# -*- coding: utf-8 -*-
DATA = {}

DATA[401] = [
 {"title": "Clinical paths", "content": "Tinea versicolor is suspected in an adolescent or young adult with multiple small, oval, scaly patches on the upper chest, back, or upper arms that vary in color (white, pink, tan, or reddish-brown) and notably fail to tan with sun exposure, appearing lighter than surrounding skin in summer. In an infant or young child, facial involvement is looked for instead, particularly the bilateral temples. It is distinguished from vitiligo (which shows depigmentation rather than fine scale and a positive KOH), pityriasis alba, seborrheic dermatitis, and pityriasis rosea based on distribution, scale character, and KOH findings; secondary syphilis is considered in a sexually active adolescent with an atypical or resistant presentation."},
 {"title": "Diagnosis", "content": "Diagnosis is confirmed with a Wood's lamp (yellowish-brown fluorescence) or KOH prep of a skin scraping, expecting the classic \"spaghetti and meatballs\" pattern of short hyphae and spore clusters."},
 {"title": "Management", "content": "Treatment starts with selenium sulfide 2.5% suspension or zinc pyrithione shampoo applied to the entire affected area (and surrounding skin) and left on overnight, repeated in 1 week and then monthly to prevent recurrence; the patient is warned about potential skin irritation from this regimen. Alternatively, a topical antifungal cream is prescribed twice daily for 1-2 weeks, or a single 400 mg dose of oral fluconazole for a simpler regimen in an adolescent or adult. Since Malassezia is normal skin flora and recurrence is common, advice is given on minimizing predisposing factors (excess heat, humidity, sweating, occlusive clothing) where practical."},
 {"title": "Prognosis and outcome", "content": "Patients are counseled that pigmentary changes (light or dark patches) can take weeks to months to fully resolve even after the infection itself has cleared, since this reflects residual pigment abnormality rather than persistent infection — this is expected and not treatment failure."},
]

DATA[402] = [
 {"title": "Clinical paths", "content": "In a neonate with a thin, whitish or yellowish vaginal discharge appearing within the first 10 days of life, perinatally acquired trichomoniasis is considered; treatment is not generally needed since this is typically self-limited, and intense social investigation is not automatically warranted given the known perinatal transmission route. In sharp contrast, any diagnosis of trichomoniasis in an older infant or prepubertal child should prompt a careful investigation for sexual abuse, including involvement of child protective services, since vaginal trichomoniasis is rare before menarche. In a postpubertal adolescent with vaginal itching, malodorous frothy discharge, or dysuria, examination looks for a strawberry cervix (present in only about 2% visibly)."},
 {"title": "Diagnosis", "content": "Before concluding a urine specimen shows pathogenic T. vaginalis, it is confirmed that this is not the nonpathogenic GI contaminant Trichomonas hominis. A saline wet mount is performed, but its sensitivity is only 60-70%, so a negative result in a symptomatic patient should prompt further testing rather than ruling out infection."},
 {"title": "Management", "content": "Self-limited neonatal trichomonal infection acquired perinatally is not treated, since this generally resolves on its own. For postpubertal patients with confirmed infection, treatment follows current CDC guidelines, and sexual partners are treated simultaneously to prevent reinfection — the single biggest driver of ongoing transmission. Retesting is scheduled 3 months after treatment given the high reinfection rate, rather than assuming a single treatment course is sufficient. Mycoplasma genitalium and [[239|bacterial vaginosis]] are kept in mind as alternative or coexisting causes of persistent symptoms if a patient does not respond as expected to trichomoniasis treatment."},
]

DATA[403] = [
 {"title": "Clinical paths", "content": "In a child with dysuria accompanied by urethral discharge or blood spotting on the underwear, urethritis is considered. In a girl with dysuria and gross [[187|hematuria]] or blood spotting, careful examination is made for urethral prolapse (complete protrusion of urethral mucosa beyond the meatus), especially if she is young or from a lower socioeconomic background, to avoid progression to mucosal necrosis. In a child with a weak urinary stream or recurrent urinary symptoms, urethral stricture is considered. When evaluating acute urinary retention in an infant or child, severe acute cystitis, urethritis, meatitis (in boys), or vaginitis are considered the most common associated conditions. In a boy, urethral valves are suspected if there is straining or dysuria without complete retention rather than full retention. In a girl with retention, retention is not attributed to labial adhesions alone (even if severe), and an uncommon lesion such as a prolapsed ureterocele is considered."},
 {"title": "Diagnosis", "content": "A urethral smear and urine culture are obtained as part of the workup, since infectious causes—though less common in children than adults—still need to be identified when present. Trauma, chemical exposure (bubble baths, soaps), and the possibility of a foreign body are specifically asked about, since these are recognized noninfectious causes of urethritis in children. Voiding cystourethrogram or cystoscopy is pursued for diagnosis of urethral stricture. Severe constipation is checked for as a contributing cause of acute urinary retention. In a boy, examination is made specifically for urethral stricture or meatal stenosis with meatitis. For any child under 2, or any boy regardless of age, presenting with urinary tract symptoms, evaluation is made for a congenital anatomic abnormality such as [[271|vesicoureteral reflux]], since these are more prevalent in this population and affect long-term management and follow-up."},
 {"title": "Management", "content": "Prompt treatment (sitz baths, antibiotics, topical estrogen, or surgical referral if needed) is given for urethral prolapse."},
]

DATA[404] = [
 {"title": "Clinical paths", "content": "A detailed history is taken covering hygiene technique (front-to-back wiping), exposure to chemical irritants (bubble baths, soaps, detergents, pools/hot tubs), tight clothing, recent diarrhea, and perianal or nighttime itching, and the possibility of a foreign body is gently asked about, recognizing a young child may not recall or disclose this. On exam, visible discharge is distinguished from irritation/erythema alone - visible discharge raises the likelihood of a specific infectious cause to about 50%, whereas irritation without discharge more often reflects nonspecific vulvovaginitis from the combination of unestrogenized mucosa, absent labial protection, and alkaline pH that predisposes all prepubertal girls. Any prepubertal child with a sexually transmitted pathogen identified on vulvovaginal culture, or with [[106|pelvic inflammatory disease]], is treated as a sexual abuse concern requiring a full evaluation - this association is close to universal at this age."},
 {"title": "Diagnosis", "content": "A culture with sensitivities is obtained using a moistened cotton or urethral (Calgiswab) swab when a specific infectious cause is suspected, particularly with blood-tinged/serosanguineous discharge (raising concern for group A streptococcus or Shigella) or a history of recent respiratory illness or diarrhea. A diagnosis of nonspecific vaginitis is reserved for after other identifiable causes have been reasonably excluded, since many of these children have already had prior evaluations and treatment failures. Candida vulvovaginitis is considered only when a predisposing factor is present (diabetes, recent systemic antibiotics or steroids) in a prepubertal, diaper-free child, since Candida is otherwise an uncommon cause at this age despite being a frequent culprit in diaper dermatitis and in postpubertal vulvovaginitis; diagnosis is confirmed with KOH prep/wet mount."},
 {"title": "Management", "content": "Candida vulvovaginitis is treated with topical azole antifungals or, in adolescents, a single dose of oral fluconazole. For nonspecific vulvovaginitis, the majority of cases, first-line management focuses entirely on hygiene counseling (front-to-back wiping, wet wipes, gentle genital cleansing, avoiding perfumed soaps and other irritants) before escalating to antimicrobial therapy, since most children improve with these measures alone."},
]