Chapter 10 - Vesicles & Bullae Flashcards
Solid and palpable lesions are ________ lesions.
primary
what are the 4 types of solid and palpable lesions?
papule, nodule, plaque, cyst, wheal
Fluid filled lesions are _____ lesions.
primary
what are the 3 types of fluid filled lesions?
vesicle, bulla, pustule
open lesions are _____ lesions.
primary
what are the 3 types of open lesions?
erosion, ulcer, fissure
Atrophy, Scar, & telangiectasia are _____ lesions.
primary
What occur as a result of a change in the primary lesions?
secondary lesions
What are the 4 secondary lesions?
scale, crust, lichenification, verrucous
A primary fluid filled lesion greater than 1 cm?
Bullae
an intraepidermal (subcorneal) bacterial infection of the skin caused by certain strains of Staphlcoccus aureus.
Bullous impetigo
a contageious bacterial skin infection forming pustules and yellow,, crusty sores
impetigo
Where is Bullous impetigo most frequently found?
preschool age children
What are the predisposing factors of impetigo?
crowding, poor hygiene, chronic dermatitis, and neglected injury of the skin
When performing a physical examination of bollous impetigo (not ruptured yet), what would you expect to see?
fragile, cear or cloudy bullae. (blister containing fluid)
What would you expect to see if the bullae was ruptured?
a thin varnish-like crust. A delicate, collarette-like remnant of the blister roof is often present at the rim of the crust.
A patient has self infected (autoinoculation) herself with bollous impetigo. What would you expect to see during her physical examination?
secondary (satellite) lesions
What part of the body are most often affected by bollous impetigo?
face, neck, and extremities
t/f Patients diagnosed with bollous impetigo may have regional adenopathy and systemic symptoms.
false. regional adenopathy may be present as a symptom…. but systemic symptoms will NOT occur.
You suspect your patient has bullous impetigo. You must perform a differential diagnosis to be sure. What three other diseases are similar?
- Contact Dermatitis
- Herpes simplex virus HSV
- superficial fungal infections
A patient presenting with chronic, apparently impetignized, plaques that have not responded appropriate to antibiotics would be suspected to have _________.
pemphigus vulgaris
What disease is primarily found in infants and is characterized by sudden onset of fever, skin tenderness, erythema, followed by formation of large, flaccid bullae and shedding of large sheets of skin.
Staphylococcal scalded skin syndrome
What is the difference in Bullae of staphylococcal scalded skin syndrome and bollous impetigo?
s. auras can be recovered in bollous impetigo but in staphylococcal scalded skin syndrome the bullae are sterile.
What is the usual source of infection in staphylococcal scalded skin syndrome?
conjunctiva, nose, or pharynx; or in a newborn an infected umbilical stump
A PA usually does not perform a biopsy on patients presenting with bullous impetigo. Why?
gram staining of the clear or cloudy fluid from a bulla reveals gram positive cocci. S. aureus grows out in more than 95% of the cultures.
definition: detachment of the horny layer by an epidermolytic toxin produced by staphylococcus aureus causes _________. *be specific
subcorneal blister
How long does it take impetigo to heal spontaneously without treatment? how long with treatment?
3-6 weeks w/out treatment
w/ antibiotic heal w/in 1 week
In _______, the toxin is produced at the site of the lesion causing the blister; but in _______ the toxin is produced remotely (no physical contact) and then carried hematogenously to the skin.
- bullous impetigo
2. staphlococcal scalded skin syndrome
What disease is caused by infection with HSV?
Herpes simplex disease
Which HSV type causes oral infection? which causes genital infection?
HSV-1 = oral HSV-2 = genital
The incidence of which type of HSV is higher?`
HSV-1 at 50% ; HSV-2 is at 20%
Primary infection with HSV-1 usually occurs in children in whom it is subclinical in 90%. The remaining 10% of infected children have what?
acute gingivostomatis - (sore mouth)
HSV-2 primary infections usually occurs after sexual contact in post pubertal individuals, and it produces ______ or _____.
acute vulvovaginitis or progenitalis
T/F Primary infection with HSV is frequently accompanied by systemic symptoms.
true. - fever, malaise, myalgia, headache, & regional adenopathy.
