EmergencyDermatology Review The gyrate, the violaceous, and the icky.
How it’s gonna work: Students/interns: describe it! (more on this in a sec) PGY2s: name the disease! PGY3s: what are you going to do about it? Attendings: thanks for coming, ya’ll
It’s always maculopapular. Great term to obfuscate patients It’s not generally helpful to obfuscate yourself The Tao that can be told is not the eternal Tao The name that can be named is not the eternal name…
Describe according to : Primary or secondary lesion type Configuration Distribution
Primary lesions are caused by disease processesmacule papule (solid, <1cm) plaque vesicle/pustule (<0.5cm) bulla wheal nodule
Secondary lesions are caused by response to the initial lesion, like scratching or healing crust (dried serum) scale (epidermal thickening) “lichenification” if skin ridges prominentfissure erosion/abrasion ulcer “excoriations” are linear erosions
Configuration is the shape/character of the lesions arcuate circinate or annular target or iris nummular linear gyrate poorly demarked orserpiginous defined margins
Distribution is where the lesions are foundlocalized generalized discrete symmetric
Practice case:This 70yo woman has had swelling of her left eye for 2days. It started with a relentless burning sensation. Thenshe noticed the development of some “pimples” aroundthe eye.
Discrete vesicles overlying edema localized to the distribution of the ophthalmic branch of the trigeminal nerve. A vesicle is present on the tip of the nose. Okay, PGY2’s – since I don’t want to insult your intelligence, tell me the disease and tell me the name of the nerve responsible for the vesicle on her nose.
Discrete vesicles overlying edema localized to the distribution of the ophthalmic branch of the trigeminal nerve. A vesicle is present on the tip of the nose. Herpes Zoster Ophthalmicus the nasocilliary nerve is involved when Hutchinson’s sign is present PGY3’s – management?
Discrete vesicles overlying edema localized to the distribution of the ophthalmic branch of the trigeminal nerve. A vesicle is present on the tip of the nose. Herpes Zoster Ophthalmicus the nasocilliary nerve is involved when Hutchinson’s sign is present oral antiviral (acyclovir 5x daily, val- or famcyclovir 3x daily), pain control (don’t be stingy), ocular lubricants, ophtho follow-up within one week, transmission precautions
Next case…This 5yo boy presents after 1 week flu-like illness thatbecame worse in the last day. This morning he developedmouth sores, red eyes, and a red, hot rash on his face.His mother became worried when the rash spread rapidlyand he started to develop blisters where the skin was red.He was started on Depakote about a week ago for hisseizure disorder.
The diagnosis is… That named physical exam finding is…
Admit to ICU, preferably burn center Volume resuscitation Pain control Identify and stop offending agent if possible Avoid Silvadene (silver SULFAdiazene) Abx only if evidence of superinfection is present
Wait.. How do I know it’s TEN and not Stevens-Johnson (SJS) or erythema multiforme (EM)? ? EM Minor EM Major = SJS TENNO epidermal <30% epidermal detachment >30% epidermal detachment Lesions arise from purpuric or detachmentNO mucosal erythematous macule (SJS) involvementTarget lesions ! @’%&$!
This 40yo man’s dentist has not been able to explain thepainful red lesions that have appearing in his mouth forthe last 3 months. Now he’s getting these huge, fragile blisters all over his body…
Pemphigus Vulgaris Autoimmune Usually starts with oral lesions, but may evolve to include other mucosa WANTED! Flaccid bullae are hallmark Reward Relatively benign bullous pemphigoid has tense bulla and appears in older patients
Discharge home? Transfer to Gainesville? Google it?
Admit Volume and electrolyte management as TEN/burn High dose steroids and other immunosupressants… Do you feel lucky, Punk? Well, do ya?
A 14yo girl is brought to the ED after developing a feverand headache. According to auntie, “she not right.” Theycan’t tell you when she developed this painful lesion onher ankle. The purple area feels raised and doesn’tblanch when you press it.
Just suppose your life depends ongetting this diagnosis.
Meningococcemia petechiae can be found anywhere and often precede purpura palpable purpura with gray, necrotic centers are pathognomonic for this disease <20yo, most prevalent in <5yo aerosolized droplet transmission
How do you treat the patient?Who else gets treated, and how?
For your patient: Think about other age-appropriate causes and treat Ceftriaxone ASAP, pronto, stat, or possibly sooner Rapid antibiotic administration reduces mortality Admit Respiratory isolationFor close contacts: Rifampin 600mg q12h x2 days or Azithro 500mg once Cipro previously used, but no longer recommended after the isolation of fluoroquinolone-resistant strains in 2008
Two more reasons to dread meningococcus Waterhouse-Friderichsen Syndrome bilateral adrenal gland hemorrhage fulminant meningococemia shock, WBC < 10k, and coagulation disorders resulting in skin necrosis (purpura fulminans) after vasculitis, septic embolus, DIC, or all of the above may develop in hours
This 9yo boy presents with 5 days offever, headache, nausea, and myalgias. His family visitedkinfolk in North Carolina 2 weeks ago. These bumps arepalpable, blanching, and seen only in the areas pictured.
