A teenage girl is brought to A&E by ambulance with a high fever and hypotension. She is confused and has abdominal pain and diarrhoea. A macular rash has been present for five days, which is now desquamating. She has not been abroad or in contact with any infections, she is currently menstruating. What is the most likely diagnosis? Gastroenteritis Scarlet fever Kawasaki disease Toxic shock syndrome Correct answer Pelvic inflammatory disease Toxic shock syndrome (TSS) is caused by a toxin that triggers a cytokine cascade and has multi-system effects. Features include high fever, macular erythaema leading to desquamation, hypotension and symptoms of other system involvement eg diarrhoea or vomiting, myalgia, thrombocytopenia and renal failure. TSS was initially associated with tampon use but can be generated by seemingly trivial staphylococcal infections. The mainstay of treatment is resuscitation, antibiotics and removal of precipitating factors; intensive care can be required. At the 6-week baby check the GP notices a blue discoloration across the buttocks of an Asian baby. The child is small for his age but there is nothing else to find on examination. He lives in a rather chaotic household with five other siblings. What is the most likely diagnosis? Accidental bruising Non-accidental injury Clotting disorder Mongolian blue spot Correct answer Contact dermatitis
Transcript
A teenage girl is brought to A&E by ambulance with a high fever and hypotension. She is confused and has abdominal pain and diarrhoea. A macular rash has been present for five days, which is now desquamating. She has not been abroad or in contact with any infections, she is currently menstruating.
What is the most likely diagnosis?
Gastroenteritis
Scarlet fever
Kawasaki disease
Toxic shock syndrome Correct answer
Pelvic inflammatory disease
Toxic shock syndrome (TSS) is caused by a toxin that triggers a cytokine cascade and has multi-system effects. Features include high fever, macular erythaema leading to desquamation, hypotension and symptoms of other system involvement eg diarrhoea or vomiting, myalgia, thrombocytopenia and renal failure. TSS was initially associated with tampon use but can be generated by seemingly trivial staphylococcal infections. The mainstay of treatment is resuscitation, antibiotics and removal of precipitating factors; intensive care can be required.
At the 6-week baby check the GP notices a blue discoloration across the buttocks of an Asian baby. The child is small for his age but there is nothing else to find on examination. He lives in a rather chaotic household with five other siblings.
What is the most likely diagnosis?
Accidental bruising
Non-accidental injury
Clotting disorder
Mongolian blue spot Correct answer
Contact dermatitis
A Mongolian blue spot is commonly seen across the lumbosacral region and buttocks of babies of Asian and Black descent. They also occur in approximately 10% of White babies. A Mongolian blue spot is a grey/blue macular discoloration, histologically a dermal melanocytic naevi. They usually fade spontaneously. It is important to be able to recognise and differentiate these birthmarks from possible non-accidental injury.
A teenager presents to A&E unwell with a high fever. He is known to have eczema and numerous allergies. You notice crusting lesions across his torso with generalised erythaema. He also has blisters around his mouth.
What is the most likely diagnosis?
Eczema herpeticum Correct answer
Infected eczema
Impetigo
Psoriasis
Dermatitis herpetiformis
Children with eczema are at risk of becoming infected with herpes simplex virus and developing eczema herpeticum. This condition can be severe, as the virus can become disseminated. Secondary bacterial infection is common. Encephalitis and ocular complications may occur. The lesions themselves may become haemorrhagic. Although not all children with eczema herpeticum need to be admitted to hospital the condition must be taken seriously in light of the possible complications. Intravenous and topical aciclovir is required as well as treatment with a broad-spectrum antibiotic to deal with any secondary bacterial infection.
A 15-year-old girl attends her GP complaining of a rash, which has developed over the preceding week. The lesions are small and well circumscribed over her trunk and arms; they are pink with silvery scales. She is usually well but had a bad throat infection requiring antibiotics two weeks previously. On further examination her nails appear to be splitting from the nail bed and small pits are noted.
What is the appropriate management for this girl? Choose three of the following:
Commence topical corticosteroids Incorrect
Commence topical antibiotics Incorrect
Commence antiviral therapy Incorrect
Send skin scrapping Incorrect
Commence methotrexate Incorrect
Commence Lassar’s paste Incorrect
Commence coal tar preparations (creams and shampoo) Incorrect
PUVA Incorrect
Commence topical corticosteroids Commence Lassar’s paste Commence coal tar preparations (creams and shampoo)
The most common form of psoriasis in children is guttate (drop-like) psoriasis occurring over the trunk and limbs, often following a streptococcal infection. It usually lasts 2–3 months and responds to simple treatment measures such as Lassar’s paste, coal tar preparations and topical corticosteroids. PUVA and systemic treatments such as methotrexate and ciclosporin are reserved for more
severe cases.
Other forms of psoriasis include: psoriasis vulgaris, commoner on older teenagers and more chronic, affecting scalp and extensor surfaces; pustular psoriasis localises to palms and soles. Nail psoriasis consists of onycholysis, nail pitting and oil droplet formation. Psoriatic arthropathy often involves distal interphalangeal joints.
A 10-year-old girl presents to A&E unwell, miserable and feverish. She has had a cough and coryzal symptoms for 72 hours. A rash began to develop 2 hours ago, beginning as patches around her ears and neck, which is now spreading down her torso.
What is the most likely diagnosis?
Viral illness
Measles Correct answer
Rubella
Chickenpox
Erythaema infectiosum
Measles has an incubation period of 8–14 days followed by coryzal symptoms and Koplik’s spots (white patches on the buccal mucosa). Fever and lymphadenopathy develop, followed by an erythaematous maculopapular rash, which classically begins as patches becoming confluent and spreads from around the ears to the legs by day 3 when the face begins to clear. Children are miserable and unwell.
