The Importance of Identifying a Morbilliform Rash

The term "morbilliform" is used to describe any skin finding that resembles the measles rash. The macular lesions are typically diffuse, red and 2-10 mm in diameter. They may become confluent (come together to form clusters) in some areas. 

It is very important for doctors to know the differential diagnosis for a morbilliform rash, since some of the conditions are deadly. The process occurring within the body leading up to the rash, known as the prodrome, will help the physician narrow the diagnosis.This prodrome can be learned by ascertaining a good history. 

Some notable causes of morbilliform rash are:

• Fifth Disease (erythema infectiosum/parvovirus B19/)
• Sixth disease (roseola infantum/herpesvirus 6)
• Streptococcal infection (Groups A, C)
• Echovirus
• Adenovirus
• Kawasaki Disease
• Rubella
• Measles
• Syphilis
• Meningeal Petechiae (or Waterhouse Friedrichsen Syndorme)
• Drug hypersensitivity Reaction (especially nevirapine, abacavir, phenytoin)

A study by Ramsay et al in 2002 evaluated the laboratory samples of 93 vaccinated children in England, and noted that the most common cause of the rash was a parvovirus B19 infection (17%). Group A strep was found in 15% of cases, and sixth disease (roseola infantum or herpesvirus 6) in 11%. None of the cases were caused by measles. The use of widespread vaccination has nearly eliminated the measles infection, making way for other viruses that cause similar rashes. It is paramount that physicians discern the cause of the findings.

Reference

Ramsay M, Reacher M, O'Flynn C, Buttery R, Hadden F, Cohen B, Knowles W, Wreghitt T, Brown D. Causes of morbilliform rash in a highly immunised English population. Arch Dis Child. 2002 Sep;87(3):202-6.

An Update on Cat Scratch Fever

Cat Scratch Disease, also known as Cat Scratch Fever, is found in more locations than just a Ted Nugent album. This disease, first isolated in 1992, is caused by a bacteria called Bartonella henselae and affects roughly 6.6 in every 100,000 children in the United States. It's mostly benign (harmless), and in some cases goes unnoticed. Every now and then, though, a mother may see this in her child and become concerned:

The bacteria is transmitted to cats, typically kittens, by fleas. When a child is scratched by the cat, or in some cases pets the cat and then rubs his or her eye, the bacteria enters their bloodstream.

In 2-3 weeks, the child will develop lymphadenopathy, or the enlargement of the lymph nodes. The most common location of the lymphadenopathy is in the neck (33% of cases), followed by the axilla (underarm, 27%) and inguinal (groin, 18%). The child will also develop the characteristic fever and may complain of a sore throat.

In children with weak immune systems (immunocompromised), the disease may become disseminated (spread throughout the body) and cause infection of the bone (osteomyelitis), brain (encephalitis, resulting in seizures) and eye (oculoglandular conjunctivitis). In children with heart valve problems, this disease may cause endocarditis (infection of heart valve). For this reason, the CDC recommends that these children and adults avoid playing with cats or kittens, especially those with fleas.

Since the disease goes away on its own, a doctor will only need to prescribe pain medication for the painful lymph nodes. There is limited evidence that antibiotics are helpful in treating Cat Scratch Fever, so put on an old record and let Ted do all of the work.

• Cases in adults are not uncommon. 80% of patients with cat-scratch disease are < 21 years old

• Cases of dogs, monkeys, porcupine quills and thorns have been reported

• The disease is not contagious. There are no reports of person-to-person transmission

• Laboratory diagnosis is difficult, since the organism can be difficult to see. Currently, polymerase chain reaction (PCR) or Warthin-Starry Stain is used

• Differential diagnosis of chronic lymphadenopathy includes L. venereum, mycobacteria, tularemia, brucellosis. mononucleosis, syphilis, toxoplasmosis, systemic fungal infections, sarcoidosis, lymphoma, connective tissue disease and kawasaki disease

Reference

Cat Scratch Disease. In DynaMed [database online]. EBSCO Information Services. 

Updated 2012 Oct 25. Accessed May 10, 2014.

Increasing Reports of Nicotine Poisoning in Children as E-cigarette Popularity Grows

As E-cigarettes gain popularity, the liquid refill bottles are mistakingly making their way into the hands of children. NEJM recently reported a case of a 10 month old boy that presented with vomiting, tachycardia, grunting respirations and truncal ataxia.

                                                              Photo courtesy of NEJM

Check out the original article here:
http://www.nejm.org/doi/full/10.1056/NEJMc1403843

The Latest Nutrition Recommendations for Your Infant or Child

Good nutrition during the developing years of life has been correlated with improved growth, body height, IQ, educational achievement and hourly wage. Are you familiar with the current guidelines for infants, adolescents and teens?

Age 0-4 months. Breast feeding only, either directly from breast or expressed via pump. Supplement with Vitamin D 400 IU/Day (800 in winter). If mother cannot breast feed, iron-fortified infant formula is recommended. Do not offer juices, water, nonhuman milk or foods.

• If family history of allergy or atopic dermatitis, using breast milk or hypoallergenic hydrolyzed (casein or 100% whey protein) infant formulas instead of cow’s milk formulas may reduce the risk in the child.
• If infant was preterm or small for gestational age (SGA), nutrient-enriched and soy formulas are not recommended.
• Many formulas boast the addition of probiotics and long chain polyunsaturated fatty acids (LCPUFA) to their products, but there is no evidence that these are beneficial to the infant.

