS, Mancini AJ (eds). Hurwitz Clini- cal Pediatric Dermatology: A Textbook of Skin fore, you empirically start oral griseo- fections such as cat scratch disease, my- Disorders of Childhood and Adolescence. 3rd fulvin at ultramicrosize 20 mg/kg/day coplasma, and S. pyogenes, which was ed. Philadelphia, PA: Elsevier/Saunders; 2006.

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