Complications include pneumonia, otitis media, encephalitis, myocarditis and lymphopenia. Subacute sclerosing panencephalitis (SSPE) can occur 5–10 years after the initial infection.
A 2-year-old girl is brought to the Emergency Department. She has become increasingly unwell over the last 24 hours. She has been grumpy, lethargic and does not like being held. Her skin has become red in colour.
On examination the girl is miserable and pyrexial. She has bilateral non-purulent conjunctivitis, cervical lymphadenopathy and red lips. She is tachycardic but well perfused. Cardiovascular, respiratory and gastrointestinal examination is normal. Her skin is generally red, especially around the right axilla. A blister has formed on her left big toe where the saturations probe was initially sited.
Which two of the following investigations will potentially give the most useful information?
Full blood count (FBC) Incorrect
C-reactive protein (CRP) Incorrect
Eye swab Incorrect
Skin swab Incorrect
Throat swab Incorrect
Blood culture Incorrect
Skin swabBlood culture
Staphylococcal scalded skin syndrome (SSSS) is caused by exfoliative toxin producing strains of Staphylococcus aureus. These strains may be located in areas of infection. The widespread clinical manifestation is initiated through release of toxin into the blood. The toxins are encoded either by the bacterial DNA itself or via plasmid DNA.
SSSS is mainly seen in infants and pre-school children. The skin manifestations may be localised or more global. A prodrome of lethargy, fever and distress may precede the red tender skin eruption. Conjunctivitis may be present and may be purulent. Peri-oral erythaema and lip redness with erosions are seen.
Nikolsky’s sign is demonstrated; shearing forces lead to separation of the epidermis in the subcorneal layer leading to sterile blister formation. Generalised desquamation occurs after 2–5 days and after 2 weeks the skin heals.
Diagnosis is aided by isolating the bacteria and phage typing. Skin swabs and blood cultures may enable this and prove the haematogenous spread of the bacterium.
Flucloxacillin is the treatment of choice.
A child presents to A&E with the formation of blisters on her hands and knees where she has started crawling. She has no other skin lesions or scarring and is systemically well.
What is the most likely diagnosis?
Allergic reaction
Epidermolysis bullosa simplex Correct answer
Dystrophic epidermolysis bullosa (recessive type)
Contact dermatitis
Hand, foot and mouth disease
Epidermolysis bullosa is a rare skin condition that affects different layers of the skin. Epidermolysis simplex affects the basal cell layer of the dermis. It is autosomal dominant and ranges from a mild to severe condition. Blisters are usually noticed on contact areas of the skin eg hands and knees, when the child
first begins to crawl. Junctional epidermolysis bullosa (autosomal recessive) presents at birth with a generalised distribution of blisters. Dystrophic epidermolysis bullosa has a milder autosomal dominant form that tends to present with blisters at the onset of crawling. The autosomal recessive form is much more severe with blistering in the upper layer of the dermis affecting the mouth, mucus membranes. Nail loss and dystrophy, plus syndactyly are common, as is oesophageal strictures. Prognosis is guarded.
A 4-month-old little boy is brought to his GP with a scaly, weeping rash across his scalp and cheeks. His mother is concerned as he is itchy and unsettled. The family recently completed a course of treatment for scabies.
What is the most likely diagnosis?
Scabies
Contact dermatitis
Seborrhoeic dermatitis (cradle cap)
Tinea corporis
Eczema Correct answer
Half of all patients who develop eczema will have symptoms in the first year of life. The peak onset is 2–6 months old. Approximately 90% of patients will be symptom free by 18 years old. Babies are affected primarily on the cheeks and face, which spreads to involve the neck, wrists, hands and extensor surfaces. Pre-school children are affected on the flexor surfaces of the popliteal and antecubital fossas, behind the ears, face and neck. Older children often have lichenification, scaling and scarring; areas affected include popliteal and antecubital fossas, forehead, wrists and dorsa of hands and feet.
A 4-year-old boy known to have eczema presents to A&E with an acute flare up of eczema across his face, hands and legs. He is systemically well and apyrexial. His parents say they have been using emollients and soap substitutes as directed by their GP.
What is the most important next management step?
Talk to parents about compliance
Prescribe topical steroid creams Correct answer
Prescribe antihistamines
Prescribe oral antibiotics
Admit to hospital for wet wraps and iv antibiotics
All aspects of acute flare-ups of eczema should be considered but the most important in this case is the instigation of topical steroids. These should be as least potent as possible with only mild creams used on the face. Antihistamines
are also important to prevent scratching; wet wraps and extra emollients can also be effective. Antibiotics are often required to treat secondary bacterial infection. Parental education and help needed must also be addressed, as compliance with treatment is difficult. Soap substitutes, bath oils and regular emollient use must be continued after the flare up has settled.
Eczema has a genetic component, ie if both parents are affected there is significant increased risk of the child also being affected; a dietary component, eg exacerbations triggered by dairy products; and exacerbating factors eg woollen clothing, humidity. These must also be considered when discussing long-term management.
A child is referred to paediatric outpatient clinic with recurrent skin infections. There are pustules and honey coloured crusting around his face. Otherwise he is well and growing and developing as expected.
