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All posts with tag: "allergy"

PEM Questions

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Parents bring in their 11 month old baby for a new-onset rash. The baby is unimmunized by parent choice. The baby had fever for the last 3 days to a maximum of 104 F. Although he had fever, he was well-appearing and still eating normally and playful. But since the fever was persistent, they took him to a clinic yesterday and he was diagnosed with a throat infection and started on amoxicillin. He has received 2 doses. Today he awoke with a fine morbilliform blanching pink rash that started on the neck and trunk, then has spread to the face and extremities. It does not seem itchy and it does not involve the mucosa. The only other medication he has had was acetaminophen yesterday at 5pm. On exam, he is nontoxic and interactive. Vital signs: temp 98.9 F, HR 132, RR 28, O2 sat 99% on room air. ENT, chest, and abdomen exams are unremarkable. 

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You are seeing a 14 month old who has a two irregularly oval yellow-tan lesions on his right upper arm, just under 1cm each. They have been present all his life and have grown slightly. Sometimes they seem to become acutely inflamed, and the boy has flushing and intense itching. 

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You are seeing a 3-year-old boy with 2 days of fever to a maximum of 102.7 F, an urticarial rash (but no enanthem), and significant arthralgias. The individual urticarial lesions are not transient, but rather present for more than 24 hours. He is not toxic but appears miserable. He was diagnosed with acute otitis media 8 days ago and is on day 8 of a 10-day amoxicillin course. 

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You are seeing a 10 month old female with profuse projectile vomiting and one episode of diarrheal stool over the last 2 hours. She is ill-appearing and has signs of significant dehydration. While obtaining vascular access and rehydrating her, you obtain additional history and peruse her chart. She has had three prior similar but more mild episodes, all diagnosed as acute gastroenteritis, starting at age 7 months. This episode began ~90 minutes after the family had dinner. The family had peanut chicken curry over rice and a salad. The baby had rice and small pieces of chicken set aside before being mixed with the peanut curry sauce. The baby has a 3-year-old sister in preschool. She is asymptomatic. 

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You are seeing a 6 year old boy who sustained a bee sting. He presents with diffuse urticaria, wheezing and shortness of breath, and crampy abdominal pain, nausea, and vomiting. There is no angioedema. His vital signs are: temperature 37.7 C, HR 140, RR 30, BP 76/36, pulse oximetry 92% on room air. 

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Tips and Tricks

Managing parent expectations is half of pediatric emergency medicine. When parents bring in kids with worsened eczema (either as a chief complaint or a side complaint), they are often frustrated that they used the prescribed cream, things got better, but now the rash is back. I like to explain that eczema is like “asthma of the skin,” and to expect “attacks” or “flares” just like asthmatics get, depending on environmental pollen counts, dry air, etc. When an asthmatic has a flare, they use their albuterol inhaler, and when someone with eczema has worsened rash, they ramp up their dry skin regimen and use steroid creams. Lately I’ve also been comparing hand-foot-mouth to “a virus in the chickenpox family” with similarities that it has to get better on its own, antibiotics don’t help, and it takes 7-10 days for the lesions to heal up.

While up to 10% of patients may think they have an allergy to beta-lactam antibiotics, fewer than 1% have a true IgE-mediated hypersensitivity, with concomitant risk of anaphylaxis. However, even if a true allergy is confirmed, this does not mean that the patient cannot receive any beta-lactam antibiotics. Whether or not there is likely to be cross-reactivity between the antibiotic to which the patient is allergic and another beta-lactam antibiotic depends on whether their structures share similar R side chains, as explained in this article. A handy can be kept on your mobile phone delineating which antibiotics cross react.

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