Clinicopathologic Correlations

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Viral exanthematous diseases of childhood are extremely common. There are now immunizations for many of the classic childhood exanthems. In the early years of the 20th century, pediatricians frequently referred to many childhood diseases by number. Scarlet fever and measles were numbers one and two, respectively; rubella became known as the third disease; fourth disease was probably a combination of scarlet fever and rubella and did not represent a distinct entity;the fifth disease was erythema infectiosum; and the sixth disease was roseola.

Rubella, or German measles, is a common communicable disease caused by a togavirus and is characterized by mild constitutional symptoms, a rash, and generalized enlargement and tenderness of the lymph nodes of the head and neck. It is transmitted by respiratory droplets. The lymphadenopathy precedes the rash, which consists of red or pink macules or papules, starting first on the face and then spreading to the extremities. Intraoral lesions—Forschheimer's spots—are often observed before development of the rash. Figure 24-43 shows Forschheimer's spots on the palate of a child with rubella. Rubella is now extremely rare as a result of the widespread use of the rubella vaccine, but it remains important to recognize this disease because of the risk to the fetus if a nonimmune woman contracts rubella during pregnancy.

Fifth disease was linked in 1983 to human parvovirus B19. Erythema infectiosum is a moderately contagious disease affecting school-aged children. It produces an asymptomatic ''slapped cheek'' erythema on the face and an erythematous maculopapular, lacy, serpiginous, blanching rash on the trunk and extremities. The rash, sometimes pruritic, lasts 2 to 40 days, with an average duration of 11 days. There is no gender predilection. Fever is usually absent or low grade. Figure 24-50 shows the classic ''slapped cheek'' rash on a child with fifth disease.

Physical Clinical DiagnosisMedicine Dross Penis Rashes

Chickenpox, or varicella, is caused by the varicella-zoster DNA virus belonging to the Herpesviridae family. The illness is extremely contagious over several days preceding the development of the rash. Before the introduction of the vaccine in 1995, it was estimated that more than 3 to 4 million cases occurred each year. The vesicular eruption begins on the trunk, and the vesicular lesions are described as ''a dewdrop on a rose,'' progressing to pustular lesions that then crust over in 3 to 5 days. New lesions appear as older ones are crusting. Mild fever, malaise, pruritus, anorexia, and listlessness accompany the rash. The vesicular rash of chick-enpox is pictured in Figure 24-51. The distribution is shown on another child in Figure 24-52, and a close-up photograph of the vesicular lesions is shown in Figure 24-53. Although it is usually a mild, self-limited illness in healthy children, varicella can be fatal in someone who is immunocompromised. Like rubella, varicella is teratogenic, causing birth defects in approximately 10% of fetuses exposed during the 5th to 14th weeks of gestation.

Herpes simplex virus is a common cause of painful oral lesions in children, especially toddlers and school-aged children. Figure 24-54 shows herpetic gingivostomatitis in a 6-year-old boy. Extensive perioral vesicles, pustules, and erosions are common. The gingivae become markedly edematous and erythematous and bleed easily. Fever, irritability, and cervical and submaxillary lymphadenopathy are common. The acute phase lasts 4 to 9 days and is self-limited, although affected children are at risk for significant dehydration during this phase because oral intake is so painful. The vesicles rupture and become encrusted. Desquamation and healing are usually complete in 10 to 14 days.

Kawasaki's disease, or mucocutaneous lymph node syndrome, is an acute febrile illness of young children. Almost all affected children are younger than 5 years, and most are younger

Penis Lymph

than 3 years. The cause is unknown, although a viral or rickettsial agent is suspected. The malefemale incidence ratio is 2.5:1, and the overall frequency is highest among Asians. Kawasaki's disease is the most frequent cause of acquired heart disease in children from 1 to 5 years of age. The histopathologic condition is a vasculitis with a predilection to aneurysmal disease of the coronary arteries. This coronary thromboarteritis occurs in 25% to 30% of untreated cases of Kawasaki's disease. The annual incidence in the United States is estimated to range from 4.5 per 100,000 children to 8.5 per 100,000 children. The illness occurs most commonly during winter and spring.

High fever, around 40° C, is usually the first sign and lasts for at least 5 days. Within a few days, an irregular, morbilliform, macular eruption develops over the trunk and legs. Figure 24-55 shows the typical rash in a patient with Kawasaki's disease. Erythema multiforme can also be seen (Fig. 24-56). Palm, sole, and fingertip desquamation occurs 10 to 18 days after the onset of fever;this is one of the most characteristic features of the disease. Figure 24-57 shows this desquamation on the hands of a child with Kawasaki's disease. Desquamation also commonly occurs in the inguinal and perineal area, and may precede the extremity changes. The conjunctiva becomes injected, and punctate redness of the palate and strawberry tongue develop, as shown in Figure 24-58. Peripheral edema and asymmetric cervical lymphadenopathy are seen early in the disease in 75% of patients. Arthritis is present in 40% of cases. Although most individuals recover without sequelae, death occurs in approximately 2% of patients as a result of coronary arteritis. The diagnostic criteria for Kawasaki's disease are as follows:

Fever for at least 5 days

Presence of four of the following:

