2. Clinical Perspectives in Skin Changes Flashcards
how does the rash present in measles
brick red, irregular, maculopapular
begins on face and proceeds down and outward and affect the palms and soles last (will see more concentrated on face/neck and sparse on trunk)
appears 3-4 days after onset of prodrome
what are symptoms beside rash that occur in measles
prodrome fever, cough, corzya and conjunctivitis
Koplik spots on the buccal mucosa
morbiliform eruption lasts 3-5 days
what are severe complications that occur with measles
pneumonia
post-measles encephalomyelitis
(illness will confer permanent immunity)
how does erythema infectiosum present?
(parvovirus/5th disease)- seen in children
fiery red “slapped cheek”
circumoral pallor
subsequent lacy, maculopapular, fading away rash on trunk/limbs
malaise, HA, pruritis (esp palm/soles)
Parvovirus is MCC of ______ in children?
(MCC = most common cause)
What else may parvovirus present with ?
How can in present in adults?
myocarditis
transient aplastic crisis and pure red blood cell aplasia
in adultls -can mimic autoimmune states (like lupus, systemic sclerosis, antiphospholipid syndrome or vasculitis)
what happens if parvovirus infection occurs in pregnancy
premature labor
hydrops fetalis
fetal loss
what presents in ehrlichiosis
fever, chills, HA, malaise, myalgia, nausea, vomiting, anorexia and photophobia
abd pain mimicking appendicitis (kids > adults)
conjunctival injection, palatal petechiae, edema of dorsal hands, calf pain
erythematous macules &/or papules, petechiae or diffuse erythema about 5 days after onset of systemic symptoms
what will labs look like in ehrlichiosis
leukopenia, lymphopenia, thrombocytopenia, transminitis (liver exams) and anemia
what respiratory symptoms occur in ehrlichiosis
cough, dyspnea, resp insufficiency
adult respiratory distress syndrome
what neurological symptoms present w/ ehrlichiosis
meningoencephalitis, altered mental status
cranial/peripheral MN paralysis
sudden transient deafness
besides respiratory and neurological symptoms, what other symptoms present w/ ehrlichiosis
acute renal failure
DIC
pericarditis
what is the first stage of lyme’s disease (aka erythema migrans)
early localized infection
= flat/kinda raised red lesion at the bite, 1 wk after the tick bite –> expands over several days (= bulls-eye lesion)
rash in area of tight clothing
(will develop viral-like illness- myalgia, arthlagia, HA, fatigue, fever)
what is stage 2 of lyme’s disease?
(in terms of skin lesion)
early diseminated infxn (wk - months later)
bacteremia (50-60% pts)
secondary skin lesions - w/i days-wks of original infection
what are symptoms that present with lyme’s disease stage 2
malaise, fatigue, fever, HA, neck pain generalized achiness
myopericarditis, w/ atrial/ventricualr arrhythmias and heart block (4-10%)
neurologic manifestations (10-15%)
conjunctivits, keratitis
how does lyme’s disease stage 3 present
late persistent infection (months-years later)
musculoskeletal manifestation (60%) - monarticular/oligoarticular arthritis of knee or other large wt-bearing joints & chronic arthritis (10%)
rare: neurological manifestations
what is acrodermatitis chronicum atrophicans
rare symptom in stage 3 of lyme’s disease
= cutaneous manifestation
usually bluish-red discolartion of distal extremity w/ associated swelling
-lesions = atrophic and sclerotic, resember localized scleroderma
how can you differentiate lyme’s disease and shingles
maculopapular rash similar in both
BUT lyme’s does NOT follow dermatomal distribution
what is the time EBV remains infectious and what is the incubation period
remain infectious during convalescence (for 6 months or longer after symptoms onset)
incubation period = last several weeks (30-50 days)
what is commonly associated with EBV
infectious mononucleosis
-transmit by saliva and also recovered from genital secretions
what are symptoms of infectious mononucleosis
-how do you diagnose
malaise, fever, exudate sore throat, uvular edema, tonsilitis, gingivitis, solt palatal petchiae, conjuctival hemorrhage, & sometimes maculopapular rash
Test: (+) heterophile agglutination test (monospot test) ; large atypical lymphocytes in blood smear, lymphocytosis
what are complications that occur with infectious mononucleosis
hepatitis, myocarditis, neuropathy, encephalitis, airway obstruction from adenitis, hemolytic anemia, thrombocytopenia
what are physical findings in infectious mononucleosis
LAD - discrete, nonsuppurative, slightly painful: esp along posterior cervical chain
transient bilateral upper lid edema (Hoagland sign)
Splenomegaly (in up to 50% pt, sometimes massive)
Syphilis:
Cause?
