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Simple cases
Case 50
5-year-old boy awoke with pruritic periorbital swelling and his mother immediately brought him to hospital
History
How long has this been present?
(History from mother)We noticed it when he got up this morning.
This problem is almost always very acute.
Did you check to see if he has fever?
(History from mother)No; but he doesn't feel warm and is otherwise o.k.
Good question for differential diagnostic considerations.
Has he taken any medications recently?
(History from mother) No not for a long time.
Good question for differential diagnostic considerations.
Does this swollen area hurt or itch?
Yes, it hurts a bit, but really itches.
This problem is usually pruritic and occasionally painful. Pulsating pain in this area would point you in a different direction.
Did he eat anything unusual yesterdaypeanuts, seafood, or ?
(History from mother) No, he ate pretty much what we always eat. Milk, bread, butter and jam for breakfast. Spaghetti with meat sauce for lunch and cold cuts at night.
Good question for differential diagnostic considerations.
Do you get an insect bite yesterday?
I don't know (History from mother) We have a pond in the garden and there are lots of bugs, so it is possible.
Good question for differential diagnostic considerations.
Was your eye red yesterday? Did you hurt your eye?
No it was fine. We didn't have soccer yesterday.
Good question for differential diagnostic considerations.
Have you been sneezing a lot or had a runny nose?
No, I haven't had a cold in a long time.
God question to rule out hay fever as part of an atopic diathesis.
Lesion
Choose the right efflorescences:
Any swelling is a tumor, but because patients so often misunderstand this term, it is not used for such conditions.
A macule is flat; this is anything but flat.
This is a special form of urticaria with transient swelling because of leakage of fluid into the skin.
Diagnosis
Choose the right diagnosis:
This is the most important differential diagnostic consideration. The patient should have fever and laboratory signs of inflammation.
Angioedema is also a serious consideration, but is usually symmetrical and triggered by medications, foods or Hymenoptera stings.
Grouped vesicles on an erythematous base are not seen. Herpes zoster is rare in this age group, but could present with marked swelling, so it must be considered.
This is an angioedema-like reaction to an insect bite or sting. Children often react more dramatically to mosquito bites than adults, so perhaps he was bitten during the evening or when playing in the garden.
Therapy
Choose the right therapy(ies):
False. It the patient had an acute anaphylactic reaction, such as angioedema from peanuts, this would be correct.
Correct. Both may help relive itch. Be careful on the face of a child; use a low-potency corticosteroid.
In theory, this is another way to treat itch, but the severity of the problem makes systemic administration more reasonable. In addition, the antihistamine gels are not designed for use around the eyes.
No antibiotic therapy is needed. On occasion, scratched insect bites may become secondarily infected, but then topical antibiotics usually suffice.
Test
The following questions are related to the current case. Try to solve them.
