WHat is this:

blue black macule found over the lumbosacral area in 90% of infants from where (ie population most affected..there are 3)

mongolian spot

Native American, AA, and Asian descent

conist of spindle-shaped pigment cells located deep in the dermis

lesions fade somewhat with time as a result of darkening of the overlying skin, but some traces may persist into adult life.

What is this:

light brown, oval macule that may be found anywhere in body

-if you have six or more of these lesions over 1.5 cm...this can clue you in pt may have _____

Cafe au Lait Macule

neurofibromatosis

What is milia?

how big? ie. how would you describe?

what do you call these if you find them in the mouth?

tiny epidermal cysts filled with keratin material

1-2 mm white papules occur predominately on the face

if found in mouth- called Epstein pearls

What is a harelequin color change? cutaneous vascular phenomenon occurs when infant place on one side. Dependent half develops an erythematous flush with a sharp demarcation at the midline

Tineaversicolor:

what causes it?

What type of organism?

What does it look like? ie how would you describe? what happens in the winter?

what causes it? Pityrosporum orbiculare

What type of organism? yeastlike fungus

What does it look like? ie how would you describe? polycyclic connected hypopigmented macules and very fine scales in areas of sun-induces pigmentation.

In the winter- polycyclic macules appear reddish brown

What are important pathogens related to Impetigo?

what's the patho causing it?

staph and group a streptococci

superficial invasion of bacteria into the upper epidermis, forming a subcorneal pustule

agent effective against staph auerus such as

b-lactamase resistant PNCS or cephalosporins

clindamycin

amoxicillin-clavulanate for 7-10 days.

Topical mupirocin and fusidic acid (3x daily effective)

ACCORDING TO ANNIE:

first line: bactroban TID

then systemic abx: second gen ceph (Keflex and Cefadroxil (for immunocompromised)

STRESS HAND WASHING!

What % of full term infants develop erythema toxicum?

When do infants usually present? how?

50%

Usually within 24-28 hours of age, blotchy erythematous macules 2-3 cm in diameter appear predom on chest..but also on back, face and extremities

What would you find if you did a Wright stain on erythema toxicum?

when does it go away?

eosinophils

no organisms on gram stain

all lesions fase and disappear within 5-7 days

What is milaria?

How do pts present?

obstruction of the eccrine sweat ducts

two presenattions:

1. superficial obstruction in the stratum corneum causes miliaria crystalline, characterized by tiny, superficial grouped vasicles without erythema over intertriginous areas and adjacent skin

2. More common: obstruction of the eccrine sweat ducts deeper in the epidermis results in erythematous grouped papules in the same areas--called miliaria rubra

What predisposes pt to miliaria?

What is tx of choice?

heat and humidity predispose

tx: removal to a cooler environment

Pt presents with the following:

acute edema, erythema, and oozing with crusting, mild erythema alone, or lichenification.

what could it be?

Where does infantile eczema usually begin? (ie. body parts)

What age?

dermatitis begins on the cheeks and scalp and frequently expresses itself as oval patches on the trunk, later involving the extensor surfaces of the extremities.

Age: usual age at onset is 2–3 months, and this phase ends at age 18 months to 2 years.

Atopic dermatitis results from an interaction among susceptibility genes, the host environment, skin barrier defects, pharmacologic abnormalities, and immunologic respons

acute phase: wet dressings and topical corticosteroids

chronic: no harsh soaps or shampoo, shower every three days/ twice daily lubricant very important; Tacrolimus and pimecrolimus ointments are topical immunosuppressive agents that are effective in atopic dermatitis.

Primary irritant dermatitis develops within a few hours, reaches peak severity at 24 hours, and then disappears.

Allergic eczematous contact dermatitis has a delayed onset of 18 hours, peaks at 48–72 hours, and often lasts as long as 2–3 weeks even if exposure to the offending antigen is discontinued.

changing diapers frequently.

Washing should be done with a wash cloth and warm water only.

avoid rubber or plastic pants bc prevent evaporation of the contactant and enhance its penetration into the skin

Air drying is useful.

Treatment of long-standing diaper dermatitis should include application of nystatin or an imidazole cream with each diaper change.

When does seborrhea dermatitis usually occur? Why?

