Pediatrics and Neonatology

Answers

473. The answer is b. (Behrman, 16/e, pp 1385-1399. Hay, 14/e, pp 496-497.) The five congenital heart disorders listed in the answer (the five T's) cause right-to-left shunts and subsequent cyanosis. Tetralogy of Fallot is the most common type of cyanotic heart lesion and consists of Pulmonary stenosis, RVH, an Overriding aorta, and VSD (PROV). Children present with dyspnea, cyanosis after the neonatal period, irritability, easy fati-gability, and retarded growth and development. Physical examination may reveal an RV lift, a murmur of VSD, and clubbing. The cyanosis of tetralogy is often relieved by increasing venous return to the heart by the knee-chest position (squatting or "tet" spells). Chest radiograph may reveal a "boot-shaped" heart due to RVH. Children with transposition of the great vessels (aorta connected to RV and pulmonary artery connected to LV), tricuspid atresia (no communication between RA and RV), truncus arteriosus (one great vessel arises from the heart to supply the arterial and pulmonary circulation), and total anomalous pulmonary venous return (blood drains into RA instead of LA) typically present with cyanosis in the neonatal period.

474. The answer is d. (Behrman, 16/e, pp 2156-2159.) Lead poisoning produces a motor neuropathy and is associated with anemia, a gingival lead line, colicky abdominal pain, and basophilic stippling of red blood cells. Patients with acute intermittent porphyria (AIP) present with recurrent bouts of abdominal pain, confusion, and peripheral and cranial neuropathies. Kernicterus is accumulation of bilirubin in the newborn that may cause neuronal death and scarring. Children with fragile X syndrome present with mental retardation, large ears, and a prominent jaw. The triad of macroglossia, abdominal distension, and constipation is consistent with cretinism.

475. The answer is c. (Behrman, 16/e, pp 2077-2078, 2083-2086. Mehta, pp 170-171.) The presence of a hump or asymmetry when the patient bends forward is the hallmark of a scoliotic deformity. Radiographic evaluation is used to determine the degree of scoliosis but would not be a cost-effective screening test since films of the entire spine are required. The Ortolani test is used to identify congenital dislocation of the hip in an infant. While the patient is in the supine position, the examiner holds the legs with the thumbs against the inside of the knee and thigh and the fingers over the posterior aspect of the proximal femur. A "click" will be noted as the examiner applies anterior force to the femur and the hip is reduced into the acetabulum.

476. The answer is c. (Behrman, 16/e, pp 1950-1959. Ludman, pp 1-8.) The most likely diagnosis in this patient is acute bacterial otitis media. A mucopurulent discharge in acute otitis media occurs only if the drum perforates; otherwise, the tympanic membrane is bulging and erythematous. The organisms responsible for this infection are Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis. Adenopathy is usually absent in simple otitis media. Perforations of the eardrum may occur with infections; sudden changes in pressure, especially when diving; and trauma. Serous otitis media will cause the tympanic membrane to be retracted and scarred. Acute mastoiditis is caused by the breakdown of the thin bony partitions between the mastoid cells and occurs when an otitis media continues, often with few symptoms, despite adequate treatment. Patients have a continuous discharge through a perforation in the eardrum and complain of swelling, tenderness, and erythema over the mastoid bone.

477. The answer is b. (Behrman, 16/e, pp 1811, 1849-1851.) Tay-Sachs disease is a progressive autosomal recessive disorder resulting from a deficiency of the enzyme hexosaminidase A with the subsequent storage of ganglioside in the lysosomes of the neurons. Infants present with hyper-acusis (startling to sound), hypotonia, and delayed motor development. Funduscopic examination will reveal a macular cherry red spot. Pompe's disease is acid maltase deficiency; infants present with weakness and flop-piness. Adrenoleukodystrophy is an inherited demyelinating disease of males resulting in an enzymatic defect in peroxisomes. Children present with behavioral problems, spasticity, deafness, visual loss, dementia, and brown skin pigmentation. Phenylketonuria (PKU) is an autosomal recessive disease in which neonates present with growth failure, seizures, and mental retardation. Patients are diagnosed by obtaining elevated phenyl-alanine levels during required screening. Cerebral palsy (CP) is a group of disorders in which patients present with motor deficits (intelligence may be spared) acquired in the prenatal or perinatal period because of an episode of hypoxemia, ischemia, or infection. There is midline cerebellar agenesis with a 4th ventricle cyst in the Dandy-Walker malformation, and this causes hydrocephalus.

