* Even so-called "good" air quality affects some children with asthma. A study published in JAMA showed that ozone levels below the current standard of the U.S. Environmental Protection Agency (120 parts per billion [ppb], one-hour average; 80 ppb, ei
Clinical Quiz questions are based on selected articles in this issue. Answers appear in this issue. American Family Physician has been approved by the American Academy of Family Physicians as having educational content acceptable for Prescribe
Synopsis: Eplerenone, a potassium-sparing diuretic similar to spironolactone, selectively blocks aldosterone to lower blood pressure. However, its safety profile is improved over spironolactone because of reduced progesterone and androgen-receptor eff
Increased use of brain imaging has resulted in more frequent recognition of unruptured intracranial aneurysms. The optimal management of these lesions is highly controversial because of uncertainty about the probability of rupture and the risks of sur
Observational studies suggest that the use of nonsteroidal anti-inflammatory drugs (NSAIDs) may prevent the development of Alzheimer's disease, but it is not clear if the benefit is a class effect or limited to specific agents. The role of aspirin has
Type 1 diabetes mellitus has been treated successfully with whole-organ pancreatic transplant. This is a major operation, with risks of graft vascular thrombosis and graft rejection. Recent interest in isolated pancreatic islet cell transplantation, f
The high rate of preterm delivery in the United States is the greatest contributor to the relatively high infant mortality rate in this country. Despite much effort, no effective method exists for prevention of preterm delivery. Progesterone has been
Increased body fat levels are related to a large number of comorbid conditions, such as cardiac disease, diabetes, and cancer. Currently available drugs are useful but do not always bring about the desired goal. Weigle reviewed the past, present, and
Because doxorubicin is one of the most widely prescribed chemotherapy agents in oncology, family physicians are likely to have a number of cancer survivors in their patient panels who have received this medicine. Study results have shown that doxorubi
The number of patients with type 2 diabetes who are treated with insulin is likely to increase rapidly. A variety of insulin compounds and regimens are available, which allows for individualized therapy but complicates the process of establishing the
Author: Alexander K.C. Leung, Massoud Rafaat
Date: March 1, 2003
A three-year-old boy presented with a vesicular rash on the right flank and right buttock (see accompanying figure). There was no associated fever. The child was delivered vaginally after a pregnancy notable for maternal varicella at 10 weeks' gestation. Apgar scores were 7 and 9 at birth. He was breastfed for four months. His past health was unremarkable. He was not known by the parents to have chickenpox. Except for varicella vaccination, his immunizations were otherwise up-to-date. There was no recent exposure to infectious diseases. He did not have any known allergies.
Question
Based on the patient's history and physical examination, which one of the following is the most likely diagnosis?
A. Varicella (chickenpox).
B. Herpes zoster (shingles).
C. Molluscum contagiosum.
D. Scabies.
E. Juvenile xanthogranuloma.
Discussion
The answer is B: herpes zoster. Herpes zoster (shingles) is caused by reactivation of varicella-zoster virus from a dorsal root ganglion to a cutaneous nerve and the adjacent skin. Herpes zoster is rare before 10 years of age. (1) The incidence increases with age and rises sharply after 50 years of age. In general, the younger a child develops chickenpox, the greater the likelihood that herpes zoster will develop in childhood or early adulthood. (1) Approximately 2 percent of children who were exposed to varicella-zoster virus in utero can develop inapparent chickenpox. (2,3) In young children, herpes zoster often occurs in areas supplied by the cervical and sacral dermatomes, rather than in the lower thoracic and upper lumbar dermatomes, which are the characteristic sites of herpes zoster in adults. (1) An area of erythema may precede the development of grouped vesicles. The eruption may be preceded or accompanied by low-grade fever, localized pain, hyperesthesias, and pruritus. In immunocompromised patients, herpes zoster can become disseminated, with lesions appearing outside the primary dermatomes and with visceral involvement.
The individual lesions of varicella are similar to herpes zoster, but the lesions of varicella are more widely distributed. They tend to be centrifugal, do not cluster in a specific dermatome, and occur in crops.
Molluscum contagiosum often presents in early childhood with clusters of discrete, pearly, flesh-colored, umbilicated papules. In contrast to herpes zoster, the lesions are not pruritic or painful, and vesicles are not seen.
Scabies presents as an intensely pruritic rash. Lesions are characteristically found on the wrist and intertriginous areas, including the diaper area in young children. Thread-like burrows are the classic sign of scabies.
The lesions of juvenile xanthogranuloma are dome-shaped, yellow, pink, orange, or brown nodules that vary in size from a few millimeters to 4 cm in diameter. They are usually present at birth or appear within the first six to nine months of life. Affected children are otherwise normal and have normal lipid levels.
REFERENCES
(1.) Leung AK, Kao CP. The truth about chickenpox. Can J Diagnosis 1999;16:79-87.
(2.) 2000 Red book: report of the committee on infectious diseases. 25th ed. Elk Grove Village, Ill.: American Academy of Pediatrics 2000:624-8.
(3.) Fisher RG, Edwards KM. Varicella-zoster. Pediatr Rev 1998;19:62-6.
The editors of AFP welcome submission of photographs and material for the Photo Quiz department. Contributing editor is Marc S. Berger, M.D., C.M. Send photograph and discussion to Marc S. Berger, M.D., C.M., P.O. Box 219, Crystal Beach, FL 34681-0219.
ALEXANDER K.C. LEUNG, M.D.MASSOUD RAFAAT, M.D.University of CalgaryAlberta Children's Hospital1820 Richmond Rd., SWCalgary, Alberta, Canada T2T 5C7COPYRIGHT 2003 American Academy of Family PhysiciansCOPYRIGHT 2003 Gale Group