A 4-year-old female presents with ulcers on her tongue and oral mucosa. The patient refuses to eat due to pain in her mouth. Her temperature is 38.3˚C (101˚F). A maculopapular, vesicular rash is also noted on the hands, feet, and buttocks. The patient is diagnosed with hand-foot-and-mouth disease.
This common disease of children is caused by:
Correct Answer E:
Hand-foot-and-mouth disease is caused by coxsackie A viruses. As with most viral exanthems, the treatment is supportive care. Anorexia may develop due to the painful ulcers in the mouth. Fluids are encouraged to maintain hydration. Some physicians recommend a mouthwash made with Maalox or Kaopectate with diphenhyramine to control the pain before meals. Acetaminophen or ibuprofen may be used to treat the fever, which usually lasts about 2-3 days.
A. Paramyxovirus causes measles.
B. Rubella virus causes rubella.
C. Herpes virus 6 is associated with roseola infantum.
D. Erythema infectiosum, or fifth disease, is caused by parvovirus B-19.
A 4-year-old white male is brought to your office in late August. His mother tells you that over the past few days he has developed a rash on his hands and “sores” in his mouth. On examination you note a vesicular exanthem on his hands, with lesions ranging from 3 to 6 mm in diameter. The oral lesions are shallow, whitish, 4- to 8-mm ulcerations distributed randomly over the hard palate, buccal mucosa, gingiva, tongue, lips, and pharynx. Except for a temperature of 37.4°C (99.3°F), the remainder of the examination is normal.
The most likely diagnosis is:
Correct Answer B:
Hand, foot, and mouth disease is a mild infection occurring in young children, and is caused by coxsackievirus A16, or occasionally by other strains of coxsackie- or enterovirus. In addition to the oral lesions, vesicular lesions may occur on the feet and non-vesicular lesions may occur on the buttocks. A low-grade fever may also develop. Herpangina is also caused by coxsackieviruses, but it is a more severe illness characterized by severe sore throat and vesiculo-ulcerative lesions limited to the tonsillar pillars, soft palate, and uvula, and occasionally the posterior oropharynx. Temperatures can range to as high as 41°C (106°F). The etiology of aphthous stomatitis is multifactorial, and it may be due to a number of conditions. Systemic signs, such as fever, are generally absent. Lesions are randomly distributed. Herpetic gingivostomatitis also causes randomly distributed oral ulcers, but it is a more severe illness, regularly accompanied by a higher fever, and is extremely painful. Streptococcal pharyngitis is rarely accompanied by ulceration except in agranulocytic patients.
An 8-year-old female presents to the clinic with painful blisters covering her hands and feet. She is also complaining of headaches and fatigue. She is running a low grade fever of 37.2°C. Upon examination of the child's mouth, small ulcerations are found in the back of the mouth around epiglottis. Her blood results show elevated reactive lymphocytes.
What is the most likely cause of this patient's clinical presentation?
Correct Answer D:
These are typical signs and symptoms of hand foot and mouth disease (HFMD) caused by the Coxsackie virus type A. HFMD typically presents with fever, poor appetite, malaise, and sore throat. One or two days after fever starts, painful sores usually develop in the mouth (herpangina). They begin as small red spots that blister and that often become ulcers. The sores are often but not limited to the back of the mouth. A skin rash develops over 1 to 2 days. The rash has flat or raised red spots, sometimes with blisters. The rash is usually on the palms of the hands and soles of the feet; it may also appear on the knees, elbows, buttocks or genital area. Rarely HFMD is associated with meningitis and encephalitis, and on occasion can cause severe complications, including neurological, cardiovascular and respiratory problems.
Coxsackie virus is a single strand RNA virus belonging to the Picornaviridae family, enterovirus genus. HFMD usually occurs in children under 10 years of age but has been known to occur in adults as well. The clinical symptoms usually resolve without treatment in approximately 10 days with no scarring, however the virus can be shed for several weeks. The virus is most commonly spread via hand-feces-mouth contamination route. Diagnosis is usually based solely on clinical features without further laboratory testing.
