426 Emergency Medicine
organisms and factors have been implicated. HSP typically occurs in the spring
months and is most common in young children between 2 and 12 years of age,
though it can occur at any age. HSP is characterized by its characteristic rash,
apurpuric rash that typically occurs on the buttocks and flexural sur-
face of the lower extremities onto the soles.Abdominal pain, joint pain
and arthritis, and hematuria with renal involvement are also common. Treat-
ment is mostly supportive with NSAIDs for pain control although steroids
are used for patients with severe abdominal pain. There is recent evidence to
suggest that steroids may benefit a larger percentage of patients. One feared
complication of HSP is intussusception. Physicians must consider this diag-
nosis in patients with abdominal pain and HSP. HSP often affects the kidney
causing hematuria. The majority of patients recover from HSP without any
complication, but prolonged renal involvement leading to renal failure and
hypertension can occur in approximately 1% of patients.
The skin lesions (b)resolve, as does the GI involvement (c)with the risk
of intussusception decreasing to baseline levels with resolution of disease. The
arthritis(d)is similarly self limiting and pain control is the best treatment
until that time. The neurologic system (e)is involved in a small percentage of
patients, but this is atypical and does not lead to lasting complications.
382.The answer is d.(Fleischer and Ludwig, pp 797-799.)This is a case of
aviral URIwith an acute otitis media (AOM).Treatment for otitis media
evolved significantly over the last several years. Otitis has traditionally been
treated in the United States with oral antibiotics but there is now data
showing that most of these infections resolve spontaneously, even those
caused by bacterial organisms. Bacterial otitis media can present similarly
but is more typical to have viral symptoms for several days leading to
eustachian tube inflammation and dysfunction, which subsequently pre-
disposes a child to secondary bacterial infection from the fluid that cannot
drain from the middle ear. In cases of AOM in children over the age of 2 years
for whom secondary complications are less likely, the recommended treat-
ment is analgesics (can be topical, oral, or a combination of both) with a
48 to 72 hour period of waiting and observing for improvement or persis-
tence of symptoms. This will avoid unnecessary antibiotics in many chil-
dren. The remainder should be treated with amoxicillin at a high dose
(80-90 mg/kg/d divided into two doses) as first-line therapy.
Analgesics only (a)is a good start, but ignores the fact that the patient
has purulent middle ear fluid and may require antibiotics in the near future
for resolution. A third-generation cephalosporin (b)has been recommended