A 4-month-old girl is brought to the office due to a rash on her cheeks for the past 2 weeks. The rash has not spread, and the patient is often seen scratching her face. There have been no changes in bath soaps and detergents; no animals or plants are in the house. Vaccinations are up to date. The patient is exclusively breastfed, with height and weight tracking along the 50th percentiles. Vital signs are normal. Skin examination is shown in the exhibit.
The remainder of the examination is unremarkable. Which of the following conditions is this patient at increased risk for developing?

Question

A 4-month-old girl is brought to the office due to a rash on her cheeks for the past 2 weeks.  The rash has not spread, and the patient is often seen scratching her face.  There have been no changes in bath soaps and detergents; no animals or plants are in the house.  Vaccinations are up to date.  The patient is exclusively breastfed, with height and weight tracking along the 50th percentiles.  Vital signs are normal.  Skin examination is shown in the exhibit. 
 The remainder of the examination is unremarkable.  Which of the following conditions is this patient at increased risk for developing?

Quizplus · Accepted Answer

11ec160b_37c6_a847_9249_238ac82c3fbc_MD0001_00 This infant with erythematous and pruritic patches on her cheeks has atopic dermatitis (eczema), a common childhood condition that typically begins in infancy or early childhood. The pathogenesis of atopic dermatitis is multifactorial and includes genetically mediated skin barrier dysfunction (eg, filaggrin mutation) resulting in loss of epidermal water content, increased permeability to environmental allergens/irritants, and skin inflammation. In addition, immune dysfunction, characterized by an underlying Th2 skewed response, promotes IL-4 and IL-13 release, which stimulates IgE production by plasma cells. Patients with atopic dermatitis and elevated IgE levels are at increased risk for other atopic diseases, such as allergic rhinitis, asthma, and food allergies. A compromised skin barrier facilitates allergen penetration (eg, from food) and subsequent sensitization, facilitating the development of food-induced urticaria and anaphylaxis. An earlier onset of atopic dermatitis (eg, infancy) is associated with a higher risk for developing these associated conditions. (Choice A) Kawasaki disease, a medium-sized vessel vasculitis, is associated with coronary artery aneurysms. Patients have a polymorphous rash, in addition to fever, mucocutaneous inflammation, cervical lymphadenopathy, and extremity changes (eg, edema), none of which are seen in this case. (Choice B) Disabling arthritis can be associated with plaque psoriasis, which classically presents with thick, silvery scales involving the knees, elbows, scalp, and lower back, features not seen in this patient. (Choice D) Proximal muscle weakness is characteristic of juvenile dermatomyositis, which can cause facial erythema but classically presents with a heliotrope rash on the upper eyelids. In addition, the onset typically occurs in school-aged children, not infants. (Choice E) Parvovirus B19 can cause transient anemia due to viral destruction of erythrocyte progenitor cells, typically in patients with red blood cell disorders (eg, sickle cell anemia). Initial symptoms include a nonspecific prodrome (eg, fever, coryza), followed by a nonpruritic, malar rash (ie, slapped cheeks) in school-aged children. This patient's age, lack of prodromal symptoms, and pruritus make this diagnosis unlikely. Educational objective: Atopic dermatitis increases the risk for allergic rhinitis, asthma, and food allergies, likely because of an immune response that favors IgE production. In addition, skin barrier dysfunction facilitates food allergen penetration and sensitization, increasing the risk for food allergies. __________ References: Controversies in allergy: food testing and dietary avoidance in atopic dermatitis. (http://www.ncbi.nlm.nih.gov/pubmed/30501976)

A 4-Month-Old Girl Is Brought to the Office Due to a Rash