Summer Break

PediatricEducation.org is taking a summer break. The next case will be published in on August 7th. In the meantime, please take a look at the different Archives and Curriculum Maps listed at the top of the page.

We appreciate your patronage,
Donna D’Alessandro and Michael D’Alessandro, curators.

What Conditions is Erythema Nodosum Associated With?

Patient Presentation
A 12-year-old male came to clinic with a history of 3-4 days of painful bruising on his shin and lower arms. He had Streptocococcal pharyngitis diagnosed by rapid strep testing approximately 4 weeks previously and had taken all of his amoxicillin antibiotic per his parents. He had recovered without any problems until 3-4 days ago when his legs and arms started to have painful bruises along the shins and lower arms. They were raised, red/purple and painful mainly in the center of the lesions. He denied pain elsewhere nor any fever (Tmax was 99.5F), chills, sweats, weight loss, joint stiffness, abdominal pain, vision or eye changes, or mucous membrane changes. He had normal bowel and bladder habits without hematuria. The family had traveled to visit relatives in Central America 3 months previously but denied any tuberculosis risks. The past medical history was non-contributory. The family history was positive for heart disease and osteoarthritis in an older grandmother. The review of systems was otherwise negative.

The pertinent physical exam had normal vital signs including weight that was 75% and consistent with previous weights. HEENT, heart, lung and abdomen examination were negative. He had some shotty nodes in the anterior cervical, posterior cervical and groin. He had 1-2 cm nodular purple/red lesions over the extensor surfaces of the bilateral anterior tibia and ulnar areas. They were painful to the touch but the bones were not painful otherwise. No pain could be elicited in the adjacent muscle groups. His extremities had full range of motion without pain and had no swelling or erythema.

The diagnosis of of erythema nodosum probably due Streptocococcus was made. The evaluation included a complete blood count, complete metabolic panel, urinalysis, chest radiograph, throat culture, and QuantiFERON-TB GOLD® were negative. His Anti-streptolysin O titre was positive, as were his erythrocyte sedimentation rate (= 42 mm/hr, normal 1-25 mm/hr) and C-reactive protein were 8 mg/L (normal < 3 mg/dL). The patient was started on ibuprofen and rest, along with clindamycin to make sure that his streptococcal infection was treated. It was felt that this was not a drug reaction but a penicillin was avoided. The patient’s clinical course over the next week was that he had no new lesions and his other lesions were slightly less painful. Over the next 3 weeks he had almost complete resolution of the lesions and they were completely gone by 6 weeks. Repeated labs were negative.

Discussion
Erythema nodosum (EN) is a common dermatological eruption characterized by inflammatory nodules of the subcutaneous fat (panniculitis) on the extensor surfaces of the extremities especially the shins, thighs, and forearms. They are usually painful, nodular, bilateral and multiple. They can be found on other areas and be unilateral. They can be red, purple or blackish. They usually resolve without problems in 3-6 weeks.

Diagnosis is usually clinical but biopsy may be needed if there is atypical presentation or history, physical examination or laboratory testing reveals potential underlying diseases. Treatment is usually conservative with rest and non-steroidal anti-inflammatory drugs. Identified underlying causes of the EN should be treated but in some studies more than 50% of the causes remain unidentified. Other treatments include steroid medication and even potassium iodide has been used.

Learning Point
A study of 39 Turkish children in 2014 found the following causes of EN (some had two infections):

  • Idiopathic = 43.5%
  • Streptococcal infection = 23%
  • Mycoplasma pneumonia = 7.7%
  • Tularemia = 10.2%
  • Tuberculosis, latent = 5%, pulmonary = 2.5%
  • Behçet disease = 2.5%
  • Cytomegalovirus = 2.5%
  • Giardia lamblia infection 2.5%
  • Sarcoidosis = 2.5%

EN has been associated with a variety of other causes including:

  • Drugs – Bromides and iodides, Oral contraceptives, Penicillin, Sulfonamides
  • Infections
    • Bacteria – Brucellosis, Campylobacter, Chlamydia trachomatis, Leprosy(*), Leptospirosis, Salmonella, Yersinia
    • Fungus – Blastomycosis, Coccidioidomycosis, Histoplasmosis
    • Viral – Bartonella henselae, Epstein Barr virus, Hepatitis B, Lymphogranuloma venereum, Paravaccinia, Psittacosis
    • Gastrointestinal – Crohn’s disease, Ulcerative colitis
  • Malignancy – Carcinosis, Leukemia, Lymphoma,
  • Other – Pregnancy, Sweet Syndrome, Whipple disease

*EN should not be confused with erythema nodosum leprosum (ENL) which is a rare immune-mediated systemic disease associated with Leprosy.

Questions for Further Discussion
1. How do you diagnosis inflammatory diseases such as Behçet disease, Crohn’s disease, or Ulcerative colitis?
2. What is the role of a consultants in the evaluation and treatment of EN?

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 these topics: Skin Conditions and Skin 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.

