Skin Diseases

A 4-year-old boy with a history of autism presents to his pediatrician’s office with a complaint of right leg pain. He is presumed to have pulled a muscle; an elastic bandage is applied and he is given ibuprofen. Over the next few days, he begins falling and tripping and is unable to maintain his balance. At a return visit, the patient’s mother says her son’s right leg is “like Jell-O” and that he appears to be dragging the leg.

A 7-year-old African American girl presented with an asymptomatic gray lesion beneath her right eye that had appeared before her first birthday. She was a healthy child with macular gray discoloration on the right infraorbital skin. There was no abnormal pigment noted on the conjunctiva.

A 12-year-old girl presented to the emergency department with progressing generalized inflammatory symptoms (fever and malaise), visual difficulty, severe inspiratory dyspnea, and 2 painless lesions on the right upper lip that had persisted for a few days. She had been well until 2 days before presentation, when she noticed a small pimple-like lesion above the right upper lip that was followed rapidly by facial edema, erythema, and constitutional symptoms.

Baby girl born at 37 weeks’ gestation to a gravida 2 para 1, 25-year-old mother by spontaneous vaginal delivery. Apgar scores, 8 at both 1 and 5 minutes. Placenta grossly normal with a 3-vessel cord. Prenatal course uncomplicated. Mother’s blood type, A-positive. Results of prenatal testing negative for hepatitis, syphilis, rubella, group B streptococcal disease, and HIV infection. No significant maternal or family history.

Most children who present with undifferentiated rash and fever-or fever and rash and nonspecific physical findings-have a benign viral illness. However, identifying those few who have an early or atypical presentation of a more serious disease is vitally important. Here-clues that can help.

A papulosquamous rash spread from this boy’s head and neck to cover most of his body; however, areas on his trunk were spared.

A 16-year-old boy presented for evaluation of his worsening behavior at school. He was very hyperactive and had difficulty in paying attention. He had always required help with reading and language. Maternal pregnancy and birth history were unremarkable.

This 11-year-old girl has had an intensely itchy rash on her left leg for the past 10 years. It has been slowly progressing, to the point that it now extends the entire length of the leg. She has become extremely frustrated by the recurring bouts of itchiness and is desperate for relief.

Obstructive sleep apnea (OSA) has a high prevalence in the pediatric population and is associated with significant morbidity, both physical and in the realms of development, cognition, behavior, and school performance.

A 16-year-old girl presented to the emergency department (ED) with an anaphylactic reaction to a bee sting on the right side of her neck. Within 15 minutes of her arrival, swelling, numbness, and pain developed at this site. She also had headache, shortness of breath, and vague abdominal pain associated with nausea.

A 20-month-old boy brought to the emergency department with swelling on the right side of the neck and fever (temperature, 39.3°C [102.7°F]) of 1 day’s duration. The parents reported that the child had had intermittent fevers and poor weight gain for the past 3 months but no vomiting, diarrhea, rash, drooling, or difficulty in swallowing.

This asymptomatic swelling above a 3-month-old boy's left eyebrow had not changed since birth. The 15 × 13-mm, soft, nontender, freely mobile nodule had no punctum, hair tuft, or other skin anomaly. The infant was born at term and was otherwise healthy. At the parents' request, the nodule was excised without complications by a pediatric surgeon. Pathological findings showed lamellated keratin within the mass and surrounding pilosebaceous units opening into the mass, consistent with a dermoid cyst.

The conditions seen in these 3 photographs are easily confused. Can you match each picture with the correct diagnosis?

Allergy testing can aid the diagnosis of allergic disorders; however, it is not diagnostic. With skin testing, in particular, a positive result does not necessarily indicate clinical allergy, and a negative result does not always exclude clinical relevance.

Bullous impetigo caused multiple areas of denuded skin, consisting of ruptured bullae with underlying erythema, on the face, lower abdomen, and thighs in this infant.

Type 1 diabetes mellitus (T1DM) is the most common type of diabetes encountered in children. The incidence of T1DM in children is increasing in some populations. Early recognition of symptoms of T1DM is critical to avoid life-threatening metabolic decompensation. Such symptoms can include polyuria, polydipsia, fatigue, weight loss, urinary tract infection, vaginal candidiasis, and “fruity” breath. In the presence of clinical symptoms of hyperglycemia, diagnosis requires just 1 laboratory blood glucose measurement above the established threshold for the child’s age. In the absence of typical symptoms, a second abnormal blood glucose measurement on a different day is needed.

An 8-year-old girl presents with a 1-year history of the progressive development of multiple 5- to 8-mm hypopigmented macules all over her body. Her parents do not recall any other skin changes, and no other skin changes are evident on presentation.

A 3-month-old African American boy was referred for evaluation of poor weight gain and vomiting. The infant had been evaluated by his primary care physician 15 times within the past 6 weeks; he had no change in symptoms despite various treatments.

Selective IgA deficiency (SIGAD) is the most common immunodeficiency disorder; it affects about 1 in 200 to 900 persons. Most affected children are asymptomatic.

A 5-ft 1-in, 183-lb 14-year-old girl was concerned about the areas of thickened hyperpigmentation on her posterior neck and in her cleavage.

For 3 months, a 9-year-old boy had swelling of the left upper arm. An MRI scan obtained at another facility 1 week after onset showed extensive edema of the soft tissue at the midhumeral level. Laboratory results, including complete blood cell (CBC) count and Lyme titer, were normal.

A 2-month-old boy is brought to the emergency department (ED) because of “noisy breathing” that has been present since birth. The parents report that they occasionally see the child’s ribs during inspiration when he is lying down.

Two girls present with toenail yellowing and thickening. What clinical clues will help you determine which toenails are mycotic?

The areas of hyperpigmentation shown here on the trunk of a 15-year-old girl appeared 2 years earlier as 1- to 2-mm hyperpigmented papules with either flat or verrucous surfaces.

A 5-year-old girl presented with a 2-day history of a widespread pruritic rash that began while the family was on vacation. The rash appeared suddenly as small pink macules and progressed to papules and pustules. Her brother had a similar-appearing but milder rash. She denied fever, chills, or constitutional symptoms. On further questioning, her father reported that she and her brother had been in a hot tub at their vacation home.

An 11-year-old boy with 4-month history of acnelike rash on his face and both upper arms. Rash is associated with redness and itching. Application of adapalene gel resulted in no change.

An itchy eruption puts a damper on a girl’s Hawaiian vacation. How might you help her avoid a similar experience on her next trip to the tropics?

A 10-month-old breast-feeding boy was taken to the emergency department (ED) with a temperature of 40°C (104°F). Because he was on day 7 of treatment with amoxicillin for a previously diagnosed ear infection, unresolved otitis media was diagnosed.

One week earlier, a 14-month-old girl with a history of eczema was evaluated because of a diffuse rash of excoriated lesions, some of them purulent. She was afebrile. Worsening eczema with secondary infection was diagnosed. Treatment with oral clindamycin was prescribed. At follow-up, the lesions had worsened. The child had multiple excoriated papules, some of which had coalesced into plaques. She also had two 5-mm vesicles on her right shoulder. Eczema herpeticum was diagnosed clinically. Culture of the vesicles later grew herpes simplex virus (HSV).

The mother of this 4-year-old boy is concerned about a small drop of fluid that she noticed on her son’s neck at the dinner table the night before.