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CONTENTS

COMMENTARY

87 The Importance of Amy Lynn

Vincent J. Menna

ARTICLES

89 Cocaine: A Review

John Wootton and Sheldon I. Miller

93 Point-Counterpoint: Otitis Media

94 Migraine Headaches in Children

Harvey S. Singer

102 Hematuria

Douglas S. Fitzwater and Robert J. Wyatt

110 Scabies

James E. Rasmussen

115 Consultation with the Specialist:

Hearing Loss in the Absence of Otitis Media

John F. Kveton

117 Index of Suspicion

Najla N. Falaki, Michael Shannon, and

Anthony M. Policastro

ABSTRACTS

87 Labial Adhesions

88 Congenital Nasolacrimal Duct Obstruction

120 Myocarditis

121 Foreign Body Aspiration

122 Common Red Cell Transfusion Reactions

COVER

“Le Gourmet,” painted in 1901 by Picasso (1881.1973) during his “BluePeriod,” demonstrates the natural appetite of the small child, who appearswell nourished and even is eating standing up. Eating problems in children

are not inherent in their stage of development but are their response toadverse environments. The blue color, however, suggests a threat to this

healthy state. Child health professionals must balance this innate healthy

aspect of childhood against the environmental threats to their well-beingand be advocates for the healthy development of children. (This painting isfrom the National Gallery of Art’s Chester Dale collection and is

reproduced with permission.)

ANSWER KEY

1. A; 2. A; 3. E; 4. D; 5. D; 6. C; 7. E; 8. B; 9. C; 10. C; 11. C; 12. D;13. D; 14. E; 15. C; 16. D; 17. A; 18. E; 19. A; 20. D; 21. B; 22. C

Printed in the USA

Pediatrics in Review

Vol 15 No 3March 1994

EDITORRobert J. HaggertyUniversity of RochesterSchool of Medicine and DentistryRochester, NY

Editorial Office:Department of PediatricsUniversity of RochesterSchool of Medicine and Dentistry601 ElmwoodAve, Box 777Rochester, NY 14642

ASSOCIATE EDITORLawrence F. NazarianPanorama Pediatnc GroupRochester, NY

CONSULTING EDITOREvan Charney, Worcester, MA

ABSTRACTS EDITORSteven P. Shelov, Bronx, NY

MANAGING EDITORJo Largent, Elk Grove Village, IL

EDITORIAL CONSULTANTVictor C. Vaughan, III, Stanford, CA

EDITORIAL BOARDMoris A. Angulo, Mineola, NYRussell W. Chesney, Memphis, TNPeggy Copple, Tucson, AZRichard B. Goldbloom, Halifax, NSJohn L. Green, Rochester, NYRobert L Johnson, Newark, NJKathi Kemper, Seattle, WAAlan M. Lake, Glen Arm, MDFrederick H. Lovejoy, Jr, Boston, MAJohn T. McBride, Rochester, NYVincent J. Menna, Doylestown, PALawrence C. Pakula, Timonium, MDJohn M. Pascoe, Madison, WIRonald L Poland, Hershey, PAJames E. Rasmussen, Ann Arbor, MIJames S. Seidel, Torrance, CARichard H. Sills, Newark, NJLaurie J. Smith, Washington, DCWilliam B. Strong, Augusta, GAJon Tingelstad, Greenville, NCVernon T. Tolo, Los Angeles, CARobert J. Touloukian, New Haven, CTTerry Yamauchi, Little Rock, ARMoritz M. Ziegler, Cincinnati, OH

EDITORIAL ASSISTANTSydney Sutherland

PUBLISHERAmerican Academy of PediatricsErrol R. Alden, Director

Department of EducationJean Dow, Director

Division of PREP/PEDIATRICSDeborah Kuhlman, Copy Editor

PEDIATRICS IN REVIEW (ISSN 0191.9601) is ownedand controlled by the American Academy ofPediatrics. It is published monthly by the AmericanAcademy of Pediatrics, 141 Northwest Point Blvd.P0 Box 927, Elk Grove Village, IL 60009-0927.

Statements and opinions expressed in Pediatricsin Review are those of the authors and not necessaniythose of the American Academy of Pediatrics or its

Committees. Recommendations included in thispublication do not indicate an exclusive course oftreatment or serve as a standard of medical care.

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92 Pediatrics in Review VoL 15 No. 3 March 1994

SUBSTANCE ABUSECocaine

treatment of suspected life-threaten-ing cocaine overdose in the infant issupportive.

