Allergy, Immunology, and ENT

A 16-month-old girl was initially brought to her primary care physician because of persistent nonproductive cough of 1 to 2 weeks’ duration, with lethargy, poor feeding, and worsening cough for the past 36 hours. She had been afebrile. The patient was noted to be pale and had a decreased level of interaction. She was promptly sent to the local emergency department. Laboratory studies showed a hemoglobin level of 3.8 g/dL and hypochromic microcytic anemia. The patient was subsequently transferred to the pediatric ICU for evaluation.

Episodic right-sided facial flushing was noted in a 2-month-old girl born at full term via forceps-assisted vaginal delivery. The erythema appeared within minutes of latching onto her mother’s breast and resolved within 5 to 10 minutes after breastfeeding. The episodes of flushing had begun a week before the clinic visit; there were no collateral symptoms of anaphylaxis. Because food allergy was suspected, the mother had eliminated all dairy products from her diet.

Circumscribed erythematous lesions developed on the back and abdomen of this 19-month-old boy. The rash was mildly pruritic. The parents gave the child 1 dose of diphenhydramine, and the rash resolved after an hour. About 12 hours later, new lesions developed on the face, neck, and upper back. The child was given the same treatment and the symptoms resolved. The following morning, widespread lesions were noted on the child's face, neck, trunk, and extremities.

A 5-month-old Asian boy was brought for evaluation of hair loss and a red, scaly rash on the scalp and body. The rash had not responded to hydrocortisone 2.5% ointment. There was a family history of asthma, food allergies, and allergic rhinitis. His mother had Hashimoto thyroiditis.

A 5-month-old girl with progressively worsening generalized rash of 3 weeks’ duration. No obvious sensitivity, fever, recent infection, medication use, or known contact with irritant.

For 2 days, a 17-year-old boy had a widespread pruritic eruption that involved the trunk and extremities but spared most of the face. Many of the lesions were annular, and they would appear and resolve within 1 day. The patient denied shortness of breath, difficulty in swallowing, and periorbital swelling.

A 7-year-old boy with annular, asymptomatic, flesh-colored lesion onthe wrist that had developed slowly over the past month. The parents hadremoved the child from school because they were told that the lesion wasringworm. The lesion had failed to resolve after application of an antifungalcream for 10 days.

A 4-year-old boy presented for further evaluation of persistent right hip painof 2 months’ duration. Before the onset of the pain, he had been limping,favoring his right side. For several days before he was brought in forevaluation, he had had fevers and sweating in addition to the right hippain.

I enjoyed Dr Kirk Barber’s interesting Dermclinic quiz featuring a 5-year-old boy with a dramatic resentation of tinea corporis (CONSULTANT FOR PEDIATRICIANS, February 2009, page 43). I am curious to know why Dr Barber prescribed oral terbinafine for this patient.

A persistent, eczematous dermatitis had developed in the perioral area during the winter months in this 10-year-old boy. Topical corticosteroid creams had been tried, and these seemed to help some, but the ondition never really cleared. Because of the failure of the corticosteroid creams, a topical antifungal cream had also been tried; however, this, too, was of limited effectiveness.

An 18-month-old white boy is brought to his well-care visit by his parents, who are concerned that for the past month he has been less social and active. He has appeared weak and has refused to walk or play with his siblings. He has also had a decreased appetite and has lost about 2 kg. He has vomited several times but with no bile or blood.

The most common chronic medical problem that we pediatricians treat is asthma. We do our best to manage our patients’ asthma by prescribing controller medications, providing asthma action plans, and guiding families through acute exacerbations. We often ask about possible environmental triggers, such as tobacco smoke and cockroaches, and we advise patients to reduce their exposure to those triggers.

The most common chronic medical problem that we pediatricians treat is asthma. We do our best to manage our patients' asthma by prescribing controller medications, providing asthma action plans, and guiding families through acute exacerbations. We often ask about possible environmental triggers, such as tobacco smoke and cockroaches, and we advise patients to reduce their exposure to those triggers.

For the past few weeks, a 10-year-old boy had a pruritic abdominal rash that had not responded to over-the-counter topical medications. The rash had appeared around the time he started wearing a new belt (shown). The child was otherwise healthy. There was a family history of asthma.

Twenty-two-month-old girl seen in the emergency department (ED) after several hours of abdominal pain associated with non-bloody, non-bilious emesis. Over past 2 months, has had 7 or 8 similar episodes of abdominal pain followed by emesis 1 to 2 hours later.

With the banning of peanut butter and jelly from some school cafeterias, peanut allergies have become a popular topic in the media and the public. Discussions often include references to an increasing prevalence of allergies, as well as to an earlier emergence of those allergies in children.

The National Heart, Lung, and Blood Institute and National Asthma Education and Prevention Program (NAEPP) released its Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma--Full Report, in August 2007.1 The EPR-3 is the fourth iteration of the guidelines, which were first released in 1991 (EPR-1), revised in 1997 (EPR-2), and partially revised in 2002 (Update on Selected Topics). For the first time since their inception, the guidelines include separate recommendations specific to children aged 0 to 4 years and 5 to 11 years. Table 1 highlights the key differences between the 1997 EPR-2 guidelines and the 2007 EPR-3 guidelines regarding treatment of pediatric asthma.

With the banning of peanut butter and jelly from someschool cafeterias, peanut allergies have become a populartopic in the media and the public. Discussions ofteninclude references to an increasing prevalence ofallergies, as well as to an earlier emergence of thoseallergies in children.

