why this lecture? - capa-acam.ca · pdf filewhy this lecture? contest is the key! ......
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Rashes to recognize in ERPeter Tzakas, MD MBChB CCFP
Nino Parunashvili, PA student
Conflictofinterest— none
Objectives• Anatomyandbasicdermatologicaltermreview
• Recognizecommondermatologicalconditions
• Recognizedangerousdermatologicalconditions
• Knowdiagnosticandtreatmentoptionsforthoseconditions
• Havesomefun
Whythislecture?
Contestisthekey!
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Anatomy Skinfunctions• Protection:
– barriertoUVradiation,mechanicalandchemicalinsults,pathogens,anddehydration
• Thermal:– insulationtomaintainbodytempincoldanddissipationofheatinwarm
environments
• Sensation:– largestsensoryorganofthebody->touch,pain,temperature
• Metabolic:– VitDsynthesis,energystorage(primarilyinformofTG)
DefinitionsProfile <1cmdiameter >1cmdiameter
Flatlesion Macule(e.g.freckle) Patch(e.g.vitiligo)
Raisedsuperficiallesion Papule(e.g.wart) Plaque(e.g.psoriasis)
Deeppalpable Nodule(e.g.dermatofibroma)
Tumour(e.g.lipoma)
Elevatedfluidfilledlesion Vesicle(e.g.HSV) Bulla(e.g.bullouspemphigoid)
MedicalHistoryquestion• Whendidtherashstart• Howdiditstart,evolve• Distribution(MM,palms,soles,etc)• Whatmakesitbetter/whatmakesitworse• Associatedsymptoms:itch,fever,viralsymptoms• Isthisfirsttimeyouarehavingsucharash• Changesindiet,environment• Sickcontacts,Travelhistory• PMH,Meds,Allergies• Familyhistory
DDx toconsider?
Tintinalli’s Emergency Medicine
1. Cellulitis• Acute,painful,spreadinginfectionofdermisand
subcutaneoustissue• Pathogens:S.aureus,Strep.Pyogenes ...• Diagnosis:clinical• Treatment:
– 1st line:Cefazolin/cephalexinorcloxacillin– 2nd line:erythromycinorclindamycin– Children:cefuroxime– Diabetics:TMP/SMXandmetronidazole
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Description?
http://www.pcds.org.uk/clinical-guidance/impetigo
2.Impetigo• Asuperficialskininfection,highlycontagious• Honeycoloredcrusting,weeping,oozingoftheskin• Pathogens:S.aureus,Strep.Pyogenes• Diagnosis:clinical• Treatment:
– Milddisease:topicalagents(Bacitracin,Mupirocin)– Severedisease:oralagents(cephalexin,dicloxacillin)
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http://philadelphiadermatology.com/medical-dermatology/keloids.php
3.Keloid• Pathologicscarformationwithexcesscollagensynthesis
• Predilectiontodarkerskin• Diagnosis:clinical• Treatment:
– Intralesional corticosteroidinjection– Cryotherapy
?
Samuel Freire da Silva, MD, Atlasdermatologico
4.Folliculitis• Domeshapedpustule,infectionatthehairfollicle• Pathogens:normalflora• Diagnosis:clinical• Treatment:
– Antiseptic,topicalantibacterial(fucidin)– OralCloxacillin 7- 10days
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?
http://www.gponline.com/clinical-review-cellulitis-erysipelas/allergic-disorders/urticaria-other-allergies/article/1106149
5.Erysipelas• Infectionin deeperlayersofskin,invadesdermallymphatics andcausesbacteremia,fever/chills.
• Bright,red,hot,welldemarcatedborders,swollen• Pathogens:Strep>Staph• Diagnosis:clinical,bloodculturesfordefinitiveDx• Treatment:
– 1st line:cefazolin,cloxacillin,penicillin– 2nd line:cephalexin,clindamycin
?
http://www.shinglesinfo.com/what-is-shingles/
6.Shingles/Herpeszoster(VZV)• Unilateraleruptionoccurring3-5daysafterpain/paresthesia ofdermatome
• Pathogens:VZVreactivation• Diagnosis: clinical• Treatment:
–acyclovir/famciclovir seemstoreducetheincidenceofpostherpetic neuralgiaifinitiatedwithin72hrs
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https://summerlindermatology.com/otw-portfolio/molluscum-contagiosum/
7.Molluscum contagiosum• Centralumbilicateddome- shapedlesion• Commoninchildren(andinimmunocompromised)• Pathogens:Poxvirus(funfact:largestDNAvirus)• Diagnosis: clinical• Treatment:Reassure
– Cryotherapywithliquidnitrogen– Topicalkeratolytic(cantharidin)– Curettage
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?
