Visual Diagnosis:
The ABCs of Rashes in Kids
Noon Conference
P.S.: It’s not all about HIV.
Ann Petru, M.D.
Pediatric Infectious Diseases
October 23, 2009
Alphabetical List of Topics
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Bullous dermatosis
Candidiasis, Cellulitis
Coccidioidomycosis
Ecthyma gangrenosa
Eczema herpeticum
Foot ulcer
Granuloma annulare
Henoch-Schoenlein purpura
Impetigo
Job’s syndrome
Kawasaki syndrome
Leishmaniasis
Lupus (Congenital, SLE)
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Meningococcemia, MRSA
Nephrotic syndrome
Neutropenia
Osteomyelitis
Peritonitis, Pott’s puffy tumor
Q-taneous larva migrans
Ritter Disease (SSSS)
STDs, Shingles, SJS, Sweet’s
Tinea,Toxoplasmosis, TB
Ulcerating hemangioma
Varicella
Warts, Yuck (pus)
Zebras……… and more.
Behcet’s disease
•14 yo boy referred to ID clinic
• 5 year hx of oral ulcers
• Intermittent fevers
• 6 wks of foot pain, redness,
swelling
• ESR 93, WBC 9.6
• Occasional bloody stools
• Weight loss
• Presented 6 months later with
acute chest pain and ECG changes.
• Eventually diagnosed with
coronary aneurysm/fistula and
subendocardial myocardial
infarction with severe MV disease.
Bullous dermatosis
• 13 yo Tongan has recurrence of this
rash after 3 years in New Zealand
• Rapid evolution
• UCSF bx: Bullous pemphigoid or
Linear IgA bullous dermatosis
• B.P. is usually men 60-80 yo
• Linear IgA dz - rare, autoimmune,
linear deposits of IgA along
basement membrane
• Pruritic, annual papules, vesicles
and bullae in groups; predilection
for extensor surfaces, symmetric
• Collarettes: blisters form as new
lesions arise in periph. of old ones
• Subepidermal PMN infiltrates
• Rx: Dapsone and steroids
Candidiasis
• 3 mo old boy with diaper
rash: Candida albicans
• Fussy, hard to console.
Seems to ‘burn’ with
every wet diaper
• Characteristic ‘satellite’
lesions at edges
• ‘id’ reaction - severe
inflammatory component
• Mgmt: Oral antifungal &
topical steroids to control
inflammatory reaction
• Response was excellent
Cellulitis of the chest wall
• 14 mo with rapidly
progressing swelling
• Seen in ER, T 102
• WBC 18K (72 polys, 12
bands)
• ESR 48, CRP 6
• Blood culture sent
• Needle aspirate: pus
obtained --> GS: GPC
• Most likely organism:
Staphylococcus aureus
• Big concern in 2005? MRSA
* Empiric antibiotic choices?
Clinda vs Vanco vs TMP-SMX
+/- rifampin
Cellulitis of the neck, premie
• Growing premature infant, was 2 weeks old and doing fairly
well, breathing on his own, until…
• He crashed: reintubated, cultured, antibiotics started
• Blood: Group B Streptococcus
• Rx amp/gent x 3 wks
• Recovered fully
• No meningitis!
• Remember: GBS may
recur (GI colonization)
Group B Strep cellulitis-adenitis syndrome
• Abrupt onset of fever, poor feeding, and irritability
• Unilateral non-discrete facial or submandibular
swelling - erythematous and tender.
• Bacteremia usually present,
• GBS isolated from aspirate of cellulitis or LN
• Ipsilateral otitis media is common.
• Suppurative submandibular lymphadenitis caused by
S. aureus is distinguished by manifestation as a
discrete mass and propensity for suppuration.
Coccidioidomycosis
• 12 year old boy from the
Central Valley was referred to
CHRCO for evaluation of this
skin lesion
• Local dermatologist had
done a biopsy, which grew
Coccidioides immitis !
• Cutaneous ‘cocci’ had not
been seen in our clinic before
• Treated with oral antifungal
and had an excellent response
Coccidioidomycosis
• Coccidioides immitis… dimorphic soil fungus.
Spores are airborne and lead to disease.
