While the cause for Bell’s palsy is still under debate, it is observed that Bell’s palsy is often preceded by a viral infection. Bell’s Palsy:Bell’s palsy (idiopathic facial palsy) is an acute unilateral lower motor neurone palsy. It typically occurs two weeks after viral infection such as Epstein–Barr, herpes simplex, herpes zoster or mumps. A careful assessment may suggest an alternative aetiology for the acute onset of weakness, e.g. acute otitis media, Lyme disease, hypertension. Causes:In childhood, Bell’s palsy is probably a post-infectious (i.e. immune-mediated) phenomenon, while in adults, there is increasing evidence that the majority of cases follow reactivation of previous HSV infection. Management:The prognosis is generally good in childhood with full recovery in the majority. However, permanent weakness is observed in around 5%. Steroids and acyclovir may have some benefit in adults with recent onset of weakness, but the evidence of the treatment benefit is much less convincing in childhood. Exposure keratitis is an important complication and children should be managed with eye drops and taping of the eyelid at night until recovery is complete.

History is suggestive of a possible hearing impairment. As the baby is vocalizing and has normal motor development, an isolated hearing problem is possible. A hearing test will confirm the diagnosis.

“Tinea incognito” is a term used to describe a tinea infection modified by topical steroids. It is caused by prolonged use of topical steroids, sometimes prescribed as a result of incorrect diagnosis. Topical steroids suppress the local immune response and allow the fungus to grow easily. As a result, the fungal infection may take on the bizarre appearance seen in this patient.The diagnosis of tinea incognito is simple to confirm by microscopic visualization of branching hyphae and spores typical of dermatophytes in a potassium hydroxide preparation.Treatment of tinea incognito requires cessation of all topical steroid use and implementation of specific antifungal treatment. A low-potency corticosteroid may be used briefly to avoid the flare often associated with abrupt cessation of a potent steroid. Patients should be warned of this possibility so they do not reinstitute use of topical steroids on their own.

One of the most common congenital viral infections is cytomegalovirus infection. It is caused by herpesvirus type 5. The clinical features include failure to thrive, intellectual disability, epilepsy, and microcephaly. The most common clinical complication is sensorineural deafness. The drug of choice for the treatment of neonatal CMV infection is ganciclovir, an anti-viral drug that has shown to prevent deafness.

Findings described are suggestive of Waterhouse-Friderichsen syndrome which develops secondary to meningococcaemia. The reported incidence of Addison’s disease is 4 in 100,000. It affects both sexes equally and is seen in all age groups. It tends to show clinical symptoms at the time of metabolic stress or trauma. The symptoms are precipitated by acute infections, trauma, surgery or sodium loss due to excessive perspiration.

The most appropriate step in this patient would be to admit the patient for enteral rehydration via a nasogastric tube.Enteral rehydration:Oral rehydration is the most preferred way of rehydrating children. If a child is not tolerating small-frequent-feeds, then nasogastric rehydration is an underused next best step. The fluid can be run through a continuous pump so that it is better tolerated. Note:Intravenous fluids are effective but can have profound effects on the serum electrolyte balance if not monitored closely. Most children will tolerate fluids in an emergency department, but failure to take fluids orally is not an indication for intravenous therapy.

Benign intracranial hypertension is characterized by an elevation of the CSF pressure that is not caused by hydrocephalus or any space-occupying lesion. The cause is most likely the decreased absorption of CSF into the dural sinuses. The main symptoms are headache and visual abnormalities. It can lead to blindness if not managed on time. The most important risk factors for BIH are female gender and obesity. The causes of BIH include iron deficiency anaemia, sarcoidosis, Lyme disease, SLE, polycythaemia vera, chronic kidney disease, meningitis, and sleep apnoea.

Atopic dermatitis (AD), also called atopic eczema, is a common chronic or recurrent inflammatory skin disease and affects 15-20% of children and 1-3% of adults worldwide. It is characterized by acute flare-ups of eczematous pruritic lesions over dry skin.The incidence has increased by 2- to 3-fold during the past decades in industrialized countries.Some of the most valuable AD prevalence and trend data have come from the International Study of Asthma and Allergies in Childhood (ISAAC). This is the biggest (close to 2 million children in 100 countries) and only allergy study that has taken a truly global approach. The strength of the study is the use of a uniformly validated methodology allowing a direct comparison of results between paediatric populations all over the world (http://isaac.auckland.ac.nz/index.html).

The CSF picture in bacterial meningitis has the following characteristics: several polymorphs, cells, protein that is maximum 5g/l, a few lymphocytes and glucose that accounts for the two thirds of the blood level.

In the final result of this double blind study, 25% or one in four of patients who received the treatment responded positively. Though the difference is significant at P<0.05, it is better to present this as a significant difference at 0.4%. The number needed to treat (NNT) is defined as the inverse of the absolute risk reduction. Taking this as 0.25 (25%), the NNT is 1/0.25 = 4. However given the 95% confidence interval is between 10-50% for absolute risk reduction, the NNT with 95% CI is between 2 and 10. Therefore we cannot say with certainty that the NNT is at least 4.