How do you treat?

infants and puberty- bc points of maximum hormonal stimulation

treat: low potency corticosteroids

What skin disorder does this describe:

erythematous papules covered by thick white scales

Where do you often see this?

psoriasis

seen where? scalp, elbows, knees, periumbilical area, ears, sacral area, and genitalia

ncreased epidermal turnover; psoriatic epidermis has a turnover time of 3–4 days versus 28 days for normal skin. These rapidly proliferating epidermal cells produce excessive stratum corneum, giving rise to thick, opaque scales.

bilateral dusky mottled discoloration of the hands, feet, and sometimes the face.

painless

pulses present

trophic changes do NOT occur

**these are referring to acrocyanosis

Raynaud: typically episodical, painful and related to arterial disease

What's tx for acrocyanosis?

Who gets it?

No tx: just keep extremities warm

usually develops in adolescence; genetically determined

 diagnosis is made by scraping thin scales from the border of the lesion, dissolving them in 20% KOH, and examining for hyphae.

What could this be:

Thickened, broken-off hairs with erythema and scaling of underlying scalp are the distinguishing features 

what causes?

tinea capitus

In endemic ringworm, hairs are broken off at the surface of the scalp, leaving a "black dot" appearance. Pustule formation and a boggy, fluctuant mass on the scalp occur in M canis and T tonsurans infections. This mass, called a kerion, represents an exaggerated host response to the organism. Diffuse scaling of the scalp may also be seen. Fungal culture should be performed in all cases of suspected tinea capitis.

If hair is involved in dermatophytosis (which is what?),

What is best tx? why?

fungal infection

griseofulvin bc topical tx will not penetrate to hair

ring worm

most infants younger than four months of age, unless a viral etiology or Chlamydia trachomatis is suspected and they are relatively asymptomatic. A child of any age whose family cannot provide appropriate care and assure compliance with the therapeutic plan needs to be hospitalized.

supportive

antipyretic/analgesic

SIADH

syndrome of inapproporiate diuretic hormone

•       Temperature

•       Respiratory rate

•       Heart rate

•       Oxygen saturation

•       Work of breathing (eg, presence of retractions, nasal flaring, grunting)

•       Auscultatory findings

viral pneumonia is ______ and associated with preceding upper airway symptoms. Auscultatory findings are usually _____ and _____. Infiltrates are usually ______.

viral pneumonia is gradual and associated with preceding upper airway symptoms. Auscultatory findings are usually diffuse and bilateral. Infiltrates are usually interstitial.

Clues to bacterial pneumonia include alveolar infiltrate, lobar or segmental consolidation, large pleural effusion, elevated CRP, leukocytosis, signs of sepsis, and chills. Other complications (pneumatoceles, cavitations, necrotizing processes) also are suggestive of typical bacterial etiology.

M. pneumoniae and Chlamydophila pneumoniae

Clues to atypical bacterial pneumonia include abrupt onset of constitutional findings (malaise and myalgia, headache, conjunctivitis, photophobia, sore throat), and gradually worsening non-productive cough despite improvement of other symptoms, wheezing, rash, and interstitial infiltrates

Streptococcus pneumoniae is the most common type of bacterial cause of pneumonia in children of all ages

S. aureus, including methicillin-resistant S. aureus,

Streptococcus pyogenes (group A streptococcus),

Haemophilus influenzae type b (if unimmunized),

nontypeable H. influenzae, and Moraxella catarrhalis 

aspiration, immunodeficiency or immunosuppression

congential anomalies (intrapulmonary sequestration, tracheoesophageal fistula or cleft plate)

abnormalities in clearance of mucus (CF, ciliary dysfunction, tracheomalacia, or bronchiectasis), congestive heart failure and perinatal contamination

True or false. 

Pt who has pneumonia. Could they complain about abdominal pain?

Bacterial pneumonia.

True or False

Clinical resolution precedes resolution apparent on chest radiograph.

viruses!!!

RSV

parainfluenza (1,2,3)

influenza A and B

human metapneumovirus

What typically precedes a viral pneumonia?

rapid viral diagnostic methods:

fluorescent antibody tests

enzyme linked immunosorbent assay

characterized by one of the following:

coughing

tachypnea

labored breathing 

hypoxia

Typical presentation:

acute onset of tachypnea, cough and expiratory wheezing after 1-2 days of rhinorrhea

what is the most common cause of bronchiolitis?

