How to differentiate clinically between LTB (croup) and epiglottitis

Which of the following best differentiates, by history, LTB (croup) from epiglottitis?

• (A) Temperature
• (B) Presence of inspiratory stridor
• (C) Length of time from onset to defining symptom
• (D) Lung field auscultation
• (E) Presence or absence of dyspnea

The answer is C.
Croup, laryngeotrachiobronchitis, a viral illness with subglottic involvement, typically exhibits the symptoms of inspiratory stridor only after 12 to 24 hours of coryza, typical of a viral “cold.” Epiglottitis, which is a much more serious condition, begins suddenly. Epiglottitis is caused by bacterial infection with supraglottic involvement, classically by H.influenzae but also by S.aureus and Corynebacterium diphtheriae.

Although epiglottitis is characterized more by high fever than is croup, this appears to be a weak factor on which to base a preliminary diagnosis. Whereas croup virtually always includes a cough, epiglottitis rarely
does so. Epiglottitis typically includes dysphagia while croup does not. The child with croup is comfortable in all positions, whereas the patient with epiglottitis will be sitting forward with the mouth open. Both conditions are characterized by inspiratory dyspnea. Croup is benign and epiglottitis is potentially critical.

Associated conditions result in intestinal intussusception in children

An 8 year old boy is seen in the emergency room secondary to abdominal pain. Further evaluation confirms the presence of intussusception. The most likely precipitating cause for this intussusception is :

• A) colon polyp
• B) Meckel's diverticulum
• C) lymphoma
• D) parasite infection
• E) foreign body

The answer is C.

Intussusception is the most common cause of intestinal obstruction in the first 2 years of life. It is more common in males than in females. In most cases (85%) the cause is not apparent. Associated conditions that can result in intussusception include :
-polyps, Meckel's diverticulum, Henoch–Schonlein purpura, lymphoma, lipoma, parasites, foreign bodies, and viral enteritis with hypertrophy of Peyer patches.

Intussusception of the small intestine occurs in patients with celiac disease and cystic fibrosis—related to the bulk of stool in the terminal ileum. Henoch–Schonlein purpura may also cause isolated small-bowel intussusception. In children older than 6 years, lymphoma is the most common cause. Intermittent small-bowel intussusception is a rare cause of recurrent abdominal pain.

Hay WW Jr, Levin MJ, Sondheimer JM, et al., eds. Current pediatric diagnosis & treatment, 18th ed. New York: McGraw-Hill; 2007:616–617

Illustrated Cephalohematoma Vs Caput succedaneum

Cephalohematoma is a collection of blood under the periosteum of a skull bone "very tough tissue covering that encapsulates bones"
Because of its location, it is impossible for cephalohematoma to cross suture lines. If more than one bone is affected, there will be a separation between the two areas at the suture line as seen in this photo at the left where  the sagittal suture separates the bilateral parietal cephalohematomas.


Unlike cephalohematoma; A caput succedaneum is caused by the mechanical trauma of the initial portion of scalp pushing through a narrowed cervix. The swelling may be on any portion of the scalp, may cross the midline (as opposed to a cephalhematoma), and may be discolored because of slight bleeding in the area. There may also be molding of the head, which is common in association with a caput succedaneum.

A cephalohematoma in a 1-week-old newborn with a right parietal bump by vacuum extractor . A plain skull X-ray lateral view revealing the linear skull fracture on the right parietal area .

Appearance of Sunset sign in infant eyes

 The sclera are visible between the upper eyelid and the iris,Sunsetting sign is seen usually in hydrocephalus due to loss of upward conjugate gaze caused by raised intracranial pressure (ICP)

The setting-sun phenomenon is an ophthalmologic sign in young children resulting from upward-gaze paresis. In this condition, the eyes appear driven downward, the sclera may be seen between the upper eyelid and the iris, and part of the lower pupil may be covered by the lower eyelid. Pathogenesis of this sign is not well understood, but it seems to be related to aqueductal distention with compression of periaqueductal structures secondary to increased intracranial pressure.
However, it can also be transiently elicited in healthy infants up to 7 months of age by changes of position or removal of light (benign setting-sun phenomenon). The benign form might represent immaturity of the reflex systems controlling eye movements.

When persistent, this sign is one of the most frequent markers of elevated intracranial pressure, appearing in 40% of children with hydrocephalus (whatever the cause of Hydrocephalus as obstructive, communicating, Dandy-Walker anomaly/syndrome) and in 13% of patients with ventriculoperitoneal shunt dysfunction. It is an earlier sign of hydrocephalus than enlarged head circumference, full fontanelle, separation of sutures, irritability or vomiting. Consequently, this sign is a valuable early warning of an entity requiring prompt neuroimaging and urgent surgical intervention.

