Pediatric care: Recognize the signs and symptoms of true emergencies

March 1, 2008

The overwhelming majority of pediatric cases that present in dermatology are not urgent. However, doctors must be able to identify those that are, such as Kawasaki disease.

Key Points

Toronto - Clinicians need to know the symptoms and signs of true pediatric dermatologic emergencies - although uncommon - so they can manage them acutely, according to Bernice Krafchik, M.B., Ch.B., professor emeritus in dermatology at the University of Toronto, and pediatric dermatologist in private practice.

The Hospital for Sick Children in Toronto conducted a study and found 6 percent to 8 percent of cases that presented to the emergency department were dermatological; two of the cases were life-threatening.

Kawasaki disease

Clinicians must also look for four out of five of the following signs: Conjunctional erythema; skin eruption; peripheral changes, such as palmar and plantar erythema and swelling of the dorsa of the hands and feet; mucosal changes, defined as dry, cracked, red lips and strawberry tongue; and lymphadenopathy of more than 1.5 cm, which can be cervical or elsewhere on the body.

It is important to ask parents if eye changes occurred in the week preceding the other symptoms, as these findings may be transient.

Unfortunately, the skin findings are not specific and may be macular papular, erythema multiforme-like, and children may also present with a generalized pustular eruption. Three-quarters of patients affected by it have sterile pyuria.

Therapy for Kawasaki disease is intravenous gamma globulin, slowly infused at a dosage of 2g/kg with 100 mg/kg/day of ASA, which should be administered until there is an absence of fever.

The ASA therapy is continued at a reduced dose of 3 to 5 mg/kg/day for two months until a repeat echocardiogram is performed. If there are changes, then it is given for life.

The presentation is often atypical in younger children. Children are extremely irritable as well. This is a very important diagnostic clue.

Kawasaki disease is different from Stevens-Johnson syndrome and toxic epidermal necrolysis, blistering eruptions affecting skin and mucous membranes. It can also be confused with mercury intoxication.

"The mortality of the condition is 2 percent, but by giving therapy that drops to 1 percent," Dr. Krafchik says.

Other conditions

Conditions like giant urticaria differ from erythema multiforme. The lesions occur in transient crops and may last longer than 24 hours.

In children, urticaria is not always pruritic, is often large, and is often edematous.

Antihistamines such as hydroxyzine should be administered three times a day for a period of 10 days.

Erythema multiforme is caused by herpes simplex infection and is uncommon in children. The presence of acral, target lesions with three rings is a means of identifying erythema multiforme. The mouth may be involved, but the condition never develops into Stevens-Johnson syndrome or toxic epidermal necrolysis.

A sudden onset of fever with erythema and sloughing of the skin characterizes toxic epidermal necrolysis, Dr. Krafchik says. The condition needs to be treated in an intensive care unit with gamma globulin.

By contrast, erythema multiforme (major) presents with a sudden onset of skin lesions that may have rings, and severe mucous membranes involvement. Patients often have a cough. The cause in the majority of cases is mycoplasma pneumonia.

Mycoplasma pneumonia can be epidemic. It occurs mainly in schoolchildren who develop coryza and/or a cough.

When a swab is done on the throat, polymerase chain reaction analysis is positive. Skin eruptions occur in 9 percent of cases of mycoplasma pneumonia. They may be macular papular or present with purpura.

Children with atopic dermatitis may develop a bullous eruption called Kaposi's varicelliform eruption. The primary infection is with herpes simplex virus (HSV) and appears in sites where the dermatitis is present and then generalizes.

Because the condition is a result of HSV infection, treatment with the antiviral drug acyclovir is warranted.

Infants with neonatal herpes, which is acquired through the birth canal, should be treated with acyclovir intravenously.

The presentation may not always be the typical grouped bullae, but may be scattered single lesions.