What Causes Bullae?

Patient Presentation
A 7-month-old male came to clinic with a severe diaper rash that had begun 2 days before. His mother said that it looked like a normal diaper rash and she was treating it with large amounts of zinc-based barrier creams but it was not improving. During the morning she had changed his diaper and thought that it was looking a beefier-red than before. About 1 hour later she changed him again and there were large fluid filled blisters on his buttocks cheeks. She was afraid she would break the blisters so she just took a picture with her cellphone, re-diapered him and called the clinic for an appointment. She denied using any other soaps/lotions/detergents. He was not taking any medicine except that she had given him some acetaminophen as his buttocks seemed painful. He was eating and drinking well and had not had a fever, diarrhea or emesis. The past medical history revealed general dry skin. The review of systems was otherwise normal.

The pertinent physical exam showed a well-appearing male with normal vital signs. His skin examination showed 4-5 cm open raw lesions centered on the buttock cheeks. There were no blisters but denuded skin could be seen. The area was generally bright red and there appeared to be some elevation of another area near the denuded skin on the right buttock. There were no satellite lesions and the intertrigenous areas were not affected. He had mildly reddened skin on his forearms and behind his knees but no blisters or crusting. The mother’s pictures looked like flaccid bullae. The laboratory evaluation of a culture of the area eventually grew Streptococcus. The diagnosis of bullous impetigo was made and the patient was started on cephalexin. Silvadene® cream was also prescribed and the patient had resolution within a few days.

Discussion
Bullae are fluid-filled epidermal lesions that are filled with serous or seropurulent fluid. They are > 1 cm in diameter and often easily rupture due to their thin walls. The differential diagnosis is different for bullae than for vesicular lesions with bullae being often more worrisome. However there is overlap and vesicular diseases can become large enough to be bullae. Drug toxicity and genetic problems are also more common in bullae whereas vesicles are more often caused by infectious diseases.

Potentially life threatening conditions such as toxic epidermal necrolysis syndrome, Stevens Johnson syndrome or meningococcemia need to be recognized and treated aggressively. Symptoms may include skin sloughing, petechiae or purpura, fever and irritability, inflammation of the mucosa, urticaria, respiratory distress, and diarrhea or abdominal pain. As bullae can cover extensive amounts of the skin and are often fragile, they may need specialized skin treatment with dermatology and burn specialists. Other supportive treatments such as fluid management, antibiotics and even respiratory support may be needed.

Vesicles are circumscribed, elevated, fluid-filled lesions < 1 cm in diameters on the skin. They contain serous exudates or a mixture of blood and serum. They last for a short time and either break spontaneously or evolve into bullae. They can be discrete (e.g. varicella or rickettsial disease), grouped (e.g. herpes), linear (e.g. rhus dermatitis) or irregular (e.g. coxsackie) in distribution.

A review and differential diagnosis of vesicles can be found here. Information about streptococcal diseases can be found here.

Learning Point

The differential diagnosis of bullae includes:

  • Trauma
    • Burns – including sunburn
    • Frostbite
    • Stings
  • Infection
    • Impetigo and Staphylococcal scalded skin syndrome
    • Herpes
    • Meningococcemia
    • Orf
    • Syphilis
  • Genetic
    • Acrodermatitis enteropathica
    • Epidermolysis bullosa
    • Incontinentia pigmenti
    • Porphyria
  • Other
    • Bullous disease of childhood
    • Drugs
    • Lupus erythematosis
    • Toxic epidermal necrolysis syndrome (TEN syndrome)
    • Pemphigus
    • Stevens Johnson syndrome

Questions for Further Discussion
1. What other disease entities are caused by Streptococcus?
2. What causes Stevens Johnson syndrome?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Streptococcal Infections.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Illingworth RS. Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1988:361-3.

Barr K. Evaluation of vesicular-bullous rash. ePocrates.
Available from the Internet at https://online.epocrates.com/u/2911775/Evaluation+of+vesicular-bullous+rash/Differential/Overview (rev.10/3/2014, cited 3/16/2015).

Author

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

How Long Do Creatine Kinase Levels Remain Elevated After Exercise?

Patient Presentation
A 15-year-old male came to clinic in the morning for his health supervision visit. He was a basketball player and runner and was at the end of the basketball season and would be starting track soon. He had had no specific injuries and was doing well in school. The past medical history showed no athletic injuries, fainting, passing out, or palpitations. The family history was negative for neurological and rheumatologic problems. The review of systems was negative.