TreatmentSeizures are best treated with diaze-pam. Imbalances in pH must be cor-

rected and the patient monitored andtreated for cardiac arrhythmias. Other

previously noted medical complica-tions are treated supportively.

Patients who present acutely intox-

icated require stimulation to be keptto a minimum until the immediate“high’ ‘ abates. Benzodiazepines may

help in the face of psychomotor agi-

tation. If psychosis is present, halo-peridol is the drug of choice.

However, neuroleptics should beused in the lowest possible dose be-cause they may lower the seizure

threshold.As noted previously, there is a

rather long period of withdrawal

from cocaine marked by depressionand anhedonia. This is a particularlyvulnerable period for the addict at-

tempting to maintain abstinence andcan last up to 3 months. Numerousdrugs have been tried to decreasecraving and reverse withdrawalsymptoms, with equivocal results.Amantadine, bromocriptine, and tn-cyclic antidepressants have been usedat standard therapeutic doses bymany and are thought to be helpfulby some. Whether these beneficialeffects derive from therapeutic ac-tions or as a placebo response tothese drugs is unclear.

The previously noted treatmentsare important. However, in addic-tion, the only acceptable goal oftreatment is a lifelong abstinencefrom all addicting psychoactive

agents, with particular emphasis onthe drug of choice. Very rarely is

this achieved through pharmacologicintervention or one-on-one psycho-logic intervention alone. The

achievement of this goal usually de-

pends on the patient’s participation ina structured intensive drug treatmentprogram. Most of these treatmentscan occur on an outpatient basis,with only a small percentage requir-ing inpatient care, and they are en-hanced greatly by the patient’sinvolvement in a 12-step self-helpgroup.

SUGGESTED READINGAdams EH, Blanken AJ, Ferguson LD,

Kopstein A. Overview of Selected Drug

Trends. Rockville, MD: National Institute

on Drug Abuse; 1989; publication NIDA

RPO-73 1

American Psychiatric Association. Diagnostic

and Statistical Manual of Mental Disorders.

3rd ed. Washington, DC: 1987

Brown ER, Zuckerman B. The infant of the

drug-abusing mother. Pediatr Ann.

1991 ;10:555-563

Chasnoff IJ, Griffith DR. MacGregor 5, et al.

Temporal patterns of cocaine use in

pregnancy. JAMA. 1989;261:1741-1744

Chasnoff IJ, Schnoll SH. Consequences of

cocaine and other drug use in pregnancy. In:Washton A, Gold MS. eds. Cocaine: A

Clinician ‘s Handbook. New York, NY: The

Guilford Press; 1987:241-251

Cregler LL, Mark H. Medical complications of

cocaine abuse. NEnglJMed. 1986;315:

1495-1500

Frances Ri, Miller SI. Clinical Textbook of

Addictive Disorders. New York, NY: The

Guilford Press; 1991

Gawn FH, Kleber HD. Abstinence symptoma-

tology and psychiatric diagnosis in cocaine

abusers: clinical observations. Arch Gen

Psychiatry. 1986;43:107-1 13.Hadeed AJ, Siegel SR. Maternal cocaine use

during pregnancy: effect on the newborn

infant. Pediatrics. 1989;84:205-210

Karan LD, HaIler DL, Schnoll SH. Cocaine.

In: Frances Ri, Miller SI, eds. Clinical

Textbook of Addictive Disorders. New York,

NY: The Guilford Press; 1991:121-145Lowenstein DH, Massa DM, Rowbotham MC,

et al. Acute neurologic and psychiatric

complications associated with cocaine abuse.

Am J Med. 1987;83:841-846

Mule SJ. The pharmacodynamics of cocaine

abuse. Psychiatr Ann. 1984;14:724-727

National Institute on Drug Abuse (NIDA).

Drug abuse warning network (DAWN)

(Data File). Rockville, MD; 1989

Ryan L, Ehlich 5, Finnegan L. Cocaine abuse

in pregnancy: effects on the fetus and

newborn. Neurotoxicol Teratol. 1987;9:295-

299

PIR QUIZI . A 1 7-year-old male Hispanic patient

acknowledges during a physical cx-

amination that he was offered crack

cocaine at a party recently. He

states that he has never used cocaine

before. He asks your help in decid-

ing whether to accept the opportu-

nity if offered again. Of the

following statements, the most ap-

propriate information for use in

counseling your patient is that:

A. He runs the risk of becoming a

compulsive user.

B. Hispanic adolescents use cocaine

less frequently than do non-

Hispanic adolescents.