Transmission?
Risk
1. Treponema pallidum, spirochete that can infect any organ and cause protein clinical manifestations
- transmitted via sexual contact or transplacenta transmission
- risk = 30-50% ppl w/ unprotected sex with ind w/ syphylis
What is the early phase of syphilis
=infectious
- primary lesion (chancre & regional LAD)
- secondary lesion (skin, mucous mem, occasionally bone, CNS and liver)
- congenital lesions
what is the late phase of syphilis
after early and latent phase
=benign (gummatous) lesions involving skin, bones and viscera
CV dz
CN & Ocular Syndrome
what is the manifestation of secondary syphilis
Rash: diffuse (MAY INCLUDE palm/sole), macular, papular, pustular and combos
condylomata lata: papular lesions on the folds of moist areas that to form flat, wartlike lesions, (esp genitalia and anus)
Mucous Patches: painless, silvery ulcerations of mucous mems w/ surrounding erythema
-low grade fever, malaise, anorexia, arthalgia/myalgia
What is another name for Coxsackievirus infxn
hand-foot-mouth dz (HFMD)
(summer months)
what are the symptoms of HFMD (subtype A & B)
stomatitis,
*vesicular rash on hands and feet: pink macules/papules –> 4-8 mm vesicles w/ surrounding erythema; erode and make. yellow-green football shape w/ erythematous halo
nail dystrophies and onychomadesis
-Enanthem similar to oral erosions on tongue bucal mucosa, hard palate & less freq oropharynx
what is herpangina
subtype A; B3 coxsackievirus infxn
=sudden onset fever, HA, myalgia
-petechia/papules on soft palate that ulcerate in about 3 days and then heal
what are complications of coxsackievirus?
- Epidemic pleuodynia (Bornholm Dz, subtype B) : pleuritic chest pain, systemic symps (HA, malaise, pharyngitis)
- Aseptic meningitis (subtype A&B) - kids/teens; HA, fever, stiff neck, CSF lymphocytosis, encephalitis and transverse myelitis
- Acute pericarditis (subtype B) - positional, plueritic chest pain, fevers, myalgia, clinical/echo sign of pericarditis
TSS:
Cause:
Presenting population:
strains of staphylococci
Women of childbearing age using tampons during menstrual periods
what are the characterisitics fo TSS
abrupt onset of fever, vomiting, & watery diarrhea
diffuse macular erythematous rash & non-purulent conjunctivitis
desquamation, esp palm/soles, during recovery
could be morbiliform, scarlatiniform or even pustular
what causes scarlet fever
and what are the lab tests to confirm your Dx
typically Group A Strep pyogenes
*most common cause of tonillopharyngitis in kids/teens*
throat culture - look for strep & Anti-streptolysin O (ASO) titers increase
how does scarlet fever present
1/2 to 2 days of malaise, sore throat, fever and vomiting
strawberry tongue
generalized punctate red rash on neck, axillae, groin and skin folds
circumoral pallor
fine desquamation involved hands/feet
what are the characteristics of erythema multiforme
=rare cutaneous/mucocutaneous eruption ==> “target” lesions on face and extremities
> in M kids and young adults
benign course but freq recurrence; possible ocular complications
what are most cases of erythema multiform related to?
infxn: HSV and Mycoplasma pneumoniae
what are the symptoms that present with erythema multiforme
prodromal symptoms - mostly absent, if present = mild URI-like
fever >38.5 C (101.3 F) (33%)
prior occurances (33%)
how does varicella present?
high contagious exanthem; mostly kids
rash begins on face and scalp and spreads rapidly to trunk, relatively spare the extremities
scattered lesions reflect viremic spread
progress sequentially from rose colored macule to papules, vesicles, pustules and crusts
**lesions in all stages present at the same time*
How is varicella eliminated
its not!