http://www.fprmed.com/Pages/Derm/Erythema_Infectiosum.html
8.Erythema infectiosum (Fifthdisease)• Initiallyflu- likesymptomswithfever• Raised,uniformmaculopapular rash• Distribution:cheeks,chin,foreheadwithcircumoral sparing,
canaffecttrunkandextremities• Pathogens:parvovirusB19(funfact:smallestDNAvirus)• Diagnosis: clinical• Treatment:supportive
?
https://www.youtube.com/watch?v=RLHbq2L_qgU
9.Hand- foot- mouthdisease(HFMD)
• Painful,red,non- pruriticblister- likelesions• Associatedwithfevers,malaise,sorethroat• Pathogens:coxsackievirus typeA• Diagnosis: clinical• Treatment:supportive(hygiene,painrelief)
Threehistoryfacts Anypattern?
https://it.pinterest.com/pin/201747258288019143/
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10.Pityriasis rosea• Typicallystartswithasinglepatchandthendisseminatesina“Christmastree”pattern
• Pathogen:Unknown?viral?fungal(druglikereactionscanmimicthis)
• Diagnosis:clinical• Treatment:
– Selfresolvingin6- 8weeks– ifsymptomatic,treatedwithsteroidsorUVlight
Benign?
http://www.mrfpaediatricguide.info/diagnosis.php.html
11.Meningococcalsepticemia• Petechialnon- blanchingrash(fromtoxinthatleadstobloodextravasation)• Pathogen:N.meningitidis,S.Pneumoniae• Diagnosis:starttreatment!Donotwaitfortests!
– CBC,bloodC&S,LumbarpunctureforCSFcellcount/differential• Treatment:medicalemergency!
– EmpiricIVantibiotics(donotdelayuntilCT/LP)->DexamethasoneIVstartedearly.
• Prevention:immunizationofchildrenforH.influenzae,S.pneumoniae,N.meningitidis (insomecasesinadultsaswell)
• Prophylaxis: rifampinorciprofloxacinforclosecontacts
?
http://www.antimicrobe.org/e1.asp
12.Necrotizingfasciitis• Rapidlyspreadingdeepertissueinfection
Ø limbandlifethreatening!!!• Painoutofproportiontoclinicalfindingsandbeyondtheborderof
erythema• Pathogen:usuallyanaerobicbacteriaorStrepPyogenes• Diagnosis: clinical,CTifsuspectedmyonecrosis (whenCKishigh)• Treatment:
– Rigorousresuscitation+urgentconsultwithID.– Multiplesurgicaldebridements->removeallnecrotictissue– IVantibiotics
?
http://www.creepybasement.com/stevens-johnson-syndrome/
http://www.hivwebstudy.org/cases/resource-limited-setting/stevens-johnson-syndrome-and-
toxic-epidermal-necrolysis-hiv-infected
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13.SJS/TENSteven- Johnson Syndrome (SJS) Toxic Epidermal Necrolysis (TEN)
Lesion Erythema multiforme with ++ mucosal involvement. Sheet- like epidermal detachment (Nikolsky sign) of <10 BSA
Severe MM involvement, blistering, more severe form of SJS with > 30% BSA, Nikolsky sign +
Etiology 15% drug related (allopurinol, penicillins, anticonvulsants, sulfonamides). Occurs 1-3 weeks post drug exposure
50% are definitely drug related, <10% due to viral infection, immunization
Course & prognosis
fever4-6 week course, 5% mortalityRegrowth of epidermis in 3 weeks.
fever, unwell30% mortality due to fluid loss, secondary infection
Management
Prolonged hospitalisation, withdraw offending drug, IV fluids, infection prophylaxis, corticosteroids (controversial), consider IVIG
As for SJS, admit to burn unit, debride frankly necrotic tissue, consider IVIG
Urgentvs non- urgent?
Life-threatening rashes: dermatologic signs of four infectious diseases. Mayo Clin Proc. 1999;74:68-72.
14.Toxicshocksyndrome• Acuteonset,fever,hypotension,involvementof3or>systems:
– GI:vomiting,diarrhea,hepaticfailure– MSK:myalgias,increasedCK– CNS:disorientation
• Pathogenesis:reactiontoatoxinonthesurfaceofStaph(strep)• Riskfactors:
– Staph:nasalpacking,tamponuse,woundinfection– Strep:minortrauma,precedingviralinfection(chickenpox)
• Diagnosis: clinical• Treatment:supportive- fluidresuscitation,antibiotics
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http://www.medpictures.org/pemphigus-vulgaris-pictures.html
15.Pemphigusvulgaris• Autoantibodiestodesmoglein :
– Bullaethatrupture– Mouthinvolvement– MostcharacteristicNikolsky sign(lossofskinfrommildpressure)
• Pathogenesis:idiopathic,drug-induced,autoimmune• Diagnosis: clinical• Treatment: withoutRxpemphigusisafataldisease
– Systemicsteroids(prednisone)– Azathioprinetoweanthept offsteroids– Rituximab(anti- CD20Ab)orIVIGinrefractorycases
?
