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Visual Diagnosis

Rakesh D. Mistry, MD, MS

Division of Emergency Medicine

Children’s Hospital of Philadelphia

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8 mo. with fever and diaper rash

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8 mo. with fever and diaper rash

Differential Diagnosis– Bullous impetigo

– S. aureus scalded skin

– Erysipelas

– Perianal group A strep

– Stevens-Johnson

– Partial-thickness burn

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Erysipelas

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10 y.o. male with rash on leg

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Ecthyma

• Local necrotizing skin infection

• Microbiology– Streptococcus pyogenes

(GABHS)

– S. aureus

– Pseudomonas aeurginosa

• Systemic– Ecthyma gangrenosa

– Immune deficiency

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Ecthyma

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Bullous impetigo

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4 y.o. girl with progressive facial swelling and fever

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Facial Swelling

• Dental abscess

• Facial cellulitis

• Parotitis

• Sinusitis

• Lymphadenitis

• Insect bite

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Another view…

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Facial Cellulitis

• Microbiology– Staphylococcus aureus– Group A ß-hemolytic Streptococcus (GABHS)– Haemophilus tnfluenzae type B

• Treatment:– Cephalosporins, clindamycin– Consider IV

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6 y.o. male with fever, neck swelling, pain with eating

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Parotitis

• Displaces ear• Obscures inferior border

and angle of mandible • Microbiology

– S. aureus– Oral flora– Infuenzae– Coxsackie/Enteroviruses– Mumps– HIV

• Consider imaging for abscess

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Lymphadenitis

• Microbiology– GABHS– H. influenzae– S. aureus– Oral flora

• Treatment– Ampicillin/Sulbactam– Clindamycin– Consider imaging for

abscess

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12 mo. female with “rash”

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Popsicle Panniculitis

• Extended contact with cold

• Subcutaneous fat necrosis

• Benign condition: Reassurance

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5 y.o. girl with blood in underwear

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• Pre-pubertal girls

• Associated with constipation, increased abdominal pressure

• Management– Sitz baths and reassurance– Topical estrogen cream– Urology follow-up

Urethral Prolapse

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13 y.o female with 6 months of episodic abdominal pain

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Hematocolpos

• Imperforate hymen

• Primary amenorrhea

• Abdominal mass

• Treatment: Surgical

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Electrical Burn

• Differential– Caustic ingestion– Infectious

• Risk for delayed labial artery bleed

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15 y.o. fever, sore throat, abdominal pain

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15 y.o. fever, sore throat, abdominal pain

• Differential Diagnosis– GABHS

– N. gonorrhea

– Adenovirus

– Influenza

– Mononucleosis• Epstien-Barr Virus

(EBV)

• Cytolomegalovirus (CMV)

• Diagnosed

GABHS (+)• Placed on penicillin

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Non-compliant…Returns in 5 days

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Peritonsillar Abscess

• Older children and adolescents

• “Hot-potato” voice

• Trismus and drooling

• Management– Needle aspiration– Antibiotic therapy

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14 y.o. male with fever, neck pain, and dysphagia

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Ludwig’s Angina

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Ludwig’s Angina

• Submandibular/sublingual infection

• Rapidly progressive

• Management– Monitor airway– IV antibiotics– Surgical drainage

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18 mo. “not using hands”

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18 mo. “not using hands”

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Vitamin D Deficiency

• Hypocalcemia• Dietary• Skeletal findings

– Bowing

– Epiphyseal widening

– “Rachitic rosary”

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3 y.o. girl not using right arm

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Radial Head Subluxation

• Typical appearance of well-appearing child not using affected arm

• Reduction– Supination-Flexion– Pronation-Extension

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8 y.o. female with fatigue and dyspnea on exertion for 2 weeks

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Pallor

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Anemia

• Typically appears with hemoglobin ~8 gm/dL

• Anemia– Nutritional

– Blood loss

– Malignancy

– RBC destruction

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Infant with severe diarrhea

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Central Cyanosis

• Severe pulmonary disease

• Shock

• R L cardiac shunt

• Polycythemia

• Abnormal hemoglobin states

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Methemoglobinemia

• Oxidative stress: diarrhea, dehydration, acidosis

• Methemogobin cannot carry O2 tissue hypoxia

• Fluid resucitation

• Methylene blue

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Fever and spreading rash

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Petechiae

• Meningococemia• Viral exanthem• Rocky Mountain Spotted Fever

(Rickettsia rickettsi)• Immune Thrombocytopenic

Purpura• Mechanical

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5 y.o. male casted 3 days ago for presumed fracture, now with rash

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Henoch-Schonlein Purpura

• Presentation– Palpable purpura– Joint swelling and pain– Abdominal Pain– Renal involvement

• Management– Pain control– Urinalysis– Consider steroids

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Malar Rash: Systemic Lupus Erythematosus (SLE)

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14 year old boy with painful rash on face and eye pain

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Herpes Zoster

• Dermatomal distribution

• Pain control

• IV or PO Acyclovir

• Trigeminal nerve: suspect ocular disease

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3 y.o. with “finger infection”

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Herpetic Whitlow

• Differential Diagnosis– Paronychia– Bullous impetigo

• Do not incise

• Treat symptomatically

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2 y.o. history of dry skin, now red painful rash

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Eczema Herpeticum

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3 y.o. girl with rash on face

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Herpes Keratoconjunctivitis

• Analgesia

• Topical Acyclovir

• Do not use steroids!