• Primary infection: respiratory
• 60% asymptomatic or self-limited
• Sympt.: flu-like, fever, cough, malaise,
myalgia, headache and chest pain
• Diffuse rash, EM, erythema nodosum, arthralgia
• 5% may develop pulmonary scars
• Extrapulmonary is rare, follows trauma,
soft tissue infection
• Dissemination is rare (<1%)
• Dx: Culture (warn lab; danger with aerosolization of organism in lab); serology (UC Davis
c/o Dr. Pappagianis).
• Rx: Ampho B (severe) or itraconazole
or fluconazole (oral)
Coccidioidomycosis:
Erythema nodosum
Cutaneous coccidioidomycosis
• Another teenager
• Central Valley
• Chronic skin
problems
• Biopsied by local
MD, sent to us.
• Cx: + for cocci
• Rx: Underway
with fluconazole
Ecthyma gangrenosa
14 yo boy with acute myelogenous leukemia
(AML) for past 2 years. Prior pneumonia
(scar) was due to Rhizopus infection (bx);
AML now relapsed and out of control
• E.G. => Painful, widespread lesions
• His culture from one grew Fusarium species
• Gram stain usually positive in cases with EG
• Other bugs: Pseudomonas, Vibrio species
Eczema = Atopic Dermatitis
with secondary infection
• 11 yo with 2-3 week hx of itchy
rash, started on right leg, spreading
rapidly. Nontoxic. Some areas
ooze purulent material. No prior dx
of atopic dermatitis!
• Cx: Meth-sensitive Staph aureus
• Dry, itchy, scratched areas become
darker & thickened (lichenified)
• Predisposed to become infected
• Commonly Staph aureus and Strep
Gp A
• Rx includes aggressive skin care
with moisturizers, antihistamines,
and potent antibiotics (IV for this).
Eczema herpeticum (HSV)
12 month old boy with
severe eczema
Thickened, rough skin
despite creams
Itching all the time
Kissed by a loving
relative with a cold sore
- no thanks!
Rx: IV acyclovir,
antihistamines, skin care
Guttate
Psoriasis
• Excessive prolif. of keratinocytes
• Thickened, scaly plaques; itching
• Inflammatory changes of
epidermis and dermis.
• Guttate psoriasis distinctive acute
form in children and young adults
• Closely associated with preceding
sore throat, tonsillitis, Strep infxn
Henoch-Schoenlein Purpura
Also called
Anaphylactoid
Purpura
Is this rash an
infection?
5 month old boy
awoke with swollen
hands, feet and face.
Henoch-Schoenlein Purpura
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HSP is a vasculitis of small blood vessels
Cause is unknown, typically follows URI
Children > adults, males > females, 9/100,000.
Mostly 2-8 yo, winter months
Lab studies are nonspecific and not diagnostic
Acute onset sx, low-grade fever, fatigue, RASH
Main consequences: GI (colicky pain, blood in
stools, diarrhea), kidneys, and arthritis (edema).
• Prognosis good; steroids for GI dz only.
Herpes Labialis with MSSA
Job’s syndrome (Hyper IgE syndrome)
• Rare disorder, autosomal
dominant inheritance (var)
• Mucocutaneous candidiasis
(yeast) early in life
• Recurrent infections
(pneumonia, skin, eczema)
• High IgE (>2000 IU/ml)
• Eosinophilia
• Dental problems
• Scoliosis, fractures
Common pathogens (lungs, skin, abscesses): Haemophilus
influenzae, Strep pneumoniae, Staph aureus
Job’s syndrome: Eczema and
secondary Staphylococcal infections
Leishmaniasis
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6 yo boy went to Middle East with family for 2 mos
3 lesions developed on arms, leg, spreading. Biopsy done.
An older man asked, “Could this be an oriental sore?”
Google: “oriental sore” = Leishmaniasis.