Hand, foot and mouth disease
Chickenpox
Herpes simplex infection
Impetigo Correct answer
Immunodeficiency
Impetigo can be caused by staphylococcal or streptococcal infection. It can be recurrent if the child is a carrier of the organism (usually in the nose). Usually the organism enters the skin via an insect bite, dermatitis or scabies. Impetigo is contagious and simple rules of hygiene such as hand washing and separate towels should be followed. Treatment is usually a course of oral antibiotics; topical antibiotics can be used to try and eliminate carriage and if there are only a few lesions. If many bullae are present the infection is termed bullous impetigo. Impetigo can have serious complications including pneumonia and osteomyelitis.
Choose the most appropriate diagnosis from the list below:
A Stevens–Johnson syndrome B Chickenpox C Aphthous ulcers D Herpes simplex E Scarlet fever F Second-degree burns G Kawasaki disease
Scenario 1
Incorrect
A young girl presents to A&E with a fever and generalised rash over her trunk, when examining her rash has a sandpaper like feel and dark red lines are apparent in the skin creases. She also has pharyngitis.
0 Your answer
E Correct answer
Scarlet fever
Scarlet fever is produced b group A streptococcal infection. The rash is a diffuse erythaema mainly over the trunk, abdomen and skin folds; it is likened to sandpaper; Pastia’s lines are dark red lines seen in the skin creases. There is perioral pallor, a strawberry tongue and sometimes desquamation of skin from fingers and feet.
Scenario 2
Incorrect
A teenage boy is being treated by his GP for pneumonia and has begun a course of antibiotics. A painful, erythaematous rash developed on his lower limbs, which has now progressed. He has ulcers in his mouth making it difficult to eat and he complains of difficultly micturating.
0 Your answer
A Correct answer
Stevens–Johnson syndrome
Stevens–Johnson syndrome is a severe, bullous form of erythaema multi-forme and involves mucous membranes eg mucositis, conjunctivitis, corneal ulceration, uveitis and/or genital ulceration. There are associated problems of pneumonia, polyarthritis, fluid and electrolyte imbalance, urine retention and inability to eat and drink. Management must include removal of cause, monitoring of fluid and electrolytes and antibiotics to treat secondary bacterial infection.
Scenario 3
Incorrect
A five-year-old girl is seen by her GP with a rash at varying stages of development from erythaema to vesicles. She has a fever and is miserable. Her older sister reports ‘something going round’ at school but is not sure what.
0 Your answer
B Correct answer
Chickenpox
Chickenpox has an incubation period of 10–14 days followed by inset of fever and malaise. The rash begins on the trunk with macules progressing to papules then to vesicles, which eventually crust over. There are usually lesions at all stages. Mucous membranes may be involved making fluid management a problem. Complications include pneumonia, encephalitis and secondary bacterial infection.
Choose the most appropriate diagnosis from the list below:
A Idiopathic thrombocytopenic purpura B Meningococcal disease C Pertussis D Henoch–Schoenlein purpura E Acute leukaemia F Non-accidental injury G Clotting dysfunction
Scenario 1
Incorrect
A 2-month-old baby girl is brought to A&E after parents noticed small purple spots appear around eyes. She has a fever and is generally unwell, parents report she seems to be struggling with her breathing. After careful examination there are no spots or rashes elsewhere.
0 Your answer
C Correct answer
Pertussis
Periorbital petechiae can be seen with coughing spasm, non-accidental injury and parturition (when the cord is wrapped around the infant’s neck). Pertussis (whooping cough) has been described as the hundred-day cough. In young children an inspiratory whoop with the coughing spasm is not always heard; babies can present with apnoea. Treatment is supportive although a course of erythromycin can be given to eliminate nasal carriage.
Scenario 2
Incorrect
A 6-year-old boy attends the GP surgery one week following a viral upper respiratory tract infection. His parents have noticed excessive bruising after a football game at school.
0 Your answer
A Correct answer
Idiopathic thrombocytopenic purpura
Superficial bruising, petechiae and sometimes mucosal bleeding from gums and nose can be the initial presentation of idiopathic thrombocytopenic purpura. It often follows a viral infection and, apart from signs of bleeding, children are usually well. There is thought to be immune destruction of circulating platelets. The serious complication to consider is intracranial haemorrhage.
Scenario 3
Incorrect
A 2-year-old girl is rushed to the A&E department with fever and a maculopapular rash. She was well at breakfast but has deteriorated rapidly over the morning and is now semi conscious.
0 Your answer
B Correct answer
Meningococcal disease
Meningococcemia is a rapidly progressive life threatening condition. The rash is classically non-blanching petechiae and purpura but can be maculopapular. The type of rash does not dictate the clinical course. The rash may progress to haemorrhagic purpura and purpura fulminans. Urgent resuscitation and prompt antibiotics are required for any child suspected of meningococcal septicaemia.
A six-year-old girl who has been under treatment for diabetes mellitus for the last three years was referred by her GP for an evaluation of weight loss over the past five months. You have ascertained from her parents that she has been taking insulin regularly and her records show that her diabetic control has been satisfactory. On examination you have recorded that her weight is in the 5th percentile for her age. You also notice pallor, a few apthous ulcers, wasting in the gluteal region and a few vesicles on the elbows. Other than this there were no abnormal findings.
The results of investigations are given below:
Haemoglobin 9. gm/dl
Total Lymphocyte count
8 x 10 9/l
Neutrophils 55%
Lymphocytes 40%
Eosinophils – 3% Platelets 240 x10 9/l
ESR 16 mm fall in first hour
C-reactive Protein 7 mg/l
Blood sugar Fasting 8 mmol/L
HbA1C 8%
Serum creatinine 88 μmol/L
Urinalysis 4 pus cells/high power field. No proteins or Sugar detected.