Could be scary meningitis, could also be…
Rocky Mountain Spotted Fever Infectious vasculitis Most lethal tick-borne illness 6% mortality if treated within 5 days 23% if treatment delayed About 50% of patients with verified diagnosis recall tick bite. “spotless” in 10-20% of cases, usually adults Rash starts 3-5 days after symptom onset and spreads centripetally
Diagnostics? Treatment? Dispo?
Diagnosis is clinical; just treat it. hyponatremia and thrombocytopenia are common Doxycycline 100mg BID for 10 days even in children Chloramphenicol for pregnant patients Admission is not mandatory. Most patients improve rapidly when treated.
Rickettsia rickettsii is the culprit obligate intracellularbacterium carried by vectors of genus Dermacentor
It’s a busy Monday in the ECC when this 20yo woman isbrought by in her roommate for acting confused. Theroommate also reports that the patient was seen atanother hospital last week for a gynecologic procedure.The patient tells you that her whole body aches and she’sbeen having diarrhea. BP 87/53, HR 110, temp 102 (oral) She’s in front of bed 5, so your skin exam is limited. Visible skin appears sunburned, but blanches when you press it. Her tongue also looks funny…
Diagnosis? Culprit bug?
Toxic Shock Syndrome TSS1 exotoxin of Staph aureus causes rapid vasodilation and movement of intravascular proteins/fluids extravascularly Hypotension with multi-organ system failure Suspect in post-op patients with diffuse erythroderma and shock Classically seen in genetically susceptible women with tampon use
5/6 diagnostic criteria: probable TSS. 6/6: confirmed1. fever ≥ 102 F2. rash: diffuse erythroderma, sometimes macular3. desquamation 1-2 weeks after onset of illness4. hypotension or symptomatic orthostasis5. ≥3 of following organ systems involved: GI msk integument (mucosal hyperemia) renal hepatic hematologic CNS6. exclusion of other etiologies by laboratory studies negative blood, urine, CSF cultures (except for S.aureus in blood) no elevation in titers for RMSF, leptospirosis, or measles
What did you do when you first saw the vitals? Meds, dispo?
Get the patient out of the aisle and on a monitor IV access Volume resuscitation/monitoring Finish the exam (retained surgical gauze?) Nafcillin or oxacillin 2g IV q4h textbook anti-staphylococcal penicillins Linezolid or clindamycin 600mg IV q12h may decrease release of exotoxin ICU admission
This 24yo woman presents with fever, joint pain, andthese painful bumps on her fingers and ankle. Thebumps started as red spots, then they became raised andsquishy. At her last ED visit 3 months ago, she wastreated for infectious cervicitis.
Diagnosis?What complications do we worry about?
Disseminated gonococcal infection Clinical diagnosis: fever, tenosynovitis, migratory polyarthritis, and skin lesions Most common complication is septic arthritis: knee > hand > ankle > elbow Rarely complicated by endocarditis and meningitis Affects 0.5-3% of patients with mucosal infection, which is often asymptomatic Increased incidence in late pregnancy, immediate post- partum period, and within one week of onset of menses
Where do I stick this swab? Treatment? Dispo?
Admit culture all mucosal surfaces if appropriate, culture synovial fluid and CSF Rocephin 1g IV daily Don’t forget to test/treat for concurrent STDs Refer sexual partner for testing/treatment
Your old college buddy, who has recently been sendingpictures chronicling his epic traverse of the northernquarter of the Appalachian trail, sends you this image ofthe crazy spider bite on his back.
Diagnosis? How about some common sequelae? What’s that rash called?
Lyme disease 1° Stage: 2-20 days from exposure Erythema chronicum migrans in 60-80% 2° Stage: days to months from initial infection Fever, cardiac conduction abnormalities (8%), asymmetric episodic oligoarticular arthopathies, and neuropathies MC exam finding is annular dermatologic lesions MC neuropathy is cranial neuritis, esp. facial nerve 3° Stage: years from initial infection Chronic arthritis, myocarditis, polyneuropathies, encephalopathy
Bring us home, PGY3s.
Doxycycline, erythromycin, amoxicillin, or cefuroxime 14-21 days primary stage 28 days advanced secondary stage IV PCN or Rocephin 28-60 days for tertiary stage ppx: doxy 200mg PO within 72hrs of exposure prevents Lyme disease
The spirochete Borrelia burgdorferi is transmitted throughvectors of genus Ixodes.If attachment ≥ 72 hours, 25% of persons will be infected.