C. Nearly all who try cocaine be-

come regularusers.D. The risk of a cocaine user being

admitted to an emergency room

has dropped dramatically during

the past decade.E. The streetcost of cocaine has

risen substantially during the

past decade.

2. During attending rounds, you arepresented a 17-year-old female pa-

tient admitted the previous night

having pelvic inflammatory disease,who reported that she began snort-

ing cocaine with her boyfriend 2weeks ago. You are asked by your

residents to review the pharmacol-

ogy and mode of action of cocaine

to explain why the method of

administration may vary among

users over time. The most appropri-

ate statement regarding repeated co-

caine use isthat:A. Of the three most common

methods of administration, free-

basing (smoking) produces themost rapid onset of action.

B. Regardless of how administered,

the amount of drug required to

achieve desired results is con-

stant over time.

C. Snorting is the most efficientway to deliver cocaine to the

brain

D. The duration of the “rush” gen-

erated by free-basing is greater

than that generated by snorting.

E. The intensity of the cocaine“rush” produced by snorting is

greaterthan thatproduced byfree-basing.

3. During an annual physical examina-

tion, a 17-year-old female patient

asks about the risks of cocaine use.

Among the medical complications

produced directly by cocaine use,you would most appropriately iden-

tify:A. Hemolytic anemia.

B. Hypoparathyroidism.

C. Malignant obesity.

D. Pathologic fracture.

E. Ventricular tachycardia.

4. An agitated, periodically violent 16-

year-old girl manifesting paranoid

ideation is admitted to the intensive

care unit following repeated intrave-

nous cocaine use at a party. You are

aware that multiple drug use is in-

creasingly common and that cocaine

frequently is cut with a variety of

substances. Aside from cocaine it-

self, which of the following sub-

stances is most likelyto beexacerbating the girl’s symptoms?

A. Ethyl alcohol.

B. Heroin.C. Lidocaine.

D. Phencyclidine.

E. Talc.

5. A homeless 19-year-old girl has de-

livered an infant weighing 2500 g.She has no history of prenatal care.She admits to use of cocaine

throughout the pregnancy, and her

urine screen is positive for benzoy-

lecgonine. Which of the following

conditions in the infant is most

likely to demand special attention in

the first 12 hours after birth?

A. Cocaine withdrawal syndrome.

B. HIV infection.

C. Hypovolemic shock.

D. Intrauterine growth retardation.

E. Respiratory distress syndrome

(hyaline membrane disease).

Pediatrics in Review Vol. 15 No. 3 March 1994 93

LII1�±�I�1 POINT-COUNTERPOINT ______

Otitis Media

A reader questioned Dr. Howie’s an-tide on otitis media (PIR 1993;14:320-323) on three counts:1. His recommendation not to use

amoxicillin as first-line treatment

for acute otitis media;2. His discussion of otitis media

with perforation; and3. His recommendation to place tym-

panostomy tubes in “any young-ster who has otitis media witheffusion that persists for 6 to 12weeks.”

Dr. Howie responds:“I share with you the frustration

of the ever-present challenge of otitismedia with effusion (OME), whether

acute, recurrent acute, or persistent,in the pediatric population that weserve. The ‘relapsogenic nature’ ofaminopenicillins (eg, ampicillin andamoxicillin) seems to be part andparcel of the problem. This observa-

tion of mine has not been confirmedor refuted by other pediatricians inclinical studies. It is based on my ob-servation of a randomized trial of103 infants, with 48 infants fallinginto the treatment group getting am-picillin for their initial and up tothird episode of OME and 55 infantsgetting either erythromycin estolateor penicillin V-K mixed with triplesulfonamide in the other group. Four-teen patients in the ampicillin groupwent on to have six or more attacksof OME requiring antibiotics,whereas only three of the ‘mixture’-

treated group had six or more epi-sodes of OME. More recently, I haveobserved that one third of patients

treated with amoxicillin-clavulanicacid who grow H influenzae or pneu-mococcus from their ears relapsewithin 72 hours after a 10-day courseof antibiotic. This ‘lighting relapse’does not seem to happen with otherantibiotics, such as cephalosporins or

mixtures of sulfonamides with eryth-

romycin or penicillin V-K or pro-caine penicillin-bicillin IM.” (In hisarticle, he recommends penicillinwith a sulfonamide or any therapy