Nitrate test negative
Stool Examination Fat content increased
Chest X-ray normal
Biopsy of the skin lesions
IgA deposits in the dermis on immunoflorescence
What are these skin lesions called?
Pyogenic granuloma
Dermatitis herpetiformis Correct answer
Dermatitis artefacta
Pemphigus
Molluscum contagiosum
This is a common association with coeliac disease. It presents as grouped vesicles onthe elbows, knees, sacrum and scalp that leave behind pink excoriated papules and plaques.
Incorrect
What is the likely cause of weight loss in this child? Choose One Answer.
Cystic fibrosis
Crohn’s disease
Coeliac disease Correct answer
Addison’s disease
Insulin autoantibodies
The clinical features in this patient are suggestive of coeliac disease, which is associated with type I diabetes mellitus.
A neonate is transferred back to the Special Care Baby Unit from the tertiary surgical centre following an operation for severe necrotising enterocolitis; he now has an ileostomy. He was born at 26 weeks’ gestation and required ventilation for 6 days,
followed by 4 days of continuous positive airway pressure (CPAP). He was initially given total parenteral nutrition, then an increasing amount of expressed breast milk. On review he is noted to have an eczematous reaction around his nappy area, which has vesicular and bullous lesions. The discharge letter from the surgeon’s reports that the rash has not responded to emollient or steroid creams. The rest of his skin is normal, apart from a small haemangioma on his left upper arm. His growth has fallen across 2 centiles to below the 3rd centile for weight and length. His chest is clear. His ileostomy site is healing well. The nurses have commented on how well the mother is coping with the bag, although she is changing it 6–8 times per day.
Given all the features, which ONE problem may account for this boy’s examination findings?
Iron deficiency Incorrect
Candida dermatitis Incorrect
Napkin dermatitis Incorrect
Trace metal deficiency Incorrect
Langerhans’ cell histiocytosis Incorrect
Secondary bacterial infection of the nappy area Incorrect
Trace metal deficiency
Neonates who have had severe necrotizing enterocolitis (NEC) may have short gut syndrome leading to nutritional deficiencies. Zinc deficiency has been described in pre-term infants and subclinical deficiency is probably more prevalent than is currently believed. Zinc absorption occurs in the small intestine. It is bound in the blood by albumin and α2-macroglobulin. Breast milk contains enough zinc for term infants, but may have insufficient levels for pre-term infants.
Clinical manifestations include eczematous perioral, perineal and scalp skin lesions, diarrhoea, stomatitis, growth faltering and hair loss. Diagnosis is with low serum zinc levels; a low alkaline phosphatase level is associated.
Acrodermatitis enteropathica is a rare autosomal recessive condition of defective zinc absorption from the gut, with the same clinical manifestations as above.
Treatment is with zinc supplementation. Zinc supplementation has been shown to improve growth in children in the developing world.
A seven-year-old girl presented with painless, red patches on her trunk, which she said had increased in number for the last fortnight. There is no history of pruritus. Her mother gave the history that the patches had followed a solitary ‘ringworm’ infection on the same site. On examination, you notice a healthy cheerful child with erythematous scaling plaques in the axillary and mammary regions. One of the plaques was bigger in size as compared to the rest.
What is the likely diagnosis? Choose one answer.
Pityriasis alba
Pityriasis versicolor
Pityriasis Pytriasis rosea
Correct answer
Tinea corporis
Scabies
This is a self-limiting condition that occurs in healthy children and lasts for about two months. The lesion starts as a ‘herald patch’ that looks similar to a ring worm lesion. This is followed by the typical rash that has a ‘Christmas tree’ distribution.
A 12-year-old boy is referred by the GP. He has had a flu-like illness in the last 3 days but presented to the surgery this morning with a developing skin rash. He is quiet, well perfused and hydrated, with a few crackles on auscultation of his chest. He has a non-itchy red rash covering his trunk and limbs, with macules and papules present. On his right hand he has two lesions that have a pink–purple spot surrounded by normal skin, then a circle of erythaema. His conjunctiva and oral mucosa is unaffected. He is normally fit and well and is not on any regular medication.
Which TWO investigations may be most helpful in the diagnosis of this boy’s condition that is associated with the rash?
Full blood count (FBC) Incorrect
C-reactive protein (CRP) Incorrect
Liver function tests (LFTs) Incorrect
Urine m/c & S Incorrect
Chest X-ray Incorrect
Mycoplasma titres Incorrect
Throat swab Incorrect
Full blood count (FBC)Mycoplasma titres
Erythaema multiforme is characterised by a rash that can include macules, papules, vesicles, bullae or urticaria. Target lesions are the typical lesions that then develop. The oral mucosa may be affected, but other mucosal surfaces are generally not involved, hence differentiating it from Stevens–Johnson syndrome. The underlying abnormality is probably related to a cell-mediated immune response causing keratocyte damage.
Investigation of children with erythaema multiforme is guided by the history and
other examination findings. Many infective causes have been described, but the most common are herpes simplex virus and Mycoplasma pneumoniae. Acute and convalescent titres for mycoplasma are necessary to confirm that particular diagnosis. Another important cause that it is prudent to rule out is leukaemia and lymphoma. Many drugs have been reported to cause erythaema multiforme including various antibiotics and antiepileptics.
Treatment is symptomatic and for the underlying cause.
A 6-year-old girl presents to A&E with an evolving purpuric rash across her lower limbs. Her parents thought the rash was related to a change in washing powder as the previous day it had looked like hives. However she began to complain of knee pain and her feet were slightly swollen.
What is the most likely diagnosis?
Reactive arthritis
SLE
Juvenile idiopathic arthritis
Henoch–Schoenlein purpura Correct answer
Hereditary angio-oedema
The rash of Henoch–Schoenlein purpura can present initially as urticaria and then progress to the classic non-thrombocytopenic purpura, mainly distributed across the legs and buttocks. There is often associated arthralgia and arthropathy but this is transient and remains within the same joints eg ankles, knees and hips. Oedema of ankles and feet are sometimes seen, but are also transient. It is important to distinguish generalised oedema, which may be an indicator of renal impairment. Differential diagnosis of an acute painful joint includes haemophilia, sepsis, trauma, reactive arthritis, sickle-cell disease crisis and tumour.
A 15-year-old girl is seen in the Emergency Department with her mother. She has been lethargic and had a fever for 6 days; she has now developed a rash over her shins. She is otherwise a fit and healthy teenager, who has never been to hospital previously. An aunt has severe rheumatoid arthritis. The girl is not on any regular medication. On examination she has a few shotty cervical lymph nodes, but otherwise systemic examination is unremarkable. Her lower legs are covered in 2–3 cm, hot, tender nodules.
Which of the following may be the cause of her rash?
Erythaema nodosum is characterised by painful subcutaneous and dermal nodules. It is a hypersensitivity reaction to various pathological stimuli. There are several causes and all must be considered in the assessment of erythaema nodosum, whether by careful history taking or investigation.
Infectious causes include EBV, hepatitis B, Streptococcus, Mycoplasma, Chlamydia, tuberculosis, Yersinia, histoplasmosis and coccidioidomycosis. Crohn’s disease may present with erythaema nodosum and ulcerative colitis is also an association. Autoimmune conditions such as sarcoidosis, systemic lupus erythematosus (SLE) and Behçet’s disease may manifest in this way. Sulphonamides and the oral contraceptive pill have been reported to cause erythaema nodosum.
The nodules generally fade over 2–4 weeks. Treatment is symptomatic with non-steroidal anti-inflammatory drugs (NSAIDs) and bed-rest may be appropriate.
An 8-year-old boy is admitted with five days of high fever. He has no coryzal or respiratory symptoms. He is miserable and complains of a headache but has no signs of meningism. On examination his lips are red and cracked and he is mildly dehydrated. He has a generalised maculopapular rash widely distributed across his back, torso and legs.
Which other clinical signs would help you confirm your diagnosis? Choose two of the following:
Kawasaki disease is a clinical diagnosis made on the basis of a high fever for at least five days and four of the following criteria: polymorphous rash (maculopapular most common); cervical lymphadenopathy; mucosal involvement with dry cracked kips and strawberry tongue; erythaema and oedema of fingertips and toes followed by desquamation after about 10 days; non-suppurative conjunctivitis.
Other complications include aseptic meningitis, urethritis and sterile pyuria, arthritis, diarrhoea and vomiting and mild hepatitis. The most important consequence to consider is cardiovascular compromise. Coronary artery aneurysms and thrombosis can develop between 2–4 weeks from the onset. Treatment to try and combat these problems involves high-dose γ-globulin and aspirin. Cardiology review and echocardiogram are required.
A two-year-old girl is referred to A&E with evolving blisters across her torso and upper limbs; some blisters have burst leaving red sore patches and she dislikes her skin being touched. There is no history of trauma. She has a fever of 38.5oC and is generally miserable and lethargic. There is no involvement of mucous membranes and no signs of meningism. She is mildly dehydrated. Chest X-ray (CXR) and urine dipstick are normal.
What are you next management steps? Choose three of the following:
Perform a lumbar puncture Incorrect
Take blood for culture Incorrect
Give an emergency fluid bolus Incorrect
Commence intravenous antibiotics Incorrect
Take samples of the blister fluid Incorrect
Prescribe emollients and analgesia only Incorrect
Discharge and review in 24 hours Incorrect
Commence aciclovir and antibiotics Incorrect
Refer to dermatology Incorrect
Exhibit the Nikolsky sign Incorrect
Take blood for cultureCommence intravenous antibioticsTake samples of the blister fluid
Staphylococcal scalded skin syndrome (SSSS) is caused by Staphylococcus aureus phage group 2, which produces toxic epidermal necrolysis. Large blisters develop which burst leaving areas of red raw underlying skin. The skin exhibits the Nikolsky sign, whereby gentle pressure exerted on the blister results in its extension as layers of epidermis separate. Other manifestations include crusting and fissuring around the eyes, nose and mouth. SSSS is usually accompanied by fever and malaise. Secondary bacterial infection, generalised sepsis, fluid and electrolyte imbalance are important consequences. The bullae are usually sterile
but samples of the fluid and blood culture samples should be taken; skin biopsy is not required. Treatment is with antibiotics either oral or intravenous depending on severity. Emollients and analgesia are also used, but topical antibiotics are unnecessary.
At the six-week baby check the GP notices a large, 22-cm brown nevus across the back of the baby. There is nothing else to find on examination and the baby is thriving. The parents are not unduly concerned about the lesion and say it is not progressing in size or changing.
What is the most important next step in management?
Review by the GP in 3 months’ time
Urgent referral to a dermatologist (4–6 weeks) Correct answer
Non-urgent referral to a dermatologist (4–6 months)
Prescribe topical steroid creams
Review at parents request
Giant (>20 cm) congenital melanocytic naevi are very rare. Melanocytic naevi, more common in later childhood can also be congenital but are <20 cm diameter. Lesions may be flat or elevated and can be various shades of brown/black. Giant hairy naevi are also seen. There is an increased risk of transformation into malignant melanoma. Currently giant congenital pigmented naevi are surgically removed before three months of age. There is controversy about the treatment of medium-sized naevi but referral to a plastic surgeon and dermatologist with regular review are recommended.
A 3-year-old girl was brought to A&E by her concerned parents when she developed a diffuse erythaematous, macular rash across her lower arms and legs, face and neck. There was marked sparing of areas which had been covered by clothes and she seemed unperturbed by the rash. The little girl had spent the afternoon in her grandparent’s house and garden.
What is the most likely diagnosis?
Sunburn
Contact dermatitis
Allergic reaction
SLE
Phytophotodermatitis Correct answer
Phytophotodermatitis has a classical distribution on peripheral sun exposed areas of skin. A combination of sunlight and many different plants are responsible for the reaction. It can cause concern to parents and medical staff but rarely presents a problem to the affected child. The skin changes are self-
limiting but can sometimes leave residual pigmentary changes.
Other disorders exacerbated by light include psoriasis, herpes simplex and SLE.
Choose the most appropriate diagnosis from the list below:
A Urticaria B Erythaema multi-forme C Erythaema nodosum D Erythaema marginatum E Erythaema chronicum migrans F Staphylococcal scalded skin syndrome G Infected eczema
Scenario 1
Incorrect
A family return from a holiday to the USA and attend their GP because the five year old has developed an erythaematous rash. There are discrete round lesions, which seem to be spreading.
0 Your answer
E Correct answer
Erythaema chronicum migrans
Lyme disease is an infection caused by Borrelia burgdorferi, transmitted by infected ticks found in parts of the USA, Australia and Europe. The rash, called erythaema chronicum migrans, begins as an erythaematous annular lesion gradually increasing in size. Serious complications include meningoencephalitis, cranial nerve palsies, pancarditis and arthritis.
Scenario 2
Incorrect
A teenager presents to her GP complaining of a strange rash with individual red rings, which seem to have creeping borders. She had an upper respiratory tract infection two weeks ago but is otherwise well. On examination small subcutaneous nodules are noted.
0 Your answer
D Correct answer
Erythaema marginatum
Approximately one-fifth of patients with rheumatic fever have erythaema marginatum. The rash is characteristically a flat, non-painful with normal areas of skin surrounded by red rings with creeping borders. Erythaema marginatum constitutes a major criteria for rheumatic fever, the others are: polyarthritis, carditis, subcutaneous nodules over joints and tendons and chorea.
Scenario 3
Incorrect
A 5-year-old boy is brought to A&E with a fever and cough. He is noted to have small target lesions on the front of both legs.
0 Your answer
B Correct answer
Erythaema multi-forme
Erythaema multi-forme can be minor–symmetrical target-shaped lesions most commonly on hands, feet and extensor surfaces or major–vesicular/bullous type where the bullae are central or around the periphery of the lesion. Lesions are non-puritic, which helps distinguish them from urticaria and usually resolve spontaneously after 4–6 weeks. There are many causes including idiopathic; infections eg herpes simplex, mycoplasma, EBV or drugs eg sulphonamides.
A 12-year-old girl is seen in your clinic with a history of painful swellings over the lower aspect of her shins which started three days ago. Her mother says that she had recovered from an attack of flu a few days back. On examination you notice a few tender, red nodules around 10mm in diameter on the anterior aspect of her tibia. A few similar lesions with a darker hue were also noticed. She appeared well nourished. She had mild pallor, and a few cervical lymph nodes were enlarged but were non-tender and mobile. Her pharynx was congested.
Investigations revealed:
Haemoglobin 11.7 gm/dl
Total Lymphocyte count
12 x 10 9/l
Neutrophils 40%
Lymphocytes 55%
Platelets 200 x 10 9/l
ESR 14 mm fall in first hour
C-reactive Protein 7 mg/l
Urinalysis4 pus cells/high power field. No proteins or Sugar detected
Nitrate test negative
Chest X-ray normal
What is the likely diagnosis? Choose one correct answer
Erythema multiforme
Erythema chronicum migrans
Erythema nodosum Correct answer
Erythema toxicum
Erythema Marginatum
Erythema infectiosum
Incorrect
What are the common causes of these typical lesions. Choose Three correct answers.
Rheumatic fever Incorrect
Lyme disease Incorrect
Tuberculosis Incorrect
Malaria Incorrect
Oral contraceptives Incorrect
Following Oral Polio Vaccine Incorrect
Sulphonamides Incorrect
Steroid therapy Incorrect
TuberculosisOral contraceptivesSulphonamides
The lesions are typical of erythema nodosum. The lesions come in crops for 3-6 weeks and may be associated with malaise, fever or arthropathy. The lesions are typical of erythema nodosum. The lesions come in crops for 3-6 weeks and may be associated with malaise, fever or arthropathy. They are associated with streptococcal infection, tuberculosis, and mycoplasma amongst others.
A teenage girl presents to her GP with acutely painful legs. She has recently been on an outward-bound course with her school. On examination red, shiny, painful lesions are noted on her lower limbs.
What is the most likely diagnosis?
Erythaema nodosum Correct answer
Erythaema multi-forme
Accidental injury
Localised allergic reaction
Insect bites
Erythaema nodosum are classically erythaematous, indurated, painful nodules that appear on the shins. They are more common in women and rarely present below the age of 6 years. They develop over a few days and then fade, looking like bruises; they can leave patches of hyperpigmentation. There are many causes, including infection eg streptococcal, mycoplasma, salmonella, EBV; drugs eg penicillin, sulphonamides, oral contraceptive pill; inflammatory bowel disease; connective tissue disease; sarcoidosis.