Herpes labials would most likely be caused from _______.
HSV-1
In which of the types of HSV is the risk of recurrence lower?
HSV-1 at 14% ; HSV-2 is at 60%
What are two distinctions of Herpes would cause a PA to almost instantaneously know to it add to their differential diagnosis if these two distinctions were presented in a patient?
if a vesicular eruption is
- recurrent in same location
- preceded by a prodrome
Recurrent attacks of Herpes are preceded by what? (prodrome)
itching or burning
**also it will occur in the same location as before
indurated erythema followed by grouped vesicles on an erythematous base is typical of _______. The vesicles quickly then becomes ______, which rupture, weep, and crust.
herpes infections (HSV infections) ; become pustules
If the skin infected by HSV becomes necrotic, what will happen?
the affected skin becomes a punched out ulcer.
________ is a type of herpes that affects the fingers?
Herpetic whitlow
What traumatic herpes simplex has been reported among wrestlers?
Herpes gladiatorum
Which herpes is a generalized cutaneous infection with HSV in individuals with predisposing skin diseases such as Atopic Dermatitis.
Eczema herpeticum - usually accompanied by severe toxic symptoms that can be fatal
The occurrence of grouped vesicles on an erythematous base is characteristic of HSV infection. It can be confirmed with ______.
Tzanck smear = reveals multi-nucleated giant cells
What do you stain with using a Tzanck smear?
Giemsa, Wright, or toluidine blue
What can prevent the transmission of HSV-2?
condom
Can treatment prevent recurrent infection of herpes?
no
The incubation period after contact with HSV is how long?
1 week
The clinical course of primary herpes is how long
3 weeks
A prodrome of 1-2 days is followed by a vesiculopustular eruption for ______ with primary herpes.
10 days
T/F A patient diagnosed with herpes, who has had varying periods of latency, should not be worrisome of overt eruptions.
true.
During a period of latency where does the herpes virus remain?
dorsal root ganglion corresponding to the site of infection
What could initiate a recurrence of herpes?
fever, UV light, physical trauma, menstruation, emotional stress
What is very common and instrumental in transmitting HSV to others?
asymptomatic, subclinical shedding of the HSV
Babies born with HSV are termed to have ______.
Neonatal herpes
Women who have evidence of active HSV infection at delivery should have what?
cesarean section
What are the 3 complications of neonatal HSV infection discussed in the text?
- cultures to screen women immediately before delivery do not predict infection for the fetus
- more than 70% of mothers of babies with neonatal HSV have no history of genital HSV infection
- symptomatic disease may not occur for as long as one month after delivery
2/3 of affected infants have ________ of HSV infection?
mucocutaneous manifestations of HSV infection
A relatively uncommon complication of HSV infection is _______, its serum is composed of antibody and HSV antigen.
erythema multiform may occur after HSV infection
What is caused by the recrudescence of latent varicella costar virus in persons who have had varicella? It occurs in a dermatomal distribution.
Herpes zoster
Vesicular dermatomal eruption is distinctive of?
Herpes zoster
Who is most at risk for herpes zoster?
patients over 50 years of age & have cancer or AIDS
8-25% of patients with ________ develop herpes zoster.
Hodgkin’s disease
Is there a low or high frequency of second attack of herpes zoster?
low- 5%
Does herpes zoster present with a prodrome?
yes - radicular paid and itching. The prodrome can mimic migraine, pleurisy, myocardial infection, or appendicitis.
In herpes zoster, the eruption is characterized by groups of vesicles on an erythematous base situated ________ along the distribution of _________.
unilaterally ; cranial or spinal nerve
**rarely bilaterally ; frequently involves dermatomes
The dermatomal distribution of herpes zoster is diagnostic. However, ______ may also occur in a dermatomal fashion.
herpes simplex
T/F You must always do a laboratory test to confirm herps zoster.
false! almost never have to
T/F Herpes zoster is not am erker for occult malignant disease. It may be the presenting sign of HIV infection.
true.