“that misses less than 10% of thehuman principal pathogens is most

desirable.”)“Your observation that very few

patients in these United States end upwith a chronic persistent perforationis very true in my experience, too.Most of these, I note, are in the

medically underserved or third-worldcountries. The persistent perforationsthat we see most often in Texas and

the adjacent states are those deliber-ately placed to ventilate fluid-filled

middle ears by medical means, forexample, pressure-equalization tubes.I have served on international com-mittees that tried to reach a consen-sus on exactly when (afterappropriate antibiotic therapy) the

ventilation tubes should be placed.The usual decision of these commit-tees has been 60 to 90 days if expert

surgeons are available to do the job.Admittedly, corticosteroids some-times will clear the fluid-filled ears,

but not as regularly or as penma-nently as ventilation tubes. It hasbeen my experience that in largermetropolitan areas, one can find askilled pediatrician or ENT surgeonwilling to place these tubes without

general anesthesia in a hospital. Icertainly try to teach pediatric resi-dents this procedure.

“This procedure can be performedon an outpatient basis under localiontophoretic anesthesia with moder-

ate sedation with mepenidine on the

‘cocktail’ of your choice. I havenever paid anything extra for mal-

practice coverage to perform this pro-cedure in states from Alabama toCalifornia and would not expect oth-ers to, unless they use general anes-thesia.”

This One

I��I�III�I�OIIII�I�III��IIUI1III�I11111I�I8YX5-9JG-JD7N

Pediatrics in Review Vol. 15 No. 3 March 1994 101

NEUROLOGYHeadaches

Igarashi M, May WN, Golden GS.Pharmacologic treatment of childhood

migraine. ] Pediatr. 1992;120:653-657

Illingworth RS. Common Symptoms of Disease

in Children. 5th ed. Oxford, UK: Blackwell

Scientific Publishers; 1975Mathew NT. Drug-induced headache. Neurol

Clipi. 1990;8:903-912

Olness KN, MacDonald iT. Recurrent head-

aches in children: diagnosis and treatment.

Pediatrics in Review. 1987;8:307-311

Peroutka Si. Developments in 5-hydroxy-

triptamine receptor pharmacology in

migraine. Neurol Cliii. 1990;8:829-839

Prensky AL. Differentiating and treating

pediatric headaches. Contemp Pediatr.

1984;!: 12-45

Prensky AL, Sommer D. Diagnosis and

treatment of migraine in children.

Neurology. 1979;29:506-5 10

Raskin NH. Modern pharmacotherapy of

migraine. Neurol Clin. 1990;8:857-865

Shinnar S. An approach to the child with

headaches. mt Pediatr. 1991;6:140-148

Silberstein SD. Advances in understanding the

pathophysiology of headache. Neurology.

1992;42(suppl 2):6-10

Singer HS, Rowe S. Chronic recurrentheadaches in children. Pediatr Ann.

1992;21 :369-373

Stang PE, Yanagihara T, Swanson JW, et al.

Incidence of migraine headache: a

population-based study in Olmsted County,

Minnesota. Neurology 1992;42: 1657-1662

Stewart WF, Lipton RB, Celentano DD, Reed

ML. Prevalence of migraine headache in the

United States. JAM.4. 1992;267:64-69Waranch HR, Keenan DM. Behavioral

treatment of children with recurrent

headaches. J Behav T/zer &p Psychiat.

1985; 16:31-38

Yuill GM, Swinburn WR, Liversedge LA. A

double-blind crossover trial of isometheptene

mucate compound and ergotamine inmigraine. BrJ Clipi Pract. 1972;26:76-79

PIR QUIZ6. Which of the following most clearly

sets the stage for the occurrence of

migraine in a child or adolescent?

A. Food intolerances.

B. Head trauma.

C. History of migraine in a parent.

D. History of seizure disorder.

E. Stress.

7. Current views of the pathophysiol-

ogy of migraine:

A. Ascribe the condition to a disor-

der of neurotransmitters.

B. Ascribe the condition to arterial

inflammation.

C. Ascribe the condition to arterial

spasm.

D. Ascribe the condition to venous

dilatation.

E. Have not reached a consensus.

8. An 8-year-old girl had the onset 2

hours ago of a mild left hemiplegia

with sensory deficit, followed in 1

hour by a severe right-sided head-

ache. She appears anxious, but is

lucid and complaining of headache.

Neurologic examination discloses a

mild left hemiplegia and left hemi-

anopsia. The optic fundus is normal.

The patient has had no previous

similar episode. Her mother reports

herself as having had two similar

episodes as a child. Among the fol-lowing diagnostic studies, you

would give highest priority at this

time to:

A. EEG.

B. MRI.

C. Measurement of cerebral blood

flow.

