Girl presents with traditional summertime problem (hint: it’s not COVID-19)
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A previously healthy 3-year-old female presents with a rash consisting of numerous vesicles and open lesions.
The onset was a few days earlier. Her past medical history is positive for moderately severe eczema, which is occasionally well controlled with topical therapy, but the therapy has been inconsistently applied.
When she has a flair-up of eczema, she is usually seen in urgent care, noting that the distribution has been primarily limited to the distal extremities and antecubital and popliteal areas (Figures 1, 2 and 3).
The current complaint is similar in that there is much pruritus with scratching and pain, and the main difference is the appearance of vesicles. There are no known sick contacts, but she does attend out-of-home care 3 days per week.
On examination, her vital signs are normal, and the only abnormal findings are patches of inflamed, weeping lesions in the usual places noted earlier, with some discrete lesions scratched open and some intact vesicles concentrated on the distal extremities (Figures 4 and 5), as well as involvement of both palms and soles (Figures 6 and 7).
There were also some scattered, widespread lesions in areas of the extremities not normally involved with past exacerbations (Figures 8 and 9), including a discrete erythematous papular lesion on the helix of the right pina (Figure 10). There are no oral lesions found.
In summary:
- A 3-year-old female has moderately severe eczema (atopic dermatitis), with periodic exacerbations. She has frequent urgent care visits.
- She presents with 2-day history of a typical exacerbation but with discrete vesicles and lesions damaged by scratching. The vesicles and lesions are clustered about the distal extremities, including her palms and soles, as well as scattered lesions, including one on the right pinna.
- The patient has no known sick contacts.
What’s Your Diagnosis?
A. Eczema coxsackium
B. Henoch-Schönlein purpura
C. Eczema herpeticum
D. Disseminated bullous impetigo
Case discussion:
The answer is A, eczema coxsackium. Normally, coxsackievirus A16 infections in children result in hand-foot-and-mouth disease, a common summertime enterovirus infection. Its cousin, coxsackievirus A6, is more vicious and likely to cause more severe disease, with or without any underlying skin disorder (Figures 11, 12 and 13), and is typically seen in the winter months.
Regardless of the season, coxsackievirus A6 or A16 infections in children with poorly controlled eczema can produce a severe, disseminated infection, much like eczema herpeticum (Figure 14), because the virus can rapidly spread to any damaged part of the skin, concentrating in areas of eczema exacerbation. An enterovirus PCR of a lesion can usually confirm the diagnosis, as it did in this patient. If uncertain with the clinical presentation, it would be advisable to test for herpes simplex virus and empirically treat with acyclovir pending PCR results.
Henoch-Schönlein purpura (HSP) is an immunoglobulin A-mediated autoimmune small vessel vasculitis, which may be triggered by a viral or bacterial infection, such as group A streptococcus, but it is not an infectious disease. HSP is found to have the following manifestations:
- maculopapular, purpuric rash (Figure 15) in almost 100% of cases occasionally with a blistering component (Figure 16);
- arthritis in about 75% of cases (Figures 17 and 18);
- gastrointestinal involvement with abdominal pain and possible hematochezia in about 50% of cases;
- renal involvement in 25% to 50% (may require dialysis); and
- central nervous system involvement, which is very rare but can be lethal.
While not commonly seen, disseminated Staphylococcus aureus pyoderma or bullous impetigo (Figure 19) can also result because of widespread colonization with the organism on damaged skin. In such cases, systemic anti-staph antimicrobials are usually needed.
Reference:
- Gunson T. DermNet NZ. Henoch–Schönlein purpura. https://dermnetnz.org/topics/henoch-schoenlein-purpura. Accessed September 21, 2020.
Special tribute
As long-time readers of this column know, I will occasionally write a memorial of a person, usually a pediatrician, who has a legacy of teaching, patient care and/or research. Such is the case with James L. (Jimmy) Simon, MD, who died on June 4 at the age of 89 years in Winston-Salem, North Carolina. At the time of his retirement in 1996, Dr. Simon was professor emeritus of pediatrics at Wake Forest School of Medicine and chair emeritus of Brenner Children’s Hospital. It was Dr. Simon who pressed for a children’s hospital, and partnered with the Brenner family to bring it to fruition. After retirement, Dr. Simon continued to teach as a volunteer, with his unique style of demanding excellence from students and residents — that is, to be “Simonized.” And while rounds were often stressful, the learners remembered most of what was taught throughout their career. A mutual acquaintance and former Simon resident at Wake Forest, Stan Block, MD, noted that Dr. Simon had a Socratic method of teaching. Another former resident, Brigadier General Warren Todd, MD, (Retired) noted that the learner was simply expected to know the patients and have read up on the latest journals before rounds. These were times when medical rounds were rigorously conducted. Some of the best attendings could do this with a touch of anxiety to inspire the student and resident to be prepared and to keep their attention but with a compassionate and often (but not always) humorous finish.
Having retired last year after 42 years in various teaching services, it is my observation that the best programs still utilize this style. In the end, more students and residents come away from their experiences wanting to “be that way” themselves. A resident in my class at Fitzsimons Army Medical Center in the late 1970s, Joel Bradley, MD, related to me that as a student at Bowman Grey Medical School when Dr. Simon was the chairman, it was Dr. Simon who inspired him to pursue pediatrics and leadership in the AAP — a story that was repeated many times over. Dr. Simon’s influence reached well beyond North Carolina. He had faculty positions in California, Oklahoma and Texas before settling in North Carolina. He was very active as a popular visiting professor to many institutions (which is how we met when I was on active duty in the Army). Additionally, he was a leader in the medical education arena within the AAP and the American Board of Pediatrics. Dr. Simon won the most prestigious education awards given by the various pediatric organizations, as well as numerous local teaching awards.
Like many men and women of the early-to-late 20th century, Dr. Simon spent time in the military (Air Force) from 1958 to 1960. He no doubt saw a similar style of teaching during that experience; that is to be prepared; attention to detail; no nonsense; and crying was strongly discouraged. I’m not suggesting that the Socratic or regimented style of medical teaching was perfect or had no flaws, but it seemed to work then, and I suspect still does in some places. Gen. Todd (noted above) was molded to be the pediatrician, military leader and teacher that he became by Dr. Simon when Gen. Todd was a resident at the University of Texas Medical Branch at Galveston in 1966. I was subsequently a student and resident under then Lieutenant Colonel Warren Todd in the mid-to-late 1970s, who I found to fit this style of teaching to a tee, molding me (good, bad or in between) into who I became. So, one could say Dr. Simon’s influence reached beyond generations, with a positive influence on people he never met. Thus is the legacy of greatness.