In herpes zoster, the succession of lesions begins with ____ , which develops into _____.
begins with macules and develops into vesicles
What are two changes that may occur in herpes zoster that may result in scarring?
- hemorrhagic bullae
2. gangrenous changes
Post-herpetic neuralgia is uncommon in patients less than _______ years old.
40 yrs old
Other than old age, what is the other risk factor to developing post-herpetic neuralgia?
female, with a prodrome, and have more severe acute pain and eruption
80T of patients with post-herpetic neuralgia become __________ within 12 months.
asymptomatic
When herpes zoster involves the tip of the nose, what should a PA suspect is involved?
the eye. Herpes opthalmicus should be suspected because the nasociliary branch of the opthalmic division innervates the eye and the tip of the nose.
T/F Bell’s palsy and full-thickness skin necrosis are two occasional complications of herpes zoster.
true
T/F Viremia (presence of virus in the blood stream) frequently occurs in herpes zoster resulting in disseminated lesions.
true
What is characterized by successive crops of rapidly progressive lesions over an 8-12 hour period with generalized vesicular eruptions; lesions are present in all stages?
Varicella (chickenpox)
90% of Varicella cases occur before the age of _____.
10
The incidence of varicella peaks sharply in which months?
March, April, & May
The lesions begin as _____ and develop quickly into ____, ____, and _____ in varicella zoster.
macules; papules, vesicles, and pustules
How do you distinguish small pox from chickenpox?
The presence of lesions in all stages in varicella is different from small pox in that small pox the lesions are in the same stage of development.
T/F Disseminated herpes simplex, coxackievirus, and echovirus, as well as rickettsialpox could all be in a PA’s differential diagnosis when a patient presents with suspected varicella zoster.
true - all of these can present with vesicular eruptions similar to varicella zoster
Chickenpox has all types of lesions. Name them.
- macules
- papules
- vesicles
- pustules
- crusts
Culture of the varicella zoster virus is difficult; therefore what test is preferred?
vesicle smears by immunofluorescent staining is the preferred test.
T/F The treatment of chickpox is largely symptomatic.
true
What should be avoided in children for treatment for chickenpox? Why?
Asprin, because of its association with Reye syndrome
Varicella vaccine that is safe and effective in health children and adults in preventing chickenpox
Varivax
Passive immunization that is used in high risk patients. It contains plasma containing high titers of varicella zoster antibody and is effective in prevention in immunodeficient patients if administered shortly after exposure.
VZIG - varicella zoster immune globulin
T/F Patients with leukemia or lymphoma, congenital or acquired immune deficiency, pt’s receiving immunosuprressive medication, and newborns of mothers who have varicella are candidates for treatment with VZIG.
true.
T/F VZIG is not administered to patients with active disease.
true
Where does varicella primary infection begin?
nasopharynx
a metabolic disorder characterized by defective heme synthesis and excessive porphyrin production
Porphyria cutanea tarda
a group of genetic disorders with mutations that produce structural defects in the epidermis or dermis
Epidermolysis bullosa
an autoimmune disorder characterized by large and tense blisters that occur on normal or erythematous/urticarial appearing skin
Bullous pemphigoid
where would u find bullous pemphigoid
flexor surfaces, groin, axillae
where is the bister location in bullous pemphigoid
subepidermal
How do the bullous pemphigoid and pemphigus vulgarism differ in regard to the bullae?
the bullae of bullous pemphigoind do not extend laterally like the bullae of vulgarism
T/F Bullous Pemphigoid heals with scaring.
false. heals without scaring
What immunoglobulin is found in bullous pemphigoid?