→ Varicella zoster (chicken pox) (choice A) usually affects the head and trunk (not hand and feet). However, mouth ulcerations and elevated reactive lymphocytes are commonly observed.
→ Physical abuse (choice B) such as burning the child's hands and feet is inconsistent with the clinical presentation however in cases of electrocution mouth ulcerations and blistering may occur.
→ Herpes simplex (choice C) usually affects oral cavity but not hands and feet.
→ Treponema pallidum (choice E) presents with similar signs and symptoms however T. pallidum is a bacterial infection and would show elevated neutrophils and reactive lymphocytes.
Key point:
A 2-week-old female is brought to the office for a well child visit. The physical examination is completely normal except for a clunking sensation and feeling of movement when adducting the hip and applying posterior pressure.
Which one of the following would be the most appropriate next step?
Correct Answer A:
Developmental dysplasia of the hip encompasses both subluxation and dislocation of the newborn hip, as well as anatomic abnormalities. It is more common in firstborns, females, breech presentations, oligohydramnios, and patients with a family history of developmental dysplasia.
Experts are divided with regard to whether hip subluxation can be merely observed during the newborn period, but if there is any question of a hip problem on examination by 2 weeks of age, the recommendation is to refer to a specialist for further testing and treatment. Studies show that these problems disappear by 1 week of age in 60% of cases, and by 2 months of age in 90% of cases. Triple diapering should not be used because it puts the hip joint in the wrong position and may aggravate the problem. Plain radiographs may be helpful after 4-6 months of age, but prior to that time the ossification centers are too immature to be seen.
Because the condition can be difficult to diagnose, and can result in significant problems, the current recommendation is to treat all children with developmental dysplasia of the hip. Closed reduction and immobilization in a Pavlik harness, with ultrasonography of the hip to ensure proper positioning, is the treatment of choice until 6 months of age. The current guidelines recommend ultrasound screening at 6 weeks for breech girls, breech boys (optional), and girls with a positive family history of developmental dysplasia of the hip. Other countries have recommended universal screening, but a review of the literature has not shown that the benefits of early diagnosis through universal screening outweigh the risks and potential problems of over-treating.
A 5-year-old white male has an itchy lesion on his right foot. He often plays barefoot in a city park that is subject to frequent flooding. The lesion is located dorsally between the web of his right third and fourth toes, and extends toward the ankle. It measures approximately 3 cm in length, is erythematous, and has a serpiginous track. The remainder of his examination is within normal limits.
Which one of the following is the most likely cause of these findings?
Correct Answer A: This patient has cutaneous larva migrans, a common condition caused by dog and cat hookworms (choice A). Fecal matter deposited on soil or sand may contain hookworm eggs that hatch and release larvae, which are infective if they penetrate the skin. Walking barefoot on contaminated ground can lead to infection.
→ Echinococcosis (hydatid disease) is caused by the cestodes (tapeworms) Echinococcus granulosus (choice B) and Echinococcus multilocularis, found in dogs and other canids. It infects humans who ingest eggs that are shed in the animal’s feces and results in slow growing cysts in the liver or lungs, and occasionally in the brain, bones, or heart.
→ Toxoplasmosis is caused by the protozoa Toxoplasma gondii (choice C), found in cat feces. Humans can contract it from litter boxes or feces-contaminated soil, or by consuming infected under cooked meat. It can be asymptomatic, or it may cause cervical lymphadenopathy, a mononucleosis-like illness; it can also lead to a serious congenital infection if the mother is infected during pregnancy, especially during the first trimester.
→ Toxocariasis due to Toxocara canis and Toxocara cati (choice D) causes visceral or ocular larva migrans in children who ingest soil contaminated with animal feces that contains parasite eggs, often found in areas such as playgrounds and sandboxes.
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