478. The answer is c. (Behrman, 16/e, pp 991, 1275-1278. Hay, 13/e, pp 435-436.) Croup (acute laryngotracheobronchitis) occurs in the fall and winter months and is most often due to one of the parainfluenzae viruses. It occurs in boys more often than girls between the ages of 3 mo and 5 years. The inflammation of croup is subglottic. Patients exhibit labored breathing, stridor, and use of the accessory muscles of respiration to assist breathing. Because of the viral etiology, temperature is typically less than 103°F and peripheral white blood cell count is usually normal. An antero-posterior radiograph of the larynx will show subglottic narrowing, known as the "hourglass" sign or the "steeple" sign. Epiglottitis is most often caused by Haemophilus influenzae type B. It is seen in children between the ages of 2 and 7 and may cause life-threatening airway obstruction. Patients present with fever, dysphagia, muffled voice, inspiratory retractions, cyanosis, and drooling. To keep the airway open, patients with epiglottitis often sit in the "sniffing dog position." The "thumbprint" sign is seen in a soft tissue lateral radiograph of the neck, but these films are rarely done since children require immediate protection of the airway with intubation. Bronchiolitis occurs in infants <6 mo old and is most likely due to RSV There is characteristic hyperinflation of the lungs and the infant appears anxious due to difficulty in expiration.

479. The answer is b. (Behrman, 16/e, pp 1315-1327. Seidel, 4/e, p 404.) The child most likely has cystic fibrosis (CF). CF is a multisystemic autosomal recessive disorder that affects the sinuses, lower respiratory tract (bronchiectasis), exocrine function of the pancreas, intestinal function (deficiencies in fat-soluble vitamins A, D, E, and K), sweat glands, and urogenital tract (infertility). Patients have episodes of recurrent respiratory tract infections and a history of failure to thrive. Salt loss in sweat is distinctive. A meconium ileus (obstruction from hardened meconium) occurs in 15% of all patients and may be the first manifestation of CF Res piratory infections are most often due to Pseudomonas aeruginosa and S. aureus. The recurrent infections produce large amounts of mucus that cause obstructive lesions in the bronchi and bronchioles. Diagnosis is made by combining the clinical presentation with an abnormal sweat chloride value (>70 mmol/L).

480. The answer is b. (Behrman, 16/e, pp 1813-1818.) Absence seizure

(petit mal) occurs in children between the ages of 3 and 10 and is characterized by numerous daily episodes of unresponsiveness often associated with lip smacking, eye rolling, eyelid fluttering, or lip movement. Atonic (astatic) seizures are called "drop attacks"; patients experience a sudden loss of tone in postural muscles. Neonatal seizures are various forms of seizures that may be seen in the newborn. Focal seizures (partial complex) involve one part of the body and are not associated with loss of consciousness. These seizures can spread to involve adjacent areas of the body ("Jacksonian march"). Psychomotor seizures (temporal lobe) are associated with automatisms (purposeless motor movements with altered consciousness). Lip smacking may be seen in tardive dyskinesia, but it is usually a consequence of the use of neuroleptics.

481. The answer is a. (Behrman, 16/e, pp 838-842, 991-993.) The clinical presentation is consistent with chlamydial pneumonia, which develops in 20% of infants born to women with chlamydia infections. Newborns will present within 3 mo of birth with a week of persistent symptoms. The majority will have bilateral crackles on lung auscultation. Inclusion conjunctivitis and pneumonia are often a consequence of the perinatal infection. The etiologic agent (C. trachomatis) is found in up to 25% of pregnant women. Pertussis or whooping cough is a highly contagious infection and is unlikely to be mild on presentation. The word pertussis means violent cough, and the disease is often called "the cough of 100 days" because of its chronic nature. The cough of pertussis is described as being paroxysmal and staccato in character, ending with a high-pitched inspiratory "whoop." Respiratory syncytial viral pneumonia (RSV) presents like chlamydial pneumonia but with no history of conjunctivitis. Patients with RSV present with rhinorrhea and cough. Aspiration of a foreign body causes cyanosis, the abrupt onset of respiratory distress, stridor, intercostal retractions, wheezing, and asymmetric breath sounds.