IgG
chronic, intensely pruritic vesicular disease characterized by grouped papules, vesicles, and urticarial plaques, which are distributed symmetrically on the elbows, knees, buttocks, low back, and shoulders
Dermatitis Herpetiformis
A patient presents with scratching excoriations, rather than vesicles, could Dermatitis Herpetiformis still be in a PA’s differential diagnosis?
YES. The vesicles are often not intact, secondary to scratching as a result of intense pruritus of Dermatitis Herpetiformis disease
What immunoglobulin will the PA see when performing an indirect immunofluorescence test on a patient presenting with Dermatitis Herpetiformis?
IgA
T/F One treatment with dapsone or sulfapyridine will cure a patient of Dermatitis Herpetiformis.
false- treatment with that will cause rapid clearing; but the disease recurs promptly when therapy is stopped
75%of patients with Dermatitis Herpetiformis have associated what?
gluten - sensitive enteropathy (usually asymptomatic)
What do you advise of your patient who has associated gluten - sensitive enteropathy due to Dermatitis Herpetiformis?
advise a strict gluten free diet to cause
1. remission
or
2. a significant reduction of the medication done
What group of disorders is characterized by mutations in genes that encode for the structural proteins of the epidermis and dermis? This results in epidermal, junctional, and sub epidermal blisters produced by minor friction or trauma.
Epidermolysis bullosa
What are the two types of Epidermolysis bullosa?
simplex and recessive dystrophic
which type of epidermolysis bullosa has blistering limited to the hands and feet? and is caused by dominant keratin 5&14 gene mutations?
Epidermolysis bullosa simplex
which type of epidermolysis bullosa results from mutations in the gene encoding type VII collagen, COL7A1. The severe form is characterized by mitten like deformity of the hands and feet, contractors, blistering and scarring of the mouth and eyes, esophageal strictures, growth retardation, anemia, and nutritional deficiency?
Recessive dystrophic epidermolysis bullosa
What would you advise for treatment of a patient with epidermolysis bullosa?
the treatment is symptomatic protect from trauma good wound care treatment of infections and nutritional supplements
autoimmune disease characterized by blistering of the skin and mucous membranes. bullae are flaccid and superficial, RUPTURE EASY leaving large denuded, bleeding, weeping, and CRUSTED EROSIONS. Pressure applied LATERALLY to the bulla result in extension (POSITIVE NIKOLSKY’S SIGN).
Pemphigus Vulgaris
what is frequently the presenting site and almost always involved in Pemphigus vulgaris
oral mucosa (erosions in the mouth)
The bulla of pemphigus vulgarism occur ______ in relation to the epidermis? *which is different from bullous pemphigoid
intraepidermally
**whereas bullous pemphigoid occurs subepidermally and does extend laterally!
before the introduction of systemic steroids, pemphigus vulgarism was associated with an extremely high mortality rate. But now that we have systemic steroids, death now occurs more frequently with _______ than from complications from the disease.
steroid-induced complications
T/F If untreated, pemphigus vulgarism will cure itself within 3 weeks.
false!!! - untreated pemphigus vulgaris has a high mortality rate!!!!!
a group of disorders characterized by abnormalities in the heme biosynthetic pathway resulting in abnormal porphyrin metabolism and excessive accumulation of various porphyrins.
porphyria cutanea tarda
subepidermal blisters on the hands and excessive uroporphyrin excretion in the urinel; bullae, vesicles, erosions, crusts, milia, and milk scarrin occur on SUN EXPOSED SKIN!!
Porphyria cutanea tarda
What can you test to diagnose porphyria cutanea tarda?
urinary levels of uroporphyrins and coproporphyrins are markedly raised with a ration of 3:1. liver function test results and serum iron levels are usually increased.
what color is urine of a patient diagnosed with porphyria cutanea tarda using woods light?
fluoresces orange-red
**but without wood light looks dark brown
T/F Variegate porphyria, hereditary coproporphyria, and porphyria cutanea tarda have identical skin findings.
true!
- so do urinary test to eliminate variegate porphyria
- do serum or fecal porphyrin measurement to diagnose hereditary coproporphyria