Other causes?

most common: RSV

other: parainfluenza, human metapneumovirus, influenza, adenovirus, mycoplasma, chlamydia, ureaplasma

young infants (<6 mts

esp if hx of prematuring

underlying cardiopulmonary disorders

respiratory pause lasting more than 20 seconds

OR any pause accompanied by cyanosis and bradycardia

A chest radiograph shows hypoexpanison and air bronchograms.

what could it be?

defienciency in surfactant

results in poor lung compliance and atelectasis

the infant must expend a great deal of effort to expand the lungs each breath, respiratory failure ensures

diffuse bilateral atelectasis, causing ground glass appearance

atelectatic air sacs create air bronchograms

In unintubated child, doming of the diaphrahm and underexpansion occur

supplemental oxygen

nasal CPAP

early intubation for surfactant administration and ventilation

placement of umbilical artery and vein lines

Survanta

Infasurf

Curosurf

vomiting usually begins btw 2 and 4 weeks

can start as late as 12 weeks

usually projectile

rarely bilious

may be blood streaked

constipation

weight loss

fretfulness

dehydration

apathy

upper abdomen may be distended after feeding

and prominent gastric peristaltic waves

oval mass in RUQ may be palpated

What lab findings are associated with pyloric stenosis?

What will you see in barium upper GI series?

hypochloremic alkalosis with K depletion

dehydration causes elevated Hgb and Hct

upper Gi series: retention of contrast in the stomach and a long narrow pyloric channel with a double track of barium; hypertrophied muscle mass produces typical semilunar filling defects in the antrum.

1. Stenosis of the pulmonary artery

2. Intraventricular communication

3. Deviation of the origin of the aorta to the right

4. Concentric right ventricular hypertrophy

Age < 6 months

Sickle cell anemia

Multi-lobe involvement

Immunocompromised child

Patient appears toxic

Severe respiratory distress

Patient needs supplemental oxygen

Patient is dehydrated

Patient is vomiting

Not responding to oral antibiotics

Non-compliant parents

What is somnambilism?

What do parents need to know?

somnambilism- sleep walking

During a night terror, the child may sit up in bed screaming, thrashing about, and exhibiting rapid breathing, tachycardia, and sweating. The child is often incoherent and unresponsive to comforting. The episode may last up to half an hour, after which the child goes back to sleep and has no memory of the event the next day. The parents must be reassured that the child is not in pain and that they should let the episode run its course.

Management of night terrors is by reassurance of the parents plus measures to avoid stress, irregular sleep schedule, or sleep deprivation which prolongs deep sleep when night terrors occur. Scheduled awakening (awakening the child 30–45 minutes before the time the night terrors usually occur) can be used in children with nightly or frequent night terrors.

Young child presents with prodrome of fever (100.4ºF)), anorexia, irritability, malaise, sleeplessness, and headache

It then develops into vesicular lesions on their mucous membranes and gingiva. What could it be?

herpes gingivostomatitis

Describe what a herpetic gingivostomatitis looks like in a young child.

What areas are affected?

The enanthem begins with red, edematous marginal gingivae that bleed easily and clusters of small vesicles.The vesicles become yellow after rupture and are surrounded by a red halo. They coalesce to form large, painful ulcers of the oral and perioral tissues .They bleed easily and may become covered with a black crust  

The lesions involve the buccal mucosa, tongue, gingiva, hard palate, and pharynx; the lips and perioral skin are affected in approximately two-thirds of cases 

How do you diagnose herpes gingivostomatitis?

What is another option?

diagnosis made clinically

HSV-1 can be diagnosed with viral culture, serology, immunofluorescence, or polymerase chain reaction (PCR)

What is the tx for apthous stomatitis?

What is it often confused with? How do you rule it out?

There is no specific therapy for this condition. Rinsing the mouth with liquid antacids provides relief in most patients. Topical corticosteroids in a gel base may provide some relief. In severe cases that interfere with eating, prednisone, 1 mg/kg/d orally for 3–5 days, will suffice to abort an episode. Colchicine, 0.2–0.5 mg/d, sometimes reduces the frequency of attacks.

confused with herpes simplex. A smear of the base of such a lesion stained with Wright stain will aid in ruling out herpes simplex by the absence of epithelial multinucleate giant cells.

What could this be?

white curdlike plaques, predominantly on the buccal mucosa, which cannot be washed away after a feeding

How do you treat?

thrush: oral candida albicans

tx: nystatin oral suspension. Treatment may begin by removing large plaques with a moistened cotton-tipped applicator, and half the nystatin may be rubbed on the lesions with an applicator.

1. From nasal colonization

2. Rarely from trauma or instrumentation

Neurosurgical procedures

Sinus fracture

3. Rarely to the newborn

Via maternal transmission

4. Impaired splenic function

What etiologies are neonates susceptible to getting meningitis?