It’s all in the history (and modern technology)
Bite of infected sandfly, inoculates parasites (Leishmania)
Leishmaniasis
• 3 different clinical syndromes
– Cutaneous: sandfly inoculates parasites into skin, proliferate in
local phagocytes -> nodule, ulcer with raised borders, face &
extremities in exposed areas, local lymph nodes react. Spontaneous
resolution, weeks to years, flat scar
– Mucocutaneous (espundia): from skin parasites
disseminate to oral and nasopharyngeal mucosa, sometimes
ulcerate, scars, mucosal perforation
– Visceral (kala-azar): Skin through mononuclear
macrophages, concentrated in spleen, liver, bone marrow -> fever,
anorexia, weight loss, HSM, enlarged lymph nodes, anemia, low
WBC, low platelets, low albumin, and high Igs. Untreated: fatal.
Congenital (Neonatal) Lupus
Baby whose mother had SLE:
• Due to placental transfer of IgG
autoantibodies between 12-16th
week of gestation to baby
• Manifestations: congenital heart
block, cutaneous lesions, liver
disease, low platelets, low WBC,
pulmonary and neurologic
disease.
• Most manifestations resolve but
congenital heart block requires
pacemaker.
• This baby recovered gradually
over a few months.
Rash mimics serious
infections, such as
meningococcemia.
Systemic lupus erythematosus
• SLE is a rheumatic disease of unknown cause
• Autoantibodies directed against self-antigens Inflammatory
damage to target organs
– Kidneys, blood cells, central nervous system
• Diff Dx: FUO, arthralgias, anemia, nephritis
• Dx: autoantibodies: antibodies to DNA, ribosomes,
platelets, coagulation factors, Ig’s, RBCs and WBCs
• ANA often present but not specific. Anti-Smith + in SLE
• Anti-double-stranded DNA more specific than ANA.
• CH50, C3 and C4 are decreased in active disease
• Dx: 4 of 11 criteria, usually ANA positive
Systemic lupus erythematosus
• 18 yo woman with multisystem disease and these
painless symmetric vasculitic changes on fingers
Systemic lupus
erythematosus
• Older teen with recent
diagnosis of SLE
• Characteristic ‘malar’
rash associated with
lupus
• Also had severe renal
involvement
• Getting high doses of
IV steroids
Meningococcemia
• Overwhelming bacterial
infection caused by
Neisseria meningitidis
• Sepsis, meningitis, or both
• Onset abrupt with fever,
chills, malaise,
prostration, and typical
rash: “purpura” or
“petechiae”
• Fulminant cases: purpura,
“DIC”, shock, coma, and
death within several hours.
Meningococcemia
Neisseria meningitidis
• Can cause meningitis, pneumonia, occult bacteremia,
conjunctivitis, chronic meningococcemia.
• Invasive disease complications: arthritis, myocarditis,
pericarditis, endophthalmitis
• 5 groups (A,B,C,Y,W135)
• Short incubation period (1-10 days, mostly < 4 d)
• Gram stain, cultures from blood/CSF/skin scraping or joint,
buffy coat smear; antigen in CSF.
• Detectable in CSF by PCR (30-50% + in UK)
• Rx: Penicillin, cefotaxime, ceftriaxone, ampicillin
• Short courses of treatment are adequate (5-7d)
Neisseria meningitidis meningitis
and meningococcemia
• Isolation: droplet precautions until 24 hours Rx.
• 4-valent vaccines available, not including group B.
• Chemoproph with rifampin, ceftriaxone or cipro
– Prophylaxis for household contacts, childcare,
nursery school contacts within 7 days, direct
exposure to patient’s secretions, mouth-tomouth resuscitation, sleeping/eating close to
patient within 7 days of onset of symptoms, and
in outbreaks.
Here’s an Easter Bunny in ICU
• This bunny
was left on
the bed of the
patient with
meningococcemia
• The boy
recovered…
• The bunny
didn’t!
Nephrotic syndrome:
spontaneous bacterial peritonitis
• 10 yo girl with long hx of
nephrotic syndrome
(proteinuria, low albumin,
edema, hyperlipidemia)
• Sunburn over bikini line ?
• Came in with fever, abdominal pain, distension, redness
• Each time her paracentesis cultures grew Strep
pneumoniae or E. coli; responded well to antibiotics.
Omphalitis: MRSA
• 6 wo boy, 3-4 days of
fussiness, ‘colic’, then
fever 102, pan-cultured
• WBC 2.7K… to CHO
• Pale, mottled, lethargic
• IV fluids, antibx for
‘compensated shock’.