Aydın-Teke T, Tanır G, Bayhan GI, Metin O, Oz N. Erythema nodosum in children: evaluation of 39 patients. Turk J Pediatr. 2014 Mar-Apr;56(2):144-9.

Jones M, de Keyser P. Rash on the arms and legs. BMJ. 2015 Aug 3;351:h4131.

Walker SL, Balagon M, Darlong J, et.al.
ENLIST 1: An International Multi-centre Cross-sectional Study of the Clinical Features of Erythema Nodosum Leprosum. PLoS Negl Trop Dis. 2015 Sep 9;9(9):e0004065.

Kroshinsky D. Erythema nodosum. UpToDate. (rev. 11/30/2016, cited 5/16/17).


Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

How Common Are STIs?

Patient Presentation
An 18-year-old male came to clinic for his health supervision visit. His past medical history showed that he was generally healthy and had all of his immunizations. During the social history he denied using alcohol, drugs, tobacco or being sexually active. The pertinent physical exam showed a healthy male with normal vital signs and BMI of 22.2, He was Tanner stage V and the rest of his examination was negative.

The diagnosis of a healthy male was made. The pediatrician recommended for him to receive his second Group B Meningococcal vaccine along with an updated tetanus vaccine as he was going to be working in construction and gardening over the summer. He said, “We also are screening all adolescents for HIV at your age. I know that you said you have not been sexually active but it is still recommended. The most important part is two-fold. One, the best way wait to prevent sexual infections and pregnancy is not to have sexual relations. So I recommend that you continue your current lifestyle. Two, if you do decide to become sexually active, use condoms each and every time along with some type of spermicide. That is also another good option to help prevent pregnancy and infections.” The physician discussed and gave the teen a handout on how to properly use a condom and when to have sexually transmitted infection testing (STI). “I always think its best to have all the information. Besides you can also keep this information for later or give it to a friend who might need it,” he remarked.

Discussion
Of the 30 different microbes which can be transmitted by sexual contact, 8 have the greatest incidence of transmitting disease. Four are curable (Chlamydia, Gonorrhea, Syphilis and Trichomoniasis) and 4 are incurable at present (Hepatitis B, Herpes simplex virus (HSV), Human immunodeficiency virus (HIV) and Human papillomavirus (HPV)).
Sexually transmitted infections (STIs) are important as they can cause:

  • Increased rates of acquisition of other STIs (ie HSV and syphilis increase the rate of HIV infection acquisition)
  • Pelvic inflammatory disease and infertility
  • Stillbirth and neonatal death
  • Neonatal morbidity including low-birth weight, prematurity, conjunctivitis, pneumonia, sepsis, and congenital abnormalities
  • Genital cancer

In high-income countries diagnosis usually includes laboratory testing and then treatment. Short-course antibiotic treatment for curable infections is effective. In low- and middle-income countries laboratory testing is often cost prohibitive and the diagnosis is made by syndromic management using symptoms and guidelines to direct care. Syndromic management is good as patients can be treated the same day, but the majority of STIs are not detected because patients are asymptomatic. Preventative vaccines for Hepatitis B and HPV have and are showing high prevention rates. Other vaccines are also being developed. Other interventions show that male circumcision decreases the risk of heterosexually transmitted HIV infection and may provide some protection against other STIs. A vaginal microbicide called Tenofovir may have some efficacy against HIV and HSV prevention.

STI screening guidelines from the Centers for Disease Control (CDC) can be found here. 2016 STI treatment guidelines from the CDC can be found here.

Learning Point
The World Health Organization estimates that more than 1 million STIs are acquired daily with 357 million new infections of one of the 4 curable STIs occurring each year. An additional 500 million people are living with HSV and another 290 million women have HPV.

The United States saw an increase in STIs in 2015. It is estimated that 20 million new STIs occurred in 2015 with more than 50% of them in the adolescent/young adult population (age 15-24 years). The large increase in Chlamydia and Gonorrhea were in this age group. There is also an increase in Syphilis reported among men, particularly those who are bisexual or gay.

Total STIs by World Region from the World Health Organization Reported in 2016

Location Total STIs
Americas 64 Million
Africa 60 Million
Eastern Mediterranean 31 Million
Europe 18 Million
South-East Asia 39 Million
West Pacific 142 Million

STIs by Age Range in the United States Reported to the Centers for Disease Control in 2015

Location Total STIs Chlamydia Gonorrhea Syphilis
Age 0-14 years N.A. 11,308 2,538 Primary and secondary 12, Congenital syphilis 487, increase 6%
Age 15-24 years N.A. 981,359 increase 2.5-4.2% 196,593 increase 5.2-7.2% Primary and secondary 5,966 increase 10.2-14.9%
Total 20 Million 1,526,658 increase 6% 395,216 increase 13% Primary and secondary 23,872 increase 19%

Increased rates are from 2014 to 2015, ranges are given if more than 1 age group is included. N.A. is not available

Questions for Further Discussion
1. What are the 5P’s of screening in a sexual health history?
2. How is teenage confidentiality handled in your practice regarding sexual health?

