Infectious Diseases
Section 4: Infectious Diseases
4.3 INFECTIOUS DISEASE EMERGENCIES Kawasaki Disease
Figure 4.3.2: Cutaneous hemorrhage and necrosis seen in pupura fulminans.
Photo Courtesy: Prabhas Prasun Giri, Kolkata
A 5 years old girl presented with meningococcemia with purpura fulminans. Fever and features of sepsis.
Purpura fulminans (also known as purpura gangrenosa).
It is a life-threatening disorder of acute onset. It is characterized by cutaneous hemorrhage and necrosis (tissue death), small vessel thrombosis and disseminated intravascular coagulation. Common causes are severe infection
(especially with Meningococcus, and Capnocytophaga canimorsus, and other gram-negative organisms), and deficiency of the natural anticoagulants protein C or protein S in the blood. In some cases, a cause is never found.
Treatment is mainly by removing the underlying cause and degree of clotting abnormalities and with supportive treatment (antibiotics, volume expansion, tissue oxygenation, etc.). Thus, treatment includes aggressive management of the septic state. Surgical debridement, escharotomies, fasciotomies, and even amputations. In many cases, digits may need to be amputated when their blood supply has ceased.
The use of full dose heparin or other anticoagulant is controversial.
Purpura Fulminans
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IAP Color Atlas of Pediatrics
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Picture Note Management
Staphylococcal Scalded Skin Syndrome
Figures 4.3.3A and B: (A) Erythematous exfoliate lesions seen in staphylococcal scalded skin syndrome; (B) Closer view of the same lesion
Photo Courtesy: Priyankar Pal, Kolkata
Staphylococcal scalded skin syndrome (SSSS) is caused by an epidermolytic toxin producing strain of staphylococci belonging to phase group II. In the initial phase, it produces a generalized macular erythema and a fine stippled, sandpaper or nutmeg-like appearance which progresses to tender scarlitiniform phase over 1 to 2 days. The erythema progresses all over the body. The lesions exfoliate, exudes and crusts around the mouth and periorbital area. Large fragments of crusts separates and within 2 to 3 days the upper layer of the epidermis becomes wrinkled and can be easily peeled off. If there is no secondary skin infection the skin heals without scarring within 14 days of the onset of the disease.
Treatment is eradication of staphylococci from the focus of infection and thus terminating the production of toxin. Topical antibiotics are ineffective. For methicillin sensitive Staphylococcus aureus one can use cloxacillin, clindamycin, cefazolin. Penicillin, and cephalosporin allergic patient should receive vancomycin as initial therapy. For methicillin resistant staphylococcal aureus (MRCA), the drug of choice is vancomycin plus gentamycin.
Other drugs which can be used are trimethoprim sulfamethoxazole, linezolid, quinupristin-dalfopristin, fluoroquinolone. Parenteral medication is indicated in case of serious infection and those who are severely ill.
Lipodystrophy in HIV
4.4 SYNDROMES
Figures 4.4.1A and B: Lipodystroply seen in the face and back
Photo Courtesy: Prabhas Prasun Giri, Kolkata
Lipodystrophy, commonly known as fat redistribution, is a condition characterized by degenerative and abnormal functioning of the adipose tissue present in an individual’s body. Patients suffering from lipodystrophy generally experience loss of fat from selective regions of the body; however, the face, arms and the back are the most commonly affected regions by this disease.
Treatment with antiretrovirals.
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Section 4: Infectious Diseases
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Picture Note Management
Picture Note Management
Post-Kala-Azar Dermal Leishmaniasis (PKDL)
Figure 4.4.2: Dermal Leishmaniasis seen in the face
Photo Courtesy: Arun Shah, Muzaffarpur
Post-kala-azar dermal leishmaniasis develop later following visceral leishmaniasis when all the parasites are not eradicated. It is seen in 20 to 30 percent of cases. The parasites proliferate locally giving rise to erythematous papule, which evolves to become a nodule with shallow ulceration and raised borders.
It is commonly seen in face and extremities.
Spontaneous resolution may take weeks to years and usually results in a flat atrophic scar. Treatment is indicated if the lesions are disfiguring, are persistent, or if the lesions are known to be or might be caused by species that might disseminate to nasopharyngeal or pharyngeal mucosa.
Recurrent Bacterial Meningitis
Figures 4.4.3A to C: (A) Frontal encephalocele;
(B) Nasal dermal sinus;
(C) Dorsal dermal sinus
Photo Courtesy: Dipankar Das, Kolkata
Recurrent bacterial meningitis is two or more episodes of meningitis with a greater-than-3-week interval after the completion of therapy for the initial episode caused by a different bacterial organism. Or a second or further episode caused by the same organism with a greater- than-3-week interval after the completion of therapy for the initial episode. Here the cause of recurrent meningitis is frontal encephalocele, nasal dermal sinus, and dorsal dermal sinus. Bacteria can migrate along congenital preformed pathways or acquired tissue planes to gain entrance into the subarachnoid space or undiagnosed immunodeficiency can render the host defenses as inadequate barriers to potential bacterial pathogens.
Work-up for immunodeficiency and treatment of the cause.
Stevens-Johnson Syndrome (SJS)
Figure 4.4.4: Erythema multiforme like lesions in Stevens-Johnson syndrome (SJS)
Photo Courtesy: Arun Shah, Muzaffarpur
Stevens-Johnson syndrome (SJS) are manifested by erythema multiforme like lesions, typically known as target lesions. Oral and mucosal erosion and ulcerations are seen in 100% cases. Skin blisters and erosion affects body surface area.
Fever and myalgia may be present.
Healing process may take about two weeks.
All the children should be admitted. Offending drug should be stopped. Thermoneutral environment (30-32°C) should be maintained. Role of corticosteroid is controversial.
Injection methylprednisolone or dexamethasone may be given.
Antihistamines and analgesics may give some symptomatic relief.
Proper skin care is very important.
Topical emollients and antibiotics may give some relief.
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Section 5
5.1 Common Conditions
5.2 Uncommon Conditions but not Rare 5.3 Neurologic Emergencies
5.4 Syndromes