ID consulted: “mass” in upper abdomen
Pressure over mass: volcanic eruption through
umbilicus, caught with dad’s cell phone camera.
Further studies: extended into porta hepatis ! I&D
done and patient recovered fully with 3 weeks IV abx.
Osteomyelitis, MRSA
(Methicillin-resistant Staph aureus)
• 13 yo boy had infected
toenail, spread up leg to
shin, eventually to tibia:
cultures grew MRSA
• Treated x 6 months with
various IV antibiotics
• Infection flared every time
we tried to stop antibiotics
• Boy faced amputation
• UCSF Dr. Dyab saved his
leg!
Pseudoverrucous papules
Boy with suprapubic
vesicostomy
and recurrent UTIs
Girl with HIV
and severe
diarrhea for
several weeks
Pott’s Puffy Tumor
• 14 yo boy with swollen,
tender forehead
• Typical of teenage boys
• Often no prior symptoms
• CT scan essential to dx
• Unrecognized sinus dz
• Extension into forehead
• CT: epidural abscess !
• Needs drainage!
Common organisms: 50% are Strep
pneumoniae or H. influenzae; others:
viridans Strep, group A Strep, or
Staph aureus
Cutaneous larva migrans
• 12 month old child from Sri Lanka,
nursed x 4 months
• Then came to US on 12/15/04 with
adoptive parents
• Poor weight gain x 3-4 mos
• Possible abdom discomfort
• 2 weeks prior parents noted red,
raised bump near anus, now expanding
in linear fashion laterally, then curled
in loop
• No visible ‘worms’ in stool
Cutaneous Larva Migrans
• Nematode larvae produce pruritic, reddish
papules at site of skin entry “creeping
eruption”
• As larvae move, leave intensely itchy
serpinigous tracks (~pathognomonic)
• Eventually self-limiting (wks-months)
• Rare complic: severe pneumonia (Loeffler
syndrome), myositis, eosinophilic enteritis.
Cutaneous Larva Migrans
• Cat and dog hookworms: Ancylostoma braziliense
and Ancylostoma caninum.
• Contact with soil contaminated with dog, cat feces
• US: Southeast.
• Dx: Clinical; +/- eosinophilia; larvae in sputum
(pneu); serology not readily available
• Rx: No Rx (self-limited) or albendazole,
ivermectin or topical thiabendazole
Staphylococcal Scalded Skin
Syndrome (SSSS) - Ritter disease
• 20 month old, East Indian
girl admitted 12 hours ago
• High fevers, irritable,
intense erythroderma
• + Nikulsky, peeling around
mouth, red eyes
• NP and skin from near
rectum both: S. aureus
• Gradually recovered on
Burow’s soaks, eucerin,
vaseline or aquaphor, and
pain meds, IV antibiotics
Staphylococcal
scalded skin syndrome
• Toxin-mediated complication of a
Staph infection (phage gp 2, strains
71, 55): exfoliative toxins A or B.
• Mostly < 3 yo
• First malaise, fever, irritability,
exquisite tenderness of skin
• Diffuse redness diffusely, worse in
creases and around mouth
• Eyes red, purulent, sticky
• Skin wrinkles, blisters, erodes.
Sheets peel off (+ Nikulsky sign).
• Peels 2-5 days later, heals without
scars. Quick recovery.
Sexually transmitted disease(s)?
• 17 yo teen came to ER
• Had 10 recent partners and
didn’t know names of any
of them
• Ulcer is painless now
• Had swollen, painful, red
nodes in groin
• Refused HIV testing
• GS: gram-neg diplococci
• Cx: Group B Strep,
• RPR: positive (syphilis)
• Suspected: H. ducreyi too
H. ducreyi = chancroid,
painful ulcer & painful nodes;
rx: Azithromycin or cipro
GND: Ns. gonorrhea?
Shingles: “Herpes zoster”, caused
by Varicella zoster virus (VZV)
• Previously well 6 yo came
in with low-grade fevers and
this blistering rash on L leg
• Often no prior history of
primary chickenpox
(typically unrecognized,
kids had it in 1st 12 months)
• Typical dermatomal
distribution (this is S1)
• Usually contagious only
with contact with blister
fluid.