482. The answer is a. (Behrman, 16/e, pp 1561-1562.) Retinoblastoma causes a white reflex (leukocoria). This is a life-threatening malignant tumor rarely seen in infants and children. Leukocoria may also be due to a cataract. Retinocerebellar angiomatosis is part of a rare autosomal dominant disease (von Hippel-Lindau disease); patients present with nystagmus, retinal detachment, cerebellar hemangioblastoma, intraabdominal cysts, and renal carcinoma. Choroidal angioma is found in Sturge-Weber disease; patients present with congenital glaucoma, cloudiness of the cornea, and marked enlargement of the eye at birth (buphthalmos). Infants with Sturge-Weber disease may also have facial angiomas. Primary congenital glaucoma is a condition of increased intraocular pressure caused by abnormal development of the aqueous drainage structures of the eye. In papilledema, the optic disc margins are bilaterally indistinct due to optic nerve swelling from increased intracranial pressure.

483. The answer is e. (Behrman, 16/e, pp 331, 531. Tintinalli, 5/e, p 759.) Retinal hemorrhages with no evidence of external trauma along with a history of irritability, lethargy, vomiting, and a bulging fontanel suggest increased intracranial pressure from a chronic subdural hematoma or "shaken baby syndrome." Increased head circumference is also suggestive of increased intracranial pressure. DiGeorge syndrome is a congenital disorder; infants present with cardiac defects, tetany from hypocalcemia secondary to an underdeveloped parathyroid gland, facial abnormalities, and thymus gland maldevelopment causing an isolated T-cell deficiency. Oligo-dendroglioma commonly involves the temporal lobe, and patients often present with seizures. Fetal alcohol syndrome is the number one cause of congenital malformations. Infants are born with developmental retardation and facial, heart, lung, and limb abnormalities.

484. The answer is b. (Behrman, 16/e, pp 1258-1259. Hay, 14/e, pp 24, 36, 42-44, 58.) Choanal atresia is a congenital nasal obstruction (due to a septum between the nose and pharynx). Newborns are obligate nose breathers and any nasal obstruction may cause respiratory distress. In choanal atresia, the baby appears to be fine when crying (breathing through the mouth) but becomes cyanotic when crying stops. The incidence of this disorder is 1 in 2500 live births. Treatment consists of maintaining the airway (which may be achieved emergently by making a large hole in the pacifier), which allows the infant to mouth-breathe. Fifty percent of infants with choanal atresia have other congenital anomalies (CHARGE syndrome = Coloboma, Heart disease, Atresia choanae, Retarded growth, hypoGonadism, and Ear abnormalities). Newborns with tracheal-esophageal (T-E) fistula present within a few hours of birth with choking, cyanosis, and respiratory distress. Hyaline membrane disease, the most common cause of respiratory distress in the premature newborn, is a deficiency of surfactant causing severe respiratory distress usually in premature newborns. Meconium aspiration syndrome occurs immediately upon birth and is associated with significant pulmonary morbidity. Tracheomalacia is a self-limited disorder that causes "noisy" breathing (wheezing or stridor) in infancy due to the lack of a rigid trachea.

485. The answer is e. (Behrman, 16/e, pp 1835-1839.) Patients with neu-rofibromatosis (NF) type 1 (classical or peripheral) typically present with multiple cafe-au-lait spots, axillary freckling, cutaneous neurofibromas, acoustic neuromas, neurilemomas, optic gliomas, Lisch nodules (hamar-tomas of the iris that appear as brown elevations), and skeletal abnormalities. Patients with neurofibromatosis type 2 (central) present with bilateral acoustic neuromas and multiple meningiomas and rarely have cafe-au-lait spots. Neurofibromatosis is also called von Recklinghausen syndrome. Tuberous sclerosis (Bourneville's disease) is a multisystem disease; patients present with skin lesions, benign tumors of the central nervous system, seizures, and mental retardation. Von Hippel-Lindau syndrome (VHL) is characterized by cerebellar hemangioblastoma, renal and pancreatic cysts, renal cell carcinoma, and retinal angiomatosis. The neurocutaneous syndromes (NF, VHL, and tuberous sclerosis) are all autosomal dominant disorders. Meningioma is a slow-growing benign tumor that arises from the leptomeningeal arachnoidal cells. Craniopharyngioma is a slow-growing cystic tumor arising from the pituitary; patients present with visual field defects and endocrine abnormalities.