A child visits her GP with small popular pearly lesions across her face and neck. They have been present for two weeks and are not itchy or painful.
What is the most likely diagnosis?
Chickenpox
Herpes simplex
Molluscum contagiosum Correct answer
Impetigo
Warts
Molluscum contagiosum is a common infection caused by poxvirus. Lesions are classically discrete, pearly/flesh coloured, approximately 3-mm papules. They have a central umbilication. Lesions may occur anywhere on the body but typically on the face, neck and axillae. Lesions do resolve spontaneously but are often treated as they can persist for months and are infectious. Individual lesions can be cleared by pricking the centre with a sharp instrument dipped in liquid phenol. This treatment, though popular, can lead to scarring.
The senior house officer calls to request a review of a baby on the post-natal ward. The midwife has noticed some blistering of the baby’s skin on the feet and hands. On examination the baby is well, not dysmorphic and all the mucosal surfaces are normal. Congenital infection is not suspected. The baby is feeding well and has passed meconium. This is the mother’s first child; there is no family history of note.
At which level of the skin is blister formation most likely to be occurring in this child? Select ONE.
Subdermal
Deep to lamina densa
Within the lamina densa
Within the lamina lucida
Intraepidermal Correct answer
Epidermolysis bullosa simplex is inherited in an autosomally dominant fashion; sporadic mutation can occur. A keratin abnormality leads to breakdown of the keratinocytes and subsequent blister formation. The condition is non-scarring. Blisters develop in the neonatal period and affect the hands, feet, limbs and scalp. The mucosal surfaces may be mildly affected. Treatment involves puncturing the blisters when they form and antibiotic treatment if infection is present.
Junctional epidermolysis bullosa is autosomal recessive with blisters forming in the lamina lucida. All of the body is affected, including the mucosal surfaces and nail beds. Scarring is present, which may lead to oesophageal strictures. It is a life-limiting condition with death by 3 years of age.
Dystrophic epidermolysis bullosa may be autosomal recessive or dominant. Blisters occur deep to the lamina densa. The recessive form is more severe and may be life-limiting due to infection or oesophageal strictures. Webbing and deformity of the digits occurs.
Psychological support for the child and the family is required.
A child presented to his GP with a history of fever and sore throat. The GP prescribed oral amoxicillin. Shortly after taking the first dose the boy developed a diffuse macular papular rash.
What is the most likely diagnosis?
Stevens–Johnson syndrome
Allergic drug reaction
Measles
Streptococcal tonsillitis
Glandular fever Correct answer
Glandular fever (infectious mononucleosis) is caused by the Epstein–Barr virus. Full blood count typically shows a lymphocytosis and the presence of atypical lymphocytes. The test for heterophile antibodies (Paul–Bunnell test) is positive in about 60% of cases. Clinical features usually include cervical lymphadenopathy, sore throat, fever and enlarged tonsils. Generalised lymphadenopathy and splenomegaly are common. Hepatitis with mildly deranged liver function tests and jaundice can also occur. A macular–papular rash can occur in the natural course of the illness but occurs in 80% of patients given amoxicillin.
For each of the following descriptions choose the most likely diagnosis.
A Enterovirus infection B Streptococcal infection
C Staphylococcal infection D Dermatophyte infection E Scabies F Kawasaki’s disease G Juvenile idiopathic arthritis
Scenario 1
Incorrect
A 2-year-old infant presents with a week of high fever, lethargy and a rash. He is miserable and looks unwell, with a temperature of 38.6 oC. He has red eyes, red cracked lips and a blanching maculopapular rash. He has cervical and inguinal lymphadenopathy, with some nodes being around 1–2 cm.
0 Your answer
F Correct answer
Kawasaki’s disease
Kawasaki’s disease is an acute vasculitis of unknown origin, which is found worldwide. It is probably secondary to an infection. Its incidence varies between ethnic groups, with children in South-East Asia having the highest. It mainly affects pre-school children. The reason for the importance of correct diagnosis lies in the associated complications. Vasculitis is found in all blood vessels, but medium-sized arteries are especially affected – including the coronary vessels. This predisposes to the formation of aneurysms and the associated risk of acute coronary symptoms and death from infarction. If untreated then 20% of children will suffer coronary artery abnormality.
Scenario 2
Incorrect
A 2-year-old child presents with a week of swinging fever, lethargy and a rash. He is miserable and looks unwell, with a temperature of 38.6 oC. The pink rash involves his trunk and is more visible when the temperature increases. He has cervical and inguinal lymphadenopathy. His liver and spleen are slightly enlarged.
0 Your answer
G Correct answer
Juvenile idiopathic arthritis
Juvenile idiopathic arthritis may present in a similar fashion to Kawasaki’s disease. Classically the rash is described as salmon-pink in colour and varies in intensity with the temperature. It should be considered a diagnosis of exclusion,
as initial presentation does not always include joint symptoms or signs. As there is often hepatosplenomegaly and lymphadenopathy a haematological malignancy must be excluded.
Scenario 3
Incorrect
A 2-year-old child presents with a week of fever, lethargy and a rash covering his trunk. Initially he vomited and was rubbing his head. He is miserable, has cervical lymphadenopathy and red tonsils, tongue and lips. There is a blanching red rash over his face, trunk and limbs; there is some peeling of the skin over the truncal rash.