Synonyms

baby, Downward deviation of eyes, Downward Ocular Deviation, EYE DEVIATION DOWNWARD, infant, Infant (person), Infant child, Infant child (person), Infants, Manifestation Neurologic, Manifestation Neurological, MANIFESTATIONS NEUROL, Manifestations Neurologic, Manifestations Neurological, neural manifestation, NEUROL MANIFESTATION, NEUROL MANIFESTATIONS, NEUROL SIGNS SYMPTOMS, neurologic manifestation, Neurologic Manifestations, Neurologic manifestations of general diseases, Neurologic Signs and Symptoms, Neurological Manifestation, Neurological Manifestations, Sunset Sign

Koplik’s spots as described

This was a patient who presented with Koplik’s spots on palate due to pre-eruptive measles on day 3 of the illness. Measles is an acute, highly communicable viral disease with fever, conjunctivitis, coryza, cough, and Koplik spots. Koplik spots are small, red, irregularly-shaped spots with blue-white centers found on the mucosal surface of the oral cavity.


The spots as described by Koplik in 1896:

If we look in the mouth at this period we see a redness of the fauces; perhaps, not in all cases, a few spots on the soft palate. On the buccal mucous membrane and the inside of the lips, we invariably see a distinct eruption. It consists of small, irregular spots, of a bright red colour. In the centre of each spot, there is noted, in strong daylight, a minute bluish white speck. These red spots, with accompanying specks of a bluish colour, are absolutely pathognomonic of beginning measles, and when seen can be relied upon as the forerunner of the skin eruption.

About head lice infestations

Which of the following statements is true regarding head lice infestations?

• A) Females are more likely affected.
• B) Retreatment with pyrethrin is rarely needed.
• C) Head lice can live off the body up to 1 week.
• D) Low socioeconomic children are more likely affected.
• E) Dogs are a common vector for head lice.

The answer is:  ( A ).

Head lice are thought to be the most common type and are developing resistance to commonly used pediculicides. Every year, between 6 million and 12 million people in the United States, primarily children 3 to 10 years of age, are infested with head lice. Girls are at greater risk because they have more frequent head-to-head contact.
Head lice affect people of all socioeconomic status. Head lice are obligate parasites that live on human skin and survive on human blood. No other animal is affected. Head lice die if they are away from the host head for more than 2 days.

Lice are wingless and cannot jump, but they climb quickly from hair to hair when the hair is dry. Lice move slowly on wet hair and can be removed more easily with a gloved hand or a fine-toothed comb. The adult female louse lays 7 to 10 eggs daily that attach to human hair with a gluelike, water-soluble substance. By 7 to 10 days, a nymph emerges from the egg and is close enough to the scalp to obtain its first meal of blood. Adult lice, after the 7- to 10-day period of molting stages, live about 30 days. Infested people usually have no more than 10 to 12 live head lice at a time, but can harbor hundreds of eggs and nits. Those affected describe itching and a sensation of “something crawling on my head"? Scratching may cause excoriations and secondary infection. Most infestations are asymptomatic.

Prior to treatment, live lice can be identified under a magnifying glass, which is best done when the hair is wet. After infestation is confirmed, treatment consists of application of a pediculicidal agent to the hair, followed by mechanical removal. 

The hair should not be washed for 2 to 3 days after the pediculicide is applied. Thorough physical removal of lice and nits with a sturdy, fine-tooth comb is recommended for several days after application because no pediculicide guarantees total eradication of lice. First-line topical agents containing pyrethrins or permethrin are available over the counter and are relatively nontoxic. Retreatment is advised 7 to 10 days after the first application of pyrethrins. Because permethrin remains active for a longer period, retreatment generally is not necessary. Permethrin 5% cream is available by prescription for use in resistant cases. Alternative agents include lindane or malathion. Lindane has been shown to have limited success and is systemically absorbed, so its use is now considered second-line. Malathion was recently labeled by the U.S. Food and Drug Administration (FDA) for the treatment of head lice and is available in a lotion that is left on the head for 8 to 12 hours. Oral agents include ivermectin and trimethoprim–sulfamethoxizole. Resistance is possible with any treatment because of reduced susceptibility or incorrect use of the medication.

All household members with active infestation should be treated simultaneously. For children younger than 2 years, there is no recommended pediculicide; therefore, treatment consists of manual removal only. Lice that remain active 8 to 12 hours after treatment may require an alternative agent. Itching may persist for up to 10 days after successful treatment and should not be mistaken for treatment failure. The Centers for Disease Control and Prevention recommend that all clothing and bedding in contact with the infested person during the 2 days before application of the pediculicide be laundered in hot water and machine dried using a hot dry cycle. All nonwashable items should be quarantined in a plastic bag for 2 weeks. Combs and brushes should be disinfected with hot water or alcohol.

Appearance of Rachitic rosary by photos

Rachitic rosary are also known as a rachitic rosary or beading of the ribs which appeare as prominent knobs of bone at the costochondral joints of rickets patients.

These knobs create the appearance of large beads under the skin of the rib cage, hence the name by analogy with the beads of a rosary.

Rachitic rosary is due to a deficiency of calcium resulting in lack of mineralization and an overgrowth of costochondral joint cartilage. The calcium deficiency may be caused by Rickets or other causes of calcium deficiency such as hypoparathyroidism.