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    Case Presentation: Pediatrics Rotation

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    klipord
    This case presentation describes a 7-year-old male presenting with multiple crusted lesions around the mouth, nose, and trunk. Based on the history, physical exam, and differential diagnosis, the diagnosis was determined to be nonbullous impetigo. The patient was prescribed topical mupirocin ointment and oral cephalexin for 10 days each. The mother was educated on proper wound care and preventing spread.

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    Case Presentation: Pediatrics Rotation

    Uploaded by

    klipord
    21 views25 pages
    This case presentation describes a 7-year-old male presenting with multiple crusted lesions around the mouth, nose, and trunk. Based on the history, physical exam, and differential diagnosis, the diagnosis was determined to be nonbullous impetigo. The patient was prescribed topical mupirocin ointment and oral cephalexin for 10 days each. The mother was educated on proper wound care and preventing spread.

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    This case presentation describes a 7-year-old male presenting with multiple crusted lesions around the mouth, nose, and trunk. Based on the history, physical exam, and differential diagnosis, the diagnosis was determined to be nonbullous impetigo. The patient was prescribed topical mupirocin ointment and oral cephalexin for 10 days each. The mother was educated on proper wound care and preventing spread.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    21 views25 pages

    Case Presentation: Pediatrics Rotation

    Uploaded by

    klipord
    This case presentation describes a 7-year-old male presenting with multiple crusted lesions around the mouth, nose, and trunk. Based on the history, physical exam, and differential diagnosis, the diagnosis was determined to be nonbullous impetigo. The patient was prescribed topical mupirocin ointment and oral cephalexin for 10 days each. The mother was educated on proper wound care and preventing spread.

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    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?
    – NO
    • Has any attempt made to self treat the rash?
    – NO
    • Is the child currently on any medications?
    – NO
    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?
    – NO
    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
    – 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???

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