Pediatric Examination and Board Review by Robert Daum, Jason Canel Read Free Book Online Page A

fewer than the usual number of criteria. Recurrent disease should only be diagnosed if there is supporting evidence of a recent streptococcal infection.

    FIGURE 4-1. Erythema marginatum on the trunk of an 8-year old caucasian boy. The pen mark shows the location of the rash approximately 60 minutes previously. (Reproduced, with permission, from Fuster V, O’Rourke RA, Walsh RA, et al. Hurst’s the Heart. 12th ed. New York: McGraw-Hill; 2008:1694.)
     
----
    6. (C) Treatment for acute rheumatic fever includes therapy directed at the streptococcal infection with penicillin followed by prevention of recurrences with either twice-daily oral penicillin or oncemonthly IM benzathine penicillin injections. Although some advocate prophylaxis to be continued at least until the patient is 21 years of age, others recommend that prophylaxis be lifelong. In patients who are penicillin allergic, prophylaxis can be substituted with either oral sulfadiazine or erythromycin. Recurrences of acute rheumatic fever usually occur within the first 5 years after the initial diagnosis and are characterized by more severe cardiac valve involvement. It is estimated that approximately 10-25% of patients with heart valve involvement will have complete resolution by 10 years.
    7. (A) The mitral valve is the most commonly affected followed by the aortic valve and, rarely, the tricuspid or pulmonary valves. Initially, the affected valves develop regurgitation as a result of inflammation and valve dysfunction. However, with healing of the inflammation, long-term development of mitral valve stenosis can occur. This may be seen as early as 2-3 years following the acute episode but usually occurs 10-20 years later.
    8. (A) The child described most likely has Kawasaki disease, an acute vasculitis of unknown etiology. Kawasaki disease is the leading cause of acquired heart disease in children in the United States. The incidence ranges from 2-6/100,000 children and is highest in Asian American children. The peak incidence is at 1-2 years of age with 85% of the cases occurring in children younger than 5 years of age. The disease is uncommon in patients older than 8 years of age or younger than 3 months of age. The clinical manifestations include the presence of fever for at least 5 days, no other reasonable etiology, and 4 of 5 of the following:
    1. A nonexudative conjunctivitis that is usually bilateral
    2. Erythema of the lips, oral mucosa, and pharynx, including a strawberry tongue and cracking or peeling of the lips later into the disease
    3. A polymorphous rash of the face, trunk, and extremities that later can involve the perineal area and is characterized by desquamation at 5-7 days ( Figure 4-2 )
    4. Cervical adenopathy greater than 1.5 cm in diameter that is usually unilateral
    5. Changes in the extremities, including edema and erythema of the hands and feet followed by periungual desquamation at 11-25 days into the disease

    FIGURE 4-2. Kawasaki disease. Desquamation of the tissue of the palm. (Reproduced, with permission, from Wolff K, Johnson RA. Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology, 6th ed. New York: McGraw-Hill; 2009: Fig. 14-45.)
     
----
    Incomplete Kawasaki disease can be diagnosed when fever is present for 5 or longer days in the presence of 2 to 3 of the preceding criteria when the CRP is 3.0 mg/dL or more and/or the ESR is 40 mm/hour or more. In this instance, certain laboratory criteria should be met including hypoalbuminemia, anemia, increased serum alanine aminotransferase, thrombocytosis, leukocytosis, and sterile pyuria.
    9. (D) Other supportive findings of the acute phase of Kawasaki disease include urethritis with sterile pyuria, aseptic meningitis, abdominal pain, hydrops of the gallbladder, and arthritis that usually involves the small joints but may involve the large joints 2-3 weeks into the disease. Also, mild carditis and arrhythmias may occur. The subacute phase occurs 11-25 days following the onset of