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: Sexually Transmitted Diseases.
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.

CDC Fact Sheet. Reported STDs in the United States. 2015 National Data for Chlamydia, Gonorrhea, and Syphilis.Available from the Internet at https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/std-trends-508.pdf (rev. October 2016, cited 5/2/17).
Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2015. Atlanta: U.S. Department of Health and Human Services; 2016.

World Health Organization. Sexually Transmitted Infections (STIs) Fact Sheet. Available from the Internet at http://www.who.int/mediacentre/factsheets/fs110/en/ (rev. 8/2016 cited 5/2/17).
World Health Organization. Global Health Sector Strategy Sexually Transmitted Infections 2016-2021. Available from the Internet at http://apps.who.int/iris/bitstream/10665/246296/1/WHO-RHR-16.09-eng.pdf?ua=1 (rev. 6/2016, cited 5/2/17).

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Do Children Grow Overnight?

Patient Presentation
A 14-year-old male came to clinic for his health maintenance examination. He was well and his mother was joking with the pediatrician saying, “He’s really growing. I measured him only 3 weeks ago and he’s already grown an inch since then. I can see it in his pants too because they were fitting a month ago and now you can see his ankles.” The past medical history was non-contributory.

The pertinent physical exam showed a well-appearing male, who was growing at the 50th percentile for height and 75% for weight. He had grown 8.5 centimeters in height over the past 12 months. He was Tanner stage 4 for pubic hair and genitalia. The diagnosis of a healthy male was made. The pediatrician said, “We hear the parents say this often that the kids grow overnight. They certain can have big growth spurts.” Later he was thinking about the conversation and decided to search the literature to see what medical literature might support this idea.

Discussion
Growth is an important vital sign for children. Normal growth patterns usually indicate healthy children and can be reassuring for both the parents and health care providers alike. Children are not usually measured very often by parents or health care providers and therefore the actual growth occurrence is not identified until after the event. Measuring small increments accurately also makes data collection difficult, along with the inconvenience of frequent serial measurements.

A review of various growth parameters in children can be found here.

Learning Point
There is evidence that children do grow over very short periods of time. Rogol writes, “…[T]here is compelling evidence to invoke a pattern characterized by short saltations flanked by longer periods of stasis, both in infant and during the pubertal growth spurt.” When these saltations or periods of rapid growth are averaged over longer periods of time, it can look like growth is a continuous process.

One adolescent male was measured almost daily for 389 consecutive days and was found to have linear growth on only 12 days. This is an average of ~1 day of growth out of 31, but the number of days between the growth days was heterogeneous ranging from 13-100 days. Another study of infants and toddlers, showed discontinuous growth spurts of 0.5-2.5 cm of linear growth separated by no measureable growth for 2-63 days. A third study of infants and toddlers, showed saltatory head circumference growth of 0.2 cm separated by no growth for 1-21 days. These head circumference growth saltations were also coupled to length growth saltations (median 2 days, range 1-8 days).

The mechanism for the saltatory growth for linear growth appears to be the chondrocytic life cycle itself and the changes that occur at the growth plates of long bones. Chondrocytes emerge from their stem cells, undergo proliferation, then a rest phase, then hypertrophy, and finally vascular invasion and mineralization. The timing of each state, especially the resting state and the hypertrophy state where linear growth occurs, is under numerous controlling factors including genetic, hormonal and nutritional. Lampl and Schoen state, “[i]n a sequence of “turn on” and “turn off” mechanisms across the chondrocytic life cycle, the final clonal chondrocyte hypertrophy operates as the cellular basis for saltatory growth, the biological process by which individuals accrue height in discrete spurts (saltations) separated by variable intervals of growth quiescence (stasis), empirically documented at the level of the whole body… and the growth plate itself….” They note that “…variation in saltatory amplitude and frequency characteristics underlie difference in growth rates, tempo, and time-based growth trajectories within and among individuals, including population-distinctive patterns.”

Questions for Further Discussion
1. What are the first signs of puberty?
2. The height spurt occurs during what Tanner stage(s) usually?

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 these topics: Child Development and Growth 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.

Lampl M, Veldhuis JD, Johnson ML. Saltation and stasis: a model of human growth. Science. 1992 Oct 30;258(5083):801-3.

Lampl M, Johnson ML. A case study of daily growth during adolescence: a single spurt or changes in the dynamics of saltatory growth? Ann Hum Biol. 1993 Nov-Dec;20(6):595-603.

Robol AD. Growth, body composition and hormonal axes in children and adolescents. J Endocrinol. Invest. 2003; 26:855-860.

Lampl M, Johnson ML. Infant head circumference growth is saltatory and coupled to length growth. Early Hum Dev. 2011 May;87(5):361-8.

Fennoy I. Effect of obesity on linear growth. Curr Opin Endocrinol Diabetes Obes. 2013 Feb;20(1):44-9.

Lampl M, Schoen M. How long bones grow children: Mechanistic paths to variation in human height growth. Am J Hum Biol. 2017 Mar;29(2).

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa