October 2004

A 6-year-old girl was referred to the pediatric infectious diseases clinic for evaluation of a rash on her right leg and trunk. The onset was about one month ago. Since then, the patient has been treated with courses of cephalexin (Keflex, Lilly) and then griseofulvin. Some improvement was noted after the cephalexin, but the lesions would not completely resolve. Examination revealed several lesions that were erythematous, scaly and thickened as shown in Figures 1-4. The rest of her exam was normal.

What’s Her Diagnosis?

1. Tinea with secondary infection
2. Resistant tinea corporis
3. Nummular eczema with secondary infection
4. Resistant impetigo

Answer

The appearance and history is most consistent with nummular eczema with secondary infection (C). This was fairly obvious (especially after one of our friendly dermatologists suggested the diagnosis). Nummular eczema can occur at any age and is by definition an annular patch of dry, inflamed skin. Nummularis is a Latin word meaning “coin-shaped,” and eczema is a Greek word meaning “to boil out.” This is a fairly good description of this condition, which often mimics tinea lesions. It is also relatively infrequent in children. The lesions tend to occur on the extensor surfaces of the extremities, shoulders, buttocks and lower trunk. They are very pruritic, and as a result, lichenification and secondary infections are common due to chronic scratching. The mainstay of therapy remains topical steroids, moisturizers and, if infected, systemic antibiotics. One common feature is the way the lesions often occur in a symmetric distribution (Figures 5 and 6 are of a different patient).

Patients with severe eczema who happen to also have cutaneous herpes simplex are at increased risk of cutaneous dissemination and/or severely infected lesions. Perhaps a future case will demonstrate this unfortunate complication (so be on the lookout). Note also that eczema is one of the contraindications to giving smallpox vaccine, for the same reason, just in case that should ever come up again. And in today’s world, it probably will.

In the meantime, something we do need to keep in mind is that influenza season is rapidly coming up, and the recommendations of the Advisory Committee on Immunization Practices (ACIP) this year include an annual influenza vaccine for all children ages 6 months to 23 months (Morbidity and Mortality Weekly Report, as reported in the Feb. 11 issue of the Journal of the American Medical Association). This will probably not be very popular with all the sticks that younger children receive in the first 2 years of life (16 to 20 depending on the schedule and products you use). However, it has been shown that these young children are a huge reservoir for the spread of influenza to high-risk patients, as well as being at increased risk themselves for significant respiratory distress requiring hospitalization, when compared with older children. The bright spot in the future may be that the intranasally administered, live-attenuated influenza vaccine could eventually be approved for these younger patients. But for the time being, however, it is not approved for children younger than 5 years of age, who will just need to get another stick. As a hospitalist, I can tell you that I have never met a parent who would not readily choose that stick over the unpleasant experience of having their child in the hospital with an influenza-related respiratory illness such as bronchiolitis, asthma or pneumonia, if they had it to do over. Remember that if the child is receiving influenza vaccine for the first time, two doses separated by at least four weeks are recommended. Sorry kids.

By the way, if you are planning on sending a soldier a Thanksgiving package, be sure to allow extra time to get it through security, and don’t send anything perishable or that cannot be opened. Keep it simple. They will appreciate anything you send, because for them, it really is the thought that counts.

For more information:

• James H. Brien, DO, Pediatric Infectious Disease, Scott and White’s Children’s Health Center and Associate Professor of Pediatrics, Texas A&M University, College of Medicine, Temple, Texas. E-mail: jhbrien@aol.com. Jared J. Lund, is a fourth-year medical student, Texas A&M University, College of Medicine, Temple, Texas.