A five-year-old child presents with fever, irritability, and sore throat. Physical exam shows numerous small ulcers and vesicles inside his mouth. See picture:
What is the most likely diagnosis?
Correct Answer A: Herpangina is a febrile disorder caused by numerous group A Coxsackie viruses and occasionally other enteroviruses. Infection produces oropharyngeal mucosal vesicular and ulcerative lesions.
Herpangina tends to occur in epidemics, most commonly in infants and children. It is characterized by sudden onset of fever with sore throat, headache, anorexia, and frequently, neck pain. Infants may vomit. Within 2 days after onset, up to 20 1- to 2-mm diameter grayish papules develop and become vesicles with erythematous areolae. They occur most frequently on the tonsillar pillars but also on the soft palate, tonsils, uvula, or tongue.
Diagnosis is based on symptoms and characteristic oral lesions. It is best confirmed by isolating the virus from the lesions or by demonstrating a rise in specific antibody titer, but such testing is not generally recommended. Treatment of herpangina is symptomatic.
A 4-year-old white male is brought to your office because he has had a low-grade fever and decreased oral intake over the past few days. On examination you note shallow oral ulcerations confined to the posterior pharynx.
Which one of the following is the most likely diagnosis?
Correct Answer B:
Herpangina is a febrile disease caused by coxsackieviruses and echoviruses. Vesicles and subsequent ulcers develop in the posterior pharyngeal area. Herpes infection causes a gingivostomatitis that involves the anterior mouth. Mononucleosis may be associated with petechiae of the soft palate, but does not usually cause pharyngeal lesions. The exanthem in roseola usually coincides with defervescence. Mucosal involvement is not noted. Rubella may cause an enanthem of pinpoint petechiae involving the soft palate (Forschheimer spots), but not the pharynx.
An infant child develops abdominal obstruction. His history includes no passing of meconium on the first day of life. You suspect Hirschsprung's disease.
Which of the following is considered the gold standard for diagnosis?
Correct Answer D: In Hirschsprung's disease (congenital megacolon), a section of the large intestine is missing the nerve network that controls the intestine's rhythmic contractions.
At the time of birth, newborns should pass a dark green fecal material (meconium). Delayed passage of meconium raises the suspicion of Hirschsprung's disease. Later in infancy, children with Hirschsprung's disease can have symptoms that suggest intestinal obstruction, bile-stained vomit, a swollen abdomen, and refusal to eat.
Rectal biopsy and measurement of the pressure inside the rectum (manometry) are the only tests that can reliably be used to diagnose Hirschsprung's disease. A barium enema may also be performed. During a barium enema, the doctor instills barium and air into the child's rectum and then takes x-rays.
A term newborn infant is noted to have abdominal distention and failure to pass meconium at 48 hours of age. Sweat chloride test is negative. Abdominal x-rays show dilated loops with air-fluid levels and a granular "ground glass" material. A gastrografin enema is administered with good effect, as the infant passes meconium.
Which one of the following investigations is indicated in the follow-up management of this infant?
Correct Answer E:
In Hirschsprung's disease (congenital megacolon), a section of the large intestine is missing the nerve network that controls the intestine's rhythmic contractions. Symptoms of intestinal obstruction occur. The large intestine depends on a network of nerves within its walls to synchronize rhythmic contractions and move digested material toward the anus, where the material is expelled as feces. In Hirschsprung's disease, the affected section of intestine cannot contract normally.
At the time of birth, newborns should pass a dark green fecal material (meconium). Delayed passage of meconium raises the suspicion of Hirschsprung's disease. Later in infancy, children with Hirschsprung's disease can have symptoms that suggest intestinal obstruction, bile-stained vomit, a swollen abdomen, and refusal to eat. If only a small section of the intestine is affected, a child may have milder symptoms and may not be diagnosed until later in childhood. These children may have ribbon like stools and a swollen abdomen; they often fail to gain weight. In rare cases, constipation is the only symptom.
Which of the following statements about hemorrhagic disease of the newborn is true?
Correct Answer D:
Hemorrhagic disease of the newborn is a bleeding problem that occurs in a newborn during the first few days of life. Babies are normally born with low levels of vitamin K, an essential factor in blood clotting. A deficiency in vitamin K is the main cause of hemorrhagic disease of the newborn.
Babies at risk for developing hemorrhagic disease of the newborn include the following: babies who do not receive preventative vitamin K in an injection at birth, exclusively breastfed babies (breast milk contains less vitamin K than cow's milk formula).
In addition to a complete medical history and physical examination, a diagnosis is based on the signs of bleeding and by laboratory tests for blood clotting times. A prolonged PT is usually the first laboratory test result to be abnormal in vitamin K deficiency bleeding.
If bleeding occurs, vitamin K is given. Blood transfusions may also be needed if bleeding is severe.
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