Age 4-6 months. Begin to introduce single grain, iron-fortified cereal (1 tbsp cereal mixed with 4tbsp breast milk, gradually increase the amount of cereal over time). Never put cereal in a bottle! Sit child upright and feed to them with a spoon.

Cues that an infant is ready for solid foods include:

• Doubled birth weight
• Ability to sit up without support with control of head and neck
• Infant shows interest in foods parents are eating

Age 6-8 months. Once all cereals have been tried, continue breast milk while gradually adding solids. Begin introducing 1-2 tbsp of both fruits and vegetables, strained, twice daily and increase to 2-3 tbsp. Try baby fruit juice in a cup and offer finely chopped or mashed fruits and cooked vegetables once all strained varieties have been tried. Introduce 1 food each week to determine which foods are poorly tolerated. Start with single ingredient baby foods before introducing mixed ones. Limit 1 serving per day of carrots, beets and spinach (may cause methemoglobinemia) and never feed them honey.

Age 8-12 months. Introduce finger foods in cups and encourage self-feeding (allow baby to get messy).  Begin to add finely chopped meats, one per week. Avoid sweetened beverages and foods that may get stuck in the throat (nuts, raw carrots, round candies, hot dogs, apple pieces, grapes and chips). Introduce no more than 4 ounces of unsweetened 100% fruit juice a day. Be sure to sit child up straight in high chair while eating, and always taste heated foods before serving. Do not restrict fat intake unless directed to do so by pediatrician.

Age 12-24 months. Add whole milk and eggs. Offer small portions. Never force toddler to eat. Continue to offer foods that have been rejected! Bedtime bottles are recommended. Transition to reduced fat (2% or fat-free) unflavored cow’s milk. Continue unsweetened 100% fruit juice and water. Limit sodium, sugar-sweetened beverages, saturated and trans fat intake. Encourage fruits, vegetables and whole grains and always offer water.

Age 2-21 years.  Primary beverage should be fat-free unflavored milk. Encourage healthy eating habits starting at age 11, stressing daily breakfast, limited fast food and eating meals as a family. Continue to limit sodium, sugar-sweetened beverages, saturated and trans fat intake. Encourage fruits, vegetables and whole grains.

• It is important not to overfeed your child. This has been associated with higher fat mass in children, insulin sensitivity (risk of diabetes) and childhood obesity.

References

Nutrition (pediatric and preventive care). In DynaMed [database online]. EBSCO Information Services. http://web.a.ebscohost.com.ezproxy.hsc.usf.edu/dynamed/detail?vid=3&sid=7ebdc599-239e-4629-b0ad-740dd1944370%40sessionmgr4005&hid=4107&bdata=JnNpdGU9ZHluYW1lZC1saXZlJnNjb3BlPXNpdGU%3d#db=dme&AN=115435.

Updated May 02, 2014. Accessed May 6, 2014.

SIRS: The End of a Deadly Disease Spectrum

When an infant or child falls very ill, one of the most feared complications is systemic inflammatory response syndrome (SIRS). 

SIRS is a deadly ending to a spectrum of bloodstream infection which begins when a bacteria or virus enters the bloodstream (bacteremia). In most cases, young bodies can successfully fight off the organism before it causes any serious problems. Unfortunately, this is not always the case. Sometimes, the immune system goes a bit too far and decides to put all of its cards on the table. It releases everything it has, including white blood cells, pro-inflammatory molecules and blood-clotting proteins. This most often leads to the loss of fluids in our blood vessels and the collapse of our circulatory system. Inside the body, the organs (heart, lungs, kidneys, brain) lose vital oxygen and nutrients and begin to shut down. Outside the body, doctors notice signs of shock, which include fever and changes in breathing, heart rate, mental status, blood pressure and temperature regulation. If caught very early, doctors can typically keep the patient alive. In many cases, however, nothing the physician does will save the patient from the downward spiral.

The inci­dence of SIRS is highest in infants (5.16 per 1000), occurring in 20% of low birthweight neonates and resulting in death in over 10% of cases. Studies show that 37% of infections leading to SIRS arise from the respiratory tract, while 25% are primary bloodstream infections (BSIs). 

The management of SIRS is performed in a neonatal intensive care unit (NICU) or pediatric intensive care unit (PICU). Doctors will culture the blood and monitor vital organs while ensuring the body is receiving adequate oxygen. A broad spectrum antibiotic (fights many different infections) is started until a culture comes back from the lab showing what specific organism is causing all the trouble. The antibiotic is then switched to one specifically formulated to kill that bug. One of the most frightening scenarios for a physician is when the culture comes back showing a bacteria that is resistant to all the drugs we have available. This is becoming the case with some gram negative bacteria (Klebsiella and E. coli) that release something called endotoxin and are resistant to our last line of antibiotic defense against them, carbapenems.

Scientists and physicians continue to conduct studies in order to discover ways to prevent SIRS from occurring. Though many different types of treatments have been attempted, the most effective of them continues to be early detection with  prompt antibiotic administration and fluid resuscitation.

• Occasionally, other conditions can trigger SIRS (trauma, ARDS, neoplasm, burn injury, pancreatitis)
• In order to reduce your child's risk, always ensure they are up to date on their vaccinations and be sure to keep them away from undercooked meat, especially beef and chicken.

References

Principles and Practice of Pediatric Infectious Diseases. Judith A. Guzman-Cottrill, Beth Cheesebrough, Simon Nadel, and Brahm Goldstein. Part II, Section A, 11: The Systemic Inflammatory Response Syndrome (SIRS), Sepsis, and Septic Shock. Pg 97-104.