486. The answer is c. (Behrman, 16/e, pp 1593-1594.) Nephrotic syndrome is a clinical complex consisting of >3.0 g proteinuria in 24 h, hypoalbuminemia, edema, hyperlipidemia, lipiduria, and hypercoagulabil-ity. Minimal change disease (MCD) accounts for 80% of nephrotic syndrome in children under the age of 16 and 20% of nephrotic syndrome in adults. Patients typically present with nephrosis and a benign urinary sediment. The etiology of MCD is unknown, but occasionally the syndrome develops after a respiratory tract infection or an immunization. Patients respond to steroids and the prognosis is excellent. RPGN and MPGN are immunologically mediated diseases characterized by oliguria, sub-nephrotic proteinuria, edema, hematuria, red blood cell casts, and hypertension (acute nephritic syndrome).

487. The answer is a. (Behrman, 16/e, pp 1543-1548.) Acute lymphoblastic leukemia (ALL) comprises 80% of all childhood leukemias (peak incidence is between 3 and 7 years of age). Most patients present with fatigue, mucosal bleeding, gum hypertrophy, and bone pain. Patients may present with an infection due to the severe neutropenia or with a dramatically high hyperleukocytosis. Physical examination is often remarkable for pallor, petechiae, purpura, mucous membrane bleeding, bone pain, generalized lymphadenopathy, and hepatosplenomegaly. The hallmark of ALL is pancytopenia with circulating blast cells on peripheral smear and a bone marrow that is replaced by at least 30% blasts. Acute nonlymphocytic leukemia (ANLL), also called acute myelogenous leukemia (AML), is primarily a disease of adults. The Auer rod is pathognomonic of AML. Atypical lymphocytosis is seen in mononucleosis.

488. The answer is d. (Behrman, 16/e, pp 2077-2078. Mehta, pp 260-263.) All newborns must be evaluated for congenital hip dislocation, but it is most commonly seen in females, firstborns, and breech presentations. The Barlow test (with the hip in 90° of flexion and maximum abduction, the femur is pushed down while trying to adduct the hip; this will dislocate an unstable hip joint) and Ortolani maneuver (thighs are abducted from the midline with anterior pressure on the greater trochanter; the femoral head is displaced anteriorly into the acetabulum and a soft click is produced) should be performed on all newborns. The Ortolani test is a maneuver to reduce a recently dislocated hip. Other maneuvers include the Trendelenburg sign (used in older children; a dip of the pelvis to the opposite side when the patient stands on the affected side or a waddling gait with bilateral dislocation of the hip) and the Allis sign, also called the Galeazzi sign, which is unequal heights of the knees (the dislocated side is lower) when the hips and knees are flexed.

489. The answer is b. (Behrman, 16/e, pp 1275-1276.) Epiglottitis is a progressive cellulitis of the epiglottis and surrounding tissues due to Haemophilus influenzae type B in children (usual age is 2-7 years) or S. pneumoccus or S. aureus in adults. Patients with epiglottitis have a high fever and complain of sore throat, drooling (inability to swallow secretions), dysphagia, odynophagia, and a muffled voice. The mnemonic to remember the symptoms of epiglottitis is the four D's (Drooling, Dysphagia, Dyspnea, and Dysphonia). Posture is usually upright, leaning forward, and in children is called the "sniffing dog" position. Stridor (a loud, high-pitched sound) may also be present. The diagnosis of a "cherry red" epiglottis is confirmed by laryngoscopy. Patients with exudative pharyngitis due to group A Streptococcus present with fever and large, tender anterior cervical lymphadenopathy. Peritonsillar abscess (quinsy) occurs as a complication of bacterial tonsillitis and is the accumulation of pus between the tonsil and its bed. Patients complain of sore throat, unilateral otalgia, dysarthria, and trismus. On throat examination, an enlarged, medially displaced tonsil (abscess) is seen in the peritonsillar area and the uvula is displaced to the opposite side. A typical gray-white membranous exudate in the pharynx is consistent with diphtheria, but this infection is rare in North America.

490. The answer is d. (Behrman, 16/e, pp 1185-1186, 1653.) Hydrocele is common in infancy; if the tunica vaginalis is not patent, the hydrocele will usually resolve in the first 6 mo of life. A spermatocele does transillu-minate, but it does not grow as large as a hydrocele and it remains localized as a cystic swelling on the epididymis. A varicocele is due to torsion of the pampiniform plexus that surrounds the spermatic cord. It usually occurs on the left side in boys or young men and is very painful. When palpated, a varicocele feels like a "bag of worms." Cryptorchidism is an undescended testis; the scrotum remains small, flat, and underdeveloped.