http://www.ilearlychildhoodfellows.org/guest-post-how-to-tell-if-your-child-has-allergies/
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16.Anaphylacticrash• Rashwith:
– Hemodynamicinstability:hypotension,tachycardia– Respiratorydistress:SOB,wheezing,swollenlips,face,
tongue• Pathogenesis:immediateIgEmediatedhypersensitivity• Diagnosis: clinical• Treatment:emergentairwayprotectionifneeded
– Epinephrine– Antihistamines:diphenhydramine(H1blockers)andRanitidine(H2blocker)– Glucocorticoids:hydrocortisone,methylprednisolone
Anothercontagionwiththestrawberrytongue?
http://monsterologist.blogspot.ca/2014/11/kawasaki-disease.html
https://www.intechopen.com/books/current-basic-and-pathological-approaches-to-the-function-of-
muscle-cells-and-tissues-from-molecules-to-humans/cardiovascular-lesions-of-kawasaki-disease-
from-genetic-study-to-clinical-management
17.Kawasakidisease• Fever>5days+CREAM(Conjunctivitis,Rash,Edema/erythema
(handsandfeet),Adenopathy,Mucosalinvolvement)• Pathogenesis:acutevasculitis ofmediumsizevessels,unknown
etiology• Diagnosis: clinical• Treatment:
– HighdoseofASAwhilefebrileandthenlowdoseASA– IVIG->reducesriskofcoronaryaneurysmformation– Baselineechoandfollowupat6weeks
?
http://www.onhealth.com/content/1/rocky_mountain_spotted_fever
18.RockyMountainspottedfever(RMSF)
• Influenza- likeprodrome:acuteonsetfever,headache,myalgias,anorexia,nausea,vomiting
• Macularrashappearsonday2-4offever• Pathogen:RickettsiaRikettsii,vector- tick(summermonths)• Diagnosis: serology- indirectfluorescentAb test• Treatment: Doxycycline,usually7daycourse
?
https://www.slideshare.net/jbearth/micro-quiz-4th-yr
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19.Endocarditis• Infectionofendocardium- leadstofeverandmurmurs• Pathogen:
o acute:Staph.Aureuso subacute:Viridans strep,culturenegative- coxiella burnetti orbartonella
• Riskfactors:valveabnormalities,IVdruguse• Diagnosis: bestinitialtestisbloodculture(99%sensitive)
– Ifnegativebloodculture,butrisks->echotolookforvegetation• Treatment:
– Bestempiricchoiceisvancomycin andgentamicin
?
http://www.fadic.net/en/node/822
20.Henoch- Schonleinpurpura(HSP)
• Systemicvasculitis associatedwithclassictriad:– GI:Abdominalpain,melena– Skin:palpablepurpura onbuttock/legs– MSK:Arthralgia
• Pathogenesis:vasculitis secondarytoIgAcomplexdeposition,associatedwithIgAnephropathy
• Diagnosis: clinical• Treatment:
– Mostcasesresolvespontaneously
Tosummarize...Condition abnorm
al vital signs
Toxic appearance
Severe pain
Diffuse erythema/ sloughing
mucosal/ oral lesion
Petechiae/ purpura
Other organ system involvement
Erysipelas ✔ ✔
Meningococcemia
✔ ✔ ✔ ✔ ✔
Anaphylaxis ✔ ✔ ✔ ✔
Endocarditis ✔ ✔ ✔
Nec fasciitis ✔ ✔ ✔ ✔
TSS ✔ ✔ ✔ ✔
TEN ✔ ✔ ✔ ✔ ✔
Ø Bacteremia+chills+fever+involvementofdermisandlymphatics
➢Clinicallysickpt+petechialrash+stiffneck
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Ø Respiratory+cardiovascularcompromise+/- Hx ofallergy
➢Fever+newmurmur+riskfactors+/- thefollowingfindings:
Roth’s spots Osler nodes
Janeway lesions
Splinter hemorrhage
Ø Rapidlyspreadingdeeptissueinfection+painoutofproportiontoclinicalfindings+tendernessbeyondborderoferythema
Ø Diffusesheet- likeepidermaldetachment+>30%BSAinvolved+MMaffected
Ø Desquamationofpalms&soles+fever+sBP <90+3or>organsysteminvolvement
➢Mucosalinvolvement,largeblistering
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Thankyou!
[email protected]@mail.utoronto.ca
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ReferencesChenetal.(2011)TorontoNotes:Comprehensivemedicalreference&reviewforMCCQEIandUSMLEII.Dermatology,1-43.TaoLeetal.(2014)FirstAidfortheUSMLEStepI.410- 438Lowelletal.(2012)Fitzpatrick'sDermatologyinGeneralMedicine,8eBologniaEtal(2015)Dermatology4eAlikhanetal.(2016)ReviewofDermatology