Re: A monthly case study featured in Infectious Diseases in Children, with treatment

February 22, 2008

KC, I just skimmed over this article. Unless I am not seeing it, does this have

anything to do with mold exposure, and do you know anyone that has this type of

rash. Could be my brain fog missing the data if related to mold. Darlene

tigerpaw2c <tigerpaw2c@...> wrote: What's

your diagnosis? There are so many diseases/symptoms that seem

to overlap and I can understand why it could be so difficult for a

proper diagnosis. The pictures of these rashes, I must say, look

awfully familiar to me, how about you? Just food for thought....

You may have to register to get the photos or read the full case

report.

http://www.idinchildren.com/200802/wyd.asp

---------------------------------

Be a better friend, newshound, and know-it-all with Mobile. Try it now.

February 22, 2008

Darlene,

Many have suffered from rashes, with burns,scars or white spots left

behind. Many times these articles speak of infection or virus and

give it some fancy name, where in reality to me it's fungus related.

Sharon had the rashes and the swelling that is also mentioned in the

article along with her C-reactive protein being off. With this

article there are several good photos.

Article below:

KC

February 2008

H. Brien

H. Brien, DO, Pediatric Infectious Disease, and White's

Children's Health Center and Associate Professor of Pediatrics,

Texas A & M University, College of Medicine, Temple, Texas.

e-mail: jhbrien@...

Because of concern for acute rheumatic fever, a 7-year-old boy was

sent for admission to the hospital with a recent history of

streptococcal pharyngitis, followed by arthritis and rash.

The history of this illness began about 10 days earlier with a sore

throat and upper respiratory congestion. His rapid strep test was

positive, so he was treated with amoxicillin. However, his fever

persisted with the development of a rash on his lower extremities

the next day, followed by pain and swelling of his ankles, knees and

wrists the day after. The antibiotic was empirically changed to a

first-generation cephalosporin without benefit.

His past medical history was normal. His vaccinations were up to

date, and there had been no travel, camping, tick bites or other

insect bites. He does live in a wooded area with deer, but his only

direct animal exposure is to the family dog.

Examination revealed normal vital signs and a rash consisting of

petechiae and nonblanching red bumps on his lower extremities and

buttocks, as shown in Figures 1 through 4. He also had painful

swelling of the joints of his right hand, knees and elbows, with

decreased range of motion testing but no erythema over the joints

(Figures 5 and 6). The rest of his examination, including his

throat, was normal.

Lab tests included a complete blood count that was normal, including

the platelet count, but he had mild elevation of the C-reactive

protein.

What is the most likely cause of this diagnosis?

Henoch-Schönlein purpura

Juvenile idiopathic arthritis

Rheumatic fever

Streptococcal scarlet fever

Answer

The answer is A. Henoch-Schönlein purpura.

Although first recognized as a distinct syndrome by the British

physician Heberden (1710-1801) in the 18th century, it was

the German physician Johann Schönlein (1793-1864) who first

described the characteristic rash. Later, the German pediatrician

Edouard Heinrich Henoch (1820-1910) described the gastrointestinal

and renal manifestations of the disease during the 19th century.

Henoch-Schönlein purpura is an immunoglobulin A-mediated autoimmune

small-vessel vasculitis that is most common in children aged between

2 and 8 years, with boys being affected about twice as often as

girls. Some infectious triggers have been identified, such as group

A streptococcus (as in the patient above), mycoplasma and viruses of

the respiratory tract. However, many cases have no identifiable

trigger.

All Henoch-Schönlein purpura patients have the rash, which can be a

mix of petechiae, purpuric and maculopapular lesions. The

distribution of the rash tends to be in gravity-dependent areas,

such as the legs and buttocks. Over time, the color of the lesions

becomes darker, changing to a rusty, brownish color, as shown in

Figure 7. Arthritis is found in about 75% of patients and

gastrointestinal pain in about 50%. Renal involvement is seen in

about 30% to 40% but can be a serious complication with the

possibility of progression to renal failure. A rare but potentially

life-threatening complication is involvement of the central nervous

system.

Diagnosis is made by recognition of the rash with one or more of the

associated findings, which may not appear at the same time. There is

no specific treatment, but antiinflammatory agents may help, or

possibly steroids for those with severe CNS involvement.

The most important diagnostic decision is to differentiate Henoch-

Schönlein purpura from meningococcemia (Figures 8 and 9), which is

why most patients are initially admitted to the hospital. There can

be enough overlap that some patients are treated empirically with

antibiotics until the diagnosis is clear, and that may take a day

under observation. However, most patients with meningococcemia are

clinically much sicker than these Henoch-Schönlein purpura patients,

and it does not take long to sort them out.

We know the patient had streptococcal pharyngitis; however, there

was no other evidence of scarlet fever. The usual scarlatiniform

rash is a fine, papular rash on a diffuse erythematous base, as

shown in Figure 10. which depicts a patient with multiple infected

insect bites with group A strep and a scarletiniform rash. The

erythema is accentuated by the " thumb print " on his back, like a

capillary refill test. This is easy to distinguish from a petechial

or purpuric rash. Other associated findings of scarlet fever include

circumoral pallor, Pastia's lines and a " strawberry " tongue, which

this patient did not have.

The other streptococcal-related disease listed among the choices was

rheumatic fever, which is the real reason the primary provider

wanted the patient admitted. However, when the criteria are

considered, the joint complaints and elevated C-reactive protein

were the only minor criteria; there were no major criteria. This,

coupled with the rarity of rheumatic fever, makes this diagnosis

very unlikely. However, an electrocardiogram was done and was

normal. The rash of rheumatic fever is referred to as erythema

marginatum and is virtually pathognomonic of rheumatic fever. I do

not have any pictures of erythema marginatum, but you can probably

find them on the internet.

Lastly, although juvenile idiopathic arthritis can have unusual

rashes, it cannot be diagnosed this early in the course of a febrile

illness. Normally, the diagnosis is not made until there have been

symptoms present for four to six weeks and no other explanation for

the illness.

What's your diagnosis? There are so many diseases/symptoms that seem

> to overlap and I can understand why it could be so difficult for

a

> proper diagnosis. The pictures of these rashes, I must say, look

> awfully familiar to me, how about you? Just food for thought....

> You may have to register to get the photos or read the full case

> report.

>

> http://www.idinchildren.com/200802/wyd.asp

>

> ---------------------------------

> Be a better friend, newshound, and know-it-all with

Mobile. Try it now.

>

February 22, 2008

KC, I know about rashes and burns, I have had rashes. I have also read where

many victims from mold exposure have had rashes, etc. I just didn't know if

there was a direct correlation to this type of rash with mold exposure. Darlene

tigerpaw2c <tigerpaw2c@...> wrote: Darlene,