1. MORNING REPORT JULY 5, 2012 Good Morning!!!

4. Derm Terms Primary Lesions Maculeflat < 1 cm Patchflat > 1 cm Papuleelevated, solid < 1 cm Noduleelevated, solid > 1 cm, deeper Plaqueelevated, flat top, solid > 1 cm Vesicleelevated, filled with serous fluid < 1 cm Bullaelevated, filled with serous fluid > 1 cm Pustuleelevated, filled with pus < 1 cm WhealEdema in the upper dermis Secondary Lesions Scaleflakes of stratum corneum Crustdried liquid debris Erosionloss of epidermis, shallow Fissurelinear cleavage Ulcerationloss of epidermis and dermis, deep Excoriationabraded skin LichenificationThickening of epidermis Atrophythinning or absence of epidermis/fat Scarpermanent fibrotic change

6. Derm Terms Pattern/Distribution AnnularRing shaped DiscreteRemain separated ClusteredGrouped together Confluent/ Coalescing Run together DermatomalFollow a dermatome GeneralizedMay be scattered or diffuse AcralDistal portion of limbs PolymorphicVaried shapes SerpiginousSnake-shaped

9. What’s your final answer? Clusters of erythematous, eroded papules with overlying hemorrhagic crust in a generalized distribution

10. Symptoms Acute /subacuteChronic LocalizedDiffuse SingleMultiple StaticProgressive ConstantIntermittent Single EpisodeRecurrent AbruptGradual SevereMild PainfulNonpainful BiliousNonbilious Sharp/StabbingDull/Vague Problem Characteristics Ill-appearing/ Toxic Well-appearing/ Non-toxic Localized problemSystemic problem AcquiredCongenital New problem Recurrence of old problem Semantic Qualifiers

11. Illness Script Predisposing Conditions  Age, gender, preceding events (trauma, viral illness, etc), medication use, past medical history (diagnoses, surgeries, etc) Pathophysiological Insult  What is physically happening in the body Clinical Manifestations  Signs and symptoms that result from the pathophysiological insult

12. Eczema Herpeticum

13. Impetigo

15. Varicella

16. Tinea

17. Erysipelas

18. Folliculitis

19. SSSS

20. Drug Allergy

21. Eczema Herpeticum

22. Eczema Herpetcium Illness Script Predisposing Conditions Eczematous skin disease: Atopic dermatitis  Most common skin disease in children (20% prevalence)  More frequently in urban areas, higher socioeconomic classes  + family history of atopy  Prone to infections with S. aureus and HSV** Can occur at any age, most common 2-3 years old Exposure to caregiver with HSV Immunocompromised patient HSV can be reactivated by fever, sunlight, trauma, stress

23. Eczema Herpetcium Illness Script Pathophysiology Defective skin barrier Most children, caused by primary HSV infection  Incubation period of 4-11 days after HSV infection, then eruption of lesions Dysregulation of cell-mediated and humoral immunity in patients with atopic dermatitis  Allows HSV to proliferate Common complication: Bacterial superinfection with staph or strep

24. Eczema Herpetcium Illness Script Clinical Manifestations** Eruption of multiple vesiculopustular lesions in disseminated pattern  Grouped fluid filled vesicles on an erythematous base  After several days, vesicles  pustules  rupture and become crusted, have ‘punched-out’ appearance  May coalesce, erode and ooze hemorrhagic exudate Irritability Pruritis Fever Anorexia, malaise, vomiting, diarrhea, lymphadenopathy Systemic and CNS spread have been reported

25. Diagnosis** Clinical diagnosis Gold standard: viral culture (not very sensitive) HSV DNA PCR from vesicle fluid Direct fluorescent antibody testing of cells from vesicle scrapings Stain with Giemsa or Wright’s stain (Tzanck test)  Very specific but not very sensitive  Can visualize multi-nucleated giant cells  Can indicate an HSV or Varicella-zoster infection

26. Treatment Early treatment is essential to prevent fulminant progression and possible mortality ALL children should receive systemic acyclovir for 5- 7days  MOST should have IV acyclovir  If patient appears well/limited disease, can do PO  Can treat longer for severely affected children  Give until no new lesions appear Local skin care, supportive care Treat with antibiotics for any suspected bacterial infection Discontinue topical steroids

27. NOON CONFERENCE: DR. CREEL – STATUS ASTHMATICUS Thanks for your attention!