Shingles:
Varicella zoster
• 14 yo with perinatally acquired
HIV/AIDS
• CD4 250 range and HIV viral
load 60,000, on “HAART” Rx
• Hx 10 varicella 1997
• 2 days left neck pain
• Rash emerged over 12-24 hours
• C3 dermatome only
• Slowly responsive to acyclovir
and gabapentin (Neurontin).
• Better with higher dose ACV
Stevens-Johnson Syndrome (SJS)
• 12 yo with 3 prior episodes of
oral erythema multiforme (bx
+), last one ‘aborted’ with
steroids. No prior skin dz.
• Evidence of HSV, mycoplasma
with high IgG and +++ IgM
• Now flu-like illness, fevers x 1
week, oral swelling, rash over
chest, rapidly spreading
• Rash worsened, mouth swollen,
progressed rapidly overnight
• Ended up in ICU
Erythema multiforme vs SJS?
• EM: Numerous skin manifestations: macules, papules,
vesicles, bullae, urticaria (hives), plaques, confluent
erythema (redness)
• Most common 10-30 yo, asymtomatic or with some
burning, itching; extremitis more than torso, face.
• Characteristic lesion is doughnut-shaped, target-like papule
with red border and inner pale ring and dusky-to-purple
center (like an iris or bull’s eye).
• Abrupt onset.
• Underlying causes, triggers may vary.
• EM minor vs EM major (Stevens-Johnson syndrome)
StevensJohnson
Syndrome
Stevens-Johnson Syndrome (1)
• Red areas that rapidly for vesicles and bullae
(blisters), and then denude
• Also involve 2 or more mucosal surfaces (eyes,
oral cavity, upper airway or esophagus, GI tract or
anogenital mucosa)
• Burning, edema, erythema of lips and mouth are
often the presenting sign (and very painful).
• Rapid skin progression to bullae, ulcers, and
hemorrhagic crusting (not so painful)
Stevens-Johnson Syndrome (2)
• Complications: corneal ulcers, uveitis,
panophthalmitis, bronchitis, pneumonitis,
myocarditis, hepatitis, enterocolitis, arthritis,
hematuria, renal failure.
• Blood loss, fluid loss, bacterial superinfection
• Crops of new lesions, scarring.
• Labs: nonspecific: high WBC, ESR, LFTs, and
low albumin.
• Causes: Mycoplasma, drugs (sulfas and NSAIDs).
Boy with SJS
Group A Streptococcus
• 14 yo boy with acute onset of
fever, vomiting, diarrhea; better
x 2 days, then fever, swelling
left knee, right foot, left arm,
wrists.
• BCx negative
• ASO +++ (Gp A Strep)
• Xrays: tenosynovitis of right
extensor digitorum tendon;
erysipelas of left forearm, and
prob osteo of right thumb!
• Rx: Clinda/oxacillin -> Keflex
Sweet’s syndrome:
Febrile neutrophilic dermatosis
Sweet’s Syndrome
• Unusual hypersensitivity
• Tender, red, edematous,
urticarial plaques or large
papules
• Irregular edges (?vesicles)
• Mimics HSV or strep
cellulitis, erysipelas if solo;
mimics bites
• Fever, high WBC, malaise,
arthralgias, myalgias,
conjunctivitis, episcleritis
• Rare: airway, meningitis
• Pathology: marked infiltration of
skin with neutrophils
• Treatment: Steroids
• Prognosis: Good with support
Tinea corporis
(inflammatory ringworm)
• 8 yo East Indian child
had been treated with
Keflex and Clinda for
suspected Staph
impetigo
• Cx: Trichophyton
tonsurans
• Rx: Griseofulvin
• Outcome: CURED!
Tinea corporis (ringworm)
Healing phase
Tinea capitis:
Ringworm or Kerion?
• 3 year old boy with HIV…..
• Teenage girl with scalp pain
and severe hairloss
Toxoplasmosis (Toxoplasma gondii)
• Newborn had apnea,
neuroultrasound and CT
with Ca++ deposits
• Had small left eye (blind)
• Developed progressive
hydrocephalus -> shunt
• Toxoplasma gondii proven
by serology of baby, mom
• Kitty litter changed by
mom thru pregnancy!