The pertinent physical exam showed a thin adolescent male with normal vital signs and mild comedomal acne. His musculoskeletal exam had normal strength and tone, and his neurological examination was also normal. The diagnosis of a healthy male was made. The patient went to the laboratory to have routine screening laboratories done including a hemoglobin/hematocrit and lipids. The laboratory evaluation was all normal, but a creatine kinase (CK) had been done inadvertently and was elevated at 420 U/L (normal 60-400 U/L). The physician called the patient that afternoon who confirmed that he wasn’t having any muscle pain, and had been drinking well during the evening before and at breakfast before the lab testing earlier. He also confirmed a normal basketball practice last evening and denied any trauma. The pediatrician felt that this was most consistent with CK elevation due to exercise, but wasn’t sure how long it took for CKs become normal after exercise. Repeat testing 2 weeks later during a break between athletic seasons showed a CK of 148 U/L on a morning blood sample.

Discussion
Acute rhabdomyolysis is an emergency that can cause acute renal failure (especially acute tubular necrosis caused by myoglobinemia) and electrolyte abnormalities. Common presenting findings are dark urine, myalgia and muscle weakness. Milder episodes can go unnoticed. Acute exertional rhabdomyolysis or unrecognized muscle injury can occur in underconditioned persons and even trained athletes who increase their exertion or exercise. Being unaccustomed to the ambient conditions such as heat, humidity and sun can also increase fluid loss and the risk of muscle injury. An overview and differential diagnosis of rhabdomyolysis can be found here.

Learning Point
Laboratory testing for rhabdomyolysis includes CK which is often used as a marker for myoglobinemia. CK remains elevated for relatively long periods of time and has slower elimination characteristics than myoglobin. Some data from military recruits and athletes has shown that CK and myoglobin increase especially at the beginning of an exercise programs but also remains elevated with ongoing exercise. Therefore, it is reasonable to conclude that this patient’s CK elevation was due to his exercise.

CK caused by rhabdomyolysis usually rises within 12 hours, peaks at 24-36 hours and then decreases 35-40% per day. Therefore levels that are not decreasing after the appropriate time indicate continued insult.

Questions for Further Discussion
1. What causes hematuria?
2. What causes proteinuria?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Muscle Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Melamed I, Romem Y, Keren G, Epstein Y, Dolev E. March myoglobinemia: a hazard to renal function. Arch Intern Med. 1982 Jul;142(7):1277-9.

Thomas BD Jr, Motley CP. Myoglobinemia and endurance exercise: a study of twenty-five participants in a triathlon competition. Am J Sports Med. 1984 Mar-Apr;12(2):113-9.

Update: Exertional rhabdomyolysis, active component, U.S. Armed Forces, 2011. MSMR. 2012 Mar;19(3):17-9.

Lappalainen H, Tiula E, Uotila L, Manttari M. Elimination kinetics of myoglobin and creatine kinase in rhabdomyolysis: implications for follow-up. Crit Care Med. 2002 Oct;30(10):2212-5.

Quinlivan R, Jungbluth H. Myopathic causes of exercise intolerance with rhabdomyolysis. Dev Med Child Neurol. 2012 Oct;54(10):886-91.

Muscal E. Rhabdomyolysis Workup. eMedicine.
Available from the Internet at http://emedicine.medscape.com/article/1007814-workup#aw2aab6b5b2 (rev. 4/24/14, cited 3/10/15).

Author

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

How Can Young Adults Keep Themselves Safe at College?

Patient Presentation
A 18-year-old male came to clinic for his health supervision visit. He was going to college in a city several hours away and wanted to make sure he had enough of his medication before leaving. The past medical history was positive for attention deficit disorder primarily inattentive type, that was diagnosed in early elementary school. He had good relief of symptoms with a consistent dose of Concerta® for several years. His immunizations, including human papilloma virus and meningococcal meningitis vaccines, were current.

The pertinent physical exam showed a healthy male with normal vital signs. The diagnosis of a healthy male with ADD was made. His physician recommended that he have a local health and mental health provider identified to help with any mental health or health care issues he might have at school. Additionally, the physician discussed some general safety recommendations such as having a carbon monoxide detector and fire extinguisher in his dorm room. He also discussed party and date safety.

Discussion
Going away to college or moving away from home brings new challenges for adolescent and young adults. New surroundings, situations, responsibilities and fewer trusted adults to help advise combine to provide new challenges for young adults. Simple things like not taking your keys with you or locking a door having different potential consequences in a new dorm or apartment. Using common sense and trusting one’s instinct and planning ahead usually keeps most young adults safe in many situations.

