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SCABIES

August 25, 2015


Soriano, Charles
Uy, Karl Francis

GENERAL DATA

DV

2 year old 6 months

Male

Roman Catholic

52 Engineering st. GSK Village Project 8, Quezon


City

CP

papules on hands and feet


CHIEF COMPLAINT

History of Present Illness

3
weeks
PTC

2
weeks
PTC

1 week
PTC

multiple erythematous papules on both hands


intense pruritus, more at night
consulted at visiting medical mission
given diphenhydramine syrup (12.5mg/5ml)
2.5ml TID
multiple erythematous pruritic papules on both
hands with excoriations
no fever
consulted at local health clinic
given
cetirizine (5mg/5ml) 2.5ml OD, and permethrin
cream OD
pruritic papules with excoriations extended to
both feet and anterior leg

CONSULT

PERSONAL HISTORY
1. Pregnancy Problems

no hypertension, no infection, no diabetes

2. Delivery

DOB: January 8, 2013

Gestational age: 39 weeks

Type of delivery: Low Transverse Caesarian section


secondary to failure of descent

Neonatal Complications/Illnesses: none

NUTRITION HISTORY
Feeding

Breastfeeding - birth to 7 months

Formula feeding - 7 months until present

Vitamin Supplement - Ceelin

Present diet and age started:

Cereal, fruits and vegetables - 7 months

A.

meat and table foods - 12 months

1.

Feeding Problems: none

GROWTH AND
DEVELOPMENT
Psycho-Motor/ Language:
Regard- unrecalled
Social mile- 2 months
Turned over- 5 months
Crept- 6 months
Sat aided- 7 months
Sat alone- 8 months
Walked independently- 12 months
1st words- 9 months
Put 3 words together- 1 year old

GROWTH AND
DEVELOPMENT
Developmental Level
a. General behavior- playful, active
b. Habits- no thumbsucking, no nail biting
c. Sleep pattern- sleeps around 9 PM and
wakes up around 6 AM

IMMUNIZATION HISTORY
C. Immunizations
BCG

at birth

Hepatitis B

1 dose

Hib

3 doses

OPV

3 doses

DTP

3 doses

Measles

1 dose

MMR

1 dose

Rotavirus

NONE

Hepatitis A

NONE

PCV

NONE

Varicella

NONE

Influenza

NONE

PAST MEDICAL HISTORY


D. Previous Illness:

No Allergies

No previous hospitalizations

No Accidents/Injuries

No previous surgeries

FAMILY HISTORY
(+) hypertension - maternal grandmother
(+) Diabetes - maternal grandmother
(-) Bronchial asthma
(-) Allergy
(-) PTB

SOCIAL AND
ENVIRONMENTAL HISTORY

lives in a 1 storey, well lit, well ventilated house

4 household members ( 2 siblings, eldest)

younger brother has the same symptoms as the


patient

Drinking water is distilled, no nearby water reservoir

Garbage is collected and segregated twice a week

No nearby factories, no exposure to smoke of


cigarette at home

REVIEW OF SYSTEMS
HEENT- no eye/nose/ear discharge
Cardiovascular- no fainting spells
Respiratory- no cough, no colds
Gastrointestinal: no abdominal pain, no vomiting, no
diarrhoea
Genitourinary- no hematuria, no pyuria
Metabolic- no heat/cold intolerance
Musculoskeletal- no swelling, no limited motion of extremities
Nervous System- no convulsions

PHYSICAL EXAMINATION
Temperature: 36.5 C
Heart rate: 117 bpm
Respiratory rate: 22 cpm
Weight: 14.1 kg (z > 0)
Length: 91 cm (z < 0)
Head circumference: 49 cm (z > 0)
Chest circumference: 52 cm
Abdominal circumference: 50 cm

PHYSICAL EXAMINATION
General Appearance: awake, alert, oriented, unkempt,
not in cardio-respiratory distress
Skin- warm, moist skin, good skin turgor, (+) multiple
erythematous papule with crusting and excoriations over
both hands, feet, and anterior legs
Lymph nodes- no cervico-lymphadenopathy
Head- normocephalic, no head lesions
Eyes- no lid lesion, anicteric sclera, pink palpebral
conjunctiva, pupils 2-3mm, equally reactive to light and
accommodation

PHYSICAL EXAMINATION
Ears - normal set ears, no aural discharge, no tragal tenderness,
nonhyperemic ear canal, intact tympanic membrane
Nose - nasal septum midline, pink nasal mucosa, no congestion
of turbinates, no discharge
Oral Cavity- moist lips, pink moist buccal mucosa, no oral ulcers,
tonsils not enlarged, non-hyperemic posterior pharyngeal wall
Chest examination- symmetric chest expansion, no visible
retractions, normal breath sounds
Heart and Vascular- adynamic precordium, normal rate, regular
rhythm, no audible murmur

PHYSICAL EXAMINATION
Abdomen- flat abdomen, normoactive bowel
sounds, soft, nontender, no palpable mass
Genitals- SMR 1, no gross lesions
Extremities- warm; full and equal pulses; CRT
<2 seconds

PHYSICAL EXAMINATION
Neurological (General)
Sensory- no sensory deficit
Motor- can move all extremities
Reflexes- ++ (all extremities)
Cranial Nerves- intact
Gait- can walk independently