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21 mo.female with right eye swelling and fever

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Eye Swelling

• Conjunctivitis

• Periorbital cellultiis

• Orbital cellulitis

• Insect bite

• Allergic reaction

• Hypoproteinemia (Nephrotic Syndrome)

• Epstien-Barr Virus

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Poked in eye at school

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Open Globe Injury

• Iris plugs defect misshapen pupil

• Stop examination immediately

Cover eye with hard protective shield

Consult ophthalmology

Avoid increases in intraocular pressure

No ointments or drops

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Neonate with fever and pus from umbilical stump

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Omphalitis

Differential• Infected urachal cyst• Umbilical hernia• Patent omphalomesenteric

duct

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4 y.o. backseat passenger in motor vehicle crash

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Seatbelt/Lapbelt Injury

• Abdominal or pelvic bruising• Intra-abdominal injuries

• Hollow viscus• Solid organs

• Lumbar spine fracture (Chance fracture)• Management

• Abdominal CT• Admit for serial exams

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20 mo. male was “playing rough” with brother

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Child Abuse

• Multiple bruises

• Soft tissues-not over bony prominences

• Shape of fist or pinch

• Loop-belt or cord marks

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3 week-old with eye swelling

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3 week-old with eye swelling

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Orbital Tumor

• Neuroblastoma

• Retinoblastoma (usually within globe)

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Ophthalmia Neonatorum

• Chlamydia trachomatis

• Neisseria gonhorrheae

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12 mo. female with rash

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12 mo. female with rash

• Differential Diagnosis– Urticaria– Stevens-Johnson Syndrome– Erythema Migrans (Lyme Disease)– Erythema Multiforme

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Erythema Multiforme Minor

• Infectious– Epstein-Barr Virus (EBV)– Mycoplasma

• Serum sickness

• Autoimmune disease

• Malignancy

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Teenager with fever, rash, red eyes

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Teenager with fever, rash, red eyes

• Differential Diagnosis– Adenovirus

– Kawasaki syndrome

– Stevens-Johnson Syndrome

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Stevens-Johnson Syndrome

• Erythema multiforme major

• Mucosal surfaces

• Etiology: infections? medications?

• Severe cases: exfoliating, similar to burn

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12 y.o. male with painful leg rash

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Erythema Nodosum

• Painful, well- circumscribed nodules

• Etiology– Infectious

– Medications

– Inflammatory bowel disease

– Malignancy

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Uvular Swelling

• Allergic/angioedema

• Infection (GABHS)

• Trauma

• Thermal or Chemical irritation

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Recurrent infection of outer ear

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The other ear…

• Pre-auricular sinus and cyst

• Diagnosis– Neonatal period– Infection later in life

• Associated with deafness

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8 y.o. fever, headache, vomiting

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8 y.o. fever, headache, vomiting

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Pott’s Puffy Tumor

• Sinusitis with:– Scalp swelling – Osetomyelitis and anterior erosion– Extradural abscess– Intracrania abscess

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2 y.o. thigh pain and redness

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2 y.o. thigh pain and redness

• Differential Diagnosis– Cellulitis– Skin abscess– Osteomyelitis with fistula – Retained foreign body– Spider bite

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Skin Abscess

• Methicillin-resistant S. aureus (MRSA)

• Incision and drainage paramount

• Clindamycin or trimethoprim-sulfa

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Venomous Snake Bite

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Venomous Snake Bite

• Crotalinae family, or “pit vipers”– Vertical, elliptical pupils

– Triangular head

– Single row of caudal plates, or rattle

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Venomous Snake Bite

• Immobilize extremity below heart

• Anti-venin required

• NOT indicated– Incision and suction– Tourniquet– Cryotherapy

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10 y.o. girl with fever, left eye pain, and diplopia

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Orbtal Myositis

• Pain

• Fever

• Ocular muscle paresis

• Proptosis

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14 y.o. female with “uneven smile” noted this AM

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Peripheral Facial Nerve Palsy

• Common etiologies– Idiopathic (Bell’s Palsy)

– Borrelia burgdorferi (Lyme Disease)

– Varicella-Zoster (Ramsay Hunt Syndrome)

– Herpes Simplex Virus

– Epstein-Barr Virus (EBV)

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Peripheral Facial Nerve Palsy

• Treatment– Fluoroscein eye– Eye patching and lubricant– Presence of Otitis media is ENT emergency!– Treat underlying condition if noted– Empiric steroids and acyclovir controversial