The Last Rash - ACEP€¦ · • Recognize the typical presentation of life- threatening rashes....

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The Last Rash

Pediatric rashes you don’t want to miss

Advanced Pediatric Emergency Medicine AssemblyMarch 18-20, 2019James (Jim) Homme, MD, FACEP


Disclosures • No financial disclosures


Learning Objectives: At the end of this session the learner will be able to:• Recognize the typical presentation of life-threatening rashes.

• Describe the variation in presentation of life-threatening rashes.

• Discuss the dynamic nature of life-threatening rashes.

• Recognize the life-threatening complications of initially benign rashes.

• Discuss the work up of the suspicious rash.


“It is a strange fate that we should suffer so much fear and doubt over so small a thing.

Such a little thing.”

Boromir, Fellowship of the Ring


1 week old afebrile infant, feeding well, normal appearance except for this rash


Erythema Toxicum Neonatorum

• Benign, self-limited• Found in approx 50% of newborns.• Lesions are yellow-white, 1-2 mm pustules with

erythematous base.• “Rash often presents on 2nd or 3rd day of life (but can

emerge as late as 2-3 weeks)

• Rash waxes and wanes over first few weeks of life.


5 day old afebrile infant. Skin with scattered pustules full of a milky fluid. Upon examining a

pustule, it easily wipes away revealing a hyperpigmented spot.


Neonatal Pustular Melanosis

• Benign, self-limited of unknown etiology.• More common in dark-skinned infants. • Vesicular rash with 2-5 mm pustules with a

hyperpigmented, nonerythematous base, which develops a central crust over time leaving a hyperpigmented macule with scale.

• Pustular stage occurs during first few days of life and hyperpigmentation lasts for weeks to months.


4 day old febrile female

born via NSVD at

home.


Neonatal Herpes Simplex Virus • Perinatal transmission occurs in 85 %

• Types:• Skin, eye, and mouth (SEM) 45%• CNS 33%• Disseminated HSV< 25%

• Invasive disease typically before 14 days but up to 28 days

• Treatment involves antiviral therapy (14 -28 days) and supportive measures


9 mo healthy appearing female with this rash


Cutis Marmorata• Reticulated pattern of constricted capillaries and

venules. • Due to vasomotor instability in immature infants or

physiologic response to hypothermia. • Generally resolves with increasing age, for most infants

is of no significance.


2 yo female seen for facial rash, started on Clindamycin

36 hours ago


Bullous Impetigo

• Staph or Strep Infection• Localized or diffuse• Treated similarly to impetigo

• Oral penicillinase resistant ABX• Parenteral penicillinase resistant Abs for more ill or uncertain

presentation



Staph Scalded Skin Syndrome (SSSS)

• Staph or Strep Infection• Toxin mediated process• Painful rash• Treatment

• Parenteral Penicillinase resistant antibiotic + Clindamycin • Pain control• Fluids


3 month old febrile, irritable infant



Meningococcemia

• Clinical presentation varies• 50% meningitis• 40% meningitis + septicemia• 10% septicemia

• 10-15% mortality rate

• 10-20% long term morbidity in survivors• Prompt empiric antibiotics (3rd gen Ceph) and resuscitation


6 month old infant with fever, splenomegaly, weight loss, irritability and rash


Hemophagocytic Lymphohistocytosis (HLH)

• Autoimmune disorder resulting in activated histiocytes• Affects Bone Marrow, Liver, Spleen, Skin, Brain, Heart…

• Mimics Malignancies and Infectious Conditions• Diagnosis

• CBC (cytopenias), smear (no blasts), Liver Function Tests (hepatitis), Ferritin (very high), fibrinogen (low), Triglycerides (high), ± Skin/Bone Marrow Biopsy

• Discovered while trying to rule out other diagnoses


12 mo male on day 7 ofAmoxicillin for AOM


Drug Rash/Eruption

• Most common clinical presentations:• Morbilliform or exanthematous eruption (erythematous macules

and papules)• Urticaria (pruritic reddish wheals) • May be associated with life-threatening anaphylaxis

• Present around 7 days after exposure and resolve after 1-2 weeks

• Most drug eruptions are not life threatening


17 mo female with pruritic rash, day 7 of amoxicillin for AOM after URI



Acute Hemorrhagic Edema of Infancy (AHEI)

• Children > 24months with recent infection• Leukocytoclastic vasculitis from immune complexes

• Cutaneous lesions are erythematous, annular, rosette, or targetoid patches that cluster and often coalesce

• Defining feature is edema of hands, feet, extremities or face

• Overall non-toxic appearance, benign course• Antihistamines for pruritus• Steroids for significant discomfort from edema


6 yo child presents with 3 days of fever, cough, runny nose and red eyes


6 yo child presents with 3 days of fever, cough, runny nose and red eyes



Measles (Rubeola) “First Disease”

• Highly contagious (>90% attack rate)

Prodrome of high fevers, often > 104° F, with the classic triad of cough, coryza, and conjunctivitis

↓

Enanthem erupts (Koplik spots) on buccal mucosa

↓

Exanthem erupts – cephalocaudal progression (~ 14 days after exposure)

2-3 days

2-3 days


9 yo female with fever, cervical

lymphadenopathy and sore throat


Uvular and Palatal Petechiae: Strep Pyogenes (GAS)

• Classic strep rash is a scarlitiniform (sandpaper) rash on the trunk

• + LR 3.91• Palatal and Uvular Petechiae

• + LR 2.69• Tonsilar Exudates

• + LR 1.85


7 yo twin afebrile female with rash and swollen left ankle



Henoch-Schönlein Purpura

• IgA mediated small vessel vasculitis• Involves Skin, Joints, GI tract, Kidneys• Most managed as outpatients

• Supportive care with NSAIDs• Monitor for renal involvement• Admission ± Steroids for severe abdominal pain


13 month old with cold exposure to left foot and nose


Next Day


Frostbite of the Nose and Foot

• First-degree frostbite:• Blanching and temporary numbness• Erythema• Stinging and burning with rewarming

• Second-degree frostbite:• Subcutaneous tissue involvement• Clear fluid blisters within 12 hours of injury• Altered sensation to skin• Stinging and burning with rewarming• White mottled appearance


Frostbite of the Nose and Foot

• Third and fourth-degree frostbite:• Muscle, tendon, and bone involvement ± Necrosis• Edema• Blue-gray discoloration of the skin• Deep burning pain on rewarming• Hemorrhagic blisters• Severe cold sensitivity

• Determining the degree of frostbite can be complicated and may take 3 to 4 days.


7 yo fully vaccinated male with 3 days of headache, eye pain and redness, and 1 day of rash


Herpes Opthalmicus

• Varicella Zoster infection in V1

• Latent infection• Prodromal symptoms followed by rash

• Risk of ocular disease and ischemic stroke• Treated with antivirals and steroids

• Ophthalmology follow-up


2 yr old with history of eczema, now with a painful rash



Eczema Herpeticum

• Superinfection (usually HSV) in skin with underlying disorder• Typically Atopic Dermatitis

• Localized can be treated outpatient with oral antivirals• Generalized

• Inpatient antivirals• Skin care (directed at underlying disorder)• Pain management• Fluids


12 yo male treated with Azithromycin for Pneumonia 1 week prior


Mucositis from Mycoplasma Disease

• Spectrum of Illness• Erythema Multiforme (EM) → Steven’s Johnson Syndrome

(SJS) → Toxic Epidermal Necrolysis (>30% BSA) (TEN)

• Treatment• Managed like a burn

• Fluids & Pain Relief• Nutrition• Prevent Infection


Teenager: sunburn appearance,hands swollen, hypotensive

http://aapredbook.aappublications.org/content/1/SEC131/SEC263/F2016.large.jpg


Toxic Shock Syndrome

• Most commonly Staph or Group A Strep Infection• Rash may look like sunburn or erythroderma• Aggressive Fluid Management• Penicillinase resistant antibiotic• Source control


Child with headache, stiff neck, fever, petechial rash



Rocky Mountain Spotted Fever


8 yo male presents with these findings. What type of rash might he have had at some point in the past?


• Vary in appearance• Homogenously erythematous• Prominent central clearing• Distinctive target-like appearance• On lower extremities, lesions may

be partially purpuric• 5% have vesicles or pustules at

center of a primary lesion• Should be ≥ 5 cm in largest

diameter for secure diagnosis

Erythema Migrans


2 yo male with fever and tachycardia




Kawasaki Disease

• Polymorphic Rash• Not vesicular

• Desquamation is a late finding• do not make the diagnosis based on this cutaneous

finding• Exception is perineal desquamation


17 yo female with rash on face, hands and elbows



Dermatomyositis

• Autoimmune myopathy• Muscles & Skin

• Rash• Eyelid edema with purplish hue or heliotrope rash• Scaly red rash over extensor surfaces, especially metacarpophalangeal

joints and proximal interphalangeal joints (Gottron rash)• Superficial dilated capillaries adjacent to cuticle of fingernails

• Muscle enzymes (creatine kinase, aspartate aminotransferase, lactate dehydrogenase, aldolase) & Autoantibodies (antinuclear antibody, extractable nuclear antigen)


• 17 year old female with weight loss for 6 months and painful lesion on leg after minor injury

• 2 courses of ABX• Clindamycin• Bactrim +

Cephalexin



Pyoderma Gangrenosum

• Neutrophilic Autoinflammatory Dermatosis (not infectious)• Pain is the major symptom• Can develop at sight of trauma (pathergy)

• Debridement makes it worse• 4% of cases present in children

• 50% associated with underlying disorder• Most common is inflammatory bowel disease

• Treated with steroids or other immune regulators



Grandmother brings toddler in with a “rash” -wonders if it is ringworm.


Inflicted burns from cigarettes

Don’t forget cutaneous manifestations of non-accidental trauma in your differential diagnosis

Failure to recognize can be fatal


Thank You

[email protected]? Diagnosis Treatment


Bonus CaseCherry Red Raised Lesion on Neck


Pyogenic Granuloma

• Small benign vascular tumor (capillary proliferation)

• Grows rapidly• Can bleed profusely with minor trauma• Treatment

• Cauterization• Excision• Pulsed laser


Bonus Case5 day old infant, afebrile, feeding well with intermittent

redness on right side of body


Harlequin phenomenon• Reddening of one side of the body and blanching of the

other half with a sharp line of demarcation in between. • Each episode may last from seconds to minutes, mostly

occurring during the first few days of life. • Thought to be a vascular manifestation of the changes

that are occurring in the autonomic system in the newborn.


Bonus CaseCircumferential “Rash” on Neck and Fingers



Second degree burns from electrical current

13-year-old female who was listening to her iPod while lying on her bed when her long metal necklace accidentally worked its way

between the iPod charger and the extension cord creating a current through the necklace.

She felt a burning on her neck and pulled the necklace off.

She experienced no loss of consciousness. Her only other symptom besides the burns was a little bit of tingling in her tongue

which resolved.

We don’t make this stuff up!!

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The Last Rash - ACEP€¦ · • Recognize the typical presentation of life- threatening rashes....

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