Learning Point
Tips for student going off to college include:

    Get yourself ready
    • Trust your instincts – if it feels wrong or seems wrong, then something probably is. Don’t make things worse by ignoring your instinct. Make a good choice – avoid or leave a situation.
    • Your cellphone is a tool. Keep it fully charged and take it with you. Have contacts entered into speed dial including police, fire, hospital, friends and family.
    • If you have specific health problems or take medicines, put that information in your cellphone too so people can help you if needed.

    • Identify help at school before you need it – student health service, mental health professional, pharmacy and a hospital. Keep a list of your hometown doctors, hospital etc. too.
    • Get a supply of your medications and know where you can get refills. You may or may not be considering having sex. Have, or know where to obtain, contraceptives to protect you, your partner or a friend.
    • You will be living in close quarters and infections travel fast. Wash your hands often or use hand sanitizers.
    • Make sure your immunizations are up to date especially meningococcal vaccine and yearly influenza vaccine. If you are traveling internationally, plan ahead w.ith enough time to get all additional vaccines and medicines.
    • Get a lanyard for your ID/keys and emergency cash. Keep a whistle with it for safety. Don’t mark your keys with your name, address, phone, license number etc. As if they are found they can provide access to your home or car. Only give a parking attendant the keys to your car, never your dorm/apartment.
    • Get insurance for your personal articles and car.

    Watch out for the other guy/gal

    • There is safety in numbers. Develop some friends (buddy system) you can trust – people who know where you are going, when you will return, people who will look out for you and people you can call anytime. Remember that people have to earn your trust. Don’t assume someone you just met will look out for you.
    • Do the same for your friends. Be the good friend even if it is an inconvenience for you. If it is a bad situation, don’t compound the problem. Do what is right for everyone’s safety and health and call the police, ambulance, etc.. Better to talk to them than to explain things to the coroner, funeral home and your friend’s family.
    • Keep people informed – your don’t have to tell everyone everything, but letting people know where you are going, when you will return and whom you are going out with is polite and can keep you safe.
    • Have a code word so that if you are in a situation you can communicate your discomfort without the person you are with knowing.

    General Safety

    • Know your way around campus. Walk around the buildings during the day and at night to make sure they are well lit, secured and patrolled. Avoid shortcuts.
    • Know where the emergency telephones are located.
    • Know several routes to use. Stick to well-lit and busy areas.
    • If you think someone is following you, go in another direction that is better lit, has more activity etc.
    • When walking:
      • Be aware of your surroundings. Don’t talk on the phone or listen to your music while walking – you are easy prey then.
      • Walk like you are calm, confident and know where you are going even if you don’t.
      • Keep your keys out and ready to use for your dorm, apartment, car or bike.
      • Keep your hands otherwise free.
      • Keep your whistle or have pepper spray handy.
      • Walk on the street side of the sidewalk away from shrubs, doorways etc. where people could be hiding.
    • At night: NEVER walk alone. If your friend is leaving, leave with them.
      Use the campus escort service or call a taxi.

    • Use your trusted friends and buddy system.
    • Be aware of your people and don’t be afraid to report suspicious activity.
    • If you need to:
      • Lie – Make up a reason to go or to stay.
      • Do something to bring attention and bring help.
      • Make a lot of noise – blow your whistle, pull the fire alarm, shout.
      • Stand in the middle of the road where there are brighter lights and you can see what is happening around you.

    Dorm/Apartment

    • Never give your keys to someone else. They now have access to everything you did.
    • Always lock your room, even for a minute. Remember, your dorm room/apartment is open. Only your actual room is locked and kept locked by you all the time.
    • Lock first and second story windows when not in the room and at night
    • Use the central dorm/apartment entrance to come and go. It is usually monitored and there are more people there. It also makes it safer for everyone, because other people can easily sneak into other entrances.
    • Don’t prop doors open or allow people access.
    • Rekey your locks if your key is lost or stolen
    • Don’t leave valuables in plain sight
    • Follow your dorms rules about cooking and electronic items and extension cords. Don’t use candles and incense.
    • Have portable fir and carbon monoxide alarms and a fire extinguisher in your room.
    • Be aware of your neighbors and don’t be afraid to report suspicious activity.

    Valuables

    • Don’t bring them to campus.
    • Don’t leave them or any other personal property unattended
    • Keep them locked up if possible.
    • Register them with local law enforcement – cars, bikes etc.
    • Engrave them with identification so they can be more easily tracked and returned
    • ATMs – use ATMs located inside a building and never count cash there. Count cash when you are in a secure location.