D. Radiography of the head.

E. Ultrasonography of the head.

9. A diagnosis of migraine is made in

the 8-year-old child described previ-

ously. The symptoms subside in

several hours. In the prevention of

further such attacks of migraine in

this child, first priority among the

following should be given to:

A. Prophylactic use of anticonvul-

sant medication.B. Prophylactic use of ergotamine.

C. Prophylactic use of propranolol.

D. Trialof behavior modificationtherapy.

E. Investigation of triggering mech-

anisms.

Pediatrics in Review Vol. 15 No. 3 March 1994 109

PIR QUIZ

RENAL DISORDERSHematurla

10. The finding most consistent with

the definition of hematuria is:A. A positive perioxidase test for

hemoglobin in the urine.B. Greater than 100 000 RBCs in

a 24-hour urine collection.

C. Greater than 2 RBCs/high-

power field of centrifuged urine

sediment.

D. Greater than 12 RBCs/0.9 mm2of unspun urine in a countingchamber.

1 1 . Among the following, the findingmost definitive for confirming thepresence of a glomerular lesion asthe cause of hematuria is:

A. A greater intensity of blood in

the last phase of voiding than

in the initial flow.

B. A positive nitrite test on a firstmorning voided urine.

C. Presence of casts containingRBCS in the urine.

D. Presence of crenated (serrated)RBCs in fresh urinary sedi-

ment.E. Presence of fresh clots of blood

in the urine.

12. A 7-year-old Caucasian girl pre-

sents with a 2-day history of sud-

den onset of painless, gross

hematuria. Her history is unre-

markable; family history is positivefor nephrolithiasis (a maternal Un-dc). Physical examination is unre-markable. The urine is positive forblood but negative for protein.

Culture is negative; renal ultrason-ography is normal. The most ap-

propnate next diagnostic study is:A. Assay for serum ANA.B. Cytoscopic examination.C. Determination of serum electro-

lytes with BUN.

D. Determination of urine calcium!

creatinine ratio.E. Measurement of serum C3 con-

centration.

13. A 5-year-old Caucasian boy hashad microscopic hematuria for 8months. He is asymptomatic. Noincrease of hematuria occurs with

intercurrent respiratory infections.

Two brothers, ages 12 and 19

years, are healthy. Repeated physi-cal examinations are normal. Dys-

morphic RBCs are present in the

urine but proteinuria is absent.

Cultures are negative. Serum elec-

trolytes, BUN, sedimentation rate,

and streptozyme are normal. Of the

following, the findings are most

consistent with the diagnosis of:A. Henoch Schoenlein purpura.

B. Hypercalciuria.

C. Membranoproliferativeglomerulonephritis.

D. Thin basement membrane

disease.

14. An 8-year-old boy presents havinga history of painless, gross hema-tuna occurring for several days

during a recent acute viral respira-tory illness. Past history is noncon-tributory. Physical examination is

unremarkable. On urinalysis, thereis microscopic hematuria. On a 12-

hour urine study, protein excretionexceeds 20 mg/M2 per hour.Serum electrolytes, BUN, strepto-

zyme, C3 concentration, and im-mune globulins are normal. Onreevaluation in 2 months, physicalexamination is normal. Micro-scopic hematuria and proteinuriapersist in the same quantities aswere found initially. The most ap-propriate next diagnostic step is to:

A. Measure 24-hour creatinineclearance.

B. Measure serum circulating IgA-containing immune complexes.

C. Obtain an ultrasonographicstudy of kidneys and bladder.

D. Refer for an audiometric exam-ination.

E. Refer to a pediatric nephrolo-

gist.

15. In children who have asymptomaticmicroscopic hematuria, the most

correct statement is:

A. An association with nondrug-

related allergic disease oftencan be documented.

B. An unsuspected coagulationdisorder often is present.

C. The majority do not have sig-nificant glomerular disease.

D. The prevalence is less than 1 ina 1000.

E. Tuberculosis of the kidneys fre-quently becomes evident inseveralyears.

114 Pediatrics in Review VoL 15 No. 3 March 1994

DERMATOLOGYScables

also consider it to be mildly antiprur-itic, although this has not been myexperience.

SULFUR

Five percent sulfur cneme on ointmentis the oldest known remedy for the

treatment of scabies. Its efficacy andtoxicity have never been studied in amodern, controlled trial. Neventhe-less, many physicians still consider5% sulfur cream to be the treatment

of choice for infants, young children,and pregnant women. No studieshave established the safety of thisdrug in the treatment of pregnancy,and experience with its use is sub-

stantially less than that of the other

major agents.

