2 History Taking of Common Pediatric Cases
2.28 Skin Rash
• Rash is a general term referring to any skin eruption.
• Although a comprehensive physical examination is essential to assess the condi-tion of the child with a skin erupcondi-tion, a thorough history and precise descripcondi-tion of the eruption can be very helpful in removing any obstacle to accurate diagno-sis (see History Station 2.27 and Table 2.9).
• Mental status deterioration that starts gradually is suggestive of an infectious process, slowly expanding intracranial mass lesion, or metabolic abnor-mality [71, 72].
• Coma that is preceded by headache with positional changes or with Valsalva maneuver may suggest raised ICP from hydrocephalus or intracranial mass lesion.
• Coma associated with headache and neck pain or stiffness may suggest men-ingeal irritation due to inflammation, infection, or intracranial hemorrhage.
• Fever in a comatose child suggests infection. However, the absence of fever does not rule out infection, especially in children under 6 months of age or those who are immunocompromised [71].
• Mental status fluctuation or abnormal movements may suggest postictal state or non-convulsive seizures.
• A previous history of unexplained episodes of coma may suggest recurrent toxic ingestions, intermittent metabolic disease, or Munchausen by proxy syndrome.
• Pre-existing neurological abnormalities and developmental delay are sugges-tive of inborn errors of metabolism or a prolonged postictal state.
• Coma in a child with a known cardiac disease should raise the possibility of circulatory collapse or hypoxic-ischemic encephalopathy.
Key Points 2.26
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Table 2.9 (continued)
Short case history Diagnosis and special points in favor A 7-year-old male child presents an
erythematous maculopapular rash, preceded by 2 days of fever and pharyngitis. The rash appeared initially on the neck and upper trunk and spread rapidly to cover the whole body. It was accentuated in the axillae and antecubital, inguinal, and popliteal creases, while the palms and soles were spared
Scarlet fever
– This starts with fever and pharyngitis, followed by the rash in 1–2 days
– A fine erythematous maculopapular rash with a sandpaper texture appears initially on the neck and upper trunk and then spreads rapidly to cover the entire body
– The patient presents with flushed face and circumoral pallor
– Initially, the tongue is white, coated, and furred (white strawberry tongue); then, within 4–5 days, it becomes red and swollen (red strawberry tongue)
– Within several days, the rash fades with a skin peeling
A 4-year-old female child presents with a pinkish maculopapular rash, which began on the face and then spread to cover the entire body. The rash was preceded by an upper-respiratory tract prodrome and associated with painful eye movements. According to the mother, postauricular small nodules were also noticed
Rubella
– Rubella may start with an upper-respiratory tract prodrome, followed by the rash
– The rash is a fine, pinkish maculopapular rash that begins on the face and spreads to involve the whole body. It typically lasts about 3 days – It may be associated with painful eye
movements, which are characteristic – Lymphadenopathy is prominent, especially in
the suboccipital and postauricular nodes A 3-year-old male child presents with a
bright-red rash over his cheeks, with pallor around the mouth. The rash spread rapidly on the trunk, buttocks, and the extensor surface of extremities.
It was associated with a low-grade fever, headache, and mild upper respiratory symptoms that started before the onset of the rash
Erythema infectiosum
– A reticulate rash spreads rapidly on the trunk, buttocks, and extensor surface of extremities – Red papules that coalesce on the face may
appear as “slapped cheeks”
– The palms and soles may be involved
A 10-month-old infant presents with a rose-colored skin rash, preceded by upper-respiratory symptoms and a high fever (>40°). The rash started on the trunk and spread to the face, neck, and limbs. It coincided with the abrupt remission of the fever
Roseola infantum
– Roseola usually occurs in children younger than 4 years old (typical age 9–12 months) – The rash consists of rose-colored discrete
blanching, small, raised lesions start on the trunk and spread to the face, neck, and limbs.
