PEDIATRICSStories From the Field

Itchy Lesions After Water Play: Pinpointing Impetigo

I saw a 7-year-old girl with a few scattered lesions on her trunk: 2–3 cm papules with central necrosis and some excoriation and scaling around them. The lesions were intensely itchy, and her sibling developed similar lesions after the two played in water together. I used VisualDx to build a differential, and impetigo was among my top five diagnoses. I diagnosed impetigo and treated her with oral antibiotics. The condition improved without scarring.

—S.S., CHOP pediatrician

A Rash on Day 8 of Amoxicillin: Could It Be Measles?

An 8-month-old presented with a rash that started on the face and progressed to cover the entire body. The patient was on day 8 of amoxicillin and had recent cold symptoms, but no fever and no Koplik spots. VisualDx helped me work through the differential diagnosis, including concerns about possible measles.

—S.B., University of Michigan pediatrician

When Motrin Made It Worse: Untangling a Toddler’s Hives

A 19-month-old boy came to the office with a small papular rash that initially looked viral. A week later, the rash had spread and looked more like mosquito bites. He was given Motrin for a questionable low-grade fever, then came back with what looked like hives.

I used VisualDx to build a differential, and it turned out he had urticaria made worse by the Motrin. I’m thankful VisualDx helped me narrow the differential and guide management.

I treated him with ranitidine, hydroxyzine, and Zyrtec, and he improved within 48 hours.

—S.S., CHOP pediatrician

The “Dirt” That Wouldn’t Wash Off: A Diagnosis Solved With an Alcohol Swab

A colleague in a busy urgent care department asked me to look at a rash they had never seen before. It was a brown rash that made the patient look as if they’d been rubbed with dirt, but the parent said it never washed off and had been there for months. I used VisualDx to build a differential and arrived at terra firma-forme dermatosis—something I had never even heard of during my pediatric training. I noticed the diagnostic pearl about rubbing the rash with alcohol, so I grabbed an alcohol swab and went into the room. The rash immediately started to come off, and the parents were thrilled. It was a great diagnosis and made me a big believer in VisualDx.

—L.U., CHOP pediatrician

From Eritrea to Germany: Recognizing Cutaneous Leishmaniasis in Refugee Teens

I’m a sixth-year German medical student doing a rotation in pediatrics. With the ongoing influx of refugees from central and northern Africa, our department provides vaccinations and infectious disease screening for underage refugees. A group of four teenagers came to us for vaccination and initial screening. All four said they were in good health, with no history of pain, fever, cough, diarrhea, rash, or itching. They had fled Eritrea together, stayed in Libya for about six months, and crossed the Mediterranean two months before we saw them.

On exam, all four had multiple (2–5) circular, papulo-ulcerative skin lesions with indurated borders and a hyperkeratotic eschar covering the central ulcer. The lesions were painless, mostly on the extremities, and all under 1 cm in diameter, with no mucosal involvement. According to the patients, the lesions had been in remission for one to two months. There were no signs of neuropathy around the lesions and no fever, and standard screening ruled out tuberculosis and HIV.

I entered “North Africa,” “ulcer,” “eschar,” and “arm/lower legs” into the VisualDx differential builder. The top results were cutaneous leishmaniasis, leprosy, and sporotrichosis. That pointed me to the right spectrum of differentials and ultimately to the diagnosis of cutaneous leishmaniasis. With little training in tropical and subtropical medicine, I rely on VisualDx to fill that gap now that I’m seeing this new spectrum of diseases. It doesn’t just help our patients—it also makes me look smarter than I am.

—M.L., University of Münster medical student

Herpes or Coxsackie? Broadening the Differential for an Unusual Rash

I saw a child with an unusual rash that looked like a cross between herpes and coxsackievirus. I entered the demographic information, the lack of fever, the location, and the child’s general appearance, took a photo of the rash, and VisualDx generated a differential. It was very useful because it added diagnoses I hadn’t been considering, and I was able to diagnose an atypical coxsackievirus infection.

—M.K., Parcare Community Health Center pediatrician

Dermoid Cyst or Inclusion Cyst? The Images Made the Difference

A 6-year-old girl came to clinic with a skin-colored lesion along her orbital ridge that had been present for many years. Using VisualDx, I was able to recognize that it was more likely a dermoid cyst than an epidermal inclusion cyst, because many of the example photos showed a lesion in that exact location.

—A.D., SUNY Downstate pediatrics resident