0 Your answer
B Correct answer
Streptococcal infection
Group A streptococcal infection exhibits itself in several different clinical guises, both with direct infection or as a result of toxin production. Scarlet fever represents streptococcal infection with an erythrogenic exotoxin producing strain. The temperature associated with scarlet fever normally peaks on day 2 of the illness and then gradually returns to baseline by one week. The temperature will respond to treatment with penicillin rapidly. Early in the illness a coated ‘white strawberry’ tongue is found with subsequent sloughing to leave a ‘red strawberry’ tongue. The red rash starts around the neck and in the axillary and inguinal regions, spreading to include the trunk and limbs. Desquamation of the skin occurs from the trunk outwards. The rash may feel dry and coarse.
For the following skin problems match the most appropriate diagnosis.
A Albinism B Incontinentia pigmenti C Hypomelanosis of Ito D Ocular albinism E Oculocutaneous albinism F Partial albinism G Vitiligo H Waardenburg syndrome
Scenario 1
Incorrect
A 5-year-old child is seen in the special needs school clinic for annual review. She has had hypopigmented linear lesions along her limbs since birth. Her antiepileptics are increased and an appointment is made to see the optometrist.
0 Your answer
C Correct answer
Hypomelanosis of Ito
Hypomelanosis of Ito is a rare disorder of localised hypopigmentation that is not inherited. The melanocytes in these areas are deficient in melanin and also smaller than expected. Unlike incontinentia pigmenti, the hypopigmented areas are present from birth and do not undergo any changes. They appear as well-defined streaks and whorls following the lines of Blaschko. There are associated seizures, learning problems, microcephaly, scoliosis, abnormal limbs, eye defects and congenital heart disease.
Scenario 2
Incorrect
A 3-year-old child attending the local health visitor clinic for child surveillance. He has hypopigmented areas over his chest and face and a white forelock. His mother has similar features. He is not dysmorphic and is developmentally normal in all areas.
0 Your answer
F Correct answer
Partial albinism
Partial albinism (or piebaldism) is an autosomal dominant disorder, where melanocytes are not present in defined areas of skin; this may derive from a failure of normal differentiation or migration from the neural crest. It is a non-progressive form of albinism. Waardenburg syndrome is also autosomal dominant and is associated with a high frequency sensorineural deafness. The affected individual may also demonstrate heterochromia, dystopia cactorum and have a thin nose and square face.
Scenario 3
Incorrect
A 10-year-old child is seen in the paediatric outpatient clinic. She has developed increasing numbers and sizes of hypopigmented areas. She is otherwise fit and well.
0 Your answer
G Correct answer
Vitiligo
Vitiligo is an acquired hypopigmentation, which presents in people aged less than 20 years old 50% of the time. It is important to recognise, as it may be associated with other conditions, such as insulin-dependent diabetes mellitus (IDDM), pernicious anaemia and other endocrine disorders. Careful examination of all the skin must be made to exclude malignant melanomas.
A 14-year-old girl is seen in clinic with acne. She is a fit and healthy teenager with no other medical problems. She exercises regularly and represents her school in the hockey team. She is not on any regular medication. The only soap she uses is a fragrance-free preparation. Her mother has bought her several commercial preparations for spots that contain antiseptic chemicals. She does not have a boyfriend. On examination she has an athletic build. Systemic examination is unremarkable. She has widespread inflamed pustular acne over her face and some spots on her shoulders. No nodular or cystic lesions are found.
Which TWO of the following treatments are most appropriate for initial management?
Benzoyl peroxide Incorrect
Topical antibiotic Incorrect
Oral antibiotic Incorrect
Topical retinoid Incorrect
Oral contraceptive pill Incorrect
Isotretinoin Incorrect
Benzoyl peroxide Topical antibiotic
Benzoyl peroxide is a useful topical antimicrobial solution that is widely available without prescription. It has been proven to be highly effective in mild to moderate acne. It is used 1–2 times daily to wash the face. It may cause excess dryness of the skin.
When treating moderate acne of moderate severity, benzoyl peroxide should be used in combination with an antibiotic. Recent research has indicated that topical antibiotics aid in the treatment of inflammatory predominant acne. For practical reasons oral antibiotics are probably more useful if the acne is widespread. Topical retinoids should be used if the acne is mainly comedogenic; decreasing the number of comedones decreases the degree of inflammation.
If these measures do not succeed in reducing the acne then hormonal therapy should be considered for teenage girls. If the acne is severe then oral isotretinoin can be used.
A 3-year-old-boy is admitted to the general paediatric ward with severe infected eczema from primary care. He has been treated by the GP before this without success. His mother does not speak any English, but brings his current medication. This
includes an aqueous moisturizing cream, hydrocortisone cream and fucidin cream. He is also asthmatic. Although he is systemically well, he has widespread infected eczema, with lichenification over his arms. His mother also offers his sister’s hands for you to examine. You notice she is scratching furiously and has pinprick-sized papules over her hands, between the fingers and around her wrists.
Which THREE of the following should be prescribed to the boy?
Eczema affects around 10% of children and varies tremendously in severity. Initial treatment includes the liberal application of emollients and topical corticosteroids. For mild eczema hydrocortisone is usually effective. Widespread severe eczema may require a more potent corticosteroid; although only hydrocortisone should be used on the face.
Secondary infection is common and will often respond to topical antibiotics. Severe infection may require enteral or parenteral antibiotics if the child is systemically unwell.
Scabies is due to an infestation with the mite Sarcoptes scabei. It is easily spread among family members and infestation in one requires treatment of the entire household. Alcohol-based Malathion solution should not be used in children with broken skin, as it will cause severe irritation.
According to the recent National Institute for Clinical Excellence (NICE) guidelines tacrolimus and pimecrolimus should be used only if optimum corticosteroids are unable to control the eczema.