    Transportation

    • Have your keys ready to unlock before you get to the car.
    • Always look in the backseat before getting in
    • Always lock your car as soon as you are inside and when you leave the car
    • Don’t leave valuables in plain sight or in the glove box.
    • Park your car in well-lit places, close to activity
    • If you think someone is following you, go to a police or fire station, gas or convenience store or other open place to get help.
    • Always keep more than 1/4 tank of gasoline, so you don’t run out of gas. Keep your spare tire inflated, a set of jumper cables handy.
    • If your car breaks down, roll up all the windows, turn on the emergency flashers, and stay in the car until help arrives. Don’t open the car unless trusted assistance arrives like police, or a wrecker service that you have called.
    • Enroll in a motorist assistance program like AAA
    • Don’t mark your keys with your name, address, phone, license number etc. If they are found they can provide access to your home or car. Only give a parking attendant the keys to your car, never your dorm/apartment.
    • Never pick up hitchhikers. Consider your safety before agreeing to share a ride with someone.

    Parties and Activities

    • Before going out to a party or activity, always have a friend with you and decide in advance when you will leave. Always leave together. Do not stay somewhere alone. Check in with your friends during the party/activity to make sure they are safe.
    • Plan in advance how you are going to get home.
    • Take a cellphone and emergency cash with you.
    • Don’t accept drinks from someone you don’t trust. Always pour your own drinks and always keep control of your drinks, so someone cannot tamper with them. If you put it down, do not drink it, get another. Rape drugs can easily be put into drinks without you knowing.

    Drinking and Drugs

    • Don’t do illegal activities.
    • Drugs and alcohol decrease your ability to care for yourself and make good decisions.
    • Don’t drink if you are under aged. Don’t put yourself in situations where people can think you are drinking under aged.
    • Don’t do drugs.
    • If you do drink, drink responsibly.
    • If someone has drunk too much, make sure they get home and are okay. Stay with them if needed or get medical help. Remember to do what is right for everyone’s safety and health. Call the police, ambulance or other help.

    Dating

    • Use common sense. If your instincts say something is not right, get out of the situation.
    • Going out in a group is safer, especially for first, blind dates or people you have met online. Meet in public places.
    • Always tell your trusted friends where you are going and when you will return.
    • Plan in advance how you are going to get home.
    • Take a cellphone and emergency cash with you.
    • Don’t leave a party/activity with someone you have just met.
    • Plan ahead to protect yourself and your partner from pregnancy and sexually transmitted infections. Remember, contraceptives do not work if they are left in your wallet, purse, etc..

      For any person, male or female, saying “No” means No. Period. No discussion. The person does not want to have sex.

    • Never have sex with anyone who is inebriated or passed out. This is sexual assault.
    • Just because someone dresses in a certain way, agrees to go home with you, is kissing you or performing other sexual intimacies, previously had sex with you, or anything else, DOES NOT MEAN THEY AGREE TO HAVE SEXUAL INTERCOURSE WITH YOU.
    • Never force or coerce someone into have sex. If you see someone who appears to be pressuring or forcing someone into a sexual or other situation, do not be afraid to intervene or call for help.
    • Always check with your partner, several times to see if they still are consenting to have sex.
    • If sexual violence occurs, get help right away by calling the police, or crisis phone numbers, or going to the hospital.

    Online

    • Set up virus protection and firewalls on your laptop.
    • Don’t use public Wi-Fi, when transmitting personal or financial information
    • Use pseudonyms online and don’t give out personal information like your address, phone etc. If you call someone you met online, use phone number ID blockers
    • Check your privacy settings on social media monthly
    • Be careful of your “away” messages as this can tell people of your activities.

Questions for Further Discussion
1. What other safety equipment should a college student have available?
2. What other tips do you recommend to college students?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: College Health.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Sarkis S. 50 Tips for College Students.
Available from the Internet at https://www.psychologytoday.com/blog/here-there-and-everywhere/201008/50-tips-college-students (rev. 8/23/10, cited 3/3/15).

Campus Safety Magazine. Back-to-School Safety Tips. 9/7/2011
Available from the Internet at http://www.campussafetymagazine.com/article/Back-to-School-Safety-Tips (rev. 9/7/11, cited 3/3/15).

State Farm Insurance. 15 Safety Tips for College Students.
Available from the Internet at http://learningcenter.statefarm.com/safety-2/family-1/15-safety-tips-for-college-students/ (rev. 7/18/13, cited 3/3/15).

Hoyt E. Top 10 Safety Tips for College Students.
Available from the Internet at http://www.fastweb.com/student-life/articles/top-10-safety-tips-for-college-students (rev. 6/27/14, cited 3/3/15).

Loyola University. Safety Tips For Students While at College.
Available from the Internet at http://finance.loyno.edu/police/safety-tips-students-while-college (rev. 2015, cited 3/3/15).