• Bilateral nonpurulent conjunctival injection

• Changes in the mucosa of the oropharynx

Cutaneous Larva Migrans Dermatology

Table 24-4 Cardiovascular Murmurs of Childhood

Condition

Cycle

Location

Radiation

Pitch

Other Signs

Ventricular septal effect

Pansystolic

Left sternal border at the fourth or fifth intercostal space

Over the precordium; in rare cases, to the axilla

High

Thrill at left lower sternal border

Mitral insufficiency

Pansystolic

Apex

Axilla

High

St decreased S3

Pulmonic stenosis

Systolic ejectior

Left second or third intercostal space

Left shoulder

Medium

Widely split S2 Right-sided S4 Ejection click

Patent ductus arteriosus

Continuous

Left second intercostal space

Left clavicle

Medium

Machinery-like, harsh sound Thrill

Venous hum

Continuous

Medial third of clavicles, often on the right

First and second intercostal spaces

Low

Can be obliterated by pressure on the jugular veins

Table 24-5 Chronology of Dentition

Deciduous Teeth

Permanent Teeth Eruption

Maxillary

(Months)

Eruption Shedding Mandibular Maxillary (Months) (Years)

Shedding

Mandibular

(Years)

Maxillary (Years)

Mandibular (Years)

Central incisors

6-8

5-7 7-8

6-7

7-8

6-7

Lateral incisors

8-11

7-10 8-9

7-8

8-9

6-7

Canines (cuspids)

16-20

16-20 11-12

9-11

11-12

9-11

First premolars (bicuspids)

— —

10-11

10-12

Second premolars

— —

10-12

11-13

First molars

10-16

10-16 10-11

10-12

6-7

6-7

Second molars

20-30

20-30 10-12

11-13

12-13

12-13

Third molars

——

17-22

17-22

Table 24-6 Exanthematous Diseases of Childhood

Disease

Cutaneous Lesion

Location

Mucous Membranes Affected

Systemic Components

Chickenpox (varicella) (see Figs. 24-51, 24-52, and 24-53)

Maculopapular, ''teardrop'' vesicles on an erythematous base

Trunk, face, and scalp;

centrifugalce:sup>/ce:sup> spread

Yes

Mild febrile disorder; malaise; rash preceded by a 24-hour prodrome of headache and malaise; all stages and sizes of lesions found at the same time and in the same area; pruritus

Measles (rubeola)

Erythematous, maculopapular, purplish-red

Scalp, hairline, forehead, behind ears, upper neck; rash starts on head and spreads rapidly to upper extremities and then to lower extremities; rash often slightly hemorrhagic; as rash fades, brown discoloration occurs and then disappears within 7-10 days

Yes{

Three- to 4-day prodrome of high fever, chills, headache, malaise, cough, photophobia, conjunctivitis; 2 days before the rash develops, Koplik's spots{ may be seen

Rubella (German measles)

Rose-pink, small, irregular macules and papules { ; rash is the first evidence of the disease

Hairline, face, neck, trunk, extremities; centripetal§ spread; rapidly involves body in 24 hours and tends to fade as it spreads

Yes{

Mild fever, if any; headache, sore throat, mild upper respiratory infection; presence of suboccipital and posterior auricular lymph nodes

Erythema infectiosum (fifth disease; see Fig. 24-50)

Erythematous malar blush

Face, upper arm, thighs; sudden rash in an asymptomatic child, in a ''slapped cheek'' appearance; maculopapular rash on upper extremities the next day; several days later, a lacy rash on proximal extremities

No

Mild fever, mild pruritus

Roseola infantum

(exanthema subitum)

Rose pink, 2- to 3-mm macules; rash appears at end of febrile period; duration of rash only 24 hours

Trunk

Rarely

Sudden onset; high fever

Scarlet fever

Fine punctate, erythematous lesions that blanch on pressure

Face, along skinfolds, buttocks, sternum, between scapulae

Yes}

Disease results from toxin produced by group A streptococci as a result of pharyngeal infection}: abrupt onset of fever, headache, sore throat, vomiting; 12-48 hours later, rash appears

•Moving outward from the center.

{Koplik's spots are highly diagnostic; these appear on the buccal mucosa opposite the first molar teeth; they often appear as bluish-white, pinpoint papules on an erythematous base. {Forschheimer's sign consists of petechiae or reddish spots on the soft palate during the first day of the illness (see Fig. 24-43). §Moving toward the center.

}Bright red lesions, often on tonsils and soft palate.

{Koplik's spots are highly diagnostic; these appear on the buccal mucosa opposite the first molar teeth; they often appear as bluish-white, pinpoint papules on an erythematous base. {Forschheimer's sign consists of petechiae or reddish spots on the soft palate during the first day of the illness (see Fig. 24-43). §Moving toward the center.

}Bright red lesions, often on tonsils and soft palate.

White Papule Tonsil
Figure 24-58 Strawberry tongue in a child with Kawasaki's disease.

• Changes of the extremities (e.g., edema, erythema, or desquamation)

• Rash (not vesicular), primarily truncal

• Cervical adenopathy

Early involvement of the cardiovascular system is manifested by tachycardia and often an S3 gallop. Early intervention with intravenous gamma globulin and antiplatelet therapy has been shown to significantly reduce coronary abnormalities.

Heart murmurs are common in the pediatric age group. Some are serious, but many normal preschool children have a short, musical systolic murmur at the lower left sternal border. Table 24-4 summarizes the more common murmurs and associated findings. Table 24-5 lists N.B. the chronology of dentition. Table 24-6 lists the more common exanthematous diseases of childhood.

Review the DVD-ROM included with this book, which demonstrates a telephone consultation with a parent as well as a history and physical examination of a newborn and toddler.

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  • archie
    How to cure rashes on penis?
    2 years ago
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    How to observe measles in penis?
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    How to treat penis rash?
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