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Items in Medical Photography
TITLE:
Skin
rash following use of amoxil antobiotic for upper
respiratory infection.
An
eight year old girl was taken to a local pediatrics
groups for fever and malaise. She was found to have a
"throat infection" and prescribed a brand
of amoxicillin and clavulanic acid. Twenty-four hours
later, she developed an eruption. She had no history
of allergies, antibiotic reactions, asthma or immune
disorder. Her clinical photo is posted. Small
placques with edema and erythema throughout the body
were noted. No chest findings or blood pressure
abnormalities were recorded. She was diagnosed
clinically with urticaria. Her symtoms abated in a
matter of 2-6 hours concommitant with therapy with
diphenhydramine elixir and decreasing dose of
medroxyprednisolone.
Amoxicillin is used frequently in pediatrics to treat
otitis and pharyngitis. In a recent report (1), 20
cases of acute otorhinolaryngological infections were
treated for 5 consecutive days with a daily dose of
amxocillin at 1,500 mg for adult and 750mg for child.
1. The effectiveness of the drug was assessed as
follows: remarkably effective in 2 of 20 cases in
total, effective in 15, slightly effective in 1 and
non-effective in 2. In that group of patients, the
sensitivity test to amoxicillin by the use of
ampicillin sensitivity disk revealed that all of
isolated bacteria were remarkably sensitive to
amoxicillin, except one strain of Staphylococcus
aureus which was moderately sensitive. However,
side effects were not uncommon affecting 25% of the
patients treated. The untoward reactions were
catallouged as follows: 4 cases of eruption and 1 of
esophagitis.
In a larger retrospective study (2) reporting
on 6,056 pediatric medical records on the incidence
of ampicillin-related rashes, 1482 children of
different agegroups were treated with ampicillin for
various diagnoses. Of these, 44 rashes developed in
treated patients, equivalent to an overall incidence
of rashes attributable to ampicillin of 2.9%. 907
newborns, in the age of 0 until 30 days, did not show
any exanthema; elder babies, aged 31 until to 365
days, showed an incidence of rashes associated with
ampicillin therapy in 4.06%. Children of the
age-groups 1 to 4, and 5 to 15 years had developed
skin reactions in 9.9% and 8.8%, respectively. If the
large group of newborn babies is not taken in
account, the average incidence of ampicillin rashes
increases from 2.9% to 7.6%. Eruption of exanthema
after start of ampicillin therapy occured changed
between the 1st and 21st day, usually after 4 and 5
or 7 to 12 days. The mostly morbilliform rashes
vanished in the average after 2 to 4 days. In the
beginning of or during exanthema the number of
eosinophile leucocytes was increased in 30% of
patients. In 93% the ampicillin therapy was ended
after skin reactions were noticed; the rashes of
children, who were treated further with ampicillin,
did not show any difference to those exanthema of
children, whose therapy was stopped. This practice is
probably tricky although there may be uimmunologic
reasons to support. For example, the amoxillin
molecule may act as a hapten yielding the undesired
immune response. The immune reaction mediated through
haptens are not necessarily reproducible, therefore,
the drug may be tried again or continued.
References:
(1).- Okamoto K; Yoshida A; Kona A; Ikeda M; Muraoka
J .Jpn J Antibiot 1976
Jan;29(1):22-6
(2).- Lehnhoff B. Uber die Haufigkeit von
Arzneimittelexanthemen nach
Ampicillin- Medikation im Kindesalter. Monatsschr
Kinderheilkd 1975
Jul;123(7):548-54
Title:
Clinical
Presentation of Dactylitis
The
fusiform appearance of a finger or several fingers
suggests a number of clinical conditions. The finger
comes to the attention of the physician because of
swelling or painful sensation usually in the absence
of trauma. The differential diagnosis of this finding
includes: inflammatory arthritides,
spondyloarthropathy, sarcoidosis, and gout. In a
recent study reported in Seminars in Arthritis and
rheumatism, dactylitis was prospectively studied
among all individuals presenting to an arthritis
clinic in Northeast Ohio from 1986 to 1996 (1).
Dactylitis was observed in 12% of individuals with
spondyloarthropathy, 17% with sarcoidosis, and 5%
with gout, but not in 96 patients with rheumatoid
arthritis or in 2,434 patients with osteoarthritis,
neck or back pain, or collagen vascular diseases.
Among individuals with the inflammatory syndromes of
spondyloarthropathy, dactylitis was present in 22%
with psoriatic, 28% with Reiter's syndrome, and only
7% with undifferentiated spondyloarthropathy. Gouty
dactylitis was found only in individuals with
polyarticular disease. One condition not observed in
this Ohio series but needs to be kept in mind is
flexor tendon sheath infections (2). In conclusion,
dactylitis is a valuable clue in the differential
diagnosis of arthritis. In other studies the presence
of dactylitis eliminated rheumatoid arthritis from
the differential diagnosis. The swelling in the
finger in sarcoidosis is due to granulomatous
infiltration of the bone, tendons and/or synovium.
(1). Rothschild BM; Pingitore C; Eaton M.
Dactylitis. Arthritis Center of Northeast
Ohio, Department of Medicine, Northeastern Ohio
Universities College of Medicine, Youngstown 44512,
USA.Semin Arthritis Rheum 1998 Aug;28(1):41-7
(2). Curco N; Pagerols X; Vives P. Fingers
Subcutaneous sarcoidosis with dactylitis. From the
Department of Dermatology, Hospital Mutua de
Terrassa, Barcelona, Spain. Clin Exp Dermatol 1995
Sep;20(5):434-5
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