PERMETHRIN

Five percent permethnin has beenmarketed in the US for approxi-mately the past 4 years. It is aproven effective medication with asingle application, which cleanly setsit apart from the other active drugs.Penmethnin also is used as a popularantipediculocide, which is sold oventhe counter. This synthetic pynethninis a neurotoxin, producing paralysisand death of a wide variety of ecto-parasites, such as lice, ticks, fleas,mites, and other anthropods. Thedrug is in pregnancy category B. It isindicated for use in patients of anyage.

Postscabetic Syndrome

Most patients will continue to havevisible lesions and pnunitus for daysto weeks following the use of any ofthe above-mentioned scabicides. It isimportant to relay this information topatients at the time of therapy so thatthey do not continue to reuse thedrug inappropriately. I treat thepostscabetic syndrome with mild-to-moderate potency topical steroids(hydnocontisone 1%, tniamcinolone

0.1% to 0.025%).

Nodular lesions of scabies may

take weeks to months to resolve. Aspreviously mentioned, these lesionsare most notable on the male geni-talia, the upper back, and the anteriorand posterior axillary fold. If theseare present at the initial evaluation,their slow progress should be pointedout carefully to the parents. This typeof patient should be seen in the of-fice after 2 to 4 weeks; moderate-to-high potency steroids, coal tan, on in-tralesional steroids should be consid-ened.

A few patients will continue to de-velop vesicles without burrows onthe hands and feet. In some situa-tions, these patients look as thoughthey have infantile acropustulosis, acondition seen primarily but not cx-elusively in African-American chil-dren less than 2 years old. Thesymptomatic lesions appearing on thepalms and soles after scabies shouldnot be retreated with scabicides un-less the scrapings remain positive.These vesicular lesions usually re-solve very slowly, and if severe, mayneed moderate-to-potent topical ster-

oids on even the occasional use ofparentenal corticostenoids.

SUGGESTED READINGArlian LG, Estes A, Vyszenski-Moher D.

Prevalences of Sarcoptes scabiei in the

homes and nursing homes of scabetic

patients. J Am Acad Dermatol.1988;19:806-81 I

Ginsburg CM, Lowry W, Reisch JS.

Absorption of lindane (gamma benzene

hexachloride) in infants and children. JPediatr. 1977;91 :998-1000

Konstantinov D, Stanoeva L. Crotamiton

cream and lotion in the treatment of infants

and young children with scabies. J Int Med

Res. 1979;7:443-448Rasmussen JE. The problem of lindane. J Am

Acad DermatoL 1981 ;5:507-516

Taplin D, Arrue C, Walker JG, et al.

Eradication of scabies with a single

treatment schedule. J Am Acad Dermatol.1983;9:546-550

Taplin D, Meinking TL, Chen JA, et al.

Comparison of crotamiton 10% cream(Eurax) and permethrin 5% cream (Elimite)

for the treatment of scabies in children. PedDermatol. 1990;7:67-73

PIR QUIZ16. The following statements about

scabies all are correct except:

A. All lesions, whether or not vis-ibly infected, should be treated.

B. Effective scabicides require twoapplications separated by I

week.C. If a diagnosis of scabies is

made, all exposed individuals,not only the symptomatic ones,need to be treated.

D. Itching symptoms cease as

soon as all the mites are killed.

17. The following statements about the

clinical presentation of scabies all

are correct except:A. African-Americans frequently

are infected with scabies.

B. Burrows can be found in 90%

to 95% of all patients.C. Infants, children, and adults are

equally susceptible to scabies.D. Secondary lesions are more

numerous and prominent thanburrows.

E. The burrow is the only charac-teristic lesion.

18. The following statements about thediagnosis of scabies all are true

except:

A. Animal scabies (mange) are not

the source of human scabiesepidemics.

B. Any patient who itches should

be suspected of having scabies.

C. Good light with appropriate

magnification is necessary for

examination of the web spaces.

D. Hands and feet yield the mostpositive results for scabies

scraping.

E. Only specialistsor speciallytrained individuals should at-tempt scabies scraping.

Match the treatment (19-22) with theappropriate statement (A-D).19. Lindane A. Contraindicated

in premature in-20. Crotamiton fants less than 2

months of age.21. 5% Sulfur

22. Permethrin

B. Efficacy and tox-icity never havebeen studied.

C. Indicatedin pa-tients of any age.

D. Must be used

daily for 5 con-secutive days.