491. The answer is c. (Behrman, 16/e, pp 1369-1371, 1409-1410.) The most common congenital heart abnormality is VSD. Small shunts may be asymptomatic, but large shunts may cause dyspnea, exercise intolerance, and congestive heart failure. Typically, patients have a loud P

2, a palpable thrill, and a pansystolic murmur. Small VSDs may close spontaneously, but others may progress to cause Eisenmenger syndrome (pulmonary hypertension that leads to right heart failure and shunt rever sal). Patients who develop Eisenmenger syndrome (irreversible) are inoperable. The three congenital heart defects that cause left-to-right shunts are the three D's (VSD, ASD, and PDA). All three may cause Eisenmenger syndrome. Endocarditis is a complication of VSD.

492. The answer is a. (Behrman, 16/e, pp 1214-1216.) Reye syndrome is an often fatal sequela to certain viral illnesses. Patients present with encephalopathy and fatty infiltration and dysfunction of the liver. Salicy-lates are suspected of potentiating this syndrome; however, they are not believed to be the primary cause of the syndrome because the illness may occur in the absence of salicylate use. The mortality rate in Reye syndrome is 50%. Infants may become flaccid after eating honey due to the inhibition of acetylcholine release (from Clostridium botulinum).

493. The answer is c. (Behrman, 16/e, pp 1142-1143. Hay, 14/e, pp 530-538.) Meckel's diverticulum rarely causes symptoms, but infants may present with the painless passage of maroon-colored stools. The diverticu-lum is a remnant of the omphalomesenteric duct and is the most common gastrointestinal tract congenital anomaly (2% of the population). It is usually 2 cm long within 2 ft of the ileocecal valve, and males (usually <2 years old) are affected 2 times more than females. It is made of 2 kinds of ectopic tissues (stomach and pancreas) and has 2 complications (bleeding and inflammation). (Meckel's diverticulum is called the rule of 2's.) Pyloric stenosis is seen in newborns. Patients present with projectile vomiting, abdominal distention, and a palpable olive-sized mass in the RUQ that appears after vomiting. Prominent persistaltic waves are often visible going from the left to the right side of the abdomen. Intussusception (one segment of the intestine prolapses into another) is the most common cause of obstruction in the first 2 years of life. Infants present with melena, abdominal pain, vomiting, and diarrhea mixed with mucus and blood, giving it a red "currant jelly" appearance. Often a sausage-shaped mass is palpable in the upper midabdominal area. Biliary atresia is a congenital obstruction or absence of the bile duct system. Newborns (2-3 wk old) present with light-colored stools, dark urine, hepatomegaly, pruritus, and jaundice. Zenker's diverticulum is a disorder of adults in which the pharyngeal mucosa protrudes through an area of weakness in the musculature proximal to the upper pharyngeal sphincter. Patients present with halitosis from retention of food and saliva in the diverticulum.

494. The answer is d. (Behrman, 16/e, pp 115-117. Hay, 14/e, pp 195-199.) The majority of victims of sexual abuse have no physical examination findings. Swelling and erythema of the vulvar tissue (genital trauma) should be a "red flag" for child abuse, especially if associated with bruising or a foul-smelling discharge. In addition to the anorectal and genitourinary problems, there can be significant behavioral changes, such as sexually provocative mannerisms, excessive masturbation, inappropriate sexual knowledge, enuresis, depression, social withdrawal, anxiety, school problems, and weight changes. A straddle injury, often from a bicycle seat, occurs over the symphysis pubis, whereas signs of sexual abuse are more posterior around the perineum.