What abx do you use empirically to treat?

1. Group B Streptococci

2. Listeria

3. Enteric gram negative pathogens

E. Coli

Abx: ampicillin and gentamicin or other aminoglycoside

OR

ampicillin and third generation cephalosporin

What etiologies are infants or older children susceptible to in getting meningitis? 

Neisseria meningitis

Strep pneumoniae

Haemophilus influenzae

Pt presents with the following sxs:

what could it be?

Fever

Stiff neck

Photophobia

Headache

Altered mental status

Seizures (up to 25% of the cases)

What will CSF fluid show in bacterial meningitis? for the following:

CSF Color

Opening Pressure

WBC

CSF color

Normal CSF is clear

Cloudy or purulent CSF

Opening Pressure

Normal opening pressure is <170 mm

Elevated opening pressure(>300mm)

WBCs (mononuclear and PMN types)

Normally <5 mononuclear cells

Mononuclear cells  are >1000/ul

In bacterial meningitis:

what will labs results be for the following:

PMNs

CSF Glucose

CSF protein

PMNs

Normally 0 percent

>80% in meningitis

CSF Glucose

 Normal > 40mg/dl)

Glucose- < 40mg/dl in meningitis

CSF Protein

 Normal < 50 mg/dl)

> 200 mg/dl in meningitis

Septic shock

DIC

Coma

Seizures

Cerebral Edema

Septic Arthritis

Deafness

Cranial Nerve Dysfunction

Recurrent Seizures

Paralysis

Subdural effusions

Hydrocephalus

Gangrene

Rifampin 600mg BID for 4 doses

Cipro 500mg for one dose

Rocephin 250mg for one dose

What causes aseptic meningitis?

How do you treat?

non bacterial organisms

self-limited disease

Enteroviruses

Herpes viruses

Polio viruses

Mumps virus

Arboviruses

Pt presents with the following:

what could it be?

–Sick but clearly not bacterial meningitis

–Fever

–Stiff neck

–Photophobia

–Lymphadenopathy

–No petechial rash

What is viral encephalitis?

define it.

viral infection of brain parenchyma producing a inflammatory response

Consider in patients that look like viral meningitis but have

New psychiatric symptoms

Cognitive deficits

Aphasia

Amnestic syndrome

Confusional states

cough lasting more than 3 weeks

fever, productive cough, constitutional sxs

What is the cause of most acute bronchitis?

Name some. (6)

virus

influenza, rhinovirus, adenovirus, coronavirus, parainfluenza, and respiratory syncytial virus

Acute bronchitis is often confused with ______.

How can you differentiate?

pneumonia

get a chest xray

asthma

CHF

reflux esophagitis

bronchogenic tumors

mainly supportive

some say bronchodilators, but not proven

spectrum of disease that ranges from inflammation of the mastoid periosteum to bony destruction of the mastoid air system (coalescent mastoiditis) or abscess development.

Strep pneumo

Strep pyogenes

(most common above)

Pt presents with the following:

postauricular pain, fever, and an outwardly displaced pinna

what could it be?

What test can you do to find out extent of the disease?

mastoiditis

Ct scan can show extent of disease

ceftriaxone plus nafcillin or clindamycin until culture results are returned

infection of the nasolacrimal sac and results in erythema and edema over the nasolacrimal sac

Acute dacryocystitis presents with inflammation, swelling, tenderness, and pain over the lacrimal sac (located inferior to the medial canthal tendon). Fever may be present. The infection may point externally. A purulent discharge and tearing can be expected, because the cause of infection is almost always nasolacrimal obstruction.

Chronic dacryocystitis are mucopurulent debris on the lids and lashes, tearing, injection of the palpebral conjunctiva, and reflux of pus at the puncta when pressure is applied over the sac. Chronic dacryocystitis and recurrent episodes of low-grade dacryocystitis are caused by nasolacrimal obstruction.

How do you treat dacrocystitis?

mild and severe cases and chronic?

mild: oral abx

severe: IV abx

chronic: warm compresses are helpful, topic abx are adjuncant

acute encephalopathy of children and adolescents, usually between 2 and 16 years of age

cause of Reye's syndrome is unknown, but it is a recognized rare complication of influenza B, influenza A, and herpesvirus varicella-zoster infections

What atypical neuroleptic causes weight gain?

Which causes galactorrhea?