remain LATENT VZV infection of sensory and autonomic neurons
provide host immunity to VZV
what does the term pemphigus mean
& what are the subtypes
=group of autoimmune blistering dz of skin & mucous membranes
- vulgaris
- foliaceus
- paraneoplastic
- IgA pemphigus
what are clinical manifestations of pemphigus
lesion = pruritic/painful
primary lesion = flaccid blister, which may occur anywhere on the skin (EXCEPT palms/soles)
blister may form in normal or erythematous skin
fragile - erosions resulting from broken blisters (which can be large and spread to the periphery)
exposure to UV can make it worse
what causes gonococcemia
how is it transmitted and spread
Neisseria gonorrhoeae (gram neg), aerobic coccus-shaped bacterium
visualized intracellularly & located w/i polymorphonuclear leukocytes
= STD
can also be transmitted vertically from mom to child during birth = manifest as inflam eye infection (opthalmia neomatorum)
disseminated infxn from primary site of inoculation to other parts by blood stream
what is the classic triad of gonoccemia
dermatitis
migratory polyarthritis
tenosynovitis
what do the gonococcemia lesions look like
cutaneous lesions 40-70% of disseminated dx
small-med macules or hemorrhagic vesicopustules on an erythematous base located on palms and soles
may develop necrotic centers - lead to gun metal gray
palm/sole lesions may be tender and others tend to be nonpruritic and painless
-disappear after treatment
what is the cause of meningococcemia
how does it present
Neisseria meningtidis
Disseminated meningococcal infxn present as :
- meningitis alone,
- acute meningococcemia w/ or w/o meningitis: classic petechial rash on extremeties (severe cases - necrosis of skin/ tissue –>may need amputation)
- chonic meningococcemia: rose colored macules & papules, wax/wane w/ periodic fevers
what is the pentad that characterizes TTP
- thrombocytopenia
- neurologic problems
- microangiopathic autoimmune hemolytic anemia
- fever
- renal failure
TTP:
population?
mutation?
40 y/o, 9x more in blacks than in non-blacks
def in ADAMTS13 (idiopathic/classic version)
what happens in TTP is untreated
mortality rate exceeds 90%
even w/ modern therapy - 20% pt die w/i 1st month from complications of microvascular thrombosis
what is the classic form of TTP
idiopathic
-due to severe deficiency in ADAMTS13
Compare the causes of palpable purpura vs non-palpable purpura
what is the most common cause of skin cancer?
how does it present?
BCC
=pearly papule w/ tenlangiectatic vessels, erythematous patch (esp >6 mm), nonhealing ulcer
on sun-exposed areas usually (face, trunk, lower legs)
on back, chest and lower leg = reddish, kinda shiny and scaly plaques
How do squamous cell carcinomas of the skin present/look
nonhealing ulcer/warty nodule
=small red, conical, hard nodules that occasionally ulcerate
may arise from an actinic keratosis (15% chance malignancy)
what are risk factors for SCC of the skin
long term sun exposure
fair skin
organ transplant recipients
other immunosuppressed pts
what are risk factors for melanoma
hx of sunburn/heavy sun exposure
blue/green eyes
red/blond hair
fair complexion
>100 typical nevi, any atypical nevi
prior personal/Fhx melanoma
p16 mutation
who is most likely to be diagnosed w/ melanoma
mean age = 63
15% younger than 45 yo
what is the most common location for melanoma
back for men
LE and trunk for women
but can occur anywhere on skin
are melanomas curable?
yes, if removed and treated early
but late –> potentially lethal
what are the ABCDE’s of melanoma
Asymmetry
Border: irregular, notched, scalloped, ragged, poorly defined
Color: varying shades; black (necrotic), blue (deeper depth invasion), white (ischemic, fibrosis, deeper invasion)
Diameter: > 5 or 6 mm
Evolution
what is the most sensitive induication of metastatic potential for melanoma
color!
greatest sensitivity and selectivity
what are things to think about before performing a skin biopsy
established/confirmed dx?
appropriate procedure/ training?
cosmetic concern?
safety? (informed consent, wound healing, infxn risk)
treatment & management along w/ dx?
what is the benefit/limits of shave biopsies
less time consuming
good cosmetic result
little downtime
limited to process occuring to dept of mid dermis
what are the benefits/limits of punch biopsy
provide full thickness skin sample
rapid healing
limited by diameter of punch tool; may not be adequate for processes in SQ tissue
what are the benefits/limits of excisional biopsy?
adequate sample down to the subQ tissue
margins can be controlled and adjusted as needed
limitations ; increase time of procedure and healing, increased chance to scar, require suture removal
how do you perform an excisional biopsy