495. The answer is e. (Behrman, 16/e, pp 2028-2029.) Impetigo, which arises from minor superficial breaks in the skin, is caused by Staphylococcus aureus or ^-hemolytic Streptococcus and usually occurs in children. It is a highly contagious epidermal rash characterized by vesicles, erosions, or ulcers that crust and appear golden-yellow and stuck on. Folliculitis, which is an infection of the upper portion of the hair follicle, may appear as an erythematous papule, pustule, erosion, or crust lesion and is usually due to S. aureus. In folliculitis due to hot tub use, the etiology is Pseudomonas aeriginosa. Kawasaki's disease (KD) or mucocutaneous lymph node syndrome is uncommon in children over the age of 8 years and is characterized by fever, a desquamating, edematous, blotchy-appearing, mucocutaneous erythema, cervical lymphadenitis, and aneu-rysms of the coronary arteries. It is idiopathic. Staphylococcal scalded skin syndrome (SSSS) is most common in neonates during the first 3 mo of life. It is a toxin-mediated epidermolytic disease characterized by tender erythema that wrinkles, resembling wet tissue paper. Bullous formation and desquamation may occur. Widespread detachment of the superficial layers of the epidermis resembles scalding. Miliaria or "prickly heat" is a burning and pruritic rash of infants localized to the upper extremities, the trunk, and the intertriginous areas. A Tzank smear is most often used to diagnose herpesvirus.

496. The answer is d. (Behrman, 16/e, pp 1797, 1873-1882.) Children with Duchenne muscular dystrophy (DMD) present between the ages of 2 and 6 years with fatigability, clumsiness, difficulty standing, difficulty walking on toes, pseudohypertrophy of the calf muscles, and a waddling gait. DMD results from a deficiency of dystrophin, while Becker MD is the result of abnormal dystrophin. Becker MD is less severe than DMD and occurs after the age of 5 years. Both Becker and Duchenne MD are X-linked myopathies. The autosomal dominant myopathies are myotonic dystrophy and facioscapulohumeral dystrophy. Myotonic dystrophy occurs in adolescence and is characterized by diminished facial movements, cataracts, tes-ticular atrophy, and muscle weakness. Facioscapulohumeral dystrophy occurs between the ages of 10 and 20 years and is characterized by facial and shoulder girdle weakness. The Gower maneuver (pushing off with the hands when rising from the floor because of proximal muscle weakness) is positive in muscular dystrophy.

497. The answer is f. (Behrman, 16/e, p 396. Fauci, 14/e, pp 2144-2145.) Tangier disease is a rare inherited disorder of lipoprotein metabolism. Patients present with a low serum cholesterol level, virtually no HDL cholesterol, a normal or elevated triglyceride level, orange-colored tonsils, corneal opacities, and a relapsing polyneuropathy. The disorder does not lead to premature atherosclerosis and treatment is not required.

498. The answer is c. (Behrman, 16/e, pp 1554-1556. Hay, 14/e, pp 782-792.) The most common renal tumor in children is Wilms tumor or nephroblastoma (an embryonal tumor of renal origin). Children present with a painful abdominal mass, dysuria, polyuria, hematuria, weight loss, nausea, and vomiting. Physical examination typically reveals fever, hypertension, and an abdominal or flank mass. Neuroblastoma is a tumor of neural crest cell origin. Patients present with fever, anorexia, malaise, an abdominal mass, diarrhea, and neuromuscular symptoms. Physical examination may reveal fever, hypertension, abdominal distension, an abdominal mass, peripheral edema, and periorbital bruises. Both Wilms tumor and neuroblastoma are seen in children <5 years old. Patients with Hodgkin's lymphoma usually present between the ages of 15 and 45 years or over the age of 60 years with the complaint of cervical lymph-adenopathy. Ewing's sarcoma is a tumor predominantly of white children that involves the diaphyses of long bones. Rhabdomyosarcoma may occur anywhere in the body; symptoms depend on the location of the progressively enlarging mass.

499-500. The answers are 499-c, 500-d. (Behrman, 16/e, pp 946-953, 964-966, 973.) Rubella (German measles or 3-day measles) is a common childhood infection manifested by a characteristic exanthem and lymph-adenopathy. Rubeola or measles is highly infectious and is characterized by fever, Conjunctivitis, Coryza, Cough (the three C's), and Koplik spots. It has a significant morbidity and mortality. Roseola (exanthem subitum) is a childhood disease due to human herpesvirus type 6 and 7 and is characterized by high fever for several days before the skin lesions. Multiple, blanchable macules and papules appear on the back as the fever resolves. Sequelae are rare. Chickenpox (varicella zoster virus) is characterized by crops of pruritic vesicles that evolve into pustules, crusts, and even scars. Most cases occur in young children and may be complicated by pneumonia or encephalitis. The incubation period is approximately 14 days. Patients may remember an exposure to another child with chickenpox or to an older person with zoster.

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