A 4-year-old girl presented with a sore throat, dysphagia, fever (temperature up to 40°C [104°F]), and a pruritic vesicular rash. On the first day of the illness, 4 days earlier, she was evaluated by her pediatrician who prescribed azithromycin for a presumed upper respiratory tract infection. About 2 days later, a papular rash developed on the abdomen and perioral skin; the fever had persisted, and the child's oral intake had decreased. The next day, the rash continued to spread, and the patient refused to take anything orally, including fluids. The mother thought that the rash was a hypersensitivity reaction to the antibiotic.

A 5-year-old boy with seizure disorder and developmental delay presented to our allergy and immunology clinic for a severe reaction that developed after he had received multiple vaccines. One month before our evaluation, the patient had been vaccinated against varicella, hepatitis A, and influenza at his pediatrician's office. Latex gloves were not used for vaccine administration.

This baby boy was born at term to an 18-year-old primigravida via spontaneous vaginal delivery. The membranes ruptured about 6 hours before delivery. The amniotic fluid was heavily stained with meconium. Forceps were not used during the delivery. The newborn initially had poor tone and no spontaneous respirations, but his heart rate exceeded 100 beats per minute. Bulb and deep suctioning as well as supplemental oxygen were provided. Apgar scores were 3 and 8 at 1 and 5 minutes.

A 15-year-old girl was brought to the emergency department because of bilateral shoulder and hip pain associated with myalgia and fatigue. The symptoms had been present for 2 months and had increased in intensity over the past few days. The patient had systemic lupus erythematosus, asthma, and seizure disorder.

The parents of a 9-month-old boy were concerned about the bright red color of their son's feces. Over the course of an hour, the infant had 3 bowel movements that appeared to the family to be "more blood than stool." He had no fever or emesis and no history of unusual contacts or travel. There had been no change in his diet; he had not been given any dietary supplements, such as iron.

Henna and Hair DyeA 16-year-old Somali girl presented with a 30-day history of bilateral arm swelling and painful vesicular eruptions.Five days before presentation, she and her friends had used henna and black hair dye to “tattoo” their skin. Theothers did not experience similar signs or symptoms. This patient had used henna since childhood for decorativepurposes. However, outlining an intricate design with hair dye was new for her.This patient was hospitalized and treated for severe cosmetic dermatitis with systemic corticosteroids,diphenhydramine, and daily dry dressing changes. Ibuprofen was given to help relieve discomfort. Antibioticswere not ordered.The patient remained afebrile and was discharged on hospital day 2 with close follow-up and daily dressingchanges. She was advised to avoid contact with all hair-dye products.Case and photo courtesy of Jennifer A. Jewell, MD, and Lorraine L. McElwain, MD.

Severe disability and even death can result from the inappropriate diagnosis and treatment of a young child's wheezing, which is heterogeneous in its origins and expression. Consequently, a differential diagnosis is necessary to determine the cause and to develop an effective management strategy. Viral-induced wheeze, especially from respiratory syncytial virus (RSV), manifests as a bronchiolitis. Recent reports show that the cysteinyl leukotrienes are an important mediator of the airway effects of RSV infection and that leukotriene receptor antagonists reduce postrespiratory syncytial virus lung symptoms. Exercise-induced bronchoconstriction manifests as wheezing and can be treated or pretreated short-term with inhaled bronchodilators or cromolyn: long-term therapy includes inhaled corticosteroids and leukotriene receptor antagonists. Allergic rhinitis-associated wheeze may be the result of acute exposure to an allergen or simply from nasal dysfunction. Control of allergic rhinitis with intranasal steroids, antihistamines, or leukotriene receptor antagonists could relieve the wheezing. Asthma-associated wheeze requires long-term use of 1 or more daily controller medications. The primary goal is to navigate the child safely through the first episode of wheezing, consider the causes of the wheeze, and then evaluate the need for further therapy. All apparent causes of wheeze should be treated with the idea that if the apparent cause turns out not to be the actual cause, treatment can be safely discontinued.

Photoclinic: Eosinophilic Esophagitis

A thriving boy was brought to the office 3 weeks after his first birthday. His mother reported that there was "something wrong with his knee." On visual examination, the knee appeared perfectly normal. On palpation, however, a 4-cm linear induration was evident over the knee fat pad, just medial and distal to the patella. It appeared soft, crepitant, and associated with the skin. No tenderness was noted on palpation; the infant did not object to palpation of this density any more than to auscultation, otoscopy, or anthropometric measurements. No erythema, ecchymosis, or signs of trauma were evident near the lesion. The only possibly relevant history was that the child had spent his birthday at his grandmother's home in the Ukraine a month earlier. He was constantly with his mother during that time, and no trauma was ever reported.

Foreign-body aspiration is a relatively common occurrence in children. It may present as a life-threatening event that necessitates prompt removal of the aspirated material. However, the diagnosis may be delayed when the history is atypical, when parents fail to appreciate the significance of symptoms, or when clinical and radiologic findings are misleading or overlooked by the physician.

e-Photo Quiz: Take the Monthly Online Challenge

For several weeks, an 18-year-old man has been bothered by itchy ears. He has seasonal allergies that are well controlled with oral antihistamines. He has not been exposed to contactants and has not used any nutritional supplements or new shampoos or conditioners. He works out at a gym 5 days a week.