It may last 1–3 days
– The rash coincided with the abrupt remission of the fever
– A febrile seizure may occur
(continued) 2.28 Skin Rash
Table 2.9 (continued)
Short case history Diagnosis and special points in favor A 5-year-old male child presents with a
skin rash, preceded by 2 days of fever, malaise, and poor appetite. The rash started as erythematous macules and papules but rapidly developed into small vesicles. These lesions existed simultaneously in varying phases of development on the face, trunk, and scalp, with minimal involvement of the distal extremities. The mucous membranes were involved, and the palms and soles were spared
Chickenpox (varicella)
– Chickenpox may be preceded by fever, malaise, poor appetite, headache, and abdominal pain
– The rash progresses from erythematous macules to papules, to fluid-filled vesicles, and occurs in the dermatome (or in two adjacent dermatomes) and finally crusts
A 2-year-old male child presents with a high-grade fever not relieved by paracetamol, lasted for a 6-day duration, associated with irritability, and a morbilliform rash started in the groin region. The child also has red eyes, cracked red lips, and cervical lymphadenopathy
Kawasaki disease
– Kawasaki disease usually occurs in children between 6 months and 5 years of age. (the median age is 2–3 years old.) It is rare in children <3 months of age
– The rash of Kawasaki disease may be morbilliform, scarlatiniform, pustular, urticarial, or erythema multiforme-like – The oropharyngeal changes are bright-red and
fissured lips with some crusting, oral erythema, and a strawberry tongue
– Bilateral non-purulent conjunctivitis occurs in
>90% of patients
– Edema and erythema of the palms and soles may occur, and peeling of fingers and toes occurs in the second or third week An 8-month-old unwell male infant
presented with an 11-h history of fever, lethargy, and a spreading purpuric rash over the trunk, extremities, and palate.
The symptoms were preceded by mild upper- respiratory symptoms
Meningococcemia
– Meningococcemia presents as a set of mild upper-respiratory symptoms, followed by fever, malaise, headache, and skin rash, which may appear as a non-blanching maculopapular purpuric rash and petechiae and then
ecchymosis over the trunk, limbs, and palate A 7-year-old female presents with
intensely itchy wheals with surrounding erythema over her chest, back, and abdomen. The lesions lasted for less than 12 h, to be replaced by new lesions at other sites. There were no other associated symptoms
Urticaria
– Urticaria typically presents as a pruritic raised central wheal with surrounding erythema – Lesions usually last for a few hours (less than
24 h)
A 6-month-old male child presents with a 2-month history of recurrent pruritic erythematous, exudative, crusty, and oozy lesions, distributed over the cheeks, scalp, trunk, and extensor aspects of the extremities. He had a family history of asthma
Atopic dermatitis
– This presents with a chronic and recurrent pruritic rash that varies with the child’s age – Infantile (from 2 months to 2 years) (described
in this case)
– In older children (from 2 years to
adolescence): lichenified, dry, itchy plaques involving flexural aspects (neck, antecubital, popliteal)
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• Identity: Age, sex, address, ethnicity/race
• Chief complaint: Rash
• History of present illness:
1. Onset: Acute vs. gradual
2. Duration: When did the rash appear?
3. Site of the first appearance of the rash: Where did the rash first appear?
What did it look like when it first appeared?
4. Features of the rash:
– Location, pattern of spread (e.g., trunk to extremities) – Configuration of the rash: What did it resemble?
– Color of the rash
– Progression of the rash over time, changes in appearance, or distribu-tion over time
5. Associated symptoms: Fever (if there is fever, ask about timing of onset of the rash in relation to fever), pruritus, scaling, joint pain, neck pain or stiff-ness, and abdominal pain. If the child has any symptoms accompanying the rash, then ask, “Did these symptoms start before, with, or after the onset of the rash?” How long has the child had these symptoms?
6. Factors that worsen or precipitate the rash: Exposure to irritants, allergens, insect bites, trauma at the site of the rash, change in seasons, cold, or sun exposure
• Past history:
A—Birth history: Maternal infections, advance maternal age, prematurity, low birth weight, twinning
B—Past medical and surgical history: Prior history of skin rashes (e.g., chickenpox, measles, etc.), allergic rhinitis, asthma, urticaria, eczema, IBD, SLE, renal disease, neurological disease, malnutrition, immunodefi-ciency, diabetes, hospitalizations, or surgery
• Medication history: Treatments that have been tried, exposure to certain medications (e.g., antibiotics, antiepileptics, steroids, chemotherapy, etc.), topical therapies may be relevant to the child’s condition (e.g., neomycin, diphenhydramine, and certain anesthetics, if applied topically, these may cause contact dermatitis), drug allergies
• Immunization history: Recent vaccination, vaccination status, MMR vac-cine (measles, mumps, rubella)
• Family history: Does anyone else in the family have a similar rash? Is there a family history of atopic disease? Allergic rhinitis? Asthma? SLE? IBD?
• Social history: Exposure to persons with rash, travel and outdoor activities, alcohol, substance abuse, home situation, psychologic stress, sexual activity (secondary syphilis and disseminated gonococcal infection, molluscum con-tagiosum, or scabies). Are there pregnant contacts?
• Review of systems: Malaise, headache, decreased activity, conjunctivitis, coryza, cough, sore throat, wheezing, rhinorrhea, decreased appetite, weight loss, diarrhea, photosensitivity, etc.
History Station 2.27: Skin Rash
2.28 Skin Rash