SALIENT FEATURES

2 year old 6 months, male

papules on both hands, feet, anterior leg

nocturnal pruritus

same symptoms with another family


member

unkempt

no fever

IMPRESSION

SCABIES

APPROACH TO
DIAGNOSIS

Look for a symptom, sign, or laboratory


finding pointing to a group of disease
(pruritic papules on hands and feet)

DIFFERENTIAL
DIAGNOSIS

Insect Bites

atopic dermatitis

Scabies

Bites

Inflammatory reaction at
the site of the punctured
skin, to the insects
venom
or
saliva
containing
histamine,
enzymes,
agglutinins,
serotonin, formic acid, or
kinins. Accompanied by
pruritic local erythema &
edema

pruritic
red
papules
typically
with
a
surrounding swelling & a
central punctum

Insect Bites
INSECT BITES
pruritic

red papules
surrounding swelling
central punctum

PATIENT
with pruritic
erythematous
and papules with excoriations

no central punctum

house has no
water reservoir

nearby

Atopic Dermatitis

1925 atopy out of place or


strange To signify the
hereditary tendency to develop
allergies to food or inhalant
substances

Tendency to develop atopic


dermatitis is inherited

Three stages: infantile,


childhood, adolescent/adulthood

Pruritus is the hallmark for all


stages

Atopic Dermatitis
ATOPIC DERMATITIS
pruritic

papules

often

PATIENT

pruritic erythematous
papules with excoriations

lichenified, indurated
plaques whch are intermingled
with isolated, excoriated
site: hands, feet, anterior
papules
legs

site

of predeliction: antecubital
no family history of atopy
and popliteal fossae, flexor
wrists, eyelids,face, and around
the neck
no chronically relapsing

family

history of atopy

chronically

relapsing dermatitis

dermatitis

SCABIES
Infestation

scabiei

by the mite Sarcoptes

Generalized

intractable pruritus

Pruritic

papular lesions,
excoriations and burrows

Finger

webs, wrists, axillae,


areolae,umbilicus, lower
abdomen, genitals and buttocks
(CIRCLE OF HEBRA)

Transmission:

contact

Skin to skin

SCABIES
SCABIES

PATIENT

Pruritic papular lesions,


excoriations & burrows

pruritic erythematous
papules with excoriations

nocturnal pruritus

pruritus widespread
concentrated on hands,
feet, and body folds

intense pruritus more at


night

lesion on both hands, feet

similar symptoms present


on his younger brother

similar skin symptoms


present on other family
members

SCABIES
CLINICAL DIAGNOSIS

SCABIES

bristles

body

legs

Sarcoptes scabiei var. hominis

ETIOLOGY

RISK FACTORS

TRANSMISSION
SKIN-TO-SKIN
CONTACT

PATHOGENESIS

CLINICAL MANIFESTATIONS
Intense and generalized pruritic rash that is

worse at night, with the face and neck


unaffected
Primary skin lesions are inflammatory pruritic

papules, pustules, vesicles, and nodules


Pathognomonic finding is a burrow, which

may not always be evident.

CLINICAL MANIFESTATIONS
Burrows are most commonly found on the

hands and feet or in the finger webs, and


appear as short, wavy, scaly gray lines on
the skin surface.
Nonspecific secondary skin findings may be

excoriations, eczematization, and pyoderma.


Infants may present with pustules on the

palms and soles of the feet, and vesicles or


lesions on the neck and face
scalp and face are usully spared in adults

CIRCLE OF
HEBRA

DIAGNOSIS
POSITIVE DIAGNOSIS IS MADE ONLY
BY THE DEMONSTRATION OF THE
MITE UNDER THE MICROSCOPE

MANAGEMENT
Permethrin 5% cream

Safest, most effective

applied to the entire body from the neck down, with particular
attention to intensely involved areas

medication is left on the skin for 8-12 hr

If necessary, it may be reapplied in 1 wk for another 8- to 12-hr


period.
Lindane
Benzyl benzoate
10% precipitated sulfur in white petrolatum
Crotamiton
Ivermectin - limited to cases resistant to topical treatment or in

advanced state (Norwegian scabies)

MANAGEMENT

All household contact, symptomatic or not, should


be treated at the same time.

Clothing, towels and bed sheets should be changed


and washed in hot water, dried under the sun and
ironed.

COMPLICATIONS

Eczematous dermatitis

Impetigo

Ecthyma

Folliculitis

Furunculosis,

Cellulitis

PREVENTION

Avoid direct skin contact with a person infested with


scabies

Avoid using items such as clothes and linens used by


a person with scabies

All household members should be treated at the same


time as the patient to prevent getting the mites again

Clean the house regularly

PLAN

Permethrin 5% cream, apply from neck down


then leave for 12 hours. Apply to all members of
the house

sulfur soap (Erasul) BID

Iterax (Hydroxizine diHCl) (2mg/ml) 2.5ml TID

immerse clothes, curtains, blankets, bedsheets


in hot water and iron well

Follow-up after 6 days

FOLLOW-UP (July 27,


2015)

S: (+) decreased papules, (-) pruritus, (-)


fever, (-) appearance of new skin lesions

O: hyperpigmented dry, crusted papules


over the hands, feet, and anterior legs

A: Scabies, resolving

P: follow-up anytime if with appearance of


new skin lesions