• Bye, bye kitty!
Congenital toxoplasmosis
• Mother acquires toxo during pregnancy or it reactivates
due to immunodeficiency (in HIV)
• 70-90% of infants are asymptomatic at birth, but visual
impairment, learning disabilities, mental retardation often
appear later
• Signs: Rash, enlarged lymph nodes, big liver, spleen,
jaundice, low platelets
• Brain infection leads to abnormal CSF, hydrocephalus,
small head, chorioretinitis (which leads to blindness and
small eye), seizures, deafness.
• Calcifications can be seen on NUS and CT of head
Congenital toxoplasmosis
Congenital toxoplasmosis and perinatal HIV infection
Congenital toxoplasmosis
• Bug: Toxoplasma gondii, protozoan parasite
• Diagnosis: Serology
– Special labs: IgM or IgA + in first 6 months
• Toxo-specific IgM by double sandwich EIA or ISA is 75-80%
sensitive; Don’t trust IFA for IgM.
– IgG + beyond 12 months of age is confirmative
– Test peripheral blood WBCs, CSF and amniotic fluid
for T. gondii by PCR in reference lab
– Can attempt to isolate T gondii from placenta, umbilical
cord or blood by mouse inoculation
Tuberculosis of the skin ?
Erythema induratum
Lower, inner left leg
Original areas involved
Newer
lesion
on arm
PPD scar
15 yo Afghani girl
with painful skin
lesions x 12 mos
Tuberculosis of the hand bones & more
• 16 yo East Indian girl presented with
massively swollen, tender left thumb,
painful left foot and some left eye vision
problems
• Left wrist draining pus intermittently
• CXR: pleural thickening and infiltrate vs
old disease (scar); bone scan + @ 3 sites
• PPD > 30mm induration!
• Cx: thumb drainage, sputum + for
Mycobacterium tuberculosis sensitive to
all TB meds
• Now doing very well x 9 mos on
multidrug regimen
• Brother with TB, too.
Ulcerating Capillary Hemangioma
• 6-8 week old born with
‘birthmark’ on cheek of her
right buttock
•Area ‘broke down’ over time
• Treated by PMD with
hydrocortisone and
bacitracin and cultured
• Grew mix of stool flora
• Treated with mix of oral
antibiotics, telfa gauze,
and referred to UCSF
dermatology.
• Challenge: mechanical!
• Eventually treated with
lasers and gradually
improved.
Varicella zoster virus (chickenpox)
• 3-4 week old infant whose
mother had chickenpox
when baby was 1-2 weeks
old. Baby has sl. fever.
• Biggest risk is if mom has
chickenpox in 5 days prior
to or up to 2 days after
birth (baby gets overwhelming disease, has no
antibodies to VZV). One
study
• This baby did well.
Varicella in boy on Remicade
• I’m taking Remicade
for my Crohn’s dis.
Warts: Verruca vulgaris
• 6 yo girl with HIV
• Stable on same regimen
since birth
• Father sent this photo
• Occlusive dressing and it
vanished!
• If immune system is
strong, response is good
YUCK ! From Ortho, “Pus is us”
• 12-13 yo boy with 2 yr chronic
leg pain and limp, increasing
bullae on anterior thigh
• Rx in Samoa with various
antibiotics serially; came to
CHRCO’s ortho clinic
• Had ‘gross’ pus on exam
• GS: gram-positive cocci
• Cx: Staphylococcus aureus, resistant to oxacillin
• Xray: Destroyed underlying femur
• Rx: Debridement and VERY longterm course of antibiotics
Zebras
• Famous quote in
medicine: “When you
hear hoofbeats, think
of horses, not zebras”
• ID Perspective: “If
you don’t think of
zebras, you’ll miss
some very interesting
diagnoses!”
References
• Bickle KM, Roark TR & Hsu S: Autoimmune
Bullous Dermatosis: A Review, Am Fam
Physician 2002:65:1861-70.
• Long’s Principles and Practice of Pediatric
Infectious Diseases, 2nd Edit, 2003, Group B
streptococcus cellulitis-adenitis syndrome, p 168.