Author

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

When Do Feet Have Arches?

Patient Presentation
A 3.5-year-old female came to clinic with a history of intermittently saying that her feet hurt. Her father said that it started recently but could not say for how long. The child only said her feet hurt but it did not stop her from playing or other activities. He was also unable to say when it occurred throughout the day or how many times per week. He was certain that it never bothered her sleep nor did she have limping, falling, or redness or stiffness of any body parts. The father was worried because he had flat feet that bothered him doing his job which required him to walk or stand for long periods of time on a hard surface. He had gotten relief with orthotically fitted shoes. He thought that his daughter should have some special shoes also because she had flat feet also. The past medical history showed a healthy child. The family history showed no orthopaedic, rheumatological or neurological problems in the family. The review of systems was negative for fevers, rashes, eye problems, excessive fatigue or lethargy.

The pertinent physical exam showed a well-appearing female with normal vital signs and growth parameters in the 10-25%. HEENT showed no obvious eye abnormalities. She had no rashes, or changes in her nails. Neurologically she had good tone and strength with normal DTRs. Her lower extremities including her hips showed no erythema or edema and had normal range of motion. No pain could be elicited with movement or pressure. She had a normal gait. When standing, her feet were flat with a minimal medial arch. When on her tiptoes or when sitting her arch became curved. Alignment of the lower leg with the foot was normal. Her shoes did not appear to have excessive or abnormal wear, and appeared to fit well.

The diagnosis of a flexible flat foot that appeared to be normal for age was made. As the child did not appear to be bothered by the flat feet and the history was somewhat vague, the pediatrician counseled to monitor the child and keep a symptom diary. She pointed out how the feet did have an arch but when standing the arch became flat and the flatness by itself was not a reason to intervene. The father agreed to followup at her next well child appointment in a couple months if the symptoms did not change or worsen before then.

Discussion
Pes planus or flat foot is a common presentation in children and is defined as the absent or diminished longitudinal medial foot arch. Parents usually become more concerned if the child appears to have problems with walking, tripping or falling, problems with alignment (i.e. feet turning outward or inward) or if there is perceived discomfort. Some parents of older children will become concerned when they notice excessive or abnormal shoe wear.

The differential diagnosis in rare cases also includes rheumatologic, neurologic, neoplastic and genetic syndromes such as Ehler-Danlos and Marfan syndrome. The differential diagnosis of leg pain can be found here, and the differential diagnosis for intoeing and outtoeing can be found here.

A history of chronic pain and/or rheumatological or neurological origins makes other diagnoses more likely. A history of trauma, gait abnormalities or refusal to bear weight should be gathered.

Examination of the entire extremity is important checking for decreased range of motion, joint swelling or specific areas of pain. Feet should be examined with barefeet on a flat surface about shoulder width apart. The foot’s longitudinal arch may be absent or minimal with the heel in slight valgus. When asked to raise on toes or when seated, the arch returns. With weight bearing the heal swings varus also. When these arch changes are accompanied by no changes in range of motion, it is called a flexible flatfoot. The legs should also examined for possible torsion, and ligamentous laxity should be assessed throughout the body. Gait should also be examined. Any decrease in motion of the foot joint should be of concern for other disease processes. However, there are many patients who also have rigid flat feet who do not have other problems or need treatment.

For most patients no testing is necessary. If a child has a significant abnormality such as severe flat feet, real pain, rigidity or other concerns for alternative diagnoses then plain radiographs are a first step. Additional imaging or blood work depends on the clinical scenario. The majority of flexible flat feet do not require any treatment. Orthotics or other specially fitted shoes are sometimes prescribed and may be helpful in truly painful flexible flat feet.

Learning Point
The natural arch in infants is flat and because of normal ligamentous laxity continues throughout early childhood. Most children < 6 years old have flexible flat feet. The arch usually fully develops by age 10 but 15-23% of adults have flat feet.

Questions for Further Discussion
1. What are indications for referral to a podiatrist?
2. How often do children outgrow their shoes?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Foot Injuries and Disorders

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Jane MacKenzie A, Rome K, Evans AM. The efficacy of nonsurgical interventions for pediatric flexible flat foot: a critical review. J Pediatr Orthop. 2012 Dec;32(8):830-4.

Graham ME. Congenital talotarsal joint displacement and pes planovalgus: evaluation, conservative management, and surgical management. Clin Podiatr Med Surg. 2013 Oct;30(4):567-81.

Dare DM, Dodwell ER. Pediatric flatfoot: cause, epidemiology, assessment, and treatment. Curr Opin Pediatr. 2